October 6, 2016
An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. You can appeal if Medicare or your plan denies one of these:
- Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
- Your request for payment for a health care service, supply, item, or prescription drug you already got
- Your request to change the amount you must pay for a health care service, supply, item or prescription drug.
You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need.
A person who has health care insurance through the Medicare or Medicaid programs.
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents.
Any drug or medication marketed under a proprietary trademark-protected name.
Once your spending on prescription drugs reaches a certain amount called the Out-of-Pocket Threshold, you automatically get “catastrophic coverage.” Catastrophic coverage means that you only pay a small coinsurance amount or a copayment for covered drugs for the rest of the year.
The federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Programs, and the federally facilitated Marketplace.
An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).
An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.
An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. This amount can include copayments, coinsurance, and/or deductibles.
A period of time in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year.
Previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy.
Prescription drug coverage (for example, from an employer or union) that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.
The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
The prescribed strength or amount of therapeutic ingredient(s) administered at prescribed intervals.
A person who is eligible to receive benefits from both the Medicare and Medicaid programs.
Certain medical equipment, like a walker, wheelchair, or hospital bed, that’s ordered by your doctor for use in the home.
The time(s) during which an eligible individual may elect a Medicare Advantage plan or Original Medicare. The type of election period determines the effective date of Medicare Advantage coverage as well as the types of enrollment requests allowed. There are several types of election periods.
A type of Medicare prescription drug coverage determination. A formulary exception is a drug plan’s decision to cover a drug that’s not on its drug list or to waive a coverage rule. A tiering exception is a drug plan’s decision to charge a lower amount for a drug that’s on its non-preferred drug tier. You or your prescriber must request an exception, and your doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.
A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
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.
A person or organization that’s licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.
Also known as a Health Maintenance Organization, an HMO is a type of health insurance plan. In most HMOs you can only go to the hospitals, doctors, and other health care providers that have agreements with the plan except in an emergency. You may also need to get a referral from your primary care doctor before seeing a specialist.
Doctors, hospitals, pharmacies, and other health care providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. In some insurance plans, your care is only covered if you get it from in-network doctors, hospitals, pharmacies, and other health care providers.
A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
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.
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
A Medicaid program that helps people with limited income and resources pay some or all of their Medicare premiums, deductibles, and coinsurance.
See Medigap, below.
Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage.
The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage. In a few cases, a note will say “Under Review” instead of a premium amount. This means Medicare and the company are still discussing the amount.
The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.
A benefit that may be provided by your Medicare Advantage plan. Generally, this benefit gives you the choice to get plan services from outside of the plan’s network of health care providers. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.
Health or prescription drug costs that you must pay on your own because they aren’t covered by Medicare or other insurance.
The name of the plan offered by the company that contracts with Medicare.
The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.
A type of optional private insurance plan that provides prescription drug coverage (Medicare Part D) to enrolled Medicare beneficiaries.
Approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered by your plan. Your Medicare drug plan may require prior authorization for certain drugs.
Limit on how much medication you can get at a time.
A type of Medicare Advantage Plan designed for certain types of people with Medicare. Some Special Needs Plans are for people with certain chronic diseases and conditions, some are for people who have both Medicare and Medicaid, and some are for people who live in an institution such as a nursing home.
A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.
A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug.
A health care program for active-duty and retired uniformed services members and their families.