In Original Medicare a benefit period begins on the first day of an inpatient hospital stay and ends when you have been out of the hospital or skilled nursing facility for 60 consecutive days.
The stage in the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,950 (for plan year 2016) in covered drugs during the covered year.
The Federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program. CMS makes sure that beneficiaries in both programs are able to get access to high-quality health care.
The percent of the Medicare-approved amount that you have to pay for a medical service. For example, if your coinsurance is 20 percent and Medicare approves a $100 doctor office visit, Medicare will pay $80 and you will pay $20. With some plans, you do not pay coinsurance until you have first paid a deductible.
In some Medicare Advantage and other health plans, this is the set amount you pay for each medical service or prescription drug you receive. For example, you may need to pay a $10 copay each time you see the doctor or pick up a prescription. Copays are also required for some hospital outpatient services in the Original Medicare plan.
This is the portion of a medical service or prescription drug that you pay. Types of cost-sharing include copayments, coinsurance or deductible. Some plans have limits on the total amount of cost sharing you pay in a year. For example, a plan may require that you pay 25 percent of the drug costs and the plan will pay 75 percent, up to a combined total of $2,000. Some plans may have flat (dollar-amount) copayments for each prescription instead of a percentage.
A set amount of money you must pay before you receive any coverage for medical services or prescription drugs. Generally, deductibles are annual and apply to Medicare Parts A, B and D. Deductibles may also apply to Medicare Supplement plans.
A Medicare health plan option in which a private health plan manages Medicare benefits for its members. The most common types of Medicare Advantage plans are HMO, PPO and PFFS plans. Some Medicare Advantage plans may also offer Medicare prescription drug (MA-PD) benefits for their members.
The Evidence of Coverage explains your Medicare coverage, what your provider must do, your rights, and what is required of you as a member of our plan.
The Evidence of Benefits is a statement that you receive every month that you use your Medicare Part D prescription drug benefits. This statement is sent to you by your plan, and provides you with complete information regarding the health and prescription drug services that you have received. Also included in your EOB are any payments and costs that you are responsible for. The EOB is not a bill, rather a statement from your plan that is provided for your convenience.
A stage that you enter after your deductible has been met, and before your total drug expenses reach $3,700. This includes amounts that you have paid, and amounts that your plan has paid on your behalf.
The Initial Election period is a 7-month period of time that begins 3 months prior to your 65th birthday, continues through the month of your 65th birthday, and extends three months after your 65th birthday.
A 7-month period when you are first able to enroll in Medicare (3 months prior to your 75th birthday, the month of your birthday, and 3 months after).
This type of Medicare plan is available in certain areas of the country. You can join a Cost plan even if you have only Medicare Part B. Generally, a Cost plan pays in-network benefits only; if you go to a non-network provider, Original Medicare benefits and cost-sharing apply. Some Cost plans also include travel benefits.
A Medicare Prescription Drug Plan may be either a stand-alone Prescription Drug Plan that you can join if you have Original Medicare or a Medigap/Medicare Supplement plan, or a Medicare Advantage (or other health plan) that includes Medicare prescription drug coverage in the plan.
Health insurance policies that typically have standardized benefits and are sold by private insurance companies. Medigap policies work together with your Medicare Part A and Part B coverage. They generally allow you to go to any doctor or hospital that accepts Medicare. There are 10 standard Medigap policies — Plans A, B, C, D, F, G, K, L, M and N. Each plan has a different set of benefits and premiums. Many Medigap plans come with options that allow you to purchase more benefits. Not all health coverage companies offer all 10 plans and, in some states, there are other types of Medigap options. If you choose a Medigap plan and want drug coverage, you must purchase a stand-alone prescription drug plan.
A network pharmacy is a pharmacy that has contracted with our Part D plan, and allows our members to receive their prescription drug benefits.
Preferred cost-sharing means lower cost-sharing for certain covered Part D drugs at certain network pharmacies.
A preferred network pharmacy is a pharmacy that contracts with a Part D plan and allows the plan’s members to receive preferred cost sharing (the lowest possible copays and coinsurance) when filling their prescriptions using their plan benefit in the Initial Coverage stage.
A time not during the annual election period or initial enrollment period when you are able to join, change, or drop your Medicare plan. An SEP can also be trigged by certain events. For example, a change in your residence may result in an SEP.
Standard cost-sharing is cost-sharing other than preferred cost-sharing offered at a network pharmacy.
A standard pharmacy is a pharmacy that contracts with a Part D plan and allows the plan’s members to fill their prescriptions using their plan benefit, but do not offer the same low copayments and coinsurance as a preferred pharmacy.