Health insurance is a type of insurance coverage that pays for medical and surgical expenses incurred by the insured. Health insurance can reimburse the insured for expenses incurred from illness or injury, or pay the care provider directly.
Health Insurance Glossary of Terms A-Z
Here is a list of insurance related terms and their definitions.
The amount you must pay for your health care or prescriptions before original medicare, your prescription drug plan, your medicare health plan, or your other insurance begins to pay. These amounts can change every year.
If "Under review" appears, it means that the coverage is still being discussed by medicare and the plan.
the average amount you might expect to spend each year for prescription drugs, depending on your health status.
the way that original medicare measures your use of hospital and skilled nursing facility (snf) services. A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility. 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.
once your spending on prescription drugs reaches a certain amount called the out of pocket threshold you automatically get "Catastrophic coverage." catastrophic coverage means that you only pay a small coinsurance amount or a copayment for covered drugs for the rest of the year.
there are no networks - you can go to any doctor, supplier, hospital or other facility that participates in medicare and is accepting new medicare patients.
an amount you may be required to pay as your share of the cost for health care services or prescriptions after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).
name of company that contracts with medicare to offer a medicare prescription drug plan or a medicare health plan. (the number next to the name is for medicare's use only.)
an amount you may be required to pay as your share of the cost for health care services, like a doctor's visit, or prescriptions. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.
the amount you may be required to pay as your share of the cost for health care services or prescriptions. Cost sharing can include copayments, coinsurance, and/or deductibles.
Medicare drug plans may have a "Coverage gap," which is sometimes called the "Donut hole." this means that after you and your drug plan have spent a certain amount of money for covered drugs, you may have to pay more for your drugs (until you reach the out-of-pocket threshold).
]]note:]] if you get extra help paying your drug costs, you won't have a coverage gap. However, you will probably still have to pay a small copayment or coinsurance amount.
the amount you must pay for health care services or prescriptions each year, before your medicare drug plan, your medicare health plan, or your other insurance begins to pay. These amounts can change every year.
special projects, sometimes called "Pilot programs" that test improvements in medicare coverage, payment, and quality of care. They usually only operate for a limited time, for a specific group of people and/or are offered only in specific areas.
ending your health care and/or prescription drug coverage with a health plan or drug plan.
the prescribed strength or amount of therapeutic ingredient(s) administered at prescribed intervals.
this tells you that a plan offers coverage of prescription drugs.
the plan may have certain coverage restrictions (including quantity limits, prior authorization, and step therapy) on a prescription drug.
a list of drugs from your processed medicare claims data that are included in the medicare.Gov drug & plan finder tool. These drugs can be added to your drug list so that you can get estimated costs and coverage details from this site.
a list of drugs from your processed medicare claims data that, while they may be covered by medicare, are not included in the medicare.Gov drug & plan finder tool. These drugs cannot be used to estimate pricing on this site. Please contact the plans for more information about the coverage of these drugs.
plans that give health and/or drug coverage to employees, former employees, and their families. These plans are offered to people through their (or a spouse's) current or former employer or employee organization.
a plan that can offer a more comprehensive level of coverage, with lower cost and/or additional coverage of certain drugs not included in the standard or basic levels of coverage. Premiums may be higher for these plans.
When using this tool, this is an estimate of the average amount you might expect to spend each year for your health coverage. The estimates include the following:
plan benefits (coverage)
costs for premiums, copayments, deductibles, coinsurance
costs not covered by your insurance
Your out-of-pocket costs are based on actual health coverage use by people with medicare, and they may differ depending on your age and health status. Also, if you have limited income and resources, your expenses may be lower.
This is an estimate of the average amount you might expect to pay each year for your prescription drug coverage. This estimate includes the following costs, as applicable:
drug costs not covered by prescription drug insurance
If you entered your drugs into the medicare plan finder, then this estimate includes the cost of those drugs.
If you selected "I don’t take any drugs," then this amount includes only the cost of the monthly premiums that you would pay for the plan and it does not include any drug costs.
If you selected "I don’t want to add drugs now," then this estimate includes the average drug costs for people with medicare and may differ depending on your age and health status.
