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Medicare Terms

Whether you are already a Medicare beneficiary, or about to become one, you’re likely to run into some new terms. When it’s time to make informed decisions about your Medicare coverage, you’ll be in a better position to understand the coverage.

Coinsurance

The amount you pay for medical services after you pay your deductible. Coinsurance is typically a percentage. For example, you may have coinsurance equal to 20 percent.

Copayments

The amount you pay for medical services or supplies, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A co-payment is typically a set amount, not a percentage. For example, you might pay $10 or $20 for a doctor’s visit or a prescription drug.

Costs Sharing

The amount paid for medical services or supplies, like a doctor’s visit, hospital outpatient visit, or prescription drug. This can include copayments, coinsurance, and/or deductibles.

Excess Charges

If you have Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.

Extra Help

A program designed to help those with limited income pay for Medicare prescription drug costs, like premiums, deductibles, and coinsurance.

Formulary

The list of medications covered by a prescription plan.

Guaranteed Issue Rights

Rights you have when insurance companies are required by law to sell or offer you a Medicare Supplement Plan. With guaranteed issue rights, an insurance company cannot deny you a policy or charge you more for a policy because of a past or present health problem.

Guaranteed Renewable

An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All policies issued since 1992 are guaranteed renewable.

High-deductible Medicare Supplement

A type of plan that has a high deductible but a lower premium. You pay the deductible before the policy pays anything. The amount can change each year.

In-Network

Doctors, hospitals, pharmacies, and other healthcare providers have agreed to provide members of a certain insurance plan services and supplies at a discounted price. With some plans, you are only covered if you receive care from in-network doctors, hospitals, and pharmacies.

Medicare Part C

A plan offered by private companies that contract with Medicare to provide Part A and Part B benefits. Most Medicare Part C plans offer prescription drug coverage.

Medicare Part D

Part D adds prescription drug coverage to Medicare. Part C may also offer prescription coverage that follows the same rules as Medicare Prescription Plans.

Prescription Tiers

Groups of medications will have different costs for each group. Generally, medication in a lower tier will cost you less than one in a higher tier.

Medicare Supplement Open Enrollment

A one-time-only, 6-month period when federal law allows you to buy any policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.

Network Providers

The facilities, providers, and suppliers of your health insurer or plan that are contracted to provide health care services.

Out-of-pocket costs

Health or prescription drug costs that you must pay on your own because they are not covered by Medicare or other insurance.

Late Enrollment Penalty

An amount is added to your monthly premium for Part B or Part D if you don’t enroll when you’re first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.

Written Referral

A written order from your primary care doctor for you to see a specialist or to get certain medical services. In many HMOs, you need to get a referral before you can get medical care from anyone except your primary doctor. If you don’t get a referral first, the plan may not pay for the services.

 

 

 

 

References:

https://www.medicare.gov/glossary/c.html

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