Assets are things that you own, like a car or a house. You can only own a certain number of assets and still qualify for most health care and disability benefit programs. The home you live in and the car you drive to work are exempt under most Social Security and state disability benefit programs.
The time period that Medicare uses to measure an individual’s use of hospital and skilled nursing facility care. A benefit period begins the day an individual enters a hospital or skilled nursing facility (SNF). The benefit period ends after the individual is released and hasn't received any further hospital care (or skilled care in a SNF) for 60 consecutive days. If an individual goes into the hospital after one benefit period has ended, a new benefit period begins. The inpatient hospital deductible may be charged for each benefit period. There is no limit to the number of benefit periods an individual may have.
Someone who can help you understand or apply for benefit programs when you become disabled or turn 65. Their goal is to help you avoid financial complications while developing a sustainable plan for the future. To find a benefits planner in California, use the DB101 Benefits Planner Directory.
The portion of the payment for medical services that an individual is responsible for. For example, your health coverage may pay for 80% of the costs of a service, while you will have to pay the remaining 20%.
The federal government pays benefits planners in communities around the country to help people think ahead about work incentives and benefits issues. CWIC'S are benefits planners who are trained by the Social Security Administration to assist beneficiaries with programs including Supplemental Security Income (SSI), and Social Security Disability Insurance (SSDI) in addition to other related programs.
A set amount you have to pay when you receive medical services. For example, you may have to pay $10 or $20 every time you visit the doctor or get a prescription refilled. This is known as a "copayment."
Coverage that is at least as good as that offered through Medicare Part D. Your health coverage plan can tell you whether or not your coverage is creditable.
A hospital facility that provides outpatient and certain inpatient services to people in rural areas. Critical Access Hospitals are given a special status by Medicare.
The amount an individual is responsible for paying before Medicare begins to pay. For Part A, the deductible must be paid each benefit period. For Parts B and D, the deductible must be paid each year.
The gap in Medicare Part D coverage when you have between $2,700.00 and $6,154.00 in total drug costs in a year. Medicare will not help pay for your drug costs during this period unless you qualify for the Low Income Subsidy.
A table of income amounts used to determine financial eligibility for federal and state programs. Each year, the Department of Health and Human Services (HHS) issues the Federal Poverty Guidelines in the Federal Register. The Federal Poverty Level for one person is $10,830. For each additional person, add $3,480. For Medi-Cal programs, these figures go into effect in March or April of each year.
The period of time between January 1 and March 31 when a Medicare beneficiary can sign up for Part B coverage. Benefits will not begin until July 1 of that year, and a beneficiary may be subject to a late enrollment fee of 10% for each 12 month period they did not have Part B Medicare.
A period of time when an individual can enroll in a Medicare supplement plan without medical underwriting or waiting periods. Medicare supplement providers cannot deny coverage during these periods.
A process that allows Medicare supplement carriers to refuse coverage based on an individual’s health history. This process is also known as medical underwriting.
Services covered by Medicare including part-time or periodic skilled nursing care; home health aide services; physical therapy; occupational therapy; speech-language therapy; medical social services; durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers); medical supplies; and other services.
Services covered by Medicare Part A for individuals with a terminal illness. Services may include prescriptions for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare. Hospice care is usually given in an individual’s home; however, Medicare may cover some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).
A person outside of a Part D plan who reviews an appeal. This is the first person outside of the plan to review an appeal during the Part D appeals process.
The period when a beneficiary can first sign up for Medicare Part B or Part D. For Social Security Disability Insurance (SSDI) beneficiaries, the initial enrollment period begins the 24th month of a beneficiary’s Social Security disability payments. In general, it begins three months before you meet Medicare's eligibility requirements and lasts seven months.
The days following a 90-day hospitalization. Medicare allows an individual 60 lifetime reserve days per benefit period that may only be used once during an individual’s lifetime. Medicare will pay for lifetime reserve days, whether used at once or over the individual's lifetime. However, the individual must pay for the daily coinsurance of $512 for 2009.
Services that assist individuals with long-term medical and personal needs. Long-term care may include medical services, physical therapy, custodial care, and assistance with activities of daily living (dressing, eating, bathing, etc.). Long-term care may be provided at home, in the community, or in facilities, including nursing homes and assisted living facilities. Medicare will not pay exclusively for custodial care.
A joint Federal and state program that provides assistance with medical costs to some low income individuals with limited resources. Medicaid programs vary from state to state. The federal Medicaid program is called Medi-Cal in California.
A Medicare Advantage (Part C) option where Medicare gives your plan money to deposit into a savings account. You can use this money to pay for Medicare costs. After you meet a high yearly deductible, the plan will help pay for Medicare services.
Medicare is a federal program that provides health insurance for people over 65 and many people under 65 who have a disability. If you receive Social Security Disability Insurance benefits you will be eligible to receive Medicare after a two year and five month waiting period.
A way to organize your Medicare benefits. When you use services within the plan’s network, it helps pay for costs. When you use services outside the plan’s network, Original Medicare helps pay.
