TERM
|
DEFINITION
|
ASSETS
|
Property the government ‘counts’ when
you apply for financial help. This
includes cash or property that can be
turned into cash within 20 days such as
checking and savings accounts, stocks,
bonds, IRAs and other similar items. |
BENEFITS
|
The money or services provided by an
insurance policy. In a health plan,
benefits are the health care you get. |
BRAND NAME DRUGS
|
Prescription drugs that are not
available as generic, such as Lipitor or
Ambien (only available as trade-marked
brand name drugs). |
CATASTROPHIC LIMIT
(COVERAGE)
|
The highest amount of money you have to
pay out of your pocket during a certain
period of time for certain covered
charges. Setting a maximum amount you
will have to pay protects you. |
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 charge for services
and prescriptions that you may have to
pay after you pay any plan deductibles.
The amount you pay changes with the
sales price of the prescription. 25%
of $100 = $25.00
25%
of $200 = $50.00 |
COPAYMENT
|
a
pre-set, flat fee for each prescription.
$20.00 payment for a prescription that
costs $100 or $200. Will change
dependent on what tier the drug is
classified. (see tier) |
COST SHARING
|
The cost for medical care that you pay
yourself like a copayment, coinsurance,
or deductible. (See Coinsurance;
Copayment; Deductible.) |
CREDITABLE COVERAGE
|
When your current prescription drug plan
is equal to or better than the standard
Medicare Part D drug benefit the
government designed. You must have a
letter, from your prescription drug
plan, stating that it is equal to or
better than Medicare Part D. If you
have “creditable coverage” you DO NOT
have to sign up for Medicare Part D will
suffer no penalty. |
DEDUCTIBLE (MEDICARE)
|
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. These amounts can
change every year. (See Benefit Period;
Medicare Part A; Medicare Part B.) |
DISCOUNT DRUG LIST
|
A
list of certain drugs and their proper
dosages. The discount drug list includes
the drugs the company will discount. |
DRUG TIERS
|
Drug tiers are definable by the plan.
The option “tier” was introduced in the
PBP to allow plans the ability to group
different drug types together (i.e.,
Generic, Brand, Preferred Brand). In
this regard, tiers could be used to
describe drug groups that are based on
classes of drugs. If the “tier” option
is utilized, plans should provide
further clarification on the drug type(s)
covered under the tier in the PBP notes
section(s). This option was designed to
afford users additional flexibility in
defining the prescription drug benefit. |
DUAL ELIGIBLES
|
Persons who are entitled to Medicare
(Part A and/or Part B) and who are also
eligible for Medicaid. |
EXCLUSIONS
|
that are not covered by the insurance
plan |
FORMULARY
|
A
list of certain drugs and their proper
dosages. In some Medicare health plans,
doctors must order or use only drugs
listed on the health plan's formulary. |
FORMULARY DRUGS
|
Listing of prescription medications
which are approved for use and/or
coverage by the plan and which will be
dispensed through participating
pharmacies to covered enrollees. |
GAPS
(COVERAGE GAP or DOUGHNUT HOLE)
|
The costs or services and prescriptions
that are not covered under the Original
Medicare Plan and Medicare Part D. |
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. |
HEALTH MAINTENANCE ORGANIZATIONS (HMO)
|
A
type of Medicare managed care plan where
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.
(see Medicare Advantage) |
LATE ENROLLMENT FEE
|
a
fee added to the monthly premium for not
signing up before the end of the
enrollment time |
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. |
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 (MA) AND MEDICARE
ADVANTAGE PRESCRIPTION DRUG PLANS
(MA-PD)
|
These
plans may provide both medical care and
prescription drugs. Only those
designated MA-PD provide both medical
care and a drug benefit. There are four
different MA-PD types, Health
Maintenance Organization (HMO),
Preferred Provider Organizations (PPO),
Fee For Service (FFS) and Special Needs
Plan (SNP). |
MEDICARE PART A (HOSPITAL INSURANCE)
|
Hospital insurance that pays for
inpatient hospital stays, care in a
skilled nursing facility, hospice care,
and some home health care. |
MEDICARE PART B (MEDICAL INSURANCE)
|
Medicare medical insurance that helps
pay for doctors? services, outpatient
hospital care, durable medical
equipment, and some medical services
that aren’t covered by Part A. |
NON-FORMULARY DRUGS
|
Drugs not on a plan-approved list. |
NETWORK
|
a
group of pharmacies that participate in
the plan. Not all pharmacies are going
to participate in all of the plans
available. It may cost you more if you
go to a pharmacy that does not
participate with your plan. |
QUANTITY LIMITS
|
some medications may only be recommended
for short term use, like sleeping
medications. If your doctor wants you to
take a medication longer than the
recommended time, they will need to get
authorization from the insurance company |
PREFERRED BRAND DRUGS
|
many insurance companies will make deals
with drug companies to get brand drugs
at a lower cost. Because of this, the
insurance company would prefer you to
use these brand drugs and can pass on
some savings to you as well. |
PREMIUM
|
a
monthly fee to participate in the
insurance plan |
PRIOR AUTHORIZATION
|
your doctor may need to contact with the
insurance plan to let them know that it
is important for you to receive this
drug instead of a different drug. |
TIER
|
is
a specific list of drugs. Your plan may
have several tiers, and your copayment
amount depends on which tier your drug
is listed. Plans can choose their own
tiers, so members should refer to their
benefit booklet or contact the plan for
more information. |
-
TRUE OUT-OF-POCKET COSTS
|
the actual amount of money you will
spend each year |
This in-service training is funded by Florida Cooperative Extension Service. EEO