Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

Glossary of Terms

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The letters at the top of the glossary chart will act as alphabetical links.

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A–B–C–D–E–F–G–H–I-J-K-L–M-N-O–P–Q–R–S–T–U-V-W-X-Y-Z

Term Definition

A

  
Affordable Care Act (ACA) "Health care reform" became law in March 2010. Through the Marketplace and expanded Medicaid, seeks to make health insurance available to all Americans.
Annual Coordinated Election Period (ACEP) Period each year (October 15 to December 7) during which beneficiaries can join or change their Part C and D plans. Also known as an Annual Election Period (AEP).
Annual Election Period (AEP) Same as the ACEP (see above)
Actuarially Equivalent (AE) Plan A Part D plan that is structured differently from the Part D Standard Benefit but that, from a fiscal point of view, offers a benefit package at least as valuable as the Standard Benefit. An actuarially equivalent plan typically has the same deductible but different cost-sharing.
Additional Low Income Medicare Beneficiary program (ALMB) A Medicare Savings Program (MSP) that pays the Medicare Part B monthly premium. There is an income test (135% of FPL).  In Connecticut there is no asset limit. It is state administered but subject to funding by Congress each year, therefore, it is operated on a “first-come-first-served” basis. Also known as the “QI” (Qualified Individual) program. Benefits paid may be subject to estate recovery, depending on the state.
Administrative Law Judge (ALJ) An individual who presides over Medicare appeal hearings, with the power to administer oaths, take testimony, rule on questions of evidence, and make determinations of fact.
Annual Notice of Change (ANOC) Notices sent each year to beneficiaries by their Part D plans informing them of changes to their plan in the coming year. ANOCs must be received at least two weeks before the October 15 start of the AEP.
Appeal A legal proceeding undertaken to reverse a decision by bringing it to a higher authority. For instance, if a Medicare beneficiary receives a notice indicating the physical therapy services in a skilled nursing facility will be discontinued, the beneficiary can appeal to the Quality Improvement Organization. (QIO)
Assignment In traditional Medicare, this means the doctor or supplier agrees to accept the Medicare-approved amount as full payment.
Authorization To formally approve or give legal authority.  Insurance companies authorize care that they may pay for.
Auto-Enrollment The process by which CMS automatically enrolls dual eligible individuals, first into a temporary plan(LINET) and then  into a Part D benchmark plans to ensure that they are not without coverage.

B

  
Basic Alternative (BA)Plan An actuarially equivalent Part D plan that is structured differently from the Part D Standard Benefit but that, on a fiscal basis, offers a benefit package at least as valuable as the Standard Benefit. Typically, has a smaller deductible, with or without different cost sharing.
Beneficiary General term used for one who receives a benefit. Used to describe those people receiving Medicare benefits, or, when accompanied by "Dual(ly) Eligible", those receiving both Medicare and Medicaid benefits.
Beneficiary Family Centered Care Quality Improvement Organization     A contractor paid by the federal government to monitor the care given to Medicare patients. It reviews complaints about the quality of care given by hospitals (inpatient and outpatient), skilled nursing facilities, and home health agencies.  It also reviews discharge appeals.  In Conencticut the BFCCQIO is Livanta.  the telephone number is 866-815-5440.
Benchmark Plans Part D plans that offer a basic (not enhanced) benefit and have premiums at or below the regional threshold amount set by CMS.
Benefit Period Begins the day the beneficiary is admitted as an inpatient to a hospital.  The benefit period ends when a beneficiary has had no hospital or skilled nursing facility level of care for 60 consecutive days.  For each new benefit period, beneficiaries must pay the inpatient hospital deductible.  There is no limit to the number of benefit periods.  Also known in Medicare as the "Spell of Illness."
Benefits Coordination and Recovery Center (BCRC) Contractor responsible for determining the respective responsibilities of two or more health plans.  The telephone number for the BCRC is 855-798-2627.

