Medicare Glossary


Terms You Should Know


Assets

Property you own that the government may review when you apply for assistance. For help with a Part D plan's costs, the government counts cash or any property that can be turned into cash within 20 days. This includes checking and savings accounts, certificates of deposit, IRAs and 401(k)s, stocks, bonds and similar items. It does not include your primary home or certain property related to burial expenses.

Benefit

Another name for coverage. See coverage.

Brand name drugs

Prescription drugs sold under a trademarked brand name.

Catastrophic coverage

A name for the step of a Part D plan in which the plan pays nearly all of your drug expenses until the end of the year, with no upper limit. In this step, you pay only a small share of your drug expenses (approximately five percent).

Centers for Medicare and Medicaid Services (CMS)

The federal agency that runs the Medicare program and works with the states to manage the Medicaid program. CMS sets standards for Part D insurance plans.

Co-insurance

A kind of cost sharing where costs are split on a percentage basis. For example, a plan might pay 75 percent and you would pay 25 percent. See cost sharing.

Co-payment

A kind of cost sharing where you pay a pre-set, flat amount for each service. In a Part D plan, for example, you might pay $10 for each prescription you receive and the plan would pay the remaining cost of the drug. See cost sharing.

Cost sharing

A term for the way an insurance plan shares its costs with a subscriber. The most common types of cost sharing are co-insurance and co-payments. See co-insurance and co-payments.

Coverage

The benefits you receive from an insurance plan. In a Part D plan, the prescription drug costs that are paid by the insurance plan are your benefits, or coverage.

Creditable coverage

Prescription drug coverage, from a plan other than a Part D plan, which meets certain Medicare standards. If you are currently enrolled in a drug plan that gives you prescription drug coverage, your plan will tell you if it meets the Medicare standards for creditable coverage. See late enrollment fee.

Deductible

In an insurance plan, the term for an amount you pay first, before your plan starts to pay. In a Part D plan, you may have to pay the first $310 of your eligible drug expenses for the year as your deductible.

Dual eligibles

People who are eligible for both Medicare and Medicaid.

Eligible drugs

Drugs that are covered by a prescription drug plan. In a Part D plan, eligible drugs are listed on the plan's formulary. See formulary.

Exclusions

Items that are not covered by an insurance policy. Part D drug plans have two types of exclusions:

  • Drugs that Medicare has excluded from coverage under Part D, such as weight-loss drugs.
  • Drugs that are excluded from a plan's list of covered drugs, or formulary.

See eligible drugs and formulary.

Formulary

A list of the prescription drugs covered by a Part D plan. Drugs listed on the formulary are also called eligible drugs. Some people call a formulary a preferred-drug list (PDL) or a select drug list.

Generic drugs

Prescription drugs that have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

Late enrollment fee

Congress wants to encourage as many eligible people as possible to enroll in a Part D prescription drug plan as soon as they are eligible for Medicare. To do this, it has created a late enrollment fee to discourage putting off enrollment. This fee is approximately one percent of your premium cost per month (or 12 percent per year) that you delay enrolling. There is no limit to the percentage and it lasts as long as you are enrolled in a Part D prescription drug plan. The fee won't apply if you move from an insurance plan that offers creditable coverage to a Part D prescription drug plan. See creditable coverage.

Medicaid

A program that pays for medical assistance for certain individuals and families with low incomes and resources. Medicaid is jointly funded by the federal and state governments to assist states in providing long-term care assistance to people who meet certain eligibility criteria.

Medicare Advantage plans

Health plans offered by private insurance companies that contract with Medicare to provide Medicare coverage. Depending on where you live, Medicare Advantage plans may be available both with and without Part D plans. You may also hear Medicare Advantage plans referred to as Medicare health plans. The Medicare Advantage plans used to be called the Medicare+Choice plans.

Medicare

A federal government health insurance program for:

  • people age 65 and older
  • people with certain disabilities
  • people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or kidney transplant).

Medicare Part D prescription drug plans

Insurance plans offering prescription drug coverage that meets the standards established by Medicare. Other names for these plans include Part D prescription drug plans, PDPs, or MA-PDs. However, not all private insurance plans offering prescription drug coverage are Part D plans. You'll want to pay close attention to whether a plan is a Part D plan.

Medicare supplement policy

The traditional federal Medicare insurance program doesn't pay your total amount of medical expenses. Expenses that are not covered are called "gaps" in Medicare coverage. Private insurance companies sell insurance policies that fill some of these gaps and pay for some of these expenses. These policies are known as Medicare supplement policies.

Medigap

See Medicare supplement policy.

Medication therapy management

The term used to describe the type of help that people with multiple prescriptions, chronic diseases and high drug costs receive to help them manage all their medications. This help makes sure all their drugs work well together.

Network

The group of doctors, hospitals and pharmacies who have contracts with an insurance plan to provide care to the plan's members. You should use your Part D prescription drug plan's network of pharmacies to save money on your drugs.

Out-of-pocket costs

The amounts you pay as your share of your prescription drug costs in a Part D plan. Out-of-pocket costs include deductibles, co-insurance and the amounts you pay in the coverage gap. In a Part D plan, any amounts you pay, but for which you are later reimbursed by someone else, such as an employer's insurance plan, do not count as part of your out-of-pocket costs. The out-of-pocket costs you pay for which you are not reimbursed are called your "true out-of-pocket costs," or TROOP. When your true out-of-pocket costs exceed $4,550, you are eligible for the catastrophic coverage step of a Part D plan. See catastrophic coverage.

Premium

The money you pay to have an insurance plan. In a Part D plan, this is usually a monthly fee.

Rx

A symbol that means "prescription drugs."


Information excerpted from Introduction to Part D: Medicare's New Prescription Drug Coverage, published by United Healthcare.