Insurance Glossary

The time period from October 15 to December 7 each year when Medicare beneficiaries can make changes to their Medicare Advantage and Part D plans for the following year.

A person who receives benefits from an insurance policy or health plan.

The percentage of costs you pay for a covered health service after you've met your deductible. For example, if your plan's coinsurance is 20%, you pay 20% of the allowed amount.

A fixed amount you pay for a covered health service, usually when you receive the service. For example, a $20 copay for a doctor visit.

Prescription drug coverage that is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. Important for avoiding Part D late enrollment penalties.

The amount you must pay for covered health services before your insurance plan starts to pay. For example, with a $500 deductible, you pay the first $500 of covered services.

A temporary gap in Part D prescription drug coverage that begins after you and your plan have spent a certain amount on covered drugs. You pay a higher percentage of costs until you reach catastrophic coverage.

People who qualify for both Medicare and Medicaid. They may be eligible for Special Needs Plans (SNPs) designed to meet their specific needs.

The date your insurance coverage begins and you can start using your benefits.

A Medicare program that helps people with limited income and resources pay for prescription drug coverage costs, including premiums, deductibles, and copays.

A list of prescription drugs covered by a health plan. Drugs on the formulary are typically organized into tiers, with lower tiers having lower costs.

A type of health plan that requires you to use doctors and hospitals in the plan's network (except in emergencies). Usually requires referrals to see specialists.

The 7-month period when you can first sign up for Medicare, starting 3 months before the month you turn 65, including your birthday month, and ending 3 months after.

An extra amount added to Medicare Part B and Part D premiums for beneficiaries with higher incomes. Based on your modified adjusted gross income from two years prior.

A Medicare Advantage plan that includes prescription drug coverage. Combines Part A, Part B, and Part D benefits in one plan.

The most you'll pay during a plan year for covered services. After you reach this limit, your plan pays 100% for covered services. Medicare Advantage plans are required to have a MOOP limit.

A Medicare-approved plan from a private company that offers an alternative to Original Medicare. These plans must cover at least everything Original Medicare covers and often include additional benefits.

Hospital insurance that covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services.

Medical insurance that covers doctor visits, outpatient care, preventive services, medical supplies, and some home health services.

Prescription drug coverage offered through private insurance companies. Helps cover the cost of prescription medications.

Private insurance that helps pay some of the out-of-pocket costs not covered by Original Medicare, such as deductibles, copayments, and coinsurance.

The doctors, hospitals, pharmacies, and other health care providers that a plan has contracted with to provide services at negotiated rates.

Medicare Part A and Part B coverage provided directly by the federal government. You can use any doctor or hospital that accepts Medicare.

Your expenses for medical care that aren't reimbursed by insurance, including deductibles, coinsurance, copays, and costs for services not covered.

A type of health plan that has a network of preferred providers but also allows you to see out-of-network providers at a higher cost. Usually doesn't require referrals.

The amount you pay, usually monthly, for your health insurance coverage, whether or not you use medical services.

Approval required from your health plan before you receive certain services, treatments, or medications. Without prior authorization, the plan may not cover the cost.

A type of Medicare Advantage plan designed for people with specific diseases or characteristics, such as those who are institutionalized or dual-eligible for Medicare and Medicaid.

A coverage policy requiring you to try one or more lower-cost drugs before your plan will cover a more expensive drug for your condition.

A category of drugs on a formulary. Lower tiers typically have lower costs. For example, Tier 1 might be generic drugs with the lowest copay, while Tier 4 might be specialty drugs with the highest costs.