C

  
Catastrophic Coverage Under the standard Part D benefit, once beneficiaries' total Part D drug costs reach a maximum amount, beneficiaries pay only a small co-insurance or co-payment for covered drug costs until the end of the calendar year.
Centers for Medicare & Medicaid Services (CMS) CMS is the Federal Agency that administers Medicare, Medicaid, and the State Children's Health Insurance Program. It is part of the U.S. Department of Health and Human Services.
Certificate of Creditable Coverage A written statement issued by an insurance company that states the period of time the beneficiary had health insurance through that company that is/was at least as good as Medicare Part D coverage.
CHOICES “Connecticut’s Programs for Health Insurance Assistance, Outreach, Information and Referral, Counseling and Eligibility Screening” (CHOICES is Connecticut’s state health insurance and assistance program (SHIP). The telephone number for CHOICES is 1 (800) 994-9422.
Code of Federal Regulations (CFR) The annual collection of executive-agency regulations published in the daily Federal Register, combined with previously issued regulations that are still in effect.
Coinsurance The amount beneficiaries pay for services after deductibles are met. For instance, in Medicare Part B, this is often a percentage (20%) of the Medicare approved amount.
Connecticut Department of Social Services (DSS) DSS provides a broad range of services to the elderly, persons with disabilities, and families. By statute it is the state agency responsible for administering a number of programs under federal legislation, including the Rehabilitation Act, the Food Stamp Act, the Older Americans Act, and the Social Security Act. DSS is also designated as a public housing agency for the purpose of administering the Section 8 program under the federal Housing Act. For general information, call 1 (800) 842-1508.
Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled (ConnPACE) 
This State funded prescription drug assistance program for qualified people with disabilities expired on December 31, 2013.  (See also "SPAP.") 
Coordination of Benefits (COB) Process for determining the respective responsibilities of two or more health plans. The telephone number for the COB contractor is 1(800)999-1118.
Copayment An amount that beneficiaries pay for each medical service, like a doctor's visit or prescription. It is a set amount rather than a percentage of costs (coinsurance). For instance, it might be $20.00 for each doctor's visit. There are sometimes copayments in Medicare Advantage and Part D plans and for some hospital outpatient services in traditional Medicare.
Cost Sharing The amount beneficiaries pay out-of-pocket for health care, services, and prescriptions. Cost-sharing includes copayments, coinsurance, and deductibles.
Covered Employee An individual who is (or was) provided coverage under a group health plan.
Creditable Coverage Past health coverage that gives beneficiaries certain rights when applying for new coverage.

 

1. Creditable coverage for purposes of Medigap plans is previous health insurance coverage that can be used to shorten a pre-existing condition waiting period.

2. Creditable coverage for purposes of Medicare Prescription Drug Coverage is prescription drug coverage that is at least actuarially equivalent to or better than the Medicare Part D Standard Benefit.

D

  
Deductible The amount beneficiaries pay for health care, services, or prescriptions before Medicare pays. For example, in traditional Medicare, beneficiaries pay an annual Part B deductible.
Demonstration/Pilot (“Demo”) Plans Medicare approved plans designed to test improvements in Medicare coverage, payments and quality of care. Usually offered to targeted populations in a specified area. In 2009, Fresenius Inc. operates a demo plan for individuals with ESRD residing in certain counties of CT.
Donut Hole The Medicare Part D coverage gap during which beneficiaries have to pay 100% for most medications. In 2015, beneficiaries will receive a 55% discount on brand name drugs and a 35% discount on generics purchased while in the Donut Hole.  Discounts will continue to increase until 2020, when the donut hole is closed.
DSS See "Connecticut Department of Social Services"
Dual Eligible A beneficiary eligible for both Medicare and Medicaid.
Durable Medical Equipment (DME) Medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, and hospital beds.
Durable Medical Equipment Regional Carrier (DMERC) A private company that contracts with Medicare to pay for durable medical equipment.