A Medicare Advantage option that can have lower copayments than the Original Medicare Plan, but generally limits individuals to visiting doctors, specialists, or hospitals within the plan's network. Plans must cover all Medicare Part A and Part B services, and some plans cover extras, like prescription drugs. Medicare Managed Care Plans are only available in some areas of the country.
Medicare Part B is the part of Medicare that helps pay for medical care you get when you are not staying in a hospital, such as when you go to see a doctor.
Medicare Part C, also known as "Medicare Advantage," is a Medicare program that offers benefits by private insurance companies. These plans can provide more choice and extra benefits. Medicare Advantage Plans include: Managed Care (Medicare HMOs), Private Fee-for-Service, Preferred Provider Organization, and Special Needs Plans. Everyone who has Medicare Parts A and B is eligible to join a plan, except most people with End-Stage Renal Disease (ESRD).
The program used to be called "Medicare + Choice."
A Medicare Advantage option that gives an individual the choice of visiting providers within the network or seeing a provider outside of the network for an additional cost. An individual does not need a referral from their primary care physician to see a specialist.
A Medicare Advantage option that allows an individual to go to any Medicare-approved doctor or hospital. The insurance plan, rather than the Medicare program, decides what services it will cover and how much it will pay. Although an individual may pay more under this plan, he/she may have extra benefits that the Original Medicare Plan doesn't offer.
A supplemental insurance policy sold by private insurance companies to fill gaps in the Original Medicare Plan. In California, there are 12 Medicare supplement plans labeled Plan A through Plan L.
Medicare supplement plans are available only to individuals using the Original Medicare Plan, and it is illegal for an insurance carrier to sell a Medicare supplement to an individual who does not have Original Medicare.
Medicare supplements are also referred to as "Medigap."
Health care services that are medically necessary and are aimed at treating illnesses, as opposed to preventing them. (Contrast: preventive care services.)
A pay-per-visit health coverage plan that allows individuals to go to any doctor, hospital, or other health care supplier who accepts Medicare and who is accepting new Medicare patients. The individual is responsible for paying a deductible and copayment. Under Original Medicare, Medicare pays a portion of the Medicare-approved amount, while the individual pays for his/her share (coinsurance). Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
A group of local pharmacies you can buy prescription drugs from. If you purchase drugs from within your pharmacy network, your prescription drug plan should cover it.
Health care services aimed at keeping you healthy by preventing illness; for example, Pap tests, pelvic exams, yearly mammograms, and flu shots. (Contrast: non-preventive care services.)
A doctor that provides basic care and acts as an individual’s first point of contact when seeking health services. In many Medicare Managed Care Plans (Medicare HMOs), an individual must see their primary care doctor before going to a specialist.
A Medicare Savings Program that pays for Medicare Part A premiums. The QDWI program is for Social Security Disability Insurance (SSDI) beneficiaries who lose their free Medicare Part A due to earnings. To qualify, an individual must:
Be less than 65 years old,
Be eligible for Medicare Part A only,
Have income at or below 200% of the Federal Poverty Level (until 3/31/2010, $1,805.00 per month for individuals, $2,428.00 for couples),
Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and
A written authorization to visit a specialist from an individual’s primary care doctor. In many Medicare Managed Care Plans (Medicare HMO), an individual must get a referral before receiving care from anyone except the primary care doctor. If an individual fails to get a referral, the plan may refuse to pay for care.
Services that include a semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies. Medicare covers skilled nursing facility care after the individual has been in the hospital for 3 days.
The period when an individual can apply for Medicare coverage without a late enrollment penalty and can sign up for Medicare supplement without a pre-existing condition waiting period. The special enrollment period typically spans the first eight months following the loss of group health coverage.
A division within Minnesota's Department of Human Services that decides whether or not you meet the state criteria for "blind" or "disabled" status. SMRT uses a standard process to make disability determinations for people with disabilities who either aren't eligible for Social Security benefits (e.g., SSI, SSDI), have an application pending for Social Security benefits, or are in their five-month waiting period for SSDI.
Rules that plans use to keep their prescription drug costs down. You may, for example, need prior authorization from the plan to use a particular drug.
A delay in covering services for an individual with a pre-existing condition. Individuals are exempt from a waiting period if they have had 6 months of previous, continuous coverage.
One of the eligibility requirements for SSDI is to have worked and paid FICA taxes for specified periods of time. If you work and earn at least $1,090 for one quarter (three months), and pay FICA taxes, you earn one SSDI "work credit." You can earn up to four credits within a 12-month period.
The number of work credits needed to qualify for SSDI depends upon how old you were when Social Security determined that you are disabled.
If you were determined disabled before age 24, you need 6 credits within the past 3 years to be eligible for SSDI.
If you were determined disabled between the ages of 24 and 31, you need 12 credits within the past 6 years to be eligible for SSDI.
If you were determined disabled after you turned 31, you need the number of work credits shown in the table below. And unless you are blind, you need to have earned at least 20 of those credits in the 10 years prior to becoming disabled.
Work Credits Required for SSDI Eligibility for those Born After 1929
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