Glossary of Terms


Assignment

This means the doctor agrees to accept Medicare’s fee as payment in full. The doctor agrees to bill no more than the approved charged for a service.

Attained Age

As you age, your premiums will become higher. This term refers to Medicare supplement plans.

Beneficiary

The person who has the health insurance through the Medicare program.

Carrier

A private insurance company.

Centers for Medicare and Medicaid (CMS)

The federal agency that runs the Medicare program.

Coinsurance

A cost sharing where costs are split on a percentage basis.

Coordinated Care

Also called managed care, your primary physician coordinates your health care services along with certain specialists and hospitals.

Copayment

A set dollar amount that you have to pay for a health service.

Credible Coverage

Health or prescription drug coverage that you have previously had.

Deductible

The fixed dollar amount you must pay for health care or prescription drugs before your health plan, drug plan, or Medicare would then pay.

Excess Charge

The difference between what your doctor charges and what Medicare would approve.

Formulary

A list of the prescription drugs that are covered by a Medicare Part D prescription drug plan. This plan would be through a private insurance company.

Guarantee Issue

Rights that you have in certain situations whereby you cannot be denied a Medicare supplement policy.

Guaranteed Renewable

Your right to automatically have your Medicare supplement policy renew year after year, unless you commit fraud or don’t pay your premiums.

HMO (Health Maintenance Organization)

A type of Advantage Plan where you need to use doctors and hospitals in the plan’s network.

Initial Enrollment Period

A seven month period that begins 3 months before you turn 65, or are otherwise eligible, and ends 3 months after the month you become eligible. This term applies to Medicare Parts B, C and D.

Issue Age

Premiums are set at the age you are when you buy a Medicare supplement policy and will not increase because you get older. Premiums will increase for other reasons.

Medicaid

A state and federally funded program that pays for health care for individuals with low income.

Medigap

A term that refers to a Medicare supplement policy.

Network

A group of doctors, hospitals, pharmacies or other health care professionals that have entered into an agreement with the health plan carrier to provide services to its members.

Open Enrollment

A period of 6 months where you can buy any Medicare supplement, as long as you sign up for Part B of Medicare. You cannot be denied coverage for health reasons.

Open Enrollment Period (OEP)

The period from October 15th through December 7th of each year. During this time, you can enroll in Medicare Advantage plans and Prescription Drug plans.

Out of Pocket Maximum

The maximum dollar limit that you will have to pay on an Advantage plan. This amount varies per plan.

PFFS (Private Fee For Service)

A type of Advantage Plan where there may not be a network, but you need to use providers who are willing to accept the terms and conditions of the plan.

POS (Point of Service)

A type of Advantage HMO plan that allows it’s members to visit doctors and hospitals outside of the network for some covered services without getting a referral. There is usually a higher cost share if you go outside of the network.

Provider

A person or organization that provides medical services, such as a hospital, doctor, clinic, lab or pharmacy.

Service Area

The geographical area where a health plan accepts members and where members must get their health care services.

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