Medicare Terms & Definitions

Source: Centers for Medicare and Medicaid Services

APPEAL- A special kind of complaint you make if you disagree with certain kinds of decisions made by your health plan. You can appeal if you request a health care service, supply or prescription that you think you should be able to get from your health plan, and the health plan denies the request. You can also appeal if you are already receiving coverage and Medicare or the plan stops paying. There are specific processes your Medicare Advantage Plan, other Medicare Health Plan, Medicare drug plan, or the Original Medicare plan must use when you ask for an appeal.

BENEFICIARY - The name for a person who has health care insurance through the Medicare or Medicaid program.

CATASTROPHIC COVERAGE - Once your total drug costs reach the $6153.75 maximum, you pay a small coinsurance (like $2.40 or $6.00 percent) or a small co-payment for covered drug costs until the end of the calendar year.

COORDINATION OF BENEFITS - Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called cross-over.

COPAYMENT - In some Medicare health and prescription drug plans, the amount you pay for each medical service, like 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.

COST SHARING - The amount you pay for health care and/or prescriptions. This amount can include copayments, coinsurance, and/or deductibles.

CREDITABLE PRESCRIPTION DRUG COVERAGE - Prescription drug coverage (like from an employer or union), that pays out, on average, as much as or more than Medicare’s standard prescription drug coverage.

DRUG LIST or FORMULARY- A list of drugs covered by a plan. This list is also called a formulary.

GRIEVANCE - A complaint about the way your Medicare health plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you are unhappy with the way a staff person at the plan has behaved toward you. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered (see Appeal).

MEDICAID - A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

MEDICARE ADVANTAGE PLAN -A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs, or Private Fee-for-Service Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plans, and are not paid for under Original Medicare.

MEDICARE ADVANTAGE PRESCRIPTION DRUG (MA-PD) PLAN - A Medicare Advantage plan that offers Medicare Prescription Drug coverage and Part A and Part B benefits in one plan.

MEDICARE COST PLANS - Medicare cost plans are a type of HMO that contracts as a Medicare Health Plan. As with other HMOs, the plan only pays for services outside its service area when they are emergency or urgently needed services. However, when you are enrolled in a Medicare Cost Plan, if you get routine services outside of the plan's network without a referral, your Medicare-covered services will be paid for under the Original Medicare Plan, and you will be responsible for the Original Medicare deductibles and coinsurance.

MEDICARE PRESCRIPTION DRUG COVERAGE - Optional coverage available to all people with Medicare through insurance companies and other private companies.

MEDICARE PRESCRIPTION DRUG PLAN - A stand-alone drug plan, offered by insurers and other private companies to beneficiaries that receive their Medicare Part A and/or B benefits through the Original Medicare Plan; Medicare Private Fee-for-Service Plans that don’t offer prescription drug coverage; and Medicare Cost Plans offering Medicare prescription drug coverage.

STATE PHARMACY ASSISTANCE PROGRAM - A state program that provides people assistance in paying for drug coverage, based on financial need, age or medical condition and not based on current or former employment status. These programs are run and funded by the states.

SUBSIDY - A monetary grant paid by the government to a private person or company to assist an enterprise deemed advantageous to the public.

TIERS - To have lower costs, many plans place drugs into different "tiers," which cost different amounts. Each plan can form their tiers in different ways. Here is an example of how a plan might form its tiers.

  • Tier 1 - Generic drugs. Tier 1 drugs will cost you the least amount.
  • Tier 2 - Preferred brand-name drugs. Tier 2 drugs will cost you more than Tier 1 drugs.
  • Tier 3 - Non-preferred brand-name drugs. Tier 3 drugs will cost you more than Tier 1 and Tier 2 drugs.