Skip to main content

Medicare 용어

Medicare에 관해 말할 때 일반적으로 사용되는 단어 및 구문들을 찾을 수 있습니다.

 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

Ambulatory Surgical Center - An entity whose sole purpose is to provide outpatient surgical services to patients (1) who do not require hospitalization and (2) whose expected stay in the center does not exceed 24 hours.

Annual Enrollment Period - A set time each fall when members can change their health or drug plans or switch to Original Medicare. The Annual Enrollment Period is from Oct. 15 until Dec. 7.

Appeal - An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs, or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving. For example, you may ask for an appeal if we do not pay for a drug, item, or service you think you should be able to receive.

초과 청구(Balance Billing) – 네트워크 서비스 제공자(의사나 병원)가 플랜의 분담액을 초과하여 환자에게 청구한 경우. 가입자로서 귀하는 플랜이 보장하는 서비스를 받았을 때 플랜의 분담액만 지급하면 됩니다. 서비스 제공자는 “초과 청구”를 하거나 가입자가 지급해야 하는 플랜 분담액을 초과하여 청구할 수 없습니다.

혜택 기간(Benefit Period) – 저희 플랜과 Original Medicare가 함께 가입자의 전문 간호 시설(SNF) 서비스 이용을 측정하는 방법입니다. 혜택 기간은 전문 간호 시설에 입소하는 날부터 시작합니다. 혜택 기간은 가입자가 SNF에서 60일 연속으로 서비스를 받지 않은 시점에 종료됩니다. 한 번의 혜택 기간이 종료된 후 전문 간호 시설에 입소하면 새로운 혜택 기간이 시작됩니다. 혜택 기간의 횟수에는 제한이 없습니다.

브랜드 약(Brand Name Drug) – 원래 해당 의약품을 연구 및 개발한 제약업체에 의해 생산 및 판매되는 처방약입니다. 브랜드 약은 복제약과 동일한 활성 성분을 가집니다. 하지만 복제약은 다른 제약회사가 제조 및 판매하며 일반적으로 브랜드 약에 대한 특허가 만료될 때까지는 구입할 수 없습니다.

재해성 보장 단계(Catastrophic Coverage Stage) - 귀하(또는 귀하를 대신하는 사람)가 역년 중 총 본인 부담 비용을 지출했으면 귀하는 보장 공백 단계에서 재해성 보장 단계로 이동합니다. 이 금액은 매년 바뀝니다. 자세한 내용은 보장범위 증명(Evidence of Coverage)을 참조해 주십시오.

Centers for Medicare & Medicaid Services (CMS) - The federal agency that administers Medicare.

Coinsurance - An amount you may be required to pay as your share of the cost for services or prescription drugs. Coinsurance is usually a percentage (for example, 20%).

Co-payment - 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 a prescription drug. A co-payment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription drug.

Cost Sharing - Cost sharing refers to amounts that a member has to pay when services or drugs are received. Cost sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed "co-payment" amount that a plan requires when a specific service or drug is received; or (3) any coinsurance amount that a plan requires when a specific service or drug is received. A daily cost sharing rate may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you are required to pay a co-pay.

Cost Sharing Tier - Every drug on the list of covered drugs is in one of the cost sharing tiers. In general, the higher the cost sharing tier, the higher your cost for the drug.

Coverage Determination - A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the service or prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription is not covered under your plan, that is not a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are also called "coverage decisions."

Covered Drugs - All of the prescription drugs covered by our plan.

Covered Services - All of the health care services and supplies that are covered by our plan.

Creditable Prescription Drug Coverage - Prescription drug coverage (for example, from an employer or union) that is 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 the coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later.

Customer Service - A department within our plan that answers your questions about membership, benefits, grievances and appeals.

Daily Cost Sharing Rate - Something that may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you are required to pay a co-pay. A daily cost sharing rate is the one month co-pay divided by the number of days in a month's supply. For example, if your co-pay for a one-month supply of a drug is $30, and a one-month's supply in your plan is 30 days, then your daily cost-sharing rate is $1 per day. This means you pay $1 for each day's supply when you fill your prescription.

Deductible - The amount you must pay for health care or prescriptions before our plan begins to pay.

Disenroll or Disenrollment - The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).

Dual Eligible Individual - A person who qualifies for both Medicare and Medicaid coverage. 

Durable Medical Equipment - Certain medical equipment that is ordered by your doctor. Examples are walkers, wheelchairs, or hospital beds.

Emergency - A medical emergency is when you, or any other person with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

Emergency Care - Covered services that are: (1) rendered by a provider qualified to furnish emergency services; and (2) needed to evaluate or stabilize an emergency medical condition.

Evidence of Coverage (EOC) and Disclosure Information - The document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan.

Exception - A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor's formulary (a formulary exception), or get a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Extra Help - A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.

Formulary or "Drug List" - A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.

Generic Drug - A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a "generic" drug works the same as a brand name drug and usually costs less.

