Medicare Advantage

A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription or over the counter.

The federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Programs, and the federally facilitated Marketplace.

The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.

A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible. Let’s say your health insurance plan’s allowable cost for a doctor’s office visit is $100. Your copayment for a doctor visit is $20. If you’ve paid your deductible: You pay $20, usually at the time of the visit. If you haven’t met your deductible: You pay $100, the full allowable amount for the visit. Copayments (sometimes called “copays”) can vary for different services within the same plan, like drugs, lab tests, and visits to specialists. Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.

The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

Services eligible to be paid for by your health plan.

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a formulary.

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Ambulance services for an emergency medical condition.

Hospital department responsible for providing immediate medical or surgical care.

Emergency services you get in an emergency room.

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

An amendment to your contract to ap or exclude coverage of benefits or modifying administrative processes (e.g., eligibility requirements or claims).

A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Some plans cover more services. Plans must offer dental coverage for children. Dental benefits for adults are optional. Specific services may vary based on your state’s requirements. You’ll see exactly what each plan offers when you compare plans.

Another term for the Health Insurance Marketplace, a service available in every state that helps individuals, families, and small businesses shop for and enroll in affordable medical insurance. The Marketplace is accessible through websites, call centers, and in-person assistance. When you fill out a Marketplace application, you’ll find out if you qualify to save money when you enroll in a medical insurance plan. You’ll also find out if you qualify for Medicaid and the Children’s Health Insurance Program (CHIP). Whether you qualify for these programs depends on your expected income, household members, and other information.

A review of a plan’s decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process isn’t yet completed. External review is available when the plan denies treatment based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, when the plan determines that the care is experimental and/or investigational, or for rescissions of coverage. An external review either upholds the plan’s decision or overturns all or some of the plan’s decision. The plan must accept this decision.

Health care services that your health insurance or plan doesn’t pay for or cover.

A prescription drug that has the same active- ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.

Health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

A complaint that you communicate to your health insurer or plan.

Health care services a person receives at home.

Care in a hospital that usually doesn’t require an overnight stay.

Services to provide comfort and support for persons in the last stages of a terminal illness and their families. Hospital and ER Physician Services Services performed by a licensed physician at a hospital or hospital’s emergency room department.

A situation where you were discharged from the hospital and wind up going back in for the same or related care within 30, 60 or 90 days. The number of hospital readmissions is often used in part to measure the quality of hospital care, since it can mean that your follow-up care wasn’t properly organized, or that you weren’t fully treated before discharge.

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

A group of physicians, hospitals and other health care providers offering pre-negotiated rates, known as Allowed Amount.

The percentage (for example, 20%) you pay for the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.

A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

Policies for people that aren’t connected to job-based coverage. Individual health insurance policies are regulated under state law.

Services received when admitted to a facility as a patient for medically necessary care or treatment offered by a licensed physician.

The maximum amount insurance will pay for benefits on specific covered expenses.

A cap on the total lifetime benefits you may get from your insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer pay for covered services.

Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.

A program allowing you to purchase prescription drugs, typically for chronic conditions needing extended use, and ship the drugs to your home.

A federal health insurance program for people 65 and older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Medicare isn’t part of the Health Insurance Marketplace. If you have Medicare coverage you don’t have to make any changes. You’re considered covered under the health care law.

A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your 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, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Coverage for 18 to 64 year olds who collect or qualify for Social Security Disability Income and are unable to work for at least a year due to a qualifying physical or mental impairment.

A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

A list of prescription drugs that may be covered by your health plan.

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

A health plan that contracts with doctors, hospitals, pharmacies, and other health care providers to provide members of the plan with services and supplies at a discounted price.

Brand name prescription drugs that may have a generic equivalent or similar drug available, but generally cost more to purchase.

A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

The yearly period when people can enroll in a health insurance plan. Outside the Open Enrollment Period, you generally can enroll in a health insurance plan only if you qualify for a Special Enrollment Period. You qualify if you have certain life events, like getting married, having a baby, or losing other health coverage.

Health care providers that are not contracted or participating providers for your health plan and may charge full price for medical care. You may be responsible for charges over your plan’s Allowed Amount (see balance billing).

The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don’t contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

A fixed amount (for example, $30) you pay for covered health care services from providers who don’t contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.

An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit doesn’t include your monthly premiums. It also doesn’t include anything you may spend for services your plan doesn’t cover.

Medical care or treatment performed in a doctor’s office, hospital or facility that does not require overnight stay, such as x-rays, ultrasounds and CAT scans.

