Terms Glossary

The monthly amount paid for Medicare coverage.

A fixed amount paid for a service (e.g., $20 per doctor visit).

The amount you must pay before coverage begins.

A percentage of costs you pay after meeting the deductible.

General term for the insured’s share of costs (copays, coinsurance, deductibles).

The most you’ll pay in a year for covered services in Medicare Advantage.

The amount Medicare agrees to pay for a covered service.

Services or supplies needed to diagnose or treat a condition per accepted standards.

The main physician for regular care and referrals.

Requires use of network providers and referrals for specialists.

Offers more provider flexibility, including out-of-network care (often at a higher cost).

Group of doctors, hospitals, and providers contracted with a Medicare plan.

Pharmacies with lower cost-sharing in your Part D or Advantage plan.

Joint federal/state program offering health coverage to low-income individuals, including some Medicare beneficiaries (dual eligible).

State programs that help pay Medicare drug plan costs.

Free counseling and assistance with Medicare choices and issues.

You pay 100% until your deductible is met.

Your plan pays a portion of drug costs, and you pay the rest (copay or coinsurance).

After reaching a set limit, you pay a higher share for drugs (gradually closing).

You pay reduced amounts once total out-of-pocket costs reach a set limit.

The list of prescription drugs covered by a plan.

Classification of drugs (usually 1–5); lower tiers cost less.

Offers the lowest copay or coinsurance for covered drugs.

Restrictions on how much of a drug you can receive.

Must try less expensive drugs before coverage for costlier alternatives.

Option to spread Medicare drug costs over time.

A program that helps low-income beneficiaries with Part D costs.

Short-term rehab or medical care provided by trained professionals after hospitalization.

Provides intensive rehab for serious injuries or illnesses.

Non-medical care for chronic conditions; generally not covered by Medicare.

Care focused on comfort for those with a terminal illness, covered under Part A.

Outpatient facilities for same-day surgeries.

Federal agency that runs Medicare and Medicaid.

Quality ratings (1–5 stars) for Medicare Advantage and Part D plans based on performance.

Geographic area where a plan is available and provides coverage.

Sent by Medicare plans each fall to explain changes for the next year.

When doctors agree to accept Medicare’s approved amount as full payment.

Starts when admitted to hospital/skilled nursing and ends after 60 days without care.

60 extra hospital days available after regular Part A benefits are used.

Screenings, vaccines, and check-ups covered by Medicare to prevent illness.

A person enrolled in Medicare.

Qualifies for automatic Medicare enrollment upon diagnosis.

Kidney failure requiring dialysis or transplant; qualifies for Medicare.

Request to confirm if a service/item will be covered before you receive it.

Request to review and change a denied coverage or payment decision.

For more information, contact the Centers for Medicare & Medicaid Services.

Complaint about a plan’s services, not related to a denial.

Right to buy Medigap without medical underwriting in specific situations.

Insurer cannot cancel your policy if you pay premiums.

Review of health status and preexisting conditions before issuing a Medigap policy (not allowed in some situations).

Legal document appointing someone to make health/financial decisions if you're unable.