COMMON MEDICARE TERMINOLOGY

 A person who has health care insurance through the Medicare or Medicaid program.

 Once your total drug costs reach the $4700 maximum, you pay a small coinsurance (like 5%) or a small copayment for covered drug costs until the end of the calendar year. 

The amount you may be required to pay for services after you pay any plan deductibles. In Original Medicare, this is a percentage (like 20%) of the Medicare approved amount. You have to pay this amount after you pay the deductible for Part A and/or Part B. In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much you have spent.

In some Medicare health and prescription drug plans, the amount you pay for each medical service, such as a doctor’s visit, or prescription. A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor’s visit or prescription. Copayments are also used for some hospital outpatient services in Original Medicare.

Also known as the “donut hole,” this is a gap in coverage that occurs when someone with Medicare goes beyond the initial prescription drug coverage limit. When this happens, the person is responsible for more of the cost of prescription drugs until their expenses reach the catastrophic coverage threshold. 

*** UPDATE*** Effective January 1, 2025, the Coverage Gap will be eliminated.  There will be a $2,000 out-of-pocket cap on prescription drugs. Once a member reaches this amount which is  they will automatically have "catastrophic coverage" and won't have to pay out-of-pocket for the rest of the year.

The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or other insurance begins to pay. For example, in Original Medicare, you pay a new deductible for each benefit period for Part A, and each year for Part B. These amounts can change every year. 

 A notice you get after the doctor or provider files a claim for Part A and Part B services in Original Medicare. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. 

A type of Medicare Advantage Plan in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for covered services at an additional cost. Referrals are not required for you to visit a specialist  

 A type of Medicare Advantage Plan that is available in some areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to a specific network of doctors, specialists, or hospitals on the plan’s list except in an emergency. In most cases, you will need to choose a primary care doctor, who you will need to get a referral from before seeing a specialist.  

A list of prescription drugs covered by a health plan.

In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges.

 A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits Original Medicare does not cover.