Your expenses may be lower if you have limited income and resources.
a list of prescription drugs covered by a prescription drug plan offering prescription drug benefits.
how often you refill your prescription.
people who qualify for both medicare and medicaid.
people who qualify for the full low-income subsidy for medicare prescription drug coverage. People who get full extra help pay $0 for their monthly medicare drug plan premium, $0 deductible, and no more than $3.40 (generic) or $8.50 (brand) for their prescriptions.
the total costs for your selected drugs when you use a network retail pharmacy. Actual amounts may vary depending on the number of months left in the year.
the total costs for your selected drugs if your enrollment starts at the beginning of next month. Costs calculations account for months that have already passed.
the total costs for your selected drugs if your enrollment starts in january.
a prescription drug that has the same active-ingredient(s) as a brand drug. Generic drugs usually cost less than brand drugs.
rights you have in certain situations when insurance companies are required by law to sell or offer you a medigap policy. In these situations, an insurance company can't deny you a policy, or place conditions on a policy, such as exclusions for pre-existing conditions, and can't charge you more for a policy because of past or present health problems.
this tells you that the plan offers health coverage and that your costs may vary depending on the services offered.
a type of health insurance plan. In most hmos you can only go to the hospitals, doctors, and other health care providers that have agreements with the plan except in an emergency. You may also need to get a referral from your primary care doctor before seeing a specialist.
a type of medigap policy that has a high dollar deductible but a lower premium. You must pay the deductible before the medigap policy pays anything. The deductible amount can change each year.
you don't qualify for extra help.
when using the medicare prescription drug plan finder, if $0 appears under the premium column, it means that the extra help you get will cover the premium for that plan. If an amount of $1 or greater appears under the premium column, it means you will have to pay part of the premium because the extra help won't cover all of it. You would be responsible for paying this monthly amount if you choose to enroll in that plan.
an independent reviewer, also known as an independent review entity (ire), is an outside organization that has a contract with medicare. If you appeal a decision about your coverage or if your plan doesn't make a timely appeals decision, the ire may review your case. The ire has no connection to the plan. Look at the materials your plan sends you each year, such as the evidence of coverage (eoc), for more details about the appeals process. Select for more information on medicare appeals:http://www.Medicare.Gov/navigation/medicare-basics/understanding-claims/medicare-appeals-and-grievances.Aspx
the initial coverage limit (icl) is a preset dollar amount set by your drug plan. After you have met your deductible and your plan and you have paid for drugs you may reach the icl. At this point the portion you pay for drugs may change as you enter the coverage gap or "Donut hole".
doctors, hospitals, pharmacies, and other healthcare providers that have agreed to provide members of a certain insurance plan with services and supplies at a pre-determined price. In some hmo plans, your care is only covered if you get it from in-network doctors, hospitals, pharmacies, and other healthcare providers.
the mbi is a unique medicare number assigned to each beneficiary. This number replaces the previous social security-based health insurance claim number (hicn) on new medicare cards for medicare transactions like billing, eligibility status, and claim status.
a joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both medicare and medicaid.
services or supplies that are needed for the diagnosis or treatment of your medical condition and accepted standards of medical practice.
medicare advantage plans (like an hmo or ppo) also called “part c” are health plans run by medicare-approved private insurance companies. Medicare advantage plans include part a, part b, and usually other coverage like medicare prescription drug coverage (part d), sometimes for an extra cost.
medicare cost plans are a type of medicare health plan available in certain areas of the country. You can join even if you have medicare part b only. You receive health care services through the cost plan’s provider network or you may go to a non-network provider and the services will be covered by original medicare, based on your eligibility for part a and b services. If you go out-of-network you pay the part a and part b coinsurance and deductibles.
a type of medicare health plan offered by a private company that contracts with medicare to provide you with all your medicare part a and part b benefits. Medicare advantage plans include health maintenance organizations, preferred provider organizations, private fee-for-service plans, special needs plans, and medicare medical savings account plans. If you’re enrolled in a medicare advantage plan, medicare services are covered through the plan and aren’t paid for under original medicare. Most medicare advantage plans offer prescription drug coverage.
a plan offered by a private company that contracts with medicare to provide part a and part b benefits to people with medicare who enroll in the plan. Medicare health plans include all medicare advantage plans, medicare cost plans , demonstration/pilot programs and programs of all-inclusive care for the elderly (pace).
an msa is a plan that combines a high-deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible).You can use the money to pay for your health care services during the year. Msa plans don’t offer medicare drug coverage. If you want drug coverage, you have to join a medicare prescription drug plan. For more information about msas, visit medicare.Gov/publications to view the booklet “your guide to medicare medical savings account plans.” you can also call 1‑800‑medicare (1‑800‑633‑4227) to find out if a copy can be mailed to you. Tty users should call 1‑877‑486‑2048
these plans (sometimes called “pdps”) add drug coverage to original medicare, some medicare cost plans, some medicare private fee-for-service (pffs) plans, and medicare medical savings account (msa) plans.
a medicaid program that helps people with limited income and resources pay some or all of their medicare premiums, deductibles, and coinsurance.
in original medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges.
medication therapy management (mtm) programs offer free services to eligible members of medicare drug plans. These services help make sure that medications are working to improve their members' health. Members can talk with a pharmacist or other health professional and find out how to get the most benefit from their medications. Members can ask questions about costs, drug reactions, or other problems. Each member gets their own action plan and medication list after the discussion. These can be shared with their doctors or other health care providers. Members who take different medications for more than one health condition may contact their drug plan to see if they're eligible.
