Glossary

The maximum amount a health plan will reimburse a doctor or hospital for a given service.

The maximum amount Premera pays for a covered service.

A facility where certain surgeries may be performed for patients who aren’t expected to need more than 24 hours of care.

During the Annual Enrollment Period you can enroll in new Medicare coverage or make changes to your existing coverage. The AEP runs from October 15 through December 7 each year. It is the designated time when you can enroll in, switch, or drop Medicare Advantage (Part C) and Medicare prescription drug plans (Part D).

The action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare prescription drug plan. You can make an appeal if Medicare or your plan denies a healthcare service, a supply item, or a prescription drug. You can also appeal if Medicare or your plan stops providing or paying for all or part of a service, supply item, or prescription drug you think you still need.

The way Original Medicare measures your hospital and skilled nursing facility (SNF) services. A benefit period begins the day you're admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.

The amount you must pay for healthcare or prescriptions before Original Medicare, your Medicare Advantage plan, your Medicare prescription drug plan, or your other insurance begins to pay during the calendar year. Calendar-year deductibles begin on January 1 and end on December 31.

A request for payment that you submit to Medicare or other health insurance when you get items or services that you believe are covered under your plan.

An amount you may be required to pay as your share of the cost for benefits after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

The set dollar amount you pay for a covered healthcare service at the time you get care or when you pick up a prescription drug.

The part of healthcare costs that a member pays, such as deductibles, coinsurance, and copay. It does not include monthly health plan bills, amounts balance billed by healthcare providers who are out of your plan network, or the cost of services not included in your plan. Also see Copay, Coinsurance, and Deductible.

A period of time in which you pay a higher cost share for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap starts when you and your plan have paid a set dollar amount for prescription drugs during that year. This is informally called a donut hole.

A service that is covered according to the terms in your health plan.

Prescription drug coverage that’s expected to pay, on average, at least as much as Medicare drug coverage. This could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, VA, or individual health insurance coverage.

The amount you pay for most covered services before your health plan starts to pay. When you see a provider in the plan's network, before you meet the deductible, you may pay a discounted amount that has been negotiated with the provider. The deductible resets at the beginning of the calendar year or when you enroll in a new plan.

If you disagree with your plan's initial denial, you can request a redetermination, but you must make your request within 60 days from the date of the coverage determination.

A prescription drug list has different levels of payment coverage arranged in tiers. These tiers determine how much you will pay out of pocket for your prescription drug, based on the terms of your pharmacy benefit and whether the drug is covered on the drug list. Drugs in a lower tier will often cost less than drugs in a higher tier. For those on Medicare, these tiers dictate the drug cost until the coverage gap (see above) is reached. At that time cost-sharing may increase.

Certain medical equipment, like a walker, wheelchair, or hospital bed, ordered by your doctor for use in the home.

A legal document that names someone else to make healthcare decisions for you. This is helpful if you become unable to make your own decisions.

Services provided for the initial outpatient treatment of an acute medical condition, usually in a hospital setting. Most health plans have specific guidelines for defining emergency medical care.

The Evidence of Coverage (EOC) is the legal contract between you and the Medicare plan. It’s generally available in September and describes costs and benefits of your plan that will take effect on January 1 of the following year.

The Explanation of Benefits (EOB) explains the actions taken on a claim, such as the amount that will be paid, the benefit available, discounts, reasons for denying payment and the claims appeal process. It is created after a claim payment has been processed by your health plan.

A Medicare program to help people with limited resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance. Also known as a Low-Income Subsidy (LIS)

The income level of an individual or household, used by the Department of Health and Human Services to determine eligibility for certain programs and benefits. Issued annually, the Federal Poverty Level (FPL) is used to determine if you are eligible for Medicaid and a Low-Income Subsidy.

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.

A prescription drug that is the generic equivalent of a brand name drug listed on your health plan's formulary and costs less than the brand name drug.

Any complaint, other than one that involves a request for an initial determination or an appeal, as described in the determinations and appeals section of your Evidence of Coverage. If you have a complaint about a plan's refusal to cover a service, supply, or prescription, you must file an appeal.

Rights you have in certain situations where insurance companies are required by law to sell to you, or offer you a Medigap policy. In these situations, an insurance company can't deny you or place conditions on a Medigap policy, like exclusions for preexisting conditions. Insurance companies can't charge you more for a Medigap policy because of a past or present health problem.

A type of health plan that provides healthcare coverage to its members through a network of doctors, hospitals and other healthcare providers.

Healthcare services and supplies a doctor decides you may get in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.

A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient's family or caregiver.

Inpatient care is provided in a hospital or other type of inpatient facility where you are admitted and stay at least one night. You are under the care of doctors, nurses, and other types of healthcare professionals within a hospital.

Doctors, healthcare professionals, providers, hospitals, or labs that contract with the health plan to provide healthcare services. Members pay less when using an in-network healthcare service.

Your Initial Enrollment Period (IEP) is an enrollment period that begins three months before you turn 65, includes the month of your birthday and continues on for three months after the month of your birthday. This is the first time you can enroll in Original Medicare (Part A and Part B).

This is a higher premium charged by Medicare Part B and Medicare Part D to individuals with higher incomes.

A list (also called a formulary) of approved prescription medications dispensed to members through participating pharmacies. Your plan may have what's called an open or voluntary formulary that allows coverage for both formulary (preferred) and nonformulary (nonpreferred) medications. Or your plan may have what's called a closed, select, or mandatory formulary that limits coverage to formulary drugs only.

A Medicare program for people with limited resources. If you qualify, this helps pay for Medicare prescription drug program costs, premiums, deductibles, and coinsurance.

Maintenance medication that can be ordered by a plan member and delivered through the mail.

