CMS Terminology Flashcards
Medicare
The federal health insurance program for:
People who are 65 or older
Certain younger people with disabilities
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)
Copayment
A copayment, also known as a copay, is a set amount you are required to pay for each medical service you receive (like $35 for a doctor’s visit).
Outpatient
An outpatient is a patient who has not been formally admitted into the hospital as an inpatient. Most outpatient care is covered under Medicare Part B (medical insurance).
Out-of-Pocket Costs
Out-of-pocket costs are health care costs that you must pay because Medicare or other health insurance does not cover them.
Preferred Pharmacy
Many Part D plans have preferred and non-preferred pharmacies in their network. You typically pay less for your prescription drugs at preferred pharmacies.
Premium
A premium is an individual’s monthly payment to a Medicare or other health insurance plan for coverage.
Prescription
A prescription is an order for a health care service or drug written by a qualified health care professional.
Preventive Care
Preventive care is care intended to prevent illness, detect medical conditions, and keep you healthy. Medicare Part B covers many preventive services, such as routine checkups, flu shots, and tests like prostate cancer screenings and yearly mammograms.
Out-of-Network
Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received.
Original Medicare
Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare.
MediGap
A Medigap is a supplemental health insurance policy that is sold by private insurance companies and works only with Original Medicare. Medigaps pay part or all of certain remaining costs after Original Medicare pays first. Depending on where you live and when you became eligible for Medicare, you have up to 10 different Medigap policies to choose from, each with a different set of standardized benefits.
Prior Authorization
Prior authorization, also known as pre-authorization or pre-approval, is a restriction placed on coverage by Part D plans and Medicare Advantage Plans. If a service or drug requires prior authorization, you must first get approval from the plan for it to be covered. If you fail to get prior authorization before you get the service or drug, your plan generally will not cover it.
Urgent Care
Urgent care is immediate medical attention for a sudden illness or injury that is not life threatening.
Supplemental Security Income
Supplemental Security Income is a monthly benefit for people with limited incomes and assets who are 65 or older, blind, or have a disability
Step Therapy
Step therapy is a restriction placed on drug coverage by Part D plans and Medicare Advantage Plans. Before your plan will cover a drug, you must first try a different or less expensive drug that treats your condition to see if it will be effective for you.