All medigap policies must cover a basic set of benefits. These basic benefits include most medicare part a and b coinsurance amounts, blood, and additional hospital benefits not covered by original medicare.
part a hospital coinsurance
days 61-90 of a hospital stay in each medicare benefit period
days 91-150 of a hospital stay. Medicare will only pay for these 60 days once during your lifetime
additional part a hospital benefits
an extra 365 days of inpatient hospital care after you use your original medicare hospital benefits
part b coinsurance
pays full or partial coverage for the part b coinsurance after you meet your annual deductible.*
pays full or partial coverage for the first three pints of blood per calendar year.
part a hospice coinsurance
pays for coverage of certain “medicare covered” part b drugs obtained in a doctor’s office, pharmacy or in a hospital outpatient setting and inpatient respite care coinsurance.
plan n covers the part b co-insurance except for a co-payment of $20 dollars for some office visits and $ 50.00 dollars for emergency room visits that don’t result in a hospital admission.
a medigap policy provides a medicare beneficiary supplemental insurance thorough a private insurance company. The policy provides coverage to help pay some of the costs that original medicare doesn't cover like copayments, coinsurance and deductibles. Medigap policies only work with original medicare.
the periodic payment to medicare, an insurance company, or a health care plan for health or prescription drug coverage. In a few cases, a note will say "Under review" instead of a premium amount. This means medicare and the company are still discussing the amount.
The list of your prescription drugs previously entered on the site to help generate better estimates of annual and monthly costs under the available plans, and also see which plans cover your drugs.
The site doesn’t show pricing for over the counter drugs or diabetic supplies (e.G. Test strips, lancets, needles). For more information, you may contact the plan.
medicare drug plans have contracts with a number of pharmacies that are part of the plan’s "Network." if you don’t go to a network pharmacy, your plan may not cover your prescription. Along with retail pharmacies, your plan’s network may include pharmacies that offer preferred cost sharing, a mail-order program, and a 60- or 90-day retail pharmacy program.
a one-time only 6-month period when federal law allows you to buy any medigap policy you want that is sold in your state. It starts in the first month that you are covered under medicare part b and you are age 65 or older (or under age 65 in some states). During this period, you can't be denied a medigap policy or charged more due to past or present health problems.
services not covered by medicare that enrollees can choose to buy or reject. Enrollees that choose these benefits pay for them directly, usually in the form of premiums and/or copayments or coinsurance. These services can be grouped or offered individually and can be different for each medicare health plan offered.
original medicare is fee-for-service coverage under which the government pays your health care providers directly for your part a and/or part b benefits.
ppos and other plan types have in-network providers that have agreed to provide members of the plan with services and supplies at a predetermined price but also allow enrollees the option to get plan services from out-of-network providers. Members usually have to pay higher out-of-pocket costs for out-of-network services.
health or prescription drug costs that you must pay on your own because they are not covered by medicare or other insurance.
like all medicare health plans, plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. (please note that you will still need to pay your monthly premiums and cost-sharing for your part d prescription drugs.)
each medicare drug plan has an out-of-pocket threshold, which is the most you will pay out-of-pocket in the coverage gap phase. Once you have paid this amount, the coverage gap phase is over and you will enter the catastrophic phase of the benefit . This means that your drug plan will pay a greater portion of your drug costs.
The overall star rating combines each plan's scores for all the types of services they offer into a single summary score that makes it easy for you to compare plans based on quality and performance. Learn more about differences among plans by looking at the detailed ratings.
for plans covering health services, the overall quality score is based on over 35 different topics. For example, plans are rated in how well they help you stay healthy as well as manage chronic (long-term) conditions. They are also rated according to results of satisfaction surveys of their members, tracking complaints filed by their members with medicare, and monitoring of their customer service calls.
for plans covering drug services, their overall quality is based on ratings in more than 12 different topics ranging from customer service of their call center and their appeals department to the accuracy of their prices on medicare's website. They are also rated on the initiatives they take to improve the safety of prescription drugs.
for plans covering both health and drug services, the overall score for quality of those services covers all of the topics described above.
