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Administrative Law Judge

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An official who oversees administrative hearings held to resolve a dispute between a government agency and a person affected by a decision of that agency. They oversee any initial appeal you may make with a government institution.

Annual Election Period

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The period from October 15 - December 7 when you can enroll in and switch Medicare Part D plans.

Appeal

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A request to have a third party review an agency’s decision. Requests may be verbal or written. Typically, appeals are requested when benefits, services, or treatments are denied, stopped, or reduced.

Assets

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Things that you own, like a car or a house. You can only own a certain amount in assets and still qualify for many 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. For Supplemental Security Income (SSI), the first $100,000 in an ABLE account is not counted as assets. For AHCCCS, Nutrition Assistance (formerly Food Stamps), and some other programs, none of the money in an ABLE account is counted.

Also called "resources."

Basic Plan

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A Medicare Part D plan that meets just the minimum requirements laid out by the Centers for Medicare and Medicaid Services (CMS).

Benchmark Plan

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A Medicare Part D plan that has its monthly premium fully covered by the Low Income Subsidy.

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.

Co-Insurance

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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%. That 20% is known as "co-insurance."

Copayment

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A set amount you have to pay when you receive medical services. For example, you may have to pay $30 every time you visit the doctor or $20 to get a prescription refilled. This is also known as a "copay."

Creditable Coverage (Medicare)

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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.

Deductible (Medicare)

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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 Parts B and D, the deductible must be paid each year.

Donut Hole

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The gap in Medicare Part D coverage when you have between $3,820 and $7,654 in total drug costs in a year.

People on Medicare who fall within the “donut hole” get a 75% discount on brand name prescription drugs and a 63% discount on generics. This discount will continue to grow until 2020, when the donut hole coverage gap is closed completely. These changes are happening as a result of the Affordable Care Act passed in 2010.

Exception (Medicare)

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A request to an insurance plan to pay for a medication that is not on the plan formulary or to otherwise bypass the plan's utilization controls (the rules that help the plan lower costs).

Fail First Rules

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An insurance requirement that you use a cheaper medication before trying more expensive options. This helps the insurance plan reduce costs.

Formulary

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A list of drugs that a health plan covers.

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.

Health Screening

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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.

If a person enrolls in a Medicare supplement during the Medigap open enrollment period, an insurance company cannot use health screening. But, if a person tries to enroll in a Medicare supplement outside of the open enrollment period, then a private insurance company can still use health screening.

Home Health Care (Medicare)

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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.

Hospice Care (Medicare)

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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).

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 (Medicare)

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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) and Childhood Disability Benefits (CDB) beneficiaries, the initial enrollment period begins during the 24th month of a beneficiary’s SSDI or CDB payments. The initial enrollment period typically lasts about 10 months.

Inpatient

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An individual who has been admitted to the hospital.

Inpatient Care

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Health services received after an individual is admitted to the hospital.

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 $682 in 2019.

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 such as dressing, eating, and bathing. 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.

Low Income Subsidy (LIS) (Extra Help)

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Help paying for Medicare Part D for people with low to moderate income and resources. Also known as "Extra Help".

There are two levels of the Low Income Subsidy:

  • The full subsidy is for people who also get AHCCCS coverage or who are in a Medicare Savings Program (MSP). You may also qualify if your countable income is less than $16,862 per year and your resources are less than $7,560, if you are single (the limits are higher for larger households).
  • The partial subsidy is for people who can’t get the full subsidy, but have less than $18,735 in countable income and less than $12,600 in resources, if you are single (the limits are higher for larger households).
    • With the partial subsidy, you will pay 0%, 25%, 50%, or 75% of the Part D premium, depending on your income, and will only have to pay a $85 deductible before you get help paying for drugs. You will have to pay coinsurance and copayments for your medications, but they will be lower than they would be without the partial LIS.

Note: Not all of your income and resources are counted when you apply for the Low Income Subsidy. You can apply for the LIS even if you are not sure that you will qualify.

Managed Care

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Health coverage that requires you to get most services within a network.

With managed care, you have a primary care provider who oversees your care and refers you to specialists within the network when needed.

Medical Savings Account (Medicare)

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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

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A federal program that provides health insurance for people 65 or older and many people under 65 who have disabilities. After a person gets Social Security Disability Insurance (SSDI) benefits for two years, he or she qualifies to get Medicare as well.

