• Advance Directive

    Advance Directives include a living will or durable power of attorney which name someone you trust to make medical decisions on your behalf if you are unable. Your living will should specify which treatments you do or do not want if your life is in danger, including:

    • Breathing machines
    • Dialysis
    • Resuscitation if you stop breathing, or if your heart stops
    • Feeding by tube
    • Organ or tissue donation upon death

  • Amyotrophic Lateral Sclerosis (ALS)

    Amyotrophic Lateral Sclerosis (ALS) also known as Lou Gehrig’s disease is a fatal disease that affects nerve cells in the brain, brain stem, and spinal cord which control voluntary muscle movement. As these cells die, nerve impulses are no longer able to be transmitted from the brain to the muscles, which causes the muscles to weaken and atrophy. Death is usually caused by respiratory failure due to the weakness of the muscles in the chest wall and diaphragm.

  • Annual Election Period (AEP)

    The Medicare Annual Election Period (AEP) runs from October 15 to December 7 of each year. During this period, you can change your Medicare Part C Advantage plan or your Medicare Part D drug coverage to become effective January 1 of the following year as long as your plan receives your enrollment application by December 7.

  • Assignment

    Assignment means that your doctor, health care provider, or supplier has agreed (or is legally required) to accept the Medicare-approved amount as full payment for covered services. No more than the applicable deductible and coinsurance amount may be collected, and the payment for the covered charge must be invoiced directly to Medicare.

  • Balance Billing

    Balance billing, sometimes referred to as extra billing, is the practice of billing a patient for the difference between what the provider has charged and the Medicare-approved amount. Medicare bans balance billing for providers who accept Medicare assignment but a provider who does not may charge up to 15% over the Medicare-approved amount. Balance billing, or the practice of billing excess fees, is prohibited in seven states by the Medicare Overcharge Measure (MOM). These states include:

    • Connecticut
    • Massachusetts
    • Minnesota
    • New York
    • Ohio
    • Rhode Island
    • Vermont

  • Benefit Period

    The Medicare Part A Benefit Period begins on the first day of your admission to a hospital and ends 60 days after your release. If you are readmitted following the 60-day post-release period, another benefit period begins. A Medicare Part A deductible is payable for each benefit period resulting in the possibility that you may have to pay multiple Medicare Part A deductibles in any given calendar year.

  • Capitation Fee

    A Capitation Fee is a fixed payment paid to a medical provider on a recurring basis for each patient enrolled in their care. This fee serves as a pre-payment for services a patient receives as the patient’s care responsibility is transferred from Medicare to that service provider. As in Original Medicare, the patient is still responsible for any deductible, copayment, and coinsurance.

  • Centers for Medicare and Medicaid Services (CMS)

    Established in 1965, the Centers for Medicare and Medicaid Services (CMS) is a federal agency organized under the Department of Health, Education, and Welfare and is responsible for the administration of several federal health care programs:

    • Medicare
    • Medicaid
    • Children’s Health Insurance Program (CHIP)
    • The Health Insurance Marketplace

    The Centers for Medicare and Medicaid Services (CMS) can be contacted at www.medicare.gov or by phone at (800) 633-4227.

  • Coinsurance

    Coinsurance is a predetermined percentage of the cost of a prescription or medical service that you will pay after having paid your full deductible. (For example, 20%)

  • Copayment

    A copayment is a predetermined, set amount that you pay for any prescription or medical service. (For example, $15.00)

  • Creditable Coverage

    Creditable Coverage is Health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy. To be considered creditable coverage, the coverage must be equal to that provided by Medicare.

  • Custodial Care

    Custodial care is non-skilled personal care that a person is usually able to do for himself. It may involve activities of daily living such as eating, bathing, dressing, using the bathroom, and getting in or out of bed. Custodial care, in most cases, is not paid for by Medicare.

  • Deductible

    A Deductible is the amount you are required to pay out-of-pocket for medical services or prescriptions before your medical insurance begins to make payment. For instance, if the policy deductible is $500, you will pay all doctor visits and medication costs until you have paid $500 in covered expenses. Thereafter, your medical insurance will make payment subject to any copayment or coinsurance provision required by the policy.

