- Coinsurance – A percentage of your medical and drug costs that you pay out of pocket.
- Copayment – The fixed dollar amount you pay when you receive medical services or have a prescription filled.
- Creditable Coverage – Health coverage you had in the past that gives you certain rights when you apply for new coverage.
- Deductible – The amount you pay for medical services or prescriptions before your plan pays for your benefits.
- Formulary – Also called a “drug list,” the formulary lists the drugs your plan covers. It’s often divided into sections – or “tiers” – based on the amount your plan will pay for the drugs in that group.
- Health Maintenance Organization (HMO) – generally, a primary care physician arranges your healthcare within the plan’s network.
- Initial Enrollment Period (IEP) – When you’re eligible to sign up for Part A and/or Part B for the first time.
- Mail-Order Pharmacy – order through a mail-order pharmacy and have your maintenance or specialty medicines and diabetic supplies delivered to your home. Using a mail-order pharmacy may help you stay on track with your doctor’s orders since you’ll receive up to a 90-day supply and regular reminders when it’s time to refill.
- Medically Necessary – Medicare defines this as services or supplies needed for the diagnosis or treatment of a medical condition. These services and supplies must meet the standards of good medical practice in the local area and can’t be mainly for the convenience of you or your doctor.
- Network – A group of healthcare providers that has agreed to provide care based on a plan’s terms and conditions. These providers include doctors, hospitals, and other healthcare professionals and facilities.
- Out-Of-Pocket Costs – Anything you pay out of your pocket for medical care, prescriptions, and other healthcare services. These include coinsurance, copayments, and deductibles
- Original Medicare – Original Medicare is the traditional fee-for-service program offered directly by the federal government and the federal government pays directly for your healthcare. You can see any doctor who takes Medicare anywhere in the country.
- Preferred Provider Organization (PPO) – This type of health plan gives you freedom to choose your own doctors and hospitals. However, your out-of-pocket costs are usually lower if you choose healthcare providers in the plan’s network.
- Premium – What you pay Medicare or a health plan for healthcare coverage.
- Private-Fee-For-Service Plan (PFFS) – Requires the member to find doctors, hospitals, and other types of providers that accept the plan’s payment terms. Some PFFS plans have a network of providers; you can still see out-of-network providers that accept the plan’s payment terms, but you may pay more.
- Special Enrollment Period (SEP) – If you are age 65 or older, you or your spouse are still working and you are covered under a group health plan based on that current employment, you may not need to apply for Medicare medical insurance (Part B) at age 65. You may qualify for a “Special Enrollment Period” (SEP) that will let you sign up for Part B:
- During any month you remain covered under the group health plan and your, or your spouse’s, current employment continues; or
- In the eight-month period that begins with the month after your group health plan coverage or the current employment it is based on ends, whichever comes first.
- Special Needs Plan (SNP) – Plans that offer benefits, providers, and drug lists designed to meet the specific needs of the groups they serve. People with chronic conditions –like diabetes or heart conditions – or are dually eligible for Medicare and Medicaid, often have this type of plan.