A health problem you had before the date that new coverage starts. Pre-Existing Condition (Job-based Coverage) Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on your enrollment date in a health insurance plan. Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. Pregnancy cannot be considered a pre-existing condition and newborns, newly adopted children and children placed for adoption who are enrolled within 30 days cannot be subject to pre-existing condition exclusions.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

The amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance. If you have a Marketplace health plan, you may be able to lower your costs with a premium tax credit.

Health insurance or plan that helps pay for prescription drugs and medications. Prevention Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.

Drugs and medications that, by law, require a prescription.

Refers to oral exams, X-rays, cleanings, and child flouride treatment.

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Focuses on preventing health problems from occurring and diagnosing health conditions early for greater chances of recovery and may be included in your plan at no additional cost. Care includes wellness exams, vaccines, routine health screenings and more.

Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists. Primary Care Physician A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

Out-of-pocket medical expenses that qualify for tax-free withdraws from a Health Savings Account (HSA), such as doctor visits, hospital care, prescription drugs, and more. See IRS publication 502 for a complete list.

A change in your situation – like getting married, having a baby, or losing health coverage – that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period.

A written order from your primary care doctor for you to see a specialist or get certain medical services. With some plans you may need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

Services Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third-party administrator, or they can be self-administered.

A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may end your coverage if you move out of the plan’s service area.

Services from a licensed nurse in your home or nursing home; or known as skilled care if from a licensed technician or therapist. Skilled Nursing Facility Offers 24-hour medical and custodial care for temporary or long-term stays.

Care Skilled nursing care and rehabilitation services provided on a continuous, daily basis in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

The amount you get from Social Security Disability, Retirement (including Railroad retirement), or Survivor’s Benefits each month.

A system that distributes financial benefits to retired or disabled people, their spouses, and their dependent children based on their reported earnings. While you work, you may pay taxes into the Social Security system. When you retire or become disabled, you, your spouse, and your dependent children may get monthly benefits that are based on your reported earnings. Your survivors may be able to collect Social Security benefits if you die.

Social Security benefits based on your record (if you should die) that are paid to your: Widow/widower age 60 or older, 50 or older if disabled, or any age if caring for a child under age 16 or disabled before age 22 Children, if they are unmarried and under age 18, under 19 but still in school, or 18 or older but disabled before age 22; and Parents if you provided at least one-half of their support. An ex-spouse could also be eligible for a widow/widower’s benefit on your record. A special one-time lump sum payment of $255 may be made to your spouse or minor children.

A time outside the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child. If you qualify for an SEP, you usually have up to 60 days following the event to enroll in a plan. If you miss that window, you have to wait until the next Open Enrollment Period to apply. You can enroll in Medicaid and the Children’s Health Insurance Plan (CHIP) any time of year, whether you qualify for a Special Enrollment Period or not. Job-based plans must provide a special enrollment period of at least 30 days.

The health care and related needs of children who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that required by children generally. Specialist A physician specialist focuses on a specific area of medicine or group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

An FDA-approved prescription drug designated by Florida Blue because it requires special handling, storage, training, distribution requirements and/or management of therapy. They can be provider administered or self administered and are identified in the Medication Guide.

A contract holder or member who consistently meets all eligibility requirements and is enrolled under the contract not as a dependent.

Health coverage available at reduced or no cost for people with incomes below certain levels. Examples of subsidized coverage include Medicaid and the Children’s Health Insurance Program (CHIP). Marketplace insurance plans with premium tax credits are sometimes known as subsidized coverage too. In states that have expanded Medicaid coverage, your household income must be below 138% of the federal poverty level to qualify. In all states, your household income must be between 100% and 400% of the federal poverty level to qualify for a premium tax credit that can lower your insurance costs.

Assistance from the government to help pay for the monthly insurance bill for those that qualify. The tax credit depends on taxable household income, family size and ages and location of residence. It does not pay for out-of-pocket health care costs, but financial assistance may be available to those who qualify. Substance Dependency A condition where alcohol or drug use injures one’s health; interferes with social or economic function; or causes loss of self-control.

An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You’ll get the “Summary of Benefits and Coverage” (SBC) when you shop for coverage on your own or through your jobs, renew or change coverage, or request an SBC from the health insurance company.

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.

A non-hospital emergency center offering medical services by physicians, nurses and x-ray technicians to treat primarily injuries and illnesses that need immediate care but do not require an emergency room visit.

A provision to continue life insurance coverage without premium payments if the insured becomes totally disabled.

A program intended to improve and promote health and fitness that’s usually offered through the workplace, although insurance plans can offer them directly to their enrollees. The progam allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings. Worker’s Compensation An insurance plan that employers are required to have to cover employees who get sick or injured on the job.