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The Medicare terms you need to know

If you’ve opened a Medicare mailer recently, chances are you’ve seen a term or two you’re not familiar with. (We’ve been there.)


That’s why we put together this glossary — for all the head-scratching, super-confusing acronyms, health terms, and insurance speak — so you can enroll, switch, or search for Medicare plans confidently.


Class is in session! Keep reading to learn more.


Medicare term glossary


ALS: Amyotrophic lateral sclerosis (also known as Lou Gehrig's disease). Those with ALS can qualify for Medicare without any age restrictions.


Annual Election Period: The enrollment period that runs from October 15 to December 7 each year in which you can change your Medicare plan or enroll in Medicare Advantage. Your benefits will go into effect on January 1 of the upcoming year.


Benefit period: Begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility (SNF). This is the way Original Medicare measures your use of hospital and SNF services. It ends when you haven’t gotten any inpatient hospital care (or care in a SNF) for 60 days in a row. If you go to a hospital or SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period.


Claim: A request for payment that you submit to Medicare or your Medicare Advantage plan when you get billed for items or services that you believe should be covered by insurance.


Coinsurance: After meeting your deductible, you still will have to pay a (smaller) portion of your medical bills — usually a percentage. For example, if you meet your deductible in June and your coinsurance is 20%, you only have to pay 20% of each medical bill that comes your way for the remainder of the calendar year, until you hit your MOOP.


Co-pay: This is the amount you owe each time you receive care. This can depend on the kind of care you’re getting, though — for example, a specialist visit might cost $60, while your visit to a general practitioner might only be $30. Typically, co-pays cannot be used to meet your deductible, but this varies. (Be sure to read the fine print on your plan to find out.)


Custodial care: Non-skilled personal care, like help with daily living activities such as bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. In most cases, Medicare doesn’t pay for custodial care.


Deductible: What you will pay for your healthcare needs before your Original Medicare, Medicare Advantage, Medicare Part D, or other Medicare plan begins to pay.


End-stage renal disease (ESRD): Permanent kidney failure that requires dialysis or a kidney transplant. Those with ESRD can qualify for Medicare without any age restrictions.


Healthcare provider: A person or organization licensed to give care. For example, a doctor, nurse, or hospital.


Health Insurance Marketplace: A service that helps people shop for and enroll in health insurance through websites, call centers, and in-person help.


Home health care: Healthcare services and supplies a doctor decides you may get in your home. Medicare only covers home health care on a limited basis as ordered by your doctor.


Hospice care: A special way of caring for people who are terminally ill, addressing the medical, physical, social, emotional, and spiritual needs of the patient. (And the patient’s family or caregiver.)


Inpatient care: Healthcare that you get when you’re admitted as an inpatient to a healthcare facility, like a hospital or skilled nursing facility.


Inpatient rehabilitation facility: A hospital (or part of a hospital) that provides a rehabilitation program to inpatients.


Long-term care: Medical and non-medical care provided to people who are unable to perform daily living activities, like dressing or bathing. Long-term care can be provided at home, in the community, in assisted living, or in nursing homes. Most Medicare plans don’t pay for long-term care.


Long-term care hospital: Acute care hospitals that provide treatment for patients that have been transferred from an intensive or critical care unit and stay more than 25 days. Care includes rehabilitation, respiratory therapy, head trauma treatment, and pain management.


Maximum out-of-pocket (MOOP): The most you’d have to pay each year for your healthcare needs. Once you’ve met your MOOP, your Medicare plan will pay for any covered services for the rest of the year.


Medicaid: A federal and state program that helps with medical costs for people with limited income and resources. Most healthcare costs are covered if you qualify for Medicare and Medicaid, but Medicaid programs vary by state.


Medicaid: The federal health insurance program for people who are 65 years of age or older, people who have certain disabilities, and people with end-stage renal disease and amyotrophic lateral sclerosis (also known as ALS).


