Glossary of Medicare and Medicare Advantage Terms

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The amount you must pay for your healthcare or prescription drugs before Original Medicare, your prescription drug plan, your Medicare Advantage plan, or your other insurance begins to pay.

Medicare sets aside this period for enrollment in Medicare Advantage (MA) and Medicare Prescription Drug Plans (PDP). From October 15th to December 7th you have the opportunity to enroll in an MA or PDP plan, switch from your current plan or return to Original Medicare for coverage effective on January 1 of the following year.

An appeal is something you do if you disagree with a decision to deny a request for healthcare services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn't pay for a drug, item, or service you think you should be able to receive.

The process of obtaining approval from the health plan or health insurance company to ensure that it will pay for the services you want or need to receive.

A way to pay your monthly premium by allowing your plan to automatically withdraw money from your bank account. If you decide to switch to Automatic Bank Withdraw or move from Automatic Bank Withdraw to a monthly premium bill, it could take up to three months for it to take effect and you are responsible for paying those premiums during that time.

The stage of Medicare Prescription Drug Coverage where you pay a low copayment or coinsurance for your drugs.

The federal agency that runs the Medicare program.

A formal request to the health plan asking for payment for services you received.

A percentage of the cost you pay when your plan does not cover 100% of the cost. For example, a plan may cover 80% of the cost of your medicine or your hospital visit; the other 20% is your coinsurance.

A fixed dollar amount that you pay as your share of the cost when your plan does not cover 100% of the cost of your medicines or your medical care. For example, if you pay a certain pre-determined amount for a medicine, or for a visit to the doctor, that amount is your copay.

The third stage of Medicare Prescription Drug Coverage (following the Initial Coverage stage). For more information, please visit the Medicare Coverage Gap page.

Prescription drug coverage that is at least as good as Medicare Prescription Drug Coverage. If you go without Creditable Prescription Drug Coverage for a period of <63> consecutive days or longer you may have to pay a Late Enrollment Penalty.

A dollar amount that you may be required to pay out-of-pocket each year before your plan begins to provide coverage for healthcare costs that are covered by the plan. Not all plans include deductibles.

A request to end your healthcare coverage with a health plan.

Medically necessary healthcare equipment prescribed by a healthcare provider to be used by a member in the home, such as hospital beds and wheelchairs.

Permanent kidney failure requiring kidney dialysis or a transplant.

A document you receive each year from your health plan that gives you information about what benefits the plan will cover, how much you pay, and more.

A type of coverage decision that, if approved, allows you to get a drug that is not on the Medicare Advantage Prescription Drug plans 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 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).

A statement you receive for each month you use your Medicare Advantage or Medicare Advantage Prescription Drug Plan benefits. This statement is from your plan and provides complete information about the health or prescription drug services you've received, payments made, and any costs you are responsible for paying. It is important to remember that the EOB is not a bill. This information is only provided for your convenience.

The program run by the Social Security Administration that helps with the costs of Medicare Prescription Drug Coverage (Part D). If you qualify, Social Security will enroll you in the program. The amount of assistance you receive will depend on your financial situation and income.

A list of generic and brand-name prescription drugs that are covered by a Medicare Part D or Medicare Advantage Prescription Drug (MA-PD) plan.

Generic drugs have the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

A formal complaint about how a Medicare Advantage or Medicare Prescription Drug plan is providing your care. If you want to request coverage for a prescription drug or service, you should request a coverage determination instead of filing a grievance.

HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. HIPAA does the following:

  • Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs;
  • Reduces healthcare fraud and abuse;
  • Mandates industry-wide standards for healthcare information on electronic billing and other processes; and
  • Requires the protection and confidential handling of protected health information.

Sometimes called "managed care organizations," HMOs contract with doctors and hospitals who agree to accept their payments. In an HMO, you typically receive your care from the doctors, hospitals, and other providers who contract with the HMO.

The phase of Medicare Part D coverage that, depending on the plan, starts after you meet your yearly deductible for Part D.

The Initial Coverage Election Period (ICEP) is the three month period before you are entitled to Medicare Part A and enrolled in Part B. For most people, this occurs three months before their 65th birthday. An individual may enroll in a Medicare Advantage (MA) plan during this period.

The first phase of Medicare Part D coverage that, depending on the plan, starts after you meet your deductible.

The period in which you are first eligible to enroll in a Medicare Prescription Drug plan (Part D). For most people, the Initial Enrollment Period begins three months before the month of your 65th birthday, during your birthday month, and up to three months after.

The amount added to your monthly premium for Medicare Part B or Medicare Part D coverage if you did not enroll when you were first eligible and did not have other coverage.

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 healthcare costs are covered if you qualify for both Medicare and Medicaid.

Medicare is a Federal health insurance program for people age 65 or older, under age 65 with certain disabilities, and any age with permanent kidney failure (called End-Stage Renal Disease).

Medicare Advantage Plans are health plan options offered by private insurance companies that have approved contracts from Medicare. If you join one of these plans, you will generally get all of your Medicare-covered healthcare through that plan. Medicare Advantage Plans (called MA Plans) combine Part A (hospital insurance) and Part B (medical insurance) together in one plan, and they can also be combined with Part D prescription drug coverage (called MA-PD Plans).

From January 1 through February 14, you may disenroll from a Medicare Advantage plan and return to Original Medicare. Requests to disenroll will be effective on the first day of the month following your disenrollment request.

Provides coverage for inpatient hospital care, inpatient stays in most skilled nursing facilities, and hospice and home health services.

Provides coverage for doctor and clinical lab services, outpatient and preventive care, screenings, surgical fees and supplies, and physical and occupational therapy.