A joint federal and state funded program that provides healthcare coverage for low-income children and families, and for certain aged and disabled individuals.

A range of services provided to individual patients to optimize therapeutic outcomes and detect and prevent costly medication problems. This includes a review of all medications, education, consultation, and advice to help insure proper use of medications. Collaboration with the patient, physician, and other healthcare providers is utilized to deveop and achieve optimal results.

The federal program established to provide healthcare coverage for eligible senior citizens and certain eligible disabled persons under age 65.

Also called gap plans, Medicare Supplement plans cover gaps in Original Medicare Part A and B. Medicare Supplement plans help pay some of the healthcare costs that the Original Medicare Plan doesn't cover. Medicare Supplement plans are not the same as Medicare Advantage plans and can only be combined with Original Medicare. You may choose to also enroll in a stand-alone prescription drug plan. Medicare Supplement plans do not cover additional benefits, such as: vision, dental and hearing.

The group of doctors, hospitals and other healthcare professionals that contract with a health plan to deliver medical services to its members.

A pharmacy that an insurance company has contracted with to provide pharmacy services for its members.

A provider that has contracted with a particular health plan to provide services to members of the plan.

A hospital that has not contracted with a particular health plan to provide hospital services to members of the plan.

Medications that are not on the preferred drug list, often because they are not as clinically effective or as reasonably priced as other medications.

Medicare Advantage Open Enrollment Period runs January 1 to March 31. This is when Medicare Advantage members can make one change during this period either to another Medicare Advantage plan or back to Original Medicare, with or without a stand alone drug plan.

An optional supplemental benefit is an added benefit option, available with select plans, that a member may choose to elect in addition to the medical benefits covered by Medicare Advantage.

Original Medicare is a federal fee-for-service health plan that has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount (80% for most services), and you pay your share (coinsurance and deductibles).

Services are considered out of network when you use a doctor, pharmacy, or another provider who doesn't have a contract with the health plan. Out-of-network services may not be covered, or may be covered at a lower level if you go out of network. You may be responsible for all or part of an out-of-network provider or pharmacy's bill.

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copays, and coinsurance, your health plan begins to pay 100% of the costs of covered benefits. The out-of-pocket maximum does not include your monthly premium payments, or anything you spend for services your plan does not cover.

Treatment provided to a patient who is able to return home after care, without an overnight stay in a hospital or other inpatient facility.

Over-the-counter (OTC) allowance is a benefit that gives you a quarterly or monthly allowance to order eligible OTC medications and health-related products. The amount of your allowance depends on your plan and may expire or roll over at the end of each period. You can order OTC items online or in a store where these items are sold on the shelf.

Part A (Hospital Insurance) covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. There is no cost for Medicare Part A for those that have worked 40 quarters in the US and paid into Medicare.

Medicare Part B helps cover medical services like doctor services, outpatient care, and other medical services that Part A does not cover. Part B helps pay for covered medical services, and items when they are medically necessary. Part B is optional and individuals must pay a monthly premium.

Also known as Medicare Advantage, this is offered by a private company that contracts with Medicare. Part C gives you all of your Part A and Part B benefits, with a few exclusions, like certain aspects of clinical trials which are covered by Original Medicare even though you’re still in the plan. Medicare Advantage Plans include:

• Health Maintenance Organizations
• Preferred Provider Organizations
• Private fee-for-service plans
• Special needs plans
• Medicare medical savings account plans

Also known as a prescription drug plan or PDP. Part D adds prescription drug coverage to:

• Original Medicare
• Some Medicare cost plans
• Some Medicare private-fee-for-service plans
• Medicare medical savings account plans

Offered by insurance companies and other private companies approved by Medicare. Medicare Advantage plans may also offer prescription drug coverage that follows the same rules as Medicare drug plans.

A health plan that supplies services at a higher level of benefits when members use contracted healthcare providers. PPOs also provide coverage for services by healthcare providers who are not part of the PPO network. The plan member generally shares a greater portion of the cost for such services.

Medicare penalties are extra charges that you may have to pay for not enrolling in Medicare Parts A and B and a prescription drug plan when first eligible.

The ongoing amount that must be paid for your health plan. You and/or your employer usually pay it monthly. The premium may not be the only amount you pay for insurance coverage. Typically you will also have a copay, coinsurance, or deductible amount as well.

Most health plans cover preventive services for a member’s general health—like routine shots and screening tests—at no out-of-pocket cost when visiting in-network providers.

The physician you choose to be your primary source for medical care. Your PCP coordinates all your medical care, including hospital admissions and referrals to specialists. Not all health plans require a PCP.

The process by which a plan member or their doctor gets approval from their health plan before the member undergoes a course of care, such as a hospital admission, or a complex diagnostic test. Also called preauthorization.

Medical professionals, such as doctors, nurses, and massage therapists, who treat patients.

The process of sending or directing patients for treatment, aid, information, or a decision that’s related to their healthcare. As of January 1, 2024, referrals are only required for out-of-network providers.

A time outside the Annual Enrollment Period (AEP) or the Open Enrollment Period (OEP) during which you can sign up for health insurance. Common examples of SEPs are losing employer coverage, moving to a different county, and qualifying for low-income subsidy.

A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services, and other related health services.

A healthcare professional whose practice is limited to a certain branch of medicine, including specific procedures, age categories of patients, specific body systems or certain types of diseases.

Services needed immediately due to a severe illness, injury, or condition. These services are not emergency services, but cannot be delayed until you can see a plan provider. Urgently needed services are covered services that are medically necessary and immediately required.

A review of the type and amount of care you are receiving. This could involve looking at the setting for your care, and its medical necessity.

A visit with a healthcare provider by phone, text, or online video (such as Zoom).