E

  
Employer Group Health Plan (EGHP) Health insurance available through an employer or union.
End Stage Renal Disease (ESRD) Kidney failure that requires a regular course of dialysis or a kidney transplant. People with ESRD are eligible to receive Medicare benefits prior to age 65.
Erectile Dysfunction (ED) Drugs Drugs that correct male erectile dysfunction. Their coverage is excluded by law under Part D and Medicaid.
Evidence of Coverage (EOC) Information sent by insurance companies to new and renewing members describing plan benefits and patient rights and responsibilities.
Expedited Appeal 1. In traditional Medicare, available to beneficiaries who disagree with a facility or agency’s discharge of the beneficiary from Medicare covered SNF, Rehab hospital, home health care, or hospice care. The beneficiary must request an expedited determination by no later than noon of the day following receipt of the initial written notice (“generic notice”). The expedited determination will be done by a QIO and should be done within 48 hours.

 

2. In Part D, a decision made as speedily as the beneficiary’s life or health requires. For a Coverage Determination, the decision must be rendered within 24 hours or faster, as required. For a Part D Redetermination or Reconsideration, the decision is required within 72 hours. In all cases, timing begins upon receipt of the physician’s information.

Expedited Organization Determination A fast decision from a Medicare Advantage Plan about whether it will provide a health service. A beneficiary may receive an expedited decision within 72 hours when life, health, or ability to regain function may be jeopardized.
Expedited Review Available to beneficiaries in traditional Medicare who disagree with a discharge from the hospital. To exercise this right, beneficiaries must contact the QIO by noon of the date of discharge. The QIO will collect relevant medical information, evaluate it, and issue a decision by close of business of the first working day after it receives all requested information
Extra Help See Low Income Subsidy (LIS).

F

  
Facilitated Enrollment 
In Part D:
1. Enrollment of LIS eligibles into Part D benchmark plans.  
2. Immediate enrollment into a temporary plan (LINET) when an LIS eligible presents at the pharmacy without Part D coverage. This is also known as "point-of-sale" (POS) enrollment.
Federal Poverty Level (FPL) The national income levels used to define poverty. New figures are issued each year in the Federal Register by the Department of Health and Human Services (HHS). The FPL is used to determine eligibility for many public programs.

 

Information available online at http://aspe.hhs.gov/poverty/.

Food and Drug Administration (FDA) The federal agency responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, the nation's food supply, cosmetics, and products that emit radiation.
Formulary A list of medications covered by a Part D plan. Formularies vary from plan to plan and also change annually.
   

G

  
Generic Substitution Part D plans are allowed to substitute generic drugs for brand name drugs at the pharmacy, without advance notice to members.
Grievance A complaint about a Medicare Advantage or Part D plan. For example, a grievance might be filed if a beneficiary is unhappy about the way a staff person at the plan treated her on the telephone.
Guaranteed Issue The duty of a company to offer an insurance plan to all. Some Medicare beneficiaries are protected in this way from discrimination by insurance companies that offer Medigap policies.
Guaranteed Renewable A law that requires insurance companies to automatically renew or continue Medigap policies, unless the beneficiary makes untrue statements to the company, commits fraud, or does not pay premiums.

H

  
Health Maintenance Organization (HMO) A type of insurance and Medicare Advantage Plan.  Members generally must obtain a referral from their primary care physician in order to see a specialist.  with some exceptions Medicare HMOs generally must cover all Medicare Part A and Part B health care.  Some HMO's offer additional benefits, such as waiving the three-day qualifying hospital stay for skilled nursing facility coverage.  In most HMOs, except in emergency or urgent situations, beneficiaries must receive care from the healthcare providers within the Plan's network. 
Home Health Care Medical and supportive care provided at home. Medicare covers part-time or intermittent skilled nursing care and home health aide services, physical therapy, speech therapy, occupational therapy, medical social services, durable medical equipment, medical supplies, and other services provided in the home. Beneficiaries must be homebound to obtain Medicare coverage.
Hospice Care Team-oriented approach to care that addresses the medical, physical, social, emotional and spiritual needs of dying patients and their caregivers. Medicare has a comprehensive hospice benefit.