Medicare Advantage Plans are health plan options offered by private insurance companies that are approved by Medicare. If you join one of these plans, you generally get all of your Medicare-covered healthcare through that plan. Medicare Advantage Plans (called MA Plans) combine Part A (hospital insurance) and Part B (medical insurance) together in one plan, and they can also be combined with Part D prescription drug coverage (called MA-PD Plans).

Medicare Prescription Drug Coverage available through either a Medicare-approved stand-alone Prescription Drug Plan or as coverage included in a Medicare Advantage plan (also called MA-PD plans).

People with Medicare who have limited income and resources may get help from their state to pay for their Medicare health care costs if they meet certain conditions. There are 4 kinds of Medicare Savings Programs: (1) Qualified Medicare Beneficiary Program (QMB); (2) Specified Low-Income Medicare Beneficiary (SLMB) Program; (3) Qualifying Individual (QI) Program; and (4) Qualified Disabled and Working Individuals (QDWI) Program. The names of these programs and how they work may vary by state.

The amount you pay every month for your Medicare Advantage plan.

Network PFFS plans are a type of Medicare Advantage plan that includes all Medicare Part A (hospital insurance) and Part B (medical insurance) benefits. These plans have a network of providers (that is, providers who have signed contracts with the plan) for all services covered under Original Medicare.

With a Network PFFS plan, you also have the freedom to choose your doctors and hospitals (as long as the provider accepts the plan's terms and conditions of payment and participates in the Medicare program). However, you might pay more for services that are received outside of the network.

A doctor, hospital, or other healthcare provider that has agreed to be part of a plan's network. Members usually pay less for their care when they use a network provider, depending on the plan.

Doctors, hospitals, pharmacies, and other healthcare professionals or suppliers who do not belong to a health plan's provider network. Members may pay more for their care when they use a provider that is out-of-network, depending on the plan.

Costs that you may pay for healthcare because they are not covered by your Medicare plan or other insurance.

Medicines that do not require a prescription.

An HMO-POS is a Medicare Advantage HMO with a Point of Service (POS) option. This type of plan allows the plan member to seek care from providers in and out of the HMO network. The services for out-of-network coverage are typically at a higher copay/co-insurance.

PPO plans are a type of Medicare Advantage plan that includes all Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) benefits. These plans are designed to reduce the cost of healthcare by contracting with certain doctors, labs, and hospitals to provide care at a discounted rate for members. A PPO plan has a list of physicians and other providers that members may visit (called a "network"). Members also have the flexibility to see any doctors, specialists, or hospitals that are not on the plan's list, however, they may pay a higher copay or coinsurance for these visits, depending on the plan. Some plans offer the same costs for in and out-of-network benefits.

The amount an individual must pay to Medicare or a health insurance plan for medical coverage and/or prescription drug coverage. It is generally paid on a monthly basis.

A Medicare "Part D" Prescription Drug Plan (or PDP) can be a stand-alone plan (not joined with other insurance) or may be combined with a Medicare Advantage plan. A Medicare Advantage plan that includes prescription drug coverage is often referred to as an MA-PD plan.

A doctor who coordinates a member's healthcare with specialists and other providers. A PCP acts as the manager of your healthcare and can assist you in finding the right specialists when necessary. Most Health Maintenance Organization (HMO) plans require you to see your PCP before you see any other healthcare provider.

PFFS plans are a type of Medicare Advantage plan that includes all Medicare Part A (hospital insurance) and Part B (medical insurance) benefits. These plans give members the freedom to choose any doctor or hospital that accepts Medicare and the plan's terms and conditions.

A limit to the amount of a particular medication a Medicare Advantage Prescription Drug plan or Medicare Prescription Drug plan will cover in a period of time.

Special Election Periods allow you to enroll into or change plans outside of Medicare's standard enrollment periods. For example, if you move out of your plan's service area, you have a Special Election Period to enroll in a plan that is available in your new location. If you move into, reside in, or move out of a nursing home you may also have a Special Election Period. If you have Medicare and Medicaid, you have a Special Election Period that allows you to change Part D drug plans at any time.

SNPs are types of Medicare Advantage Plans designed for people with certain chronic diseases and conditions or who have special needs (such as people with both Medicare and Medicaid, or people who live in certain institutions). SNPs provide members with all Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance) services, and Medicare prescription drug coverage (Part D).

A doctor who treats only certain parts of the body, certain health problems, or certain age groups. For example, some doctors treat only heart problems.

The percentage of the cost you pay for specialty prescriptions, such as injectable drugs and biopharmaceuticals.

A Specialty tier drug is a very high cost or unique prescription drug which may require special handling and/or close monitoring. Specialty drugs typically treat complex, chronic conditions and are often injected.

A state program that provides assistance in paying for drug coverage, based on financial need, age, or medical condition and not based on current or former employment status. These programs are run and funded by the states.

An optional plan requirement to first try certain drugs for treatment of a medical condition before a different drug will be covered for that same condition. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you the plan will then cover Drug B.

This benefit was designed to assist those who are aged, blind, or disabled and who have little or no income, with monetary benefits for basic needs such as food, clothing and shelter.

Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost less than a drug in a higher tier.

A yearly calculation of what you have paid for Part D prescription drugs while on a Medicare Advantage Prescription Drug Plan, including any deductibles and copays. When your TrOOP costs reach a specific dollar amount you become eligible for catastrophic coverage, which allows you to get medicines at a lower cost.

Additional discounts available to you through your Medicare Advantage or Medicare Part D plan.

A Private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with our plan are not required to see you except in an emergency.


Enrollment disclaimer information:
A Private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with our plan are not required to see you except in an emergency.

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