  • Diabetic Nephropathy

    Diabetic Nephropathy is the loss of kidney function due to Diabetes Mellitus and is the number one cause of kidney failure. Approximately one third of diabetic patients develop diabetic nephropathy.

    Symptoms of diabetic nephropathy include:

    • Protine (Albumin) in the urine
    • Hypertension
    • Face, ankle and leg swelling and leg cramps
    • Weakness
    • Loss of appetite
    • Upset stomach
    • Itching
    • Insomnia
    • Increased urination at night
    • High BUN (blood urea nitrogen) and serum creatinine levels

    In advanced stages, diabetic nephropathy can lead to dialysis or a kidney transplant.

  • Diabetic Neuropahty

    Diabetic Neuropathy is a type of nerve damage that is brought on by the increased blood glucose levels resulting from Type ll diabetes. Diabetic Neuropathy may be classified into the following four types:

    • Peripheral – Peripheral Neuropathy affects the extremities. Symptoms may include tingling, numbness, burning, and pain of the feet and hands.
    • Autonomic – Autonomic Neuropathy refers to damage to the nerves that control the internal organs, such as the heart, digestive system, bladder, sex organs, sweat glands, and eyes.
    • Proximal – Proximal Neuropathy typically affects only one side of the body and attacks the nerves in the hip, buttock, or thigh.
    • Focal – Focal Neuropathy attacks a single nerve, most often in the hand, leg, torso, or head. Commonly, a focal neuropathy is an entrapment syndrome, e.g. carpal tunnel syndrome.

     

  • Diabetic Retinopathy

    Diabetic Retinopathy is caused by changes in the blood vessels in the retina (the light-sensitive tissue at the back of the eye) due to diabetes mellitus. This is the most common eye disease brought on my diabetes and is a major cause of blindness in adults.

  • Diagnostic Mammogram

    A diagnostic mammogram begins with the 4 standard x-ray images of a screening mammogram and then may be supplemented with additional views, a physical exam, ultrasound, and an MRI if needed. A diagnostic mammogram is indicated for a woman is having a problem such as a lump, unusual nipple discharge, or pain.

  • Durable Medical Equipment (DME)

    Medicare Durable Medical Equipment (DME) refers to medically necessary equipment that a doctor prescribes for use in the home. These qualifications apply to durable medical equipment:

    • It must be long-lasting (expected to last 3 years)
    • It must be used for a medical reason
    • It must not be useful to someone who is not sick or injured
    • It must be used in your home

  • End-Stage Renal Disease (ESRD)

    End-Stage Renal Disease (ESRD) is the last stage of Chronic Kidney Disease (CKD) which has resulted in permanent kidney failure which requires dialysis or a kidney transplant.

  • Excess Charges

    In Original Medicare, an Excess Charge is the amount a doctor or other health care provider who does not accept assignment is permitted to charge over the Medicare-approved amount. (Also see Mom States and [Limiting Charge Rule)

  • General Enrollment Period (GEP)

    The General Enrollment Period (GEP) begins on January 1 and runs through March 31 each year. During this period, those who did not enroll in Medicare during their Initial Enrollment Period (IEP) may enroll. Those who wait to enroll during the General Enrollment Period (GEP) may have to pay a 10% per year late enrollment penalty for waiting. Enrolling in Medicare during this period will begin your coverage on July 1.

  • Health Maintenance Organization (HMO)

    A Health Maintenance Organization (HMO) is a type of health care provider that offers “managed care” for a fixed annual payment or (capitation fee) which Medicare pays for each covered patient. Patients are restricted, except in the case of an emergency, to receiving care only from doctors, hospitals, or other healthcare providers that work for or have contracted with the HMO.  These providers are known as the HMO’s network.  Care received outside the HMO’s network of providers is generally not covered unless that treatment isn’t available within the network and is preapproved. Each patient is assigned a primary care physician, also known as a gatekeeper, who oversees the patient’s medical care and who is required to make a referral for the patient to see a specialist. A primary component of an HMO is an emphasis on prevention and wellness.

