An appeal is something you and your doctor can do if you disagree with a coverage or payment decision made by your Medicare plan.
Copay
Also called copayment, this is the amount you may be required to pay for a medical service or supply, like a doctor’s visit or a prescription drug. A copay 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.
Deductible
The amount you are responsible to pay for healthcare or prescriptions before your healthplan begins to pay.
Exception
A type of Medicare prescription drug coverage determination in cases where a medication is not covered under the health plan’s formulary. If you would like to request an exception, your doctor or other prescriber must send a supporting statement explaining the medical reason for the exception.
Extra Help
Also known as Low Income Subsidy (LIS), this is a Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.
Formulary
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
Medicare
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).
Medicare Part A
Medicare Part A covers:
- Inpatient hospital care
- Skilled nursing facility care
- Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
- Hospice care
- Home health care
Medicare Part B
Part B covers physician visits, outpatient services, preventive services, and some home health visits. It also covers:
- Clinical research
- Ambulance services
- Durable medical equipment (DME)
- Mental health: Inpatient, Outpatient, Partial hospitalization, and Intensive outpatient program services (starting January 1, 2024)
- Limited outpatient prescription drugs
Medicare Part C (Medicare Advantage Plan)
A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits and most offer prescription drug coverage.
Medicare Part D
Part D is Medicare prescription drug coverage. These are optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.
Out-of-Pocket Costs
Healthcare or prescription drug costs that you must pay on your own because they aren’t covered by Medicare or other insurance.
Premium
The monthly payment to Medicare, an insurance company, or a healthcare plan for health or prescription drug coverage.
State Pharmaceutical Assistance Program (SPAP)
A state program that provides help paying for drug coverage based on financial need, age, or medical condition.