Medicare Part A (hospital insurance): These benefits include inpatient hospital stays, care in a nursing facility, hospice care, and some home health care. These benefits do not cover regular doctor visits or prescription drugs. To enroll, you can get Part A directly from the government, or through a Medicare Advantage plan.


Medicare Part B (medical insurance): These benefits include certain doctors’ services, outpatient care, labs, medical supplies, and preventive services. To enroll, you can get Part B directly from the government, or through a Medicare Advantage plan.


Medicare Part C (Medicare Advantage): Privatized, all-in-one health insurance. These benefits are the alternative to Original Medicare, bundled together with Parts A, B, and usually D. These benefits also sometimes cover dental care, vision care, over-the-counter items, and other specialized health needs. To enroll, you must have Part A and Part B Medicare and live within the service area of your Medicare Advantage plan. Medicare Advantage plans can specifically include:


  • Routine services: Think vision insurance, dental insurance, and even hearing aids — what once used to be additional coverage you had to enroll in can be bundled with Medicare Advantage.
  • Wellness services: Gym memberships and fitness programs are usually covered, so you can stay active.
  • Clinical services: Things like routine foot care or acupuncture and chiropractic services, because even the slightest joint pain can have a big impact on your daily life.
  • Support services: While home meal deliveries and non-emergency transportation might not be a priority when comparing your health plan options, these benefits provide peace of mind — and make your recovery time after a hospital stay or surgery that much easier.

Medicare Part D: Helps cover your prescription drug costs if you have Original Medicare. These plans have a monthly premium, yearly deductible, co-pays, and coinsurance.


Medicare’s Open Enrollment Period: The time in which those that are already enrolled in a Medicare Advantage plan have the opportunity to change plans.


Medigap (or Medicare Supplement): Extra health coverage you can buy from a private insurance company to help fill the “gaps” in Original Medicare. Some Medigap policies even cover medical care when you travel outside of the U.S. Medigap is an additional cost, with a monthly premium, yearly deductible, co-pays, and coinsurance.


Original Medicare: A fee-for-service health plan that includes Medicare Part A and Part B. After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (co-pays, coinsurance, and deductibles).


Original Medicare: A fee-for-service health plan that includes Medicare Part A and Part B. After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (co-pays, coinsurance, and deductibles).


Out-of-pocket costs: Health costs that you must pay on your own because they aren’t covered by a Medicare plan.


Premium: A set amount of money that you pay each month, once a quarter, or once per year to keep your Medicare plan active.


Preventive services: Healthcare to prevent or detect illness at an early stage. For example, flu shots and mammograms.


Primary care provider: The doctor you see first for most health problems and who can refer you to specialists. In many Medicare Advantage Plans, you must see your primary care provider before you see any other healthcare provider.


Rehabilitation services: Healthcare services that help you keep, get back, or improve skills and functioning for daily living that you’ve lost or have been impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services.


Service area: A geographic area where your plan accepts members and (generally) where you can get routine services.


Skilled nursing care: Care that can only be given by a registered nurse or doctor.


Special Enrollment Period: A 60-day enrollment period for when certain qualifying life events occur, like retirement, losing employer-covered insurance, or if you move out of your plan’s service area.


Supplemental Security Income (SSI): A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 or older. SSI benefits are not the same as Social Security retirement or disability benefits.


Telemedicine: Medical or other healthcare services given to a patient through a computer, phone, or television by a practitioner in a location different than the patient’s.


Tiers: Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost less than a drug in a higher tier.


Still have a few questions?

We know how confusing Medicare can be, which is why Kasasa Care partnered with KindHealth and their team of Licensed Medicare Advisors. Get the answers you need (or even enroll in a plan!) in one free phone call. Click here to get started and learn more.


Before you know it, you’ll be everyone’s go-to source for all things Medicare. (And we couldn’t be more proud.)

Tags: Health, Care, Medicare

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