Where does the information for the overall star rating come from?
for quality of health services, the information comes from sources that include:
member surveys done by medicare
information from clinicians
information submitted by the plans
results from medicare's regular monitoring activities
for quality of drug services, the information comes from sources that include:
results from medicare's regular monitoring activities
reviews of billing and other information that plans submit to medicare
member surveys done by medicare
a special type of health plan that provides all the care and services covered by medicare and medicaid as well as additional medically-necessary care and services based on your needs as determined by an interdisciplinary team. Pace serves frail older adults who need nursing home services but are capable of living in the community. Pace combines medical, social, and long-term care services and prescription drug coverage.
the container(s) your medicine comes in.
the part of medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.
medicare medical insurance that helps pay for certain doctors' services, outpatient hospital care, durable medical equipment, and some medical services that aren't covered by part a.
the standard part b deductible is $185 for 2019. This is the amount you pay before medicare begins to pay its share for services like doctors’ visits, outpatient care, durable medical equipment and other medical services.
this plan, medicaid, and/or a third-party may pay for all or part of your part b premium. You must pay your portion of the medicare part b premium if it isn't paid in full by the plan, medicaid, and/or another third-party. Please contact the plan for additional information.
people who are in a medicare savings program run by their state.
people who qualify for the partial low-income subsidy for medicare prescription drug coverage. People who get partial extra help may pay a percentage of their monthly medicare drug plan premium depending on their income and resources, $85 for their annual deductible, and may pay up to 15% coinsurance for the cost of their prescriptions.
the password used to retrieve a saved drug list.
pharmacies that have agreed to provide members of certain plans with services and supplies at a discounted price. In some plans, your prescriptions are only covered if you get them filled at network pharmacies.
the type of pharmacy you get your medicine from. For example, a mail order pharmacy or , retail pharmacy.
these plan members qualify to get extra help from medicare paying their prescription drug coverage costs. This extra help is also known as the “low-income subsidy.” people who qualify for this program get help paying their plan's monthly premiums, as well as the yearly deductible and co-payments for their prescription drugs.
the name of the plan offered by the company that contracts with medicare.
an hmo option that lets you use doctors and hospitals outside the plan for an additional cost.
a health problem you had before the date that a new insurance policy starts.
if your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
a pharmacy that’s part of a medicare drug plan’s network. You may pay lower out-of-pockets costs for some of your prescription drugs if you get them from a preferred cost sharing pharmacy instead of a standard cost sharing pharmacy.
a type of medicare advantage plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
the periodic payment to medicare, an insurance company, a health care plan, or a drug plan for health care or prescription drug coverage.
Insurance companies set their own premiums for medigap (medicare supplement insurance) policies. How they set the price affects how much you pay now and in the future. Medigap policies can be priced or "Rated" in three ways:
community-rated (or "No-age-rated")
generally the same monthly premium is charged to everyone who has the medigap policy, regardless of age. Your premium isn’t based on your age. Premiums may go up because of inflation and other factors but not because of your age.
the premium is based on the age you are when you buy (are “issued”) the medigap policy. Premiums are lower for people who buy at a younger age and won’t change as you get older. Premiums may go up because of inflation and other factors but not because of your age.
the premium is based on your current age (the age you have “attained”), so your premium goes up as you get older. Premiums are low for younger buyers but go up as you get older. They may be the least expensive at first, but they can eventually become the most expensive. Premiums may also go up because of inflation and other factors.
prior authorization means that you and/or your prescriber must contact the drug plan to determine if specific criteria is met before you can fill certain prescriptions. Call your plan or visit their web site to learn more about specific prior authorization requirements. Many prior authorization requirements can be resolved at the point of sale and don’t require any additional information from your doctor. Knowing what the prior authorizations are before going to your doctor's office may save you time at the pharmacy counter.
a type of medicare advantage plan in which you may go to any medicare-approved doctor or hospital that agrees to treat you under the plan and that accepts the plan's payment terms. The plan decides how much you must pay for services.
a medicaid program for people with medicare who need help paying for medicare services. The person with medicare must have medicare part a and limited income and resources. For those who qualify, the medicaid program pays medicare part a and part b premiums, and medicare deductibles and coinsurance amounts for medicare services.
quality is how well the health plan keeps its members healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person-and getting the best possible results.
the amount of medication you receive each time you refill a prescription.