  • Health Risk Assessment

    Health Risk Assessment is completed at the annual “Wellness” visit to assist the doctor in developing a plan to prevent disease and to keep you healthy. The assessment includes:

    • A review of your medical and family history
    • Your current list of prescriptions
    • Routine measurements, including height, weight, and blood pressure
    • Cognitive imapirment assessment
    • Personalized health care advice
    • Personalized list of risk factors and treatment options
    • A checklist of recommended preventive services

  • High Blood Sugar (Glucose)

    Blood sugar levels vary from person to person and only your doctor can assess what is normal for you. Most healthy people without diabetes have blood sugar levels before meals of 70 to 80 mg/dL. This is a generalization as for some, 60 is normal while for others, 90. Current standards call a glucose reading of 100 pre-diabetes.

  • HMO Point-of-Service (HMOPOS)

    The HMO Point of Service (HMOPOS) is a type of managed care plan that incorporates aspects of an HMO and a PPO. Like an HMO, an HMOPOS plan may require you to have a primary care physician who oversees your health care and who makes referrals to specialists. Like a PPO plan, you are able to receive care from out-of-network providers at additional costs. The care administered by your primary care physician is usually not subject to a deductible and the plan usually includes preventive care. For out-of-network care, you may have to pay an annual deductible, copayments, and coinsurance.

  • Initial Enrollment Period (IEP)

    The Initial Enrollment Period (IEP) begins when you are first eligible to sign up for Medicare. This 7 month period includes the following time frames:

    • The three months prior to the month in which you turn 65
    • Your birth month
    • The three months that follow your birth month

    The one exception is that if your birthday falls on the first of the month and you enroll two or three months prior to your birthday, your coverage will begin the month prior to your birth month.

    Sign-up Date Coverage Begins
    During the 3 months prior to your 65th birthday The first day of your birth month
    During your birth month The first day of the month following your birth month
    During the month after your birth month Three months after your birth month
    During the second month after your birth month Five months after your birth month
    During the third month after your birth month Six months after your birth month

    During your Initial Enrollment Period (IEP) you may enroll in a Medicare Supplement Policy (Medigap) without having to go through underwriting. This is very important if you have health conditions which would prevent you from qualifying for a Medicare Supplement policy based on having to answer the plan’s underwriting health questions. During your IEP, your acceptance by a Medicare Supplement insurer is guaranteed, no matter the condition of your health.

  • Limiting Charge Rule

    In original Medicare, the Limiting Charge Rule specifies that a doctor or other health care provider who doesn’t accept Medicare assignment may not charge more than 15% over Medicare’s approved amount. This limiting charge applies only to certain services and doesn’t apply to supplies or equipment. e.g. Aunt Em has a mole removed by a doctor who doesn’t accept Medicare assignment. He bills Medicare $125 for the procedure. Medicare’s approved amount is $100 and so Medicare pays $80.00 (80%) and Aunt Em pays $20.00 (her 20% co-insurance) plus an additional $15.00 (15% of the Medicare approved charge of $100.00) At this point the doctor has been paid $115.00 and he will write off the remaining $10.00. (Also see Excess Charges and MOM States)

  • Long-Term Care

    Long-term care is a type of care which is usually custodial and non-skilled care but may include skilled nursing care. Long-term care can be given at home, in nursing homes, or in assisted living facilities. It is generally comprised of help with activities of daily living such as eating, dressing bathing, using the bathroom, and transferring (moving to or from a bed or chair). Medicare does not cover long-term care that is only custodial.

  • Low Dose Computed Tomography (LDCT)

    Low Dose Computed Tomography (LDCT) is a form of radiography using computer software to create images, or slices, at various planes of depth from images taken around a body that limits the radiation exposure to the patient and produces high-resolution three-dimensional images.

  • Medically Necessary

    Health care services or supplies are deemed medically necessary if they are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms. The other qualification is that they must meet accepted standards of medicine.

  • Medicare Assignment

    Medicare Assignment means that your doctor, health care provider, or supplier has agreed (or is legally required) to accept the Medicare-approved amount as full payment for covered services. No more than the applicable deductible and coinsurance amount may be collected, and the payment for the covered charge must be invoiced directly to Medicare.