Grievance - A type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

Home Health Aide - A home health aide provides services that do not require the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out prescribed exercises). Home health aides do not have a nursing license or provide therapy.

Hospice - An enrollee who has six months or less to live has the right to elect hospice.  We, your plan, must provide you with a list of hospices in your geographic area. If you elect hospice and continue to pay premiums, you are still a member of our plan. You can still obtain all medically necessary services, as well as the supplemental benefits we offer. The hospice will provide special treatment for your state. 

Hospital Inpatient Stay - A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an "outpatient."

Independent Practice Association (IPA) - An association of physicians, including PCPs and specialists, and other health care providers, including hospitals, that contracts with an HMO to provide services to enrollees. Some IPAs have formal referral circles, which means that their providers will only refer patients to other providers belonging to the same IPA.

Initial Coverage Limit - The maximum limit of coverage under the Initial Coverage Stage.

Initial Enrollment Period - When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you are eligible for Medicare when you turn 65, your Initial Enrollment Period is the seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65.

의료기관 SNP(Institutional Special Needs Plan) - 장기 치료(LTC) 시설에 90일 이상 연속 거주하거나 거주할 것으로 예상되는 적격 개인이 가입하는 특별 요구 플랜. 이러한 LTC 시설에는 전문 간호 시설(SNF), 간호 시설(NF), SNF/NF, 정신 지체자를 위한 중간 치료 시설(ICF/MR) 및/또는 정신질환 입원 시설이 포함될 수 있습니다. LTC 시설의 Medicare 거주자를 위한 기관 특별 요구 플랜은 특정 LTC 시설(들)과 계약을 체결해야 합니다(또는 소유 또는 운영해야 합니다).

지연 가입 벌금(Late-Enrollment Penalty) - 신뢰할 만한 보장(평균적으로 표준 Medicare 처방약 보장 이상을 지급해야 하는 보장)이 Medicare 자격을 취득한 후 63일 이상 연속적으로 없는 경우, Medicare 처방약 보장에 대한 월납 보험료에 추가되는 금액. 이 높은 보험료는 귀하가 Medicare 약 플랜에 가입할 때까지 납부합니다. 몇 가지 예외도 있습니다. Medicare로부터 처방약 비용 지급을 위한 Extra Help를 받을 경우, 지연 가입 벌금을 납부하지 않습니다.

List of Covered Drugs - See Formulary or Drug List.

Low Income Subsidy - See Extra Help.

Maximum Charge - The amount set by an insurance company as the highest amount than can be charged for a particular medical service.

Maximum Out-of-Pocket Amount - Once you have paid out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered in-network Part A and Part B services for the rest of the calendar year. Amounts you pay for your Medicare Part A and Part B premiums, and prescription drugs, do not count toward the maximum out-of-pocket amount.

Medicaid (or Medical Assistance) - A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medically Accepted Indication - A use of a drug that is either approved by the Food and Drug Administration (FDA) or supported by certain reference books.

Medically Necessary - Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.

Medicare - The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare, a Medicare Cost Plan, a PACE plan or a Medicare Advantage plan.

Medicare Advantage Open Enrollment Period - The period from January 1 – March 31 each year when members in a Medicare Advantage Plan can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan).

Medicare Advantage (MA) Plan - Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

Medicare Cost Plan - A plan operated by a Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbursed contract under section 1876(h) of the Act.

Medicare Coverage Gap Discount Program - A program that provides discounts on most covered Part D brand name drugs to Part D enrollees who have reached the Coverage Gap Stage and who are not already receiving Extra Help. Discounts are based on agreements between the Federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted.

Medicare-Covered Services - Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.

Medicare Health Plan - A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-Inclusive Care for the Elderly (PACE).

Medicare Prescription Drug Coverage (Medicare Part D) - Medicare prescription drug coverage (Part D) helps cover the cost of prescription drugs, including many recommended shots or vaccines. Part D is offered through Medicare-approved private insurance companies as either a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD).

"Medigap" (Medicare Supplement Insurance) Policy - Medicare supplement insurance sold by private insurance companies to fill "gaps" in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)

Member (Member of our Plan, or "Plan Member") - A person with Medicare who is eligible to get covered services, who has enrolled in our plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Network Pharmacy - A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them "network pharmacies" because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

Network Provider - "Provider" is the general term we use for doctors, other health care professionals, hospitals and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. We call them "network providers" when they have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Our plan pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as "plan providers."

Organization Determination - A Medicare Advantage organization's decision about whether items or services are covered or how much you have to pay for covered items or services. The Medicare Advantage organization's network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service. Organization determinations are called "coverage decisions."

Original Medicare ("Traditional Medicare" or "Fee-for-service" Medicare) - Original Medicare is coverage managed by the federal government that includes two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). Under Original Medicare, you usually pay a monthly Part B premium and must meet yearly deductibles. Original Medicare will then cover 80% of the approved amount and you’re responsible for the remaining 20% of the cost. Original Medicare doesn’t cover everything. Items and services like most prescription drugs, hearing aids, and routine dental care are not covered. There’s no yearly limit to what you pay out-of-pocket.

