Medicare Common Terms
Last Updated on June 15, 2023 by Chris Franchina
-
-
Premium: The amount you pay each month to be enrolled in Medicare or a Medicare plan. It’s like a subscription fee for your healthcare coverage.
-
Deductible: The amount you must pay out of pocket for healthcare services before Medicare starts to pay. Once you reach the deductible, Medicare will contribute its share towards the cost of your care.
-
Copayment: A fixed amount you pay for a healthcare service or prescription medication. For example, you might have a copayment of $20 for each doctor’s visit or a copayment of $10 for each prescription.
-
Coinsurance: The percentage of the cost of a healthcare service that you’re responsible for paying after reaching your deductible. For instance, if your coinsurance is 20%, you would pay 20% of the total cost, and Medicare would cover the remaining 80%.
-
Out-of-Pocket Maximum: The maximum amount you will have to pay for covered services in a calendar year. Once you reach this limit, Medicare will cover 100% of your healthcare costs for the rest of the year.
-
Original Medicare: The traditional fee-for-service Medicare program offered directly by the federal government. It includes Medicare Part A (hospital insurance) and Part B (medical insurance).
-
Medicare Advantage (Part C): Private insurance plans approved by Medicare that offer an alternative way to receive Medicare benefits. These plans often include additional benefits and may have provider networks.
-
Medicare Part D: Prescription drug coverage offered through private insurance companies approved by Medicare. Part D helps pay for the cost of prescription medications.
-
Medigap: Medicare Supplement Insurance plans sold by private insurance companies to help cover some of the costs that Original Medicare doesn’t pay, such as deductibles, copayments, and coinsurance.
-
Initial Enrollment Period (IEP): The seven-month period surrounding your 65th birthday when you are first eligible to enroll in Medicare. This is the best time to sign up to avoid potential late enrollment penalties.
-
Special Enrollment Period (SEP): A period outside the initial enrollment period when you can sign up for Medicare due to certain life events, such as losing employer coverage or moving to a new area.
-
Formulary: A list of prescription drugs covered by a Medicare Part D plan. Each plan has its own formulary, so it’s important to check if your medications are covered before choosing a plan.
-
Network: The group of doctors, hospitals, and other healthcare providers that have contracted with a specific Medicare Advantage plan or private insurance company to provide services to plan members.
-
Prior Authorization: The process of getting approval from Medicare or your insurance company before receiving certain healthcare services, medications, or procedures. It ensures that the treatment is medically necessary.
-
Annual Wellness Visit: A yearly appointment with your healthcare provider to create or update a personalized prevention plan based on your current health and risk factors. This visit is covered by Medicare at no cost to you.
-