Glossary: Medicare

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

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.

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 Medi-Cal, CalFresh (formerly Food Stamps), and some other programs, none of the money in an ABLE account is counted.

Also called "resources."

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

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.

A trained expert who can help you understand and apply for benefit programs. Their goal is to help you develop a plan for your future and organize your financial life to run as smoothly as possible.

• For questions about work and your Social Security benefits, use Social Security's "Find Help" tool to locate a WIPA project near you. You can also call the Ticket to Work Help Line at 1-866-968-7842 / 1-866-833-2967 (TTY/TDD). The Department of Rehabilitation (DOR) also has Work Incentives Planners (WIPs).
• If you need assistance with your Medicare, the Health Insurance Counseling & Advocacy Program can help. HICAP provides free information and counseling to people with Medicare. You can call HICAP at 1-800-434-0222 or visit the HICAP website.
• If you need assistance with Medi-Cal and have a disability, you can contact Disability Rights California at 1-800-776-5746 or visit their website. You may also be able to get help with Medi-Cal from a local legal aid organization. The Health Consumer Alliance website has a lot of useful information about Medi-Cal, including a web page that can direct you to a local legal organization for assistance.
• If you have questions or need assistance with a program or benefit not listed here, contact an Independent Living Center. Independent Living Centers provide peer support and information on a wide range of topics for people with disabilities.

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."

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.

Prior to 2020, there was a gap in Medicare Part D coverage where Part D beneficiaries had to pay more of their prescription drug expenses. The Medicare Part D Coverage Gap, also called the "Donut Hole," has closed completely, for both brand-name and generic prescriptions. If this gap has affected you before 2020, this means your prescription expenses may be lower.

Monthly and annual income amounts used to determine financial eligibility for state and federal benefit programs.

Each year, the U.S. Department of Health and Human Services (HHS) issues the Federal Poverty Guidelines (FPG) in the Federal Register. The current FPG for one person is $15,060 per year; for two people, it's $20,440. Add $5,380 for each additional person.

Some agencies refer to these guidelines as the "Federal Poverty Level (FPL)" or "Federal Poverty Line (FPL)."

Note: Different state and federal programs adopt the new Federal Poverty Guidelines on different dates each year.

A list of drugs that a health plan covers.

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).

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 seven months.

An individual who has been admitted to the hospital.

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

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.

Help paying for Medicare Part D for people with low to moderate income and resources. Also known as "Extra Help". With it, you will not have to pay a Part D premium or deductible, and there may be lower copayments.

You may qualify if you are in one of these situations:

• You also get Medi-Cal coverage
• You are in a Medicare Savings Program (MSP), or
• You have countable income below $22,590 per year if you are single ($30,660 for couples) and resources less than $15,720 if you are single ($31,360 for couples).

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.

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.

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.

See Medicare Advantage Plan.

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

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.

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.

Also known as "Medicare Managed Care Plan."

See Medicare HMO.

Combined managed care plans for some people with both Medicare and Medi-Cal. These plans exist in some California counties.

Read more about combined managed care for Medicare and Medi-Cal or call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.

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

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.

The part of Medicare that helps pay for prescription drugs.

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.

Medicare Savings Programs are programs that help people with low income pay for their Medicare expenses, such as Medicare Part A and Medicare Part B premiums, coinsurance, and deductibles. There are four Medicare Savings Programs:

• The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of the Federal Poverty Guidelines (FPG) or less ($1,255 per month or less if you live alone). QMB helps pay for your Part B premium, copayments, and deductibles. Note: If you have disability-based or SSI-linked Medi-Cal coverage, you automatically qualify for QMB.
• The Specified Low-Income Beneficiary (SLMB) program helps people with countable income that’s more than 100% of FPG, but at or below 120% of FPG ($1,506 per month or less if you live alone). SLMB helps pay for the Part B premium, but does not help with anything else.
• The Qualified Individual-1 program, also called QI-1, helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,695 per month or less if you live alone). QI-1 helps pay for the Part B premium, but does not help with anything else.

• The Qualified Disabled Working Individual (QDWI) program helps people who have lost their SSDI benefits because they earn more than the Substantial Gainful Activity (SGA) level ($1,550 per month), but have countable income that’s 200% of FPG or less ($2,510 per month or less if you live alone). It lets you stay on Medicare Part A even though you don’t get SSDI anymore and it will pay for the Part A premium that would otherwise apply.

For MSPs, less than half of your earned income is counted. That means you might qualify even if you think your income is over the limits.

Learn more about MSPs.

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."

See Medicare supplement.

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

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

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.

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.

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

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 $174.70 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.

A Medicare Part D plan that only offers drug coverage. Also known as a "stand-alone" plan.

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 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.

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

A Medicare Savings Program that pays for Medicare Part B premiums. To qualify, an individual must:

• Be eligible for Medicare Part A and B
• Have countable income that's 135% of the Federal Poverty Guidelines (FPG) or less ($1,695 or less per month for individuals, $2,300 or less for couples), and
• Meet all other Medi-Cal eligibility requirements.

A Medicare Savings Program that pays for Medicare Part A and Part B premiums, coinsurance and deductibles. To qualify, you must:

• Be eligible for Medicare Part A and Part B,
• Have countable income that's 100% of the Federal Poverty Guidelines (FPG) or less ($1,255 or less per month for individuals, $1,704 or less for couples), and
• Meet all other Medi-Cal eligibility requirements.

This program does not apply benefits retroactively.

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 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.

A Medicare Savings Program that pays for Medicare Part B premiums. To qualify, you must:

• Be eligible for Medicare Part A and Part B,
• Have countable income that's 120% of the Federal Poverty Guidelines (FPG) or less ($1,506 or less per month for individuals, $2,044 or less for couples), and
• Meet all other Medi-Cal eligibility requirements.

State programs that receive money from the federal government to provide free, local health insurance counseling on Medicare. In California this program is known as Health Insurance Counseling and Advocacy Program (HICAP).

Work incentives are rules that help people who get public benefits and work. They let people get a benefit while they're working, keep a benefit longer while they work, or get a benefit back quickly if it stops due to work.

All public benefits in California have work incentives, including Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, and Medi-Cal.