Medicare is a federal health insurance program for 65 and older individuals and under 65 with certain illnesses. There are many parts, plans, and Medicare terms that can be confusing, and The Fussell Group is here to simplify things. We’ve picked one key Medicare term — for each letter of the alphabet — and explained it below.

ALS

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is a disease in the nervous system that weakens muscles and affects physical function. Medicare is available for most people who have been diagnosed with ALS — regardless of age.

Broker

A Medicare broker is an independent insurance agent who represents many companies. They work on your behalf, giving an unbiased opinion on your plan options. At Temmen Insurance, we focus on finding the right fit for you instead of promoting one company. Our Medicare is FREE! We make a commission from the insurance carrier for selling their product(s). 

Related Post: Medicare 101 — What You Need to Know 

Coinsurance

An amount you may have to pay as your portion of the cost for medical services — after you pay deductibles. It’s typically a percentage, like 20%, for example. 

Durable Medical Equipment

Equipment serving a medical purpose, able to endure repeated use, and is fitting for home use. This equipment, like a wheelchair, walker, or hospital bed — ordered by your doctor — is covered under Medicare Part B. 

Excess charge

If you have Original Medicare and the doctor (or another provider) is legally allowed to charge a higher amount than what Medicare approves, the difference is known as the “excess charge.” Medigap plans F and G cover 100% of the Medicare Part B excess charges.  

Related Post: High Deductible Plan F vs. High Deductible Plan G

Formulary

Every Medicare Part D plan has a list of covered drugs, called a formulary. The covered drugs, then, are put into “tiers” on the formulary. Usually, a drug in a lower tier will be cheaper than one in a higher tier. Your plan could make changes to its list throughout the year as new drugs get released and/or new medical info becomes available.  

Guaranteed Renewable Policy

An insurance policy that can’t be revoked by a carrier unless you commit fraud or don’t pay your premiums. All Medicare Supplement plans — issued since 1992 — are guaranteed renewable. 

Hospice

A program that cares for and supports people with a terminal illness. Hospice care involves a team that tends to the patient’s physical, mental, social, and spiritual needs. Medicare covers hospice when it’s medically necessary and if the provider is Medicare-approved. The patient must also meet certain requirements.  

In-Home Care

Services that can help an aging person live independently, manage chronic health problems, recover from a setback, or manage special needs or a disability. The in-home care covered by Medicare will depend on the kind of care involved. It also must be “medical” in nature.

Junk Mail

When you turn 65 (and likely the months leading up to it), you’ll get an abundance of Medicare-related mail. You’ll likely get mail from insurance companies, like Blue Cross Blue Shield and Mutual of Omaha, the Social Security Administration, brokerages, CMS, and scammers (junkmail). It can be overwhelming and hard to know what to trust. 

Watch out for scams. If they include words like “FREE,” it’s probably rubbish. Here are some other tips to help you separate junk mail from urgent pieces of information. 

Kidney Failure

Individuals who suffer from permanent kidney failure, also called end-stage renal disease (ESRD), will need a lot of medical care. Fortunately, they can get Medicare benefits that will help cover the high costs. If you need regular dialysis or have had a kidney transplant, you’re eligible for Medicare — no matter your age.

Large Group Health Plan

A group health insurance plan that provides coverage for employees — of either an employer or organization with at least 100 employees. You can have Medicare and employer coverage. In this case, your employer coverage would be primary and Medicare would be secondary.

MA-PD

A Medicare Advantage Prescription Drug Plan (MA-PD) is a Part C program that includes Part D coverage. These plans are offered by private carriers, contracted with Medicare, to provide Parts A, B, and D benefits. If you have slightly more to spend on premiums, this is a good option for you. MAPDs offer other coverage like vision and dental.    

Network-Participating Provider

Medicare Advantage plans usually have networks. You’ll need to see a provider that participates in the network to receive the highest level of benefit. With some programs, if you go outside the network — unless it’s a “true emergency” — you’ll pay the full cost for the services. 

Original Medicare

A fee-for-service health plan with two parts: Part A is your hospital insurance, and Part B is your medical insurance. Once you pay a deductible, Medicare will pay its portion of the approved amount, and you pay yours (coinsurance and deductibles). 

Preventative Services

Medical care (like outpatient physical, speech, and occupational therapy) that prevents illness or detects it at an early stage — when treatment may be most effective. Flu shots would be an example. As long as a Medicare-certified therapist administers these services, Medicare Part B will cover them.

Qualified Beneficiary

(QMB) A person for whom the government has to cover certain medical costs, including deductibles, copays, and premiums. People must be Medicare-eligible and meet income and asset guidelines to qualify for the program: the individual monthly income limit is $1,060, and the married couple’s monthly income limit is $1,430.

Referral

A written order from your primary care physician allowing you to visit a specialist or get particular medical services. In many HMO (Medicare Advantage) plans, you must obtain a referral before you can get health care from anyone — except for your primary doctor. Failing to get a referral first may result in the plan not paying for the services. 

Service Area

A geographic region where a Medicare plan accepts members if membership is based on where folks live. Some health insurance programs vary. For plans with limited doctors and hospitals than you can use, it’s usually the zone where you can get routine services. If you move out of the service area, the plan may disenroll you.  

Telemedicine

Medical services given to a patient using a computer, phone, or television — by a practitioner — in a different location than the patient’s. 

Urgently Needed Care

Care received outside of the Medicare plan’s service area for an illness or injury that needs immediate medical attention but isn’t fatal. The health plan will pay for the care if it’s too risky to wait until you get home to receive care from a plan doctor.   

Vision Coverage

Original Medicare doesn’t cover dental, vision, or hearing coverage. However, Medicare Advantage plans can offer these extra benefits, so call us to see what’s available in your area.

Waiting Period

If you’re over 65, there’s no Medicare waiting period.

People (under 65) who are eligible for Social Security Disability Insurance (SSDI) benefits are eligible for Medicare, too — after a two-year qualifying period. The first two years of disability benefit entitlement is known as the waiting period for Medicare coverage.

However, the waiting period is waived if you have ESRD or ALS.

X-Rays

All x-rays and lab tests ordered by a doctor are covered under Medicare Part B. 

Yearly Deductible

Every year the Medicare premiums, deductibles, and copayment rates are modified according to the Social Security Act. In 2021, the annual deductible for Medicare Part B recipients is $203, an increase of $5 from $198 in 2020.

Zero-Premium Health Insurance Plans

Zero-dollar Medicare Advantage plans exist, but this doesn’t mean you pay $0 for coverage. You’ll likely have copays, coinsurances, and deductibles to pay out-of-pocket. Still, many members are attracted to these programs, and for good reasons. If you need help finding a zero-premium plan to save money, The Fussell Group is here for you. 

Now that you know many common Medicare terms, it’s time to choose the best insurance plan for your situation. Contact us online or call 1-877-874-0711 to speak with an advisor.