I

  
Initial Coverage Election Period (ICEP) See "Initial Enrollment Period"
Initial Coverage Period During this period, members of standard Part D Plans pay 25% of their drug costs until the annual threshold amount is reached (The plan’s 75% share of costs also goes toward the threshold amount.) Members of actuarially equivalent and enhanced plans may have a system of tiered co-pays and co-insurance, instead of 25% cost-sharing, during this period. Once the threshold amount is reached, the member goes into the Donut Hole.
Initial Enrollment Period (IEP) The seven-month period in which individuals are initially eligible to enroll in traditional Medicare, Part B and Part D. For purposes of Part C, this same period is called the Initial Coverage Election Period (ICEP). The seven-month period consists of the three months before, the month of, and the three months after the individual’s 65th birthday or 24th month of disability.
Insurance Department Each state has an insurance department which provides assistance and information, regulates the insurance industry, and enforces insurance laws. In Connecticut, the insurance department can be reached at 1(800)203-3447.
Inpatient Care Healthcare received in a hospital of a skilled nursing facility. It does not include outpatient services at a hospital.

L

  
Late Enrollment Penalty (LEP) An amount added to monthly premiums for Medicare Part B or Part D (and Part A for voluntary enrollees) if a Medicare beneficiary fails to enroll during the initial enrollment period and does not qualify for a "good cause" exemption.
Lifetime Reserve Days In traditional Medicare, a total of 60 extra days that Medicare will pay for when beneficiaries are hospitalized for more than 90 days during a benefit period. Once these 60 days are used, they are exhausted. In other words, they cannot be used again.
Limiting Charge In traditional Medicare, the amount of money beneficiaries can be charged by doctors who do not accept assignment. The limiting charge is 15% over Medicare's approved amount. The limiting charge does not apply to supplies or equipment.
LINET 
The Limited Income Newly Eligible Transition program that:
1. Provides temporary coverage for newly auto-enrolled dual eligibles.
2. Provides immediate coverage for LIS eligibles who present at the pharmacy without drug coverage
3. Reimburses individuals who paid for drugs during a period of retroactive Medicaid coverage
Lock In Prohibition against changing Medicare Advantage and Part D plans except during specific periods during each year or during special enrollment periods.
Low Income Subsidy (LIS) Also known as "Extra Help." LIS is administered by the Social Security Administration and helps pay for Part D premiums and drug costs, for eligible individuals.