  • Medicare Medical Savings Account (MSA)

    The Medicare Medical Savings Account (MSA) offered as a Medicare Advantage Plan is offered by a private insurance company and is much like the Health Savings Account found outside of Medicare. A Medicare Medical Savings Account plan combines high-deductible health coverage with a medical savings account that you can use to pay your medical costs

    In a high-deductible plan, the plan will only begin to pay your medical costs after you have satisfied a high annual deductible which may vary from plan to plan. The second part of this plan is a Medical Savings Account into the plan deposits part of the money it receives from Medicare. The amount deposited is less than the high deductible and you can use these funds to pay your medical costs prior to meeting the deductible. Medicare Medical Savings Account Plans do not include drug coverage so you’ll need to join a Medicare Part D Prescription Drug Plan. In a Medicare Medical Savings Account Plan, you do not need a primary care physician and you don’t need a referral to see a specialist.

    While the deductible is quite high, all monies spent for Medicare Part A and Part B services count towards the plan’s deductible. Your plan will cover all your Medicare-approved health care expenses in full once you reach your maximum out-of-pocket limit. Any money left in your Medical Savings Account at the end of the year remains in the account to be joined by the deposit in the subsequent year.

  • Medicare Overcharge Measure

    The Medicare Overcharge Measure prohibits health care providers from charging patients more than the medicare-allowed amount. The practice of billing Medicare excess charges is also known as balance-billing and is prohibited by the Medicare Overcharge Measure in seven states:

    • Connecticut
    • Massachusetts
    • Minnesota
    • New York
    • Ohio
    • Pennsylvania
    • Rhode Island
    • Vermont

  • Medicare-Approved Amount

    In Original Medicare, the medicare-approved amount refers to the actual amount the doctor, health care provider, or supplier can be paid. This amount includes what Medicare pays as well as any deductible, coinsurance, or copayment that you pay. This amount may be less than what the doctor, health care provider, or supplier actually charges. Providers who accept assignment accept the medicare-approved amount as payment in full and cannot charge you any additional fees. If your provider does not accept assignment, you may pay more depending on the laws of your state. The MOM states, Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont,  make it illegal for health care providers to charge a higher fee than the medicare-approved amount.

  • MOM States

    The term MOM States refers to the seven states which, due to the MOM Law (Medicare Overcharge Measure) do not allow a Medicare healthcare provider to charge any excess charges. These states are:

    • Connecticut
    • Massachusetts
    • Minnesota
    • New York
    • Ohio
    • Pennsylvania
    • Rhode Island
    • Vermont

     

  • Osteopenia

    Osteopenia, considered to be a precursor to osteoporosis, is a condition in which bone mineral density is lower than normal as measured by a bone mineral density T-score between 1.0 and 2.5. While not as severe as osteoporosis, the decreased bone density of osteopenia can lead to bones that are fragile and in danger of breaking. Women are more likely to be affected than men and can help to prevent osteopenia by ensuring adequate intake of calcium and vitamin D, by avoiding excessive alcohol, by exercising, and by not smoking.

  • Osteoporosis

    Most common among the elderly, Osteoporosis (porous bones) is a disease in which decreased bone strength increases the risk of a broken bone. The bones most commonly broken are the spine, the wrist, and the hip. Women are more susceptible to osteoporosis (accounting for 80% of estimated cases) because their bones are lighter and less dense and because of the hormonal changes that occur after menopause. During the first 5 to 7 years after menopause, loss of bone density speeds up and then tapers off. This rapid bone loss is due to the sharp decline in the body’s estrogen production, as estrogen appears to help keep calcium in the bones.

  • Pack Years

    Medicare defines a “pack year” as smoking 1 pack a day for 1 year. Relative to cancer screenings, Medicare Part B covers a lung cancer screening  if you have a history of at least 30 “pack years.”

  • Preferred Provider Organization (PPO)

    A Preferred Provider Organization (PPO) is a type of managed care organization of doctors, hospitals and other health care providers created by a private insurance company.  In a PPO, Medicare contracts with a third-party administrator to provide Medicare Advantage or Medicare Part C health care benefits. Unlike a Health Maintenance Organization, a Preferred Provider Organization usually does not require a patient to have a primary care physician and the patient is free to go to any doctor or medical facility within the PPO network of contracted providers without a referral. Patients are encouraged to use providers that belong to the plan’s network, however, they may use doctors, hospitals and other health care providers outside the plans network but at a higher cost. Many PPO plans offer prescription drug coverage. PPO plans often come with extra benefits, but you may have to pay for these extras.

