Beneficiary: The name for a person who has health care insurance through the Medicare or Medicaid program.

Carrier: A private company that has a contract with Medicare to pay your Part B bills.

Centers For Medicare & Medicaid Services (CMS) The Federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

Coinsurance: The percentage of the plan charge for services that you may have to pay after you pay any plan deductibles. Usually, the coinsurance payment is a percentage of the cost of the service (like 20%).

Co-Payment (Co-Pay): The cost for medical care that you pay yourself. Usually, the co-pay is a pre-determined dollar amount you pay each time you utilize a particular service (like $10 each time you fill a prescription or $20 each time you visit your doctor).

Creditable Drug Coverage: Prescription drug coverage (like from an employer or union), that is, on average, at least as good as the Part D standard prescription drug coverage.

Deductible: The amount you must pay for health care before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B and Part D. These amounts can change every year.

Disenroll: Ending your health care coverage with a health plan.

Dual Eligibles: Persons who are entitled to Medicare (Part A and/or Part B) and who are also eligible for Medicaid.

Durable Medical Equipment (DME): Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs or hospital beds. DME is paid for under both Part A and Part B for home health services.

Formulary: A listing of prescription medications and their proper dosages that are approved for use and/or covered by the plan and which will be dispensed through participating pharmacies to covered enrollees. In some Medicare health plans, doctors must order or use only drugs listed on the health plan’s formulary.

Gaps: The costs or services that are not covered under the Original Medicare Plan.

Gatekeeper: In a Managed Care Plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.

Generic Drug: A prescription drug that has 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.

Group Health Plan: A health plan that provides health coverage to employees, former employees and their families, and is supported by an employer or employee organization.

Guaranteed Issue Rights: Rights you have in certain situations when insurance companies are required by law to sell or offer you coverage. In these situations, an insurance company can’t deny you insurance coverage or place conditions on a policy, must cover you for all pre-existing conditions, and can’t charge you more for a policy because of past or present health problems.

Health Maintenance Organization (HMO): A type of Medicare Advantage plan in which a group of doctors, hospitals and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. You usually must get your care from the providers in the plan.

Intermediary: A private company that has a contract with Medicare to pay Part A and some Part B bills.

Managed Care Plan: In most Managed Care Plans, you can only go to doctors, specialists or hospitals on the plan’s list except in an emergency. Plans must cover all Part A and Part B health care. Some Managed Care Plans cover extra benefits, like extra days in the hospital. Your costs may be lower than in the Original Medicare Plan.

Medicaid: A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medically Necessary: Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition; are provided for the diagnosis, direct care and treatment of your medical condition; meet the standards of good medical practice in the local area; and aren’t mainly for the convenience of you or your doctor.

Medicare: The Federal health insurance program for: people 65 years of age or older; certain younger people with disabilities; and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).

Medicare Advantage Plan (MA): A Medicare program that allows you to choose private health plans to help provide your health care. Everyone who has Part A and Part B is eligible, except those who have End-Stage Renal Disease (unless certain exceptions apply). Medicare Advantage plans used to be called Medicare + Choice plans.

Medicare-Approved Amount: The fee Medicare sets as reasonable for a covered medical service. This is the amount a doctor or supplier is paid by you and Medicare for a service or supply. It may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the “Approved Charge.”

Medicare Supplement Insurance: A Medigap policy which is sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage. Except in Minnesota, Massachusetts and Wisconsin, there are 12 standardized policies labeled Plan A through Plan L. Medigap policies only work with the Original Medicare Plan.

MMA: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Network: A group of doctors, hospitals, pharmacies and other health care experts contracted or hired by a health plan to take care of its members.

Non-Formulary Drugs: Drugs not on a plan-approved list.

Out-Of-Pocket Costs: Health care costs that you must pay on your own because they are not covered by Medicare or other insurance.

Preferred Provider Organization (PPO): 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 of the network for an additional cost.

Preventive Services: Health care to keep you healthy or to prevent illness (for example, Pap tests, pelvic exams, flu shots, mammograms and other screenings).

Private Fee-For-Service Plan (PFFS): A type of Medicare Advantage plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn’t cover.

Provider: A doctor, hospital, health care professional or health care facility.

Referral: A written OK from your primary care doctor for you to see a specialist or get certain services. In many Medicare Managed Care Plans, 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, the plan may not pay for your care.

Service Area: The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan’s service area.

TROOP: The “true out-of-pocket” costs incurred by an individual in a Part D plan. These can include the initial deductible and any coinsurance amounts, co-pays and coverage gaps in the Part D plan. Under Part D, TROOP is counted to determine when a beneficiary qualifies for catastrophic coverage after reaching the coverage gap.



Glossary Sources Referenced

• www.medicare.gov
• Medicare's Medicare & You
• "TROOP" from Walgreens' Introduction to Part D: Medicare's New Prescription Drug Coverage