Glossary and Terms
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 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, such as a doctor’s visit. For example, this could be $10 or $20 for a doctor’s visit. Copayments are also used for some hospital outpatient services in the Original Medicare plan.
This is the copayment, coinsurance or deductible you pay under a particular benefit design. Some plans have limits on the total amount of cost sharing you pay in a year. For example, the standard plan requires that you pay 25% of the drug costs and the plan will pay 75%, 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 coverage for benefits. Generally, deductibles apply to Medicare Parts A, B and D. Deductibles may also apply to Medicare Supplement plans.
A Medicare Advantage plan is a program under which a non-government entity arranges for all Medicare covered services, including physicians, labs and hospitals. Some Medicare Advantage and other health plans may offer the Medicare Prescription Drug Benefit to their enrollees.
A Medicare Advantage PPO, or Preferred Provider Organization is a type of Medicare Advantage Plan in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals and providers outside the network for an additional cost.
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 offers Medicare prescription drug coverage.
Insurance sold by private companies that you may purchase to cover what Medicare does not. These plans are a type of Medigap/Medicare Supplement plan. They are often called Plan A, Plan B, Plan C, Plan D, Plan E and so on up to Plan L.
Medicare Part A typically pays for inpatient hospital expenses.
Medicare Part B typically covers outpatient health care expenses including doctor fees.
The part of the Medicare program that provides prescription drug coverage.
The payment to an insurance carrier for medical benefits purchased.
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