for safety and cost reasons, plans may limit the quantity of drugs that they cover over a certain period of time. If the drug has a quantity limit restriction, you should contact the plan for more details. For example, if you currently take 2 tablets per day, or 60 tablets per month, and the quantity limit is 30 tablets per month, you would need to work with the plan to get authorization for the higher quantity.
a written order from your primary care doctor for you to see a specialist or get certain services. In many hmos, you need to get a referral before you can get care from anyone except your primary care doctor. If you don't get a referral first, t he plan may not pay for your care
your list of drugs that is saved with a unique id number. This list can be retrieved at any time by entering the saved drug list id and password date.
the area where a health plan accepts members. For plans that limit which doctors and hospitals you may use, it’s generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of the plan's service area.
a nursing facility with the staff and equipment to give skilled nursing care and, in most cases skilled rehabilitation services and other related health services on a continuous daily basis.
medicare special needs plans are a type of medicare advantage plan designed for certain types of people with medicare. Some special needs plans are for people with certain chronic diseases and conditions, some are for people who have both medicare and medicaid, and some are for people who live in an institution such as a nursing home.
some pharmacies have a special distinction because they distribute limited access drugs, home infusion drugs, or are considered a long term care (ltc) pharmacy. Please contact the plan to find out more about this specific pharmacy type within their network.
a medicaid program that pays medicare part b premiums for people who have medicare part a and limited income and resources.
a network pharmacy that offers covered drugs to plan members at higher out-of-pocket costs than what the member would pay at a preferred cost sharing pharmacy.
the standard 2019 part b premium is $135.50. This is the amount that most people pay monthly for services like doctors’ visits, outpatient care, durable medical equipment, and other medical services.
stars for each plan show how well the plan performs in a particular category. Star ratings range from 1 star to 5 stars, where a rating of 1 star means "Poor" quality, 2 stars means "Below average" quality, 3 stars means "Average" quality, 4 stars means "Above average" quality and 5 stars means "Excellent" quality.
in some cases, plans require you to first try one drug to treat your medical condition before they will cover another drug for that condition. For example, if drug x and drug y both treat your medical condition, a plan may require your doctor to prescribe drug x first. If drug x doesn’t work for you, then the plan will cover drug y. If a drug has step therapy restrictions, you may work with the plan and your doctor to get an exception.
This summary rating gives a score for the health plan's quality and performance on over 35 different topics in 5 categories. For example, plans are rated in how well they help you stay healthy as well as manage chronic (long term) conditions. They are also rated according to results of satisfaction surveys of their members, tracking complaints filed by their members with medicare, and monitoring of their customer service calls.
The information described is based on member surveys, information from clinicians, or information from plans. In other cases it’s based on results from medicare's regular monitoring activities.
In addition to using the summary rating:
you can look up how well the health plan is doing in each of the 5 categories that make up the summary rating.
you can also look up how well the health plan is doing in the 36 individual topics that make up the ratings in those 5 categories.
This summary rating gives a score for the drug plan's quality and performance on over 12 different topics in 4 categories ranging from customer service of their call center and appeals departments to the accuracy of their prices on medicare's website. They are also rated on initiatives they take to improve the safety of prescription drugs. This information is gathered from medicare's regular monitoring activities, reviews of billing and other information that plans submit to medicare, and medicare's member surveys.
In addition to using the summary rating:
you can look up the drug plan's rating in each of the 4 categories that make up the summary rating.
you can also look up how well the drug plan is doing in the 17 individual topics that make up the rating in those 4 categories.
ssi is a monthly amount paid by social security to people with limited income and resources who are disabled, blind, or age 65 or older. Ssi benefits provide cash to meet basic needs for food, clothing, and shelter. Ssi benefits aren’t the same as social security benefits.
Drugs on a formulary are often organized into different drug "Tiers" . Your cost depends on which drug tier your drug is in. For example, a plan may form tiers this way:
tier 1 - generic drugs.
tier 2 - preferred brand-name drugs.
tier 3- non-preferred brand name drugs.
Contact the plan to learn more about its specific tier structure.
an appeals decision is considered to be timely when it meets medicare's appeals timeframes. The specific timeframe depends on the type of appeal and level of review in the appeals process. Appeal timeframes range from 72 hours to 30 days (and up to 60 days for some cases involving payment of a service you’ve already received). Look at the materials your plan sends you each year, such as the evidence of coverage. (eoc), for more details about the appeals process.
true out-of-pocket (troop) costs are amounts you pay for covered part d drugs that count towards your drug plan’s out-of-pocket threshold. Your yearly deductible, coinsurance or copayments, and what you pay in the coverage gap all count toward this out-of-pocket limit. The limit doesn’t include the drug plan’s premium.