Glossary of Terms
Beneficiary - General term used for one who receives a benefit. Used on this site to describe those people receiving Medicare benefits, or Medicare and Medicaid benefits when preceded by "Dual Eligible".
CMS - Abbreviation for the Centers for Medicare & Medicaid Services, the federal agency that administers the Medicare program and works in partnership with the states to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards.
Creditable Coverage - Any health insurance coverage you had within 63 days of securing a new insurance policy that can be used to shorten the waiting period for pre-existing conditions.
Disenrollment - Leaving a health plan like an HMO.
Dual Eligible - A person who has both Medicare and Medicaid.
Doughnut Hole - deliberately designed gap in coverage in Medicare Part D; essentially a second huge deductible.
Election Periods - The times when a Medicare-eligible person can choose to join or leave Original Medicare or a Medicare Advantage plan. There are four types of election periods: the annual election period, the initial election period, the special election period, and the open enrollment period.
Enrollment - Joining Original Medicare or becoming a member of a private health plan, like a Medicare HMO.
FAQs - Frequently Asked Questions
Formulary - List of covered drugs
Lock-in - Inability to change Medicare plans for a certain amount of time
LIS - Low Income Subsidy, also called "Extra Help" that offers reduced cost-sharing to eligible beneficiaries.
Medicare Advantage - Formerly "Medicare+Choice", or "Medicare Part C"; Medicare managed care/non-traditional Medicare plans; Medicare plans offered by Private companies, rather than through the traditional Medicare program
MA-PD - Medicare Advantage Plan with Prescription Drug Coverage
Medicare Part B - Medicare coverage for physicians' services, some outpatient services & therapy, durable medical equipment, prosthetic devices, ambulance services, home health services not covered under Part A, some pap smear and mammography screens, flu shots, and some therapeutic shoes.
Medicare Part C - See Medicare Advantage
Medicare Part D - The Medicare prescription drug program
Medicare Portability - The ability - currently nonexistent - of a Medicare Eligible person to receive services from a Medicare approved provider outside the United States. Portability may also be an issue between states or service areas of Medicare Advantage plans, which are not always accepted nationwide, as traditional Medicare is.
Medicare Savings Programs (MSP) - Also known as Medicare Buy-In programs, they help pay your Medicare premiums and sometimes also coinsurance and deductibles. There are three Medicare Savings Programs, with different eligibility limits: QMB, SLMB, and QI-1.
Part D - Shorthand for Medicare Part D, the Medicare prescription drug program.
Plan - A program or policy stipulating services or benefits. In relation to Medicare, "plan" may be used in reference to Medigap, managed care, or prescription drug services.
Preferred Drug List - A drug list (formulary) includes selected brand name drugs that are considered preferred because of their overall ability to meet patient needs at a reasonable cost. If a brand-name drug is necessary, those classified as preferred may result in lower cost-sharing than non-preferred brand-name drugs.
Prescription Drug Plan - (PDP) Stand-alone drug plans under Part D. These plans offer drug Coverage only, allowing the beneficiary to remain in the traditional Medicare program for their other needs.
Re-importation - Purchasing prescription drugs from foreign countries
Rx - Prescription Drug
SPAP - State Pharmaceutical Assistance Plans
Special Needs Plan - MA plans in that they are intended to enroll, exclusively or disproportionately, only specific high-needs subpopulations of the Medicare population (dually eligibles, institutionalized beneficiaries, or beneficiaries with chronic conditions or disabilities). A SNP must be a "coordinated care" plan, either a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) and must provide coverage for Part D, as well as for Parts A and B.
Spend-down - Process by which individuals who would be eligible for Medicaid except for their monthly income subtract their medical costs from their income to get it down to or below the limits for Medicaid.
True Out-of-Pocket Costs - (TrOOP) Prescription drug expenses paid by beneficiary, charity or SPAP.
Wrap around - Supplemental coverage offered in some states to fill in the gaps left by the Part D program.