Medicare Glossary
A
Annual Enrollment Period (AEP)
The time period each year during which people can sign up for a medical insurance plan is known as the annual enrolment period. AEP begins on October 15th and ends on December 7th.
Annual Notice of Change (ANOC)
A notice you get in late September from your Medicare Advantage or Part D carrier. Any modifications to the plan's fees and coverage that will take effect on January 1 of the following year are summarized in the ANOC.
Appeal
A formal request to have a decision by your health plan reviewed if you are dissatisfied with it.
B
Brand-name drug
A prescription medication produced and marketed by the firm that conducted the initial study and development of the medication. A brand-name medicine and its generic equivalent share the same formula and active components.
C
Claim
A request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered.
Complaint
"Filing a grievance" is the legal term for "making a complaint." For certain issues with the service provided by your plan, you can file a complaint.
Copayment (copay)
An amount of money you give the doctor when you visit.
Cost Share
How much you spend on care. Deductibles, copayments, and coinsurance are a few instances of cost-sharing.
Coverage Gap
The process of a Medicare Part D prescription plan where you pay all of your out-of-pocket costs for eligible medications.
D
Deductible
The annual out-of-pocket maximum for qualified expenses that a covered person must pay before the plan will pay.
Disenroll
This signifies the cancellation of your plan membership. Involuntary or voluntary disenrollment are also options
Donut Hole
A time frame that starts once you and your drug plan have spent a specific amount on covered medications. When you are in the donut hole, your copay or coinsurance may be higher than usual because you are only responsible for paying 25% of the cost of the approved prescription drugs under your plan. When you have spent enough to be eligible for catastrophic coverage, the donut hole is closed.
Drug List
See definition under Formulary.
E
Eligibility Date
The specified day on which a member first qualifies for benefits under a current contract.
Enrollee: A member of our Medicare plan.
Evidence of Coverage (EOC)
The EOC provides comprehensive information on your plan's benefits, fees, and membership rights and obligations.
Exception
A type of Medicare prescription drug coverage determination. A formulary exception is a drug plan's decision to cover a drug that's not on its drug list or to waive a coverage rule.
F
Formulary
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
G
Generic Drug
A prescription medication that the Food and Drug Administration (FDA) has acknowledged as containing the same active ingredient(s) as the name-brand medication. A "generic" medicine generally has the same effect as a brand-name drug and is less expensive.
Grievance
Your complaint regarding any aspect of your care. Grievances must be submitted directly to your plan over the phone or in writing.
H
Health care provider
An entity or person with a license to provide healthcare. Health care providers include, for example, physicians, nurses, and hospitals.
Home health agency
A company that offers healthcare services at home.
Health Maintenance Organization (HMO)
A company that makes health services available to or organizes for plan participants.
Hospice
A unique approach of providing care for those who are terminally sick. A team-oriented strategy is used in hospice care to address the patient's medical, physical, social, emotional, and spiritual needs.
I
Initial Enrollment Period (IEP)
This time frame is seven months long. It focuses on the circumstance that makes you eligible for Medicare. That occasion is typically your 65th birthday.
In network
This denotes that we have an agreement with a physician or other healthcare professional. To save you money, we arrange lower rates with network providers.
L
Living will
In the event that you are unable to express yourself, it demonstrates the kind of treatments you favor or reject, such as if you want life support. Normally, only after you are unconscious does this paper take effect.
Long-term care
Services that are offered to people who are incapable of performing daily tasks like clothing or bathing, including both medical and non-medical care. Support and services for the long term can be offered at home, in the area, in assisted living, or in nursing facilities.
M
Medicare
A comprehensive, government run health insurance program that pays for hospitalization, medical care, and some related services for those who qualify, mostly those who are 65 or older and disabled people under 65.
Medicare Advantage Plan (Part C)
A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits, with a few exclusions, for example, certain aspects of clinical trials which are covered by Original Medicare even though you’re still in the plan
Medicare Part D
Insurance for prescription drugs. A Medicare Advantage plan that provides prescription medicines can help you get Part D. or by means of a different prescription drug plan.
Member
An individual who joined a health plan throughout the reporting period. All directly enrolled individuals (enrollees/subscribers) and their qualified dependents are considered members. Also known as a participant in a plan and a covered person.
N
Network
A network of contracted doctors, medical facilities, and support services that offers members medical treatment.
Network Provider
A company that has an agreement with the health plan to offer covered people with medical services. The provider could be a doctor, hospital, pharmacy, or another type of healthcare facility.
O
Original Medicare
Part A (Hospital Insurance) and Part B (Fee-for-Service Health Plan) are the two components of Original Medicare (Medical Insurance). Medicare pays half of the Medicare-approved amount after you pay a deductible, and you pay your share (coinsurance and deductibles).
Out-of-pocket costs
Costs associated with your health or prescription medications that Medicare or other insurance does not cover.
P
Preferred Provider Organization (PPO)
Premium
The sum a member pays a carrier in exchange for their providing coverage under a contract.
Prior authorization
Before you fill your prescription, you must receive approval from a Medicare drug plan in order for it to be covered by your plan.
Provider
Any individual or organization that offers health care services, such as a doctor, hospital, group practice, nursing home, pharmacy, etc.
Q
Qualified Medicare Beneficiary (QMB)
A person for whom the state is required to cover the Medicare Part B premiums, deductibles, and copayments because their income is below 100% of the federal poverty threshold.
R
Referral
A referral from your primary care physician is a form of preapproval before you visit a specialist. Your doctor notifies the expert of the reason for the referral when they issue one.
S
Service area
The region that the health plan covers. Service area is usually dictated by county and is made up of select counties.
Summary Plan Description
A summary of the full range of benefits that an employee may receive as needed.
T
Telemedicine
Using a communications device (such as a computer, phone, or television), a practitioner in a location other than the patient provides medical or other health services to a patient.
Tiers
Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.
TTY
A TTY (teletypewriter) is a type of communication aid used by those who are profoundly deaf, hard of hearing, or have difficulty speaking. Through a message relay center, people without TTYs can communicate with TTY users (MRC). TTY operators are on hand at an MRC to transmit and decipher TTY communications.