HMO Guide for Seniors - Office of the Patient Advocate - State of ...

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medically necessary services
Services you need in order to stay healthy or
treat your medical condition; these services must
meet the standards of good medical practice
Medicare
A national health insurance program for people
65 and older and for some younger people with
disabilities
Medicare Advantage plan
A private health plan that has a contract with
the government to provide health care to people
who have Medicare
Medicare Advantage HMO/Medicare HMO
An HMO that has a contract with Medicare to
provide health care to people with Medicare
Medicare Part A
Medicare hospital, nursing, hospice, and home care
benefits
Medicare Part B
Medicare benefits for doctor visits, lab tests, and
other outpatient care
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Medicare Part C
Medicare Advantage health plans
Medicare Part D
Medicare prescription drug benefits
Medigap policy (Medicare Supplemental
Insurance)
Private insurance for people with Original
Medicare; Medigap helps cover the services and
costs that Medicare does not cover
network
All the doctors, labs, hospitals, and other providers
that have contracts with an HMO or work for it
Original Medicare
This is also called fee-for-service or traditional
Medicare; the government pays your providers
directly for the services you get, and you usually
pay part of the cost
pre-existing condition
An illness, health condition, or disability that you
have before you join a health plan
premium
A monthly fee you pay for health insurance
primary care provider (PCP)
Your main doctor, who gives you most of your care
and oversees your other health care services
second opinion
Advice from a second doctor about the cause or
nature of your illness or your choice of treatments
service area
The area you must live in to join a Medicare HMO
urgent care
Care that you need soon, usually within 24 hours,
for a sudden illness or injury