Out-of-Network Pharmacy - A pharmacy that does not have a contract with our plan to coordinate or provide covered drugs to members of our plan. Most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.

Out-of-Network Provider or Out-of-Network Facility - A provider or facility with which we have not arranged to coordinate or provide covered services to members of our plan. Out-of-network providers are providers that are not employed, owned, or operated by our plan or are not under contract to deliver covered services to you.

Out-of-Pocket Costs - A member's cost-sharing requirement to pay for a portion of services or drugs received is also referred to as the member's "out-of-pocket" cost requirement.

PACE plan - A PACE (Program of All-Inclusive Care for the Elderly) plan provides medical, social, and long-term care services to elderly people with chronic care needs to help them stay independent and living in their community (instead of moving to a nursing home) as long as possible, while getting the high-quality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid benefits through the plan.

Part C - See Medicare Advantage (MA) Plan.

Part D - See Medicare Prescription Drug Coverage (Medicare Part D) 

Part D Drugs - Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.

Point-of-Service - The HMO with a Point-of-Service (POS) option is an additional benefit that covers certain medically necessary services you may get from out-of-network providers. When you use your POS (out-of-network) benefit, you are responsible for more of the cost of care. Always talk to your Primary Care Provider (PCP) before seeking care from an out-of-network provider. Your PCP will notify us by requesting approval from the plan ("prior authorization").

Preferred Cost Sharing - Preferred cost sharing means lower cost sharing for certain covered Part D drugs at CVS/Caremark mail-service pharmacy.

Preferred Provider Organization (PPO) Plan - A Medicare Advantage Plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they are received from network or out-of-network providers. Member cost sharing will generally be higher when plan benefits are received from out-of-network providers. PPO plans have an annual limit on your out-of-pocket costs for services received from network (preferred) providers and a higher limit on your total combined out-of-pocket costs for services from both in-network (preferred) and out-of-network (non-preferred) providers.

Premium - The amount you pay to your Medicare Advantage and/ or Prescription Drug Plan each month in order to receive their coverage.

Preventive services - Health care meant to prevent illness or detect illness at an early stage when treatment is likely to work best.  For example, preventive services include screening mammograms and Pap tests. 

Prescription Drug Benefit Manager (or PBM) - Companies that contract with Medicare Advantage Prescription Drug Plans to manage pharmacy services.

Primary Care Provider (PCP) - Your primary care provider is the doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare health plans, you must see your primary care provider before you see any other health care provider.

Prior Authorization - Approval in advance to get services or certain drugs that may or may not be on our formulary. Some in-network medical services are covered only if your doctor or other network provider gets "prior authorization" from our plan. Some drugs are covered only if your doctor or other network provider gets "prior authorization" from us. Covered drugs that need prior authorization are marked in the formulary.

Quality Improvement Organization (QIO) - A group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients.

Quantity Limits - A management tool that is designed to limit the use of selected drugs for quality, safety or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.

Referral - A written order from your primary care physician for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs) plans, you need to get a referral before you can get medical care from anyone except your primary care physician. If you don’t get a referral first, the plan may not pay for the services.

Rehabilitation Services - These services include physical therapy, speech and language therapy, and occupational therapy.

Service Area - A geographic area where a health plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it is also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you permanently move out of the plan's service area.

Skilled Nursing Facility (SNF) Care - Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

Special Enrollment Period - A set time when members can change their health or drug plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting Extra Help with your prescription drug costs, if you move into a nursing home or if we violate our contract with you.

Special Needs Plan - A special type of Medicare Advantage Plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.

표준 비용 분담(Standard Cost Sharing) - CVS/Caremark 우편 서비스 약국을 제외한 모든 네트워크 약국에서 제공되는, 우선적 비용 분담이 아닌 비용 분담 종류.

단계적 치료(Step Therapy) - 의사가 처음에 처방한 약을 플랜이 보장하기 전에 가입자의 의학적 상태를 치료하기 위해 다른 약을 먼저 시도해야 하는 정책.

보충적 소득 보장(Supplemental Security Income, SSI) – 사회보장국이 장애인, 시각 장애인 또는 65세 이상의 소득 및 재산이 제한적인 사람들에게 지급하는 월간 보조금. SSI 혜택은 사회보장 보조금과 다릅니다.

긴급 진료(Urgently Needed Care) - 즉시 치료가 필요하고 비응급적이며 예측하지 못한 질병, 부상 또는 상태를 치료하기 위해 제공되는 진료입니다. 긴급 진료는 네트워크 서비스 제공자 또는 네트워크 서비스 제공자가 일시적으로 일할 수 없거나 이용이 불가능한 경우 네트워크 외부 서비스 제공자가 제공할 수 있습니다.

맨 위로 이동

연락처 아이콘

도움이 필요하세요? 기꺼이 도와드리겠습니다.

연락 정보
Y0020_WCM_100876E 최근 업데이트 날짜: 2022년 10월 1일