M

  
Medicaid State administered medical assistance for low income families, disabled and elderly individuals. In Connecticut. Medicaid is also known as Title 19, as it is Title XIX of the Social Security Act.
Medical Savings Account (MSA) A type of Medicare Advantage plan consisting of a high deductible health plan and a bank account. Medicare gives the plan a certain amount of money each year for a beneficiary's health care, and the plan deposits a portion of the money into an account. The amount deposited is usually less than the deductible amount, so a beneficiary will have to pay out-of-pocket for medical costs before coverage begins. MSAs do not offer prescription drug coverage; therefore, members can purchase drug insurance through a PDP.
Medicare Advantage Disenrollment Period (MADP) The period from January 1 – February 14 each year when individuals in a Medicare Advantage plan may switch back to original Medicare and enroll in a PDP.
Medicare Advantage Plan (MA or MA-PD) A private plan, often an HMO, that provides the benefits of Medicare Part A and Part B (MA plan) or Part A, Part B, and Part D (MA-PD plan). Medicare Advantage Plans include PPOs, HMOs, PFFS plans, MSA plans and SNPs.
Medicare Coordinated Care Plan A collective term used for the various private Medicare Advantage plan options: HMOs, PSOs, PPOs and other "network" plans (except MSA and PFFS plans).
Medicare Cost Plans Medicare Advantage plans that are a type of HMO. The plans only pay for services outside their networks when they are emergencies or urgently needed services. However, those who enroll in a Medicare Cost Plan can get routine services outside of the plan's network without a referral. These services will be billed to traditional Medicare and the beneficiary will be responsible for traditional Medicare's deductibles and coinsurance. There are no Medicare Cost Plans in CT in 2009.
Medicare Health Plans A collective term used by Medicare to refer to Medicare Advantage plans, Medicare Cost Plans, Demonstration Plans and PACE programs.
Medicare Part A The component of Medicare that covers inpatient hospital care, skilled nursing (not custodial or long term care), hospice services, and home health care.
Medicare Part B The component of Medicare that covers medically necessary doctor’s services, outpatient care (laboratory, x-ray, etc), durable medical equipment, ambulance, and many other services, including some preventive services.
Medicare Part C The component of the Medicare Act that establishes private “Medicare Advantage” plans to finance services enumerated in Medicare Part A and Part B, and sometimes additional benefits.
Medicare Part D The component of Medicare that covers outpatient prescription drugs via private plans.
Medicare Savings Programs (MSP) Programs that assist lower income people pay for Medicare Part A, B and D premiums, deductibles, and copayments. There are three MSP programs: QMB, SLMB, and ALMB (the latter is also called the QI program). Beneficiaries who are enrolled in MSP programs automatically qualify for the Medicare Part D low-income (LIS) subsidy.
Medicare Summary Notice (MSN) Notices Medicare beneficiaries receive that list all medical claims billed to Medicare Parts A and B. They list what the provider billed, Medicare's approved amount, how much Medicare paid, beneficiary liability, and appeal rights.
Medicare Approved Amount In traditional Medicare, Medicare's system for paying providers is based on a fee schedule. The fee schedule assigns a dollar value to each medical service based on work, the cost of running a practice, and the cost of malpractice insurance. As a general rule, Medicare Part B pays providers 80% of the approved amount. Beneficiaries are responsible for paying the remainder (generally 20% for providers who take assignment).
Medigap
(Also known as Medicare Supplement Insurance)
 Insurance sold by insurance companies to fill in the "gaps" of traditional Medicare.  Except in Massachusetts, Minnesota, and Wisconsin These plans are standardized. 
"Medicare Prescription Drug, Modernization and Improvement Act of 2003" (MMA) Federal law that, among other provisions, created the Medicare Part D prescription drug program, the Medicare Advantage private plan system, and added some preventive care coverage to the Part B benefit.
"Medicare Improvement for Patients and Providers Act" (MIPPA) 2008 Federal legislation that makes significant changes to the Part D, LIS and MSP programs. Changes will be rolled out over several years, beginning in 2009.

O

  
Outpatient Hospital Care Medical or surgical care provided at the hospital without the beneficiary being admitted as an inpatient. This includes emergency room care and, per Medicare policy, care provided on observation status, even if the beneficiary remains in the hospital overnight.
Over-the-Counter (OTC) Drugs Drugs that may be purchased without a medical prescription.

