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Individual | Group | Medicare
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Benefit Period
The way that the original Medicare Plan measures your use of hospital and skilled nursing facility services. A benefit period begins the day you go to a hospital or skilled nursing facility and ends when you haven’t received any hospital or skilled nursing care for 60 days in a row.
Coinsurance
The amount you may be required to pay for services after you pay any plan deductible.
Copayment
The amount you pay for some medical services according to your health plan details. A copay does NOT usually go towards meeting your deductible or coinsurance amount.
Credible Prescription Drug Coverage
Prescription drug coverage that pays out as much as or more than Medicare’s standard prescription drug coverage.
Deductible
The amount you must pay for some medical services according to your health plan details before the carrier begins to pay. Lab, x-ray, office procedures, outpatient surgery, hospitalization and emergency department benefits usually require you to meet your deductible first.
Formulary
A list of generic and brand names drugs that are covered under a specific health plan. Usually there are NO benefits for drugs not on the formulary.
HMO – Health Maintenance Organization
A type of Medicare Advantage Plan available is some parts of the country that will likely require you to use doctors and other providers within a specific network. Your cost may be lower for these plans and you may have additional benefits.
Medicaid
A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources.
Medicare
Medicare is a health insurance program for people age 65 or older (or under 65 with certain disabilities or people with End-Stage-Renal Disease). There are multiple parts to Medicare:
Part A – Hospital Insurance: helps cover your inpatient care in hospitals and skilled nursing facilities. It also helps cover hospice care and some home health care. This insurance is free-of-charge if you have worked and paid Medicare taxes in the past. Part A has an annual deductible.
Part B – Medical Insurance: helps cover your doctor’s services and outpatient care including some physical and occupational therapy. You must pay a monthly premium for Part B. If you don’t take Part Be when you are first eligible there may be a 10% per year penalty imposed. Part B has an annual deductible.
Part D – starting January 1, 2006, Medicare offered a new prescription drug coverage plan through private companies. Everyone with Medicare can join one of the many approved drug plans to obtain this coverage. If you do NOT take Part D by May 15, 2006 there may be a 1% per month penalty imposed. It is important to ensure your medications are covered on the carrier’s formulary.
Medicare Advantage Plans: additional Medicare health plan options including Medicare HMOs, PPOs, Special Needs Plans and Private Fee-for-Service Plans offered by a private company that contracts with Medicare. If you join one of these plans, you generally get all your Medicare-covered health care through the plan. Usually there are extra benefits to these plans and lower copayments. However, you may be required to see providers in a specific network.
Medicare Supplement / Medigap Plans
Insurance sold by private insurance companies that is designed to cover Medicare deductibles and other payments that you would be expected to cover. You will pay a monthly premium for a Medicare Supplement plan. In Texas, there are 12 plans standardized by the federal government known as plan A through L. Medicare Supplement plans work with Medicare Part A and B to provide you with comprehensive care.
PPO - Preferred Provider Organization
A type of Medicare Advantage Plan in which you pay less if you use doctors, and other providers that belong to the network. You can use doctors and other providers outside of the network for an additional cost.
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