Administrative Law Judge |
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Annual Election Period |
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The period from November 15 through December 31 when you can enroll in and switch Medicare Part D plans. |
Appeal |
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A process undertaken when an individual disagrees with an insurance carrier's decision to reduce services or deny treatment or payment.
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Basic Plan |
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Benchmark Plan |
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Benefit Period |
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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. |
Benefits Planner |
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| 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.
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Coinsurance |
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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%.
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Community Work Incentives Coordinator (CWIC) |
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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.
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Copayment |
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A set amount an individual must pay upon receiving medical services. For example, you may have to pay $10 each time you visit the doctor.
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Creditable Coverage |
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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. |
Critical Access Hospital |
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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.
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Deductible |
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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 Part B, the deductible must be paid each year. |
Donut Hole |
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The gap in Medicare Part D coverage when you have between $2,510 and $5,726.25 in total drug costs in a year. Medicare will not help pay for your drug costs during this period unless you qualify for a Low Income Subsidy. |
Dual-Eligibles |
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Exception |
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A request to the plan to either cover a drug that is not on the formulary or to bypass utilization controls. |
Fail First Rules |
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A utilization control that requires you to use a cheaper drug before trying more expensive options. |
Federal Poverty Level (FPL) |
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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 $10,400. For each additional person, add $3,480. For Medi-Cal programs, these figures go into effect in March or April of each year. |
FICA Requirements for Social Security Disability Insurance (SSDI) |
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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 $1,050 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
Became Disabled At Age: |
Number of Credits Needed |
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31 through 42 |
20 |
44 |
22 |
46 |
24 |
48 |
26 |
50 |
28 |
52 |
30 |
54 |
32 |
56 |
34 |
58 |
36 |
60 |
38 |
62 or older |
40 |
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Formulary |
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A list of drugs that a health plan covers.
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General Enrollment Period |
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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. |
Guaranteed Issue Period (Medigap) |
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A period of time when an individual can enroll in a Medigap plan without medical underwriting or waiting periods. Medigap providers cannot deny coverage during these periods.
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Health Screening |
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A process that allows Medigap carriers to refuse coverage based on an individual’s health history. This process is also known as medical underwriting. |
Home Health Care |
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Services covered by Medicare that include: 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.
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Hospice Care |
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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).
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Hospital Stays |
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Services covered by Medicare Part A that include a semiprivate room, meals, general nursing, and other hospital services and supplies.
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Independent Review Entity |
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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. |
Initial Enrollment Period |
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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 24 th 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. |
Inpatient Care |
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Health services received when an individual is admitted to the hospital.
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Lifetime Reserve Days |
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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 2008. |
Long-term Care |
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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.
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Low Income Subsidy |
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Help paying for Medicare Part D costs for those who meet income and asset rules. Also known as "Extra Help".
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Medicaid |
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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. |
Medically Necessary |
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Services or supplies that are considered by Medicare to be appropriate and needed for treatment. |
Medicare + Choice Plan |
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Medicare Advantage |
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Formerly known as Medicare + Choice.
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Medicare Advantage Prescription Drug (MA-PD) Plan |
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Medicare Appeals Council |
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Medicare Carrier |
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A private insurance company that contracts with Medicare.
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Medicare HMOs |
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Medicare Managed Care Plan |
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A Medicare Advantage option that can have lower co-payments 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. Also know as Medicare HMOs.
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Medicare Modernization Act |
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The 2003 law that created the Medicare Part D program.
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Medicare Plans |
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Medicare Preferred Provider Organization (PPO) Plan |
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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. |
Medicare Private Fee-for-Service Plan |
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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. |
Medicare Special Needs Plan |
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A Medicare Advantage option that provides health care focused on certain health conditions. These plans provide comprehensive Medicare coverage to manage a particular disease or condition, such as congestive heart failure, diabetes, or End-Stage Renal Disease (ESRD). Medicare Special Needs Plans are only available in some areas of the country. |
Medicare Supplement |
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Medigap |
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A supplemental insurance policy sold by private insurance companies to fill gaps in the Original Medicare Plan. In California, there are 12 Medigap plans labeled Plan A through Plan L. Medigap policies are available only to individuals using the Original Medicare Plan, and it is illegal for an insurance carrier to sell a Medigap policy to an individual who does not have Original Medicare. Also known as Medicare Supplement.
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Medi-Medi |
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A name used to describe individuals who are eligible for both Medi-Cal and Medicare. |
Original Medicare Plan |
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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 the Original Plan, Medicare pays a portion of the Medicare-approved amount, while the individual pays for his/her share (coinsurance). The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). |
Out-Of–Pocket Cost |
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The costs an individual pays without assistance from Medicare, Medi-Cal, or other insurance.
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Point-of-Service (POS)
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An option offered by some Medicare Managed Care Plans that allows an individual to use doctors and hospitals outside the plan at an additional cost. |
Premium |
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A regularly scheduled payment to an insurer or health care plan.
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Prescription Drug Plan (PDP) |
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A Medicare Part D plan that only offers drug coverage. Also known as a "stand-alone" plan. |
Preventive Services |
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Health care services aimed at keeping an individual healthy by preventing illness; for example, Pap tests, pelvic exams, yearly mammograms, and flu shots.
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Primary Care Doctor |
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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. |
Prior Authorization |
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A utilization control that requires you to have a drug plan's permission to use a certain drug. |
Qualified Disabled Working Individual (QDWI) |
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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 3/31/2009, $1,734 per month for individuals, $2,282 for couples), Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and Meet all other Medi-Cal eligibility requirements.
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Qualified Invidiual-1 (QI-1) |
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A Medicare Savings Program that pays for Medicare Part B premiums. To qualify, an individual must:
Be eligible for Medicare Part B Have countable income less than 135% of the Federal Poverty Level (until 6/30/2008, $1,170 per month for individuals, $1,575 for couples), Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and Meet all other Medi-Cal eligibility requirements.
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Qualified Medicare Beneficiary (QMB) |
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- Be eligible for Medicare Part A and Part B,
- Have countable income at or below 100% of the Federal Poverty Level (until 3/31/2009, $867 per month for individuals, $1,167 for couples),
- Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and
- Meet all other Medi-Cal eligibility requirements.
This program does not apply benefits retroactively.
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Referral |
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Skilled Nursing Facility Care |
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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.
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Special Enrollment Period |
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The period when an individual can apply for Medicare coverage without a late enrollment penalty and can sign up for Medigap without a pre-existing condition waiting period. The special enrollment period typically spans the first eight months following the loss of group health coverage. |
Specified Low-Income Medicare Beneficiary (SLMB) |
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- Be eligible for Medicare Part A and Part B,
- Have countable income less than 120% of the Federal Poverty Level (until 3/31/2009, $1,040 per month for individuals, $1,400 for couples),
- Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and
- Meet all other Medi-Cal eligibility requirements.
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State Health Insurance Assistance Programs (SHIP) |
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Tiered Drug Levels |
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Utilization Controls |
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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. |
Waiting Period (Medigap)
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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. |
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