P

  
Programs of All-Inclusive Care for the Elderly (PACE) Medicare approved programs that offer medical, social, long term care and prescription drug coverage for the frail elderly and disabled. CT does not have a PACE program at this time.
Point of Service Option (POS) An insurance coverage option that permits beneficiaries to use doctors and hospitals outside of the plan’s network for an additional cost to the beneficiary.
Point of Sale Enrollment See "Facilitated Enrollment."
Pre-Existing Condition A medical condition that exists prior to enrolling in an insurance policy.
Preferred Provider Organization (PPO) A Medicare Advantage plan that encourages members to use providers in its network by requiring those who use providers outside of the network to pay additional costs.
Premium The periodic payment required to keep insurance in effect.
Prescription Drug Plan (PDP) A Part D plan that covers outpatient prescription drug coverage only (no hospital or medical coverage). PDPs are regulated and subsidized by Medicare. They are sometimes referred to as "stand alone" drug plans and are always private plans.
Preventive Services Health care offered for purposes of prevention or early diagnosis. Examples include flu shots and mammograms.
Primary Care Physician (PCP) A doctor who provides basic (non-specialized) health care. In many Medicare Advantage plans, beneficiaries must see their primary care physician and obtain a referral before they can see a specialist.
Prior Authorization (PA) A utilization management tool used by Medicare Advantage and Part D plans to control costs. The beneficiary's physician must obtain approval from the beneficiary's plan before the plan will cover the given service, item or payment for a prescription medication.
Private Fee-For-Service Plan (PFFS) A type of Medicare Advantage private plan in which enrollees may go to any Medicare-approved provider that accepts the plan's payment. The insurance company that runs the plan (rather than CMS) decides how much it will pay and how much cost-sharing enrollees must bear.

Q

  
QIO See "Beneficiary Family Centered Care Quality Improvement Organization "
Qualified Individual (QI) Program One of three Medicare Savings Programs (see also "SLMB" and "QMB"). It pays for the Part B monthly premium. There is an income test (135% of FPL).  There is no asset test in Connecticut. It is state administered but subject to funding by Congress each year, therefore, it is operated on a “first-come-first-served” basis. It is also known as the “ALMB” program. Benefits paid may be subject to estate recovery depending on the state.
Qualified Medicare Beneficiary Program (QMB) One of three Medicare Savings Programs (see also "ALMB" and "SLMB"). For some lower income people it pays Medicare Part A and B coinsurance, deductibles, and premiums for beneficiaries with incomes below 100% of the FPL and with limited assets. In this way, it is like a Medigap policy, however, payment is only made to Medicaid providers and is capped at Medicaid rates.
Quantity Limits (QL) One of three utilization management tools used by Part D plans to control costs. The plan places limits on the drug dosages or quantities it will cover.

R

  
Referral A written order from a primary care physician to see a specialist. In many Medicare Advantage plans, payment will not be made for specialist care unless the beneficiary first obtains a referral.
Rehabilitation Services to promote recovery from illness or injury or to prevent or slow deterioration. Generally provided by nurses and physical, occupational, and speech therapists.
Regional Office (RO) of the Centers for Medicare & Medicaid Services CMS has 10 regional offices responsible for the consistent application of Medicare policy and guidance in their respective territories. CT is covered by RO 1 in Boston, which also oversees Maine, Massachusetts, New Hampshire, Rhode Island and Vermont.

