This glossary explains terms in the Medicare program.
Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace.
See "Medicare-certified provider."
Children's Health Insurance Program (CHIP)
Insurance program jointly funded by state and federal government that provides health coverage to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but can’t afford to purchase private health insurance coverage.
A request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered.
Clinical breast exam
An exam by your doctor or other health care provider to check for breast cancer by feeling and looking at your breasts. This exam isn't the same as a mammogram and is usually done in the doctor's office during your Pap test and pelvic exam.
An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).
Comprehensive outpatient rehabilitation facility
A facility that provides a variety of services on an outpatient basis, including physicians' services, physical therapy, social or psychological services, and rehabilitation.
Coordination of benefits
A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.
An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription.
A device used to keep an artery open.
An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or prescription drug. This amount can include copayments, coinsurance, and/or deductibles.
Coverage determination (Part D)
The first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits, including:
- Whether a particular drug is covered
- Whether you have met all the requirements for getting a requested drug
- How much you’re required to pay for a drug
- Whether to make an exception to a plan rule when you request it
The drug plan must give you a prompt decision (72 hours for standard requests, 24 hours for expedited requests). If you disagree with the plan’s coverage determination, the next step is an appeal.
Coverage gap (Medicare prescription drug coverage)
A period of time in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year.
See "creditable coverage (Medigap)" or "creditable prescription drug coverage."
Creditable coverage (Medigap)
Previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy.
Creditable prescription drug coverage
Prescription drug coverage (for example, from an employer or union) that's expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.
Critical access hospital (CAH)
A small facility that provides outpatient services, as well as inpatient services on a limited basis, to people in rural areas.
Non-skilled personal care, like help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn't pay for custodial care.
This glossary explains terms in the Medicare program, but it isn't a legal document. The official Medicare program provisions are found in the relevant laws, regulations, and rulings.