Medicare Terms

The period used to measure inpatient hospital or skilled nursing facility use. It starts when you enter a facility and ends after 60 days without care.

The percentage of the cost of a service you pay after meeting your deductible, e.g., 20%. 

A fixed fee you pay for a covered service, such as $10 for a visit with a primary care doctor.

The amount you pay out-of-pocket for covered services before your plan starts paying. Your deductible could be $0 for certain plans.

Specialized Medicare Advantage plans for people enrolled in both Medicare and Medicaid.

A formulary is the list of prescription drugs covered by the Medicare Part D or Medicare Advantage plan you select. If you don’t see your medications on the formulary, you may be able to take a similar medication that does the same thing. Or, you can ask your doctor to apply for an exception to have the medication covered.

A medication equivalent to a brand-name drug in safety, strength, and effectiveness.

 A type of health insurance that limits coverage to network doctors contracted with the plan. An HMO generally won’t cover out-of-network care except for emergency care.

The first time you can sign up for Medicare, usually around your 65th birthday.

A generic term for Medicare Part C plans. 

 January 1-March 31 of each year, for changes to Medicare Advantage plans.

Medicare Advantage plans that include prescription drug coverage. 

Original Medicare refers to Medicare Part A and Part B.

This is the maximum amount (for example, $6,700) you can spend each year on deductibles, copayments and coinsurance for in-network services. If you reach your out-of-pocket maximum, you will pay nothing for your care for the rest of the year. Get help with more health insurance terms with our health insurance glossary, or learn more about your options for Medicare coverage.

A formulary is the list of prescription drugs covered by the Medicare Part D or Medicare Advantage plan you select. If you don’t see your medications on the formulary, you may be able to take a similar medication that does the same thing. Or, you can ask your doctor to apply for an exception to have the medication covered.

Covers doctor visits, outpatient care, preventive services, and some home health services.

Private insurance plans that include Part A and B benefits and may offer extras like dental or vision coverage and Part D coverage (see below).

Helps cover the cost of prescription medications, available as standalone plans or included in Part C plans .

A type of health insurance that partners with a network of preferred providers (doctors, clinics, hospitals, etc.) Members can still see out-of-network providers but will pay less out of pocket seeing network providers. 

The fixed amount you pay for Medicare or a private plan. Your premium could be $0 for certain plans.
Get an estimate of your premium amount here.

Allows enrollment outside regular periods if you meet certain conditions.

A facility that provides rehabilitation and medical care after illness or injury.