S

  
Secondary Payer An insurance policy, plan, or program that pays second on a claim for medical care.
Service Area The area where a Medicare Advantage Plan or Part D Prescription Drug Plan accepts members and, as a general rule, covers services
Skilled Care Health care that must be administered, managed, supervised, observed or assessed by a licensed professional.
Skilled Nursing Facility (SNF) A licensed facility that has the staff and equipment necessary to provide skilled nursing and rehabilitation. To be covered by Medicare the facility must also be certified by Medicare.
Skilled Nursing Facility Level of Care Care that requires the involvement of nurses or rehabilitation staff and that, as a practical matter, can not be provided on an outpatient basis.
Special Enrollment Period (SEP) A period triggered by exceptional conditions, as defined by law and CMS policy, during which beneficiaries can enroll or disenroll from their Part C or D plans, outside the normal Annual Election Period.  Changes may include leaving Medicare Advantage and returning to traditional Medicare.
Special Enrollment Period (Part B) A period during which beneficiaries can sign up for Medicare Part B if they did not sign up during the Initial Enrollment Period because either the beneficiary or beneficiary's spouse continued to work and thus the beneficiary continued to be insured by an employee group health plan. The period lasts for eight months, beginning the month after the employment or employee group health coverage ends (whichever comes first).
Special Needs Plan A type of Medicare Advantage plan that is supposed to provide focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who are institutionalized, or who have chronic medical conditions.
Specialist A physician who treats only certain parts of the body, certain health problems, or certain age groups. For instance, nephrologists diagnose and manage kidney disease.
Specified Low-Income Medicare Beneficiaries (SLMB) One of three Medicare Savings Programs (see also "ALMB" and "QMB").  It pays for the Medicare Part B monthly premium for certain low income individuals with income below 120% of FPL there is no asset limit in Connecticut.   Unlike ALMB, which also pays the Part B premium, SLMB is not subject to re-funding each year, therefore, it is operated as an entitlement.  Benefits may be subject to estate recovery, depending on the state.
Spend-down Process by which individuals who would be eligible for Medicaid except for their monthly income subtract their incurred medical bills from their income to get it down to, or below, the medically needy income limits for Medicaid. Eligibility is recalculated every six months.
State Health Insurance Assistance Program (SHIP) A state program that is funded in part by the federal government to give free local health insurance counseling to people with Medicare. CHOICES is Connecticut's SHIP. See www.shiptalk.org.
State Pharmacy Assistance Program (SPAP) State funded prescription drug assistance for certain lower income older people (65 +) and people with disabilities.
Step Therapy (ST) A utilization management tool used by Part D plans to control costs. Requires a trial of a less expensive medication and failure on that medication before the plan will pay for a more expensive prescribed medication. (Also known as “Fail First”.)
Social Security Administration (SSA) The federal agency that administers the Social Security Program, including the retirement benefit. Medicare is administered by another agency, the Centers for Medicare & Medicaid Services (CMS), but the SSA district offices determine eligibility for Medicare and process premium payments.
Social Security Disability Insurance (SSDI) Social Security benefits paid to individuals and certain members of their families after the individual has been found to be disabled. To qualify, beneficiaries must have earned enough credits by working enough work quarters. This program is administered through SSA.
Supplemental Security Income (SSI) Program administered through SSA. It provides limited financial assistance to elderly and disabled individuals who have insufficient work quarters to collect Social Security retirement or disability benefits.

T

  
Tiers To control costs, many Part D plans place medications on different "tiers". This means they have different cost sharing requirements, with brand name drugs, for example, having higher co-pays than generics,.
Traditional Medicare The Medicare system as originally designed: a national public program, including coverage under Parts A and B. (Sometimes referred to as the “fee-for-service” program and as “original” Medicare.
TriCare A public health insurance program for active duty service members, National Guard and Reserve members, retirees, their families, survivors, and certain former spouses.
TriCare for Life (TFL) Additional, “wrap around” insurance for individuals eligible for Tricare who are also Medicare beneficiaries. For most medical care, TFL pays second, after Medicare pays.
True Out-of-Pocket costs (TrOOP) The cost of formulary drugs paid by the plan member (or family, a charity, the LIS or an SPAP) and applied toward the Donut Hole threshold amount. Once TrOOP costs reach the annual threshold amount, the member goes into the final stage of the Part D annual drug benefit, Catastrophic Coverage.

U

  
United States Code (USC) A multivolume, published codification of federal statutory law.
Urgently Needed Care Care for a sudden illness or injury that needs medical care right away, but is not life threatening. If a member of a Medicare Advantage plan is out of the plan's service area and requires urgently needed care, the plan must pay for the care.
Utilization Management Tools In Part D, this refers to the three ways plans use certain approaches to control costs: prior authorization, quantity limits, and step therapy.

W

  
Workers Compensation Insurance that employers are required to have to cover medical costs for employees who get sick or injured on the job.
Wrap-around Coverage provided by the State of Connecticut to dual eligible beneficiaries that fills in Part D gaps in coverage.  Includes coverage during the deductible and Donut Hole periods,   coverage of excluded drugs and coverage of All but $15.00 in co-pays for dual eligibles.  Also, Tri-Care For Life  is said to “wrap-around” Medicare for certain veterans and family members.

 

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