Healthcare Glossary

The time frame between October 15 through December 7 each year when you can enroll in or change your Medicare Advantage or Prescription Drug coverage. 

The cost shared by you and your insurance plan. Coinsurance is usually a percentage of the total amount due.

The fixed amount you pay each time for certain services, like a doctor visit or prescription drugs.

What you have to pay when you get services or drugs. Cost-sharing includes copayments and coinsurance.

This refers to all the prescription drugs covered by our plan.

The amount you must pay each year for healthcare or prescriptions before your Medicare Advantage plan begins to pay.

Services given by trained emergency service providers to treat a medical emergency.

This document explains what your health plan covers, how it works and how much you will pay for services. 

This shows you the costs of your healthcare services and how much you owe. (For Part D Prescription Drugs, it shows how much you paid.) The EOB is not an invoice, and you do not pay your Medicare plan. It is provided to you for your information. Please note, it is NOT a BILL.

A law in the United States that requires those in the healthcare field to protect your personal health information.

A doctor or pharmacy included in our network.

A list of prescription drugs covered by your health plan. The drug list is divided into tiers to help you see how much— if anything—you have to pay.

The most you will have to pay on deductibles, copayments, and coinsurance for covered services before your health plan pays 100% of the costs of covered benefits.

Your Medicare member ID number shown on your Medicare ID card from the Centers for Medicare and Medicaid Services.

A Medicare plan (also known as Part C) is a Medicare-approved plan offered by private insurance companies that are contracted with the Federal Government.Medicare Advantage plans include all of your Medicare Part A and Part B benefits, along with extra benefits not covered by Original Medicare. Many Medicare Advantage plans also include prescription drug coverage (Part D).

The Medicare prescription drug benefit program. Part D covers outpatient prescription drugs, most Medicare Part D (drug coverage) helps cover the cost of prescription drugs, including many recommended shots or vaccines.  Part D is offered through Medicare-approved private insurance companies as either a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD).  

The period of time from January 1 to March 31 each year in which Medicare Advantage enrollees can either switch to Original Medicare (plus the option for a Part D plan) or select a different Medicare Advantage plan. Enrollees are only allowed to make one change during this time period.

Original Medicare is coverage managed by the federal government that includes two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).  Under Original Medicare, you usually pay a monthly Part B premium and must meet yearly deductibles.  Original Medicare will then cover 80% of the approved amount and you’re responsible for the remaining 20% of the cost.   Original Medicare doesn’t cover everything. Items and services like most prescription drugs, hearing aids, and routine dental care are not covered.  There’s no yearly limit to what you pay out-of-pocket.  

A doctor or pharmacy not included in our network. If you use an out-of-network provider, you will likely pay more for the care you receive.

This is what you actually pay for your healthcare services.

Drugs a consumer can get without a prescription.

The amount you pay each month to your Medicare Advantage plan in order to receive their coverage.

Prescription Drug coverage (Part D) helps cover the cost of prescription drugs. To receive drug coverage, you have to purchase a Prescription Drug Plan (PDP) to add to Original Medicare or enroll in a Medicare Advantage plan with Part D prescription drug coverage (MAPD).

A primary care provider is the doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In some Medicare health plans, you must see your primary care provider before you see any other health care provider.

Approval in advance to get services or certain drugs that may or may not be on our list of drugs. Some medical services and drugs are covered only if your doctor gets “prior authorization” from our plan.

The recommendation, usually by your doctor, to see a specialist within your network for specific treatments or examinations.

A special type of Medicare Advantage Plan that provides more focused healthcare for specific groups of people, like those who have both Medicare and Medicaid, who live in a nursing home or who have certain chronic medical conditions.

A doctor who provides healthcare for a specific disease or part of the body.

Expenses that count toward a person’s Medicare drug plan out-of-pocket threshold. 

A temporary supply (up to 30 days at retail and 31 days at Long Term Care) of your drug that your Medicare drug plan must cover when you switch from one plan to another to allow you time to obtain coverage for the drug or change to another drug covered on our drug list.

A facility that provides a quick diagnosis or treatment of a non-life-threatening illness, injury or other medical condition when you are unable to see your doctor. Always check to make sure an urgent care facility is in-network.