Medicare Advantage (Part C)

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A way of getting combined Medicare coverage through a health plan run by a private insurance company, instead of getting Original Medicare (Parts A, B, and D). Medicare Part C plans can be Managed Care (Medicare HMOs), Private Fee-for-Service, Preferred Provider Organization, and Special Needs plans. If you get Medicare Parts A and B, you can choose whether you want to join a Part C plan or prefer staying enrolled in Original Medicare.

Medicare Advantage Prescription Drug (MA-PD) Plan

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Medicare Part D drug coverage that is offered through a Medicare Advantage plan.

Medicare Appeals Council

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A group of people within the Centers for Medicare and Medicaid Services (CMS) who hear Medicare appeals after they have gone to an Administrative Law Judge.

Medicare Cost Plan

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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.

Medicare Health Maintenance Organization (HMO)

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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.

Also known as "Medicare Managed Care Plan."

Medicare Managed Care Plan

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Medicare Part A

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The part of Medicare that helps pay for medical care you get while you’re in a hospital.

Medicare Part B

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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 D

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The part of Medicare that helps pay for prescription drugs.

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 Savings Program (MSP)

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The Medicare Savings Programs pay for some of the Medicare expenses for people who are entitled to Medicare Part A and Part B. There are four cost sharing programs, each of which has different requirements.

Medicare Savings Programs are managed by the Arizona Health Care Cost Containment System (AHCCCS). AHCCCS determines if you are eligible and will help you manage your care.

Medicare Supplement Insurance (Medigap)

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A supplemental insurance policy sold by private insurance companies to fill gaps in the Original Medicare Plan. There are many standardized Medicare supplement plans offered through a number of carriers. You can find a list of carriers on the Arizona Department of Insurance website. Medicare supplements are also referred to as "Medigap."

Note: In Arizona, you cannot get a Medigap policy if you are under age 65.

Nonpreventive Care Services

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Health care services that are medically necessary and are aimed at treating illnesses, as opposed to preventing them. (Contrast: preventive care services.)

Original Medicare

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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 Original Medicare, Medicare pays a portion of the Medicare-approved amount, while the individual pays for his/her share (coinsurance).

Individuals with Medicare choose to either stay in Original Medicare or enroll in a Medicare Advantage Plan. Medicare Advantage plans will have different costs and covered services than Original Medicare.

Out-Of-Pocket Costs

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The health care related costs you pay yourself without help from Medicare, AHCCCS, or other health insurance.

Outpatient Services

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Health services received outside of hospital care, including after an individual is released from the hospital.

Pharmacy Network

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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.

Pre-Existing Condition

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Any condition for which “medical care” was received within six months prior to the effective date of insurance coverage. Medical care includes the use of prescription drugs and physician consultations and services. During a pre-existing condition exclusionary period, coverage for that condition is either not provided or can be limited.

The Affordable Care Act prohibits health insurance companies from doing medical underwriting and excluding pre-existing conditions from coverage. Other forms of insurance, like private disability insurance, can do medical underwriting and exclude pre-existing conditions.

Preferred Provider Organization (PPO)

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A type of health insurance plan. You pay a monthly premium and — when you use medical services — copayments and deductibles. PPOs have networks of physicians. You can see any doctor in the network without getting prior authorization from a primary care physician. Seeing a doctor outside of the network is more expensive.

Premium (Medicare)

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A regularly scheduled payment to an insurer or health care plan.

If you're on SSDI or CDB and Medicare, you likely won't have to pay a premium for Medicare Part A coverage. You may have to pay a Part B premium, however. For most people, the premium for Part B coverage is $135.50 per month or a bit less, depending on their situation. If you qualify, a Medicare Savings Program or other programs can help pay for your Part B premium.

If you sign up for Part D prescription drug coverage or have a Medicare Advantage (Part C) plan instead of Original Medicare, you will also usually have to pay a premium. The exact amount of your premium will depend on the plan you choose.

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 Care Services

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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.)

Primary Care Physician (Medicare)

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A doctor who 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 may need to see their primary care doctor before going to a specialist.

Prior Authorization (Medicare)

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A requirement to get an insurance plan's permission to use a certain medication. This helps the insurance plan reduce costs.

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 three days.

Special Enrollment Period (Medicare)

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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.

Special Needs Plan (SNP)

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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.

Learn more about Special Needs Plans on Medicare.gov.

Tiered Drug Levels

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Different levels of coverage offered by Medicare Part D (prescription drug) plans. Drugs in lower levels usually have lower copayments and drugs in higher levels usually have higher copayments.

Utilization Controls

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Rules that insurance 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 (Medicare Supplement)

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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.

Work Incentives

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Rules used to encourage people to work when they use public benefits. Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, and AHCCCS all have work incentive rules.