  • Premium

    An insurance premium is the periodic cost of financing the purchase of an insurance policy, usually paid on a monthly, quarterly, semi-annual, or annual basis.

  • Primary Hyperparathyroidism

    Primary Hyperparathyroidism is usually caused by an enlargement of, or a tumor within, the parathyroid gland which causes an excess of parathyroid hormone (PTH) to be released into the bloodstream. This excess hormone can pull calcium from the bones causing elevated calcium levels (hypercalcemia) which can lead to digestive symptoms, kidney stones, and psychiatric abnormalities. The condition is most common in people over 60 and more common in women than in men. Your risk is increased by receiving radiation to the head and neck.

  • Private Fee For Service (PPFS)

    A Private Fee For Service (PFFS) plan is a type of plan offered by private insurance companies in which the plan determines its payment schedule for doctors, hospitals, and other health care providers as well as the amount you will pay to receive service. You have the choice to go to any Medicare-approved provider that accepts the plan’s payment terms and agrees to treat you. In a PFFS plan, you do not need to have a primary care doctor nor do you need a referral to see a specialist. Not all providers will accept Medicare’s fee schedule, however, and those who do may decide at every visit whether to accept your plan’s terms and conditions of payment. Once enrolled in a PFFS plan, you cannot use your Original Medicare card for service as Original Medicare will not pay for your health care while you are enrolled in a PFFS plan. Your prescription drug coverage may be part of the plan’s offering but if not, you are eligible to enroll in a Medicare Part D Prescription Drug Plan.

  • Railroad Retirement Board (RRB)

    Established in 1935 under President Franklin D. Roosevelt, the Railroad Retirement Board (RRB) is an independent federal agency assigned the task of providing a social insurance program for railroad workers. These workers are not covered under the Social Security Administration as the Railroad Retirement Board fulfills this function and provides retirement, unemployment, disability, sickness, and survivor benefits to its covered workers. Railroad workers are the only private-sector employees who don’t participate in the Social Security system and who have a separate, federally administered retirement plan.

  • Screening Mammogram

    A screening mammogram consists of two x-ray images of each breast and is usually done on a woman who has no signs or symptoms of breast cancer.  A technologist takes the images and checks them for quality. These images allow the detection of tumors that cannot be felt. A screening mammogram also enables microcalcifications to be found. These tiny deposits of calcium sometimes indicate the presence of breast cancer.

  • Social Security Administration (SSA)

    Established in 1935 under President Franklin D. Roosevelt, the Social Security Administration is an independent agency of the federal government that administers social insurance consisting of

    • Retirement Benefits
    • Disability Benefits
    • Survivors’ Benefits
    • Supplemental Security Income Benefits

    The Social Security Administration (SSA) can be reached online at www.ssa.gov or by phone at (800) 772-1213.

  • Special Needs Plan (SNP)

    A Special Needs Plan (SNP) is like an HMO or PPO and is a type of Medicare Advantage Plan that limits its membership to patients with specific diseases. It arranges benefits, providers, and prescription drug formularies to meet the very specific needs of the patients it treats. Prescription drug coverage is mandatory in an SNP.

    Special Needs Plans restrict their membership to certain groups:

    • Patients who live in certain institutions (like a nursing home) or who require home-based nursing care
    • Dual Eligibles – Patients who are eligible for both Medicare and Medicaid
    • Patients who have chronic or disabling conditions. [diabetes, HIV/AIDS, chronic heart failure, dementia, or End-Stage Renal Disease (ESRD)]

    Generally, SNPs require patients to have a primary care physician and referrals are necessary for specialists except for yearly screening mammograms or in-network pap tests and pelvic exams which are covered as least every other year. Care is required to be obtained from doctors or hospitals in the SNP network except for emergency or urgent care, or if you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis.

  • State Health Insurance Assistance Program (SHIP)

    The State Health Insurance Program is a FREE service for  Medicare recipients and their families or caregivers that provides health benefits counseling. There is a SHIP agency in every state and in four territories. The agency works out of the insurance commissioner’s office, never charges for their services, and never tries to sell a client anything. You can find the contact information for the SHIP office in your state here.