Income Related Monthly Adjustment Amount (IRMAA)
If your income is above a certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium. For example, individuals with income greater than $85,000 and married couples with income greater than $170,000 must pay a higher Medicare Part B (medical insurance) and Medicare prescription drug coverage premium amount. This additional amount is called the income-related monthly adjustment amount. Less than 5 percent of people with Medicare are affected, so most people will not pay a higher premium.
Initial coverage limit
The maximum limit of coverage under the Initial Coverage Stage.
Initial coverage stage
This is the stage before your total drug costs including amounts you have paid and what your plan has paid on your behalf for the year have reached $3,750.
Initial enrollment period
When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you’re eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
Late enrollment penalty
An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions. For example, if you receive “Extra Help” from Medicare to pay your prescription drug plan costs, you will not pay a late enrollment penalty.
List of covered drugs (Formulary or “Drug list”)
A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.
Low Income Subsidy (LIS)
Maximum Out-of-Pocket Amount
The most that you pay out-of-pocket during the calendar year for in-network covered Part A and Part B services. Amounts you pay for your plan premiums, Medicare Part A and Part B premiums, and prescription drugs do not count toward the maximum out-of-pocket amount.
Medicaid is a program sponsored jointly by the state and federal government that helps to alleviate medical costs for individuals with limited income. The requirements and benefits of Medicaid vary across different states, although if you qualify for both Medicare and Medicaid, most of your health care costs will be covered at minimal to no cost to you.
Medi-Cal (Medicaid or Medical assistance)
A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medi-Cal programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medi-Cal.
Medically accepted indication
A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books.
Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.
The Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original, a PACE plan, or a Medicare Advantage Plan.
Medicare Advantage (MA) Plan
Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).
Medicare Advantage Plan (Part C)
Offered by a private health insurance provider, this is a type of Medicare health plan that also contracts with the Medicare program. This plan allows you to receive all of your Part A and Part B benefits. This type of plan may include Health Maintenance Organizations, Private Fee-For-Service Plans, Medicare Medical Savings Account Plans and Special Needs Plans. Most Medicare services are covered under this type of plan, and most of these plans provide prescription drug coverage.
Medicare Advantage plans with prescription drug coverage
Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).
Medicare coverage gap discount program
A program that provides discounts on most covered Part D brand name drugs to Part D enrollees who have reached the Coverage Gap Stage and who are not already receiving “Extra Help.” Discounts are based on agreements between the Federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted.
Medicare health plan
A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).
Medicare Part A (Hospital Insurance)
This Medicare coverage is provided for inpatient hospital stays, Skilled Nursing Facility (SNF) stays, hospice care and some home health care.
Medicare Part B (Medical Insurance)
This Medicare coverage is provided for outpatient care to include services from specific doctors, medical supplies and preventive care.
Medicare Prescription Drug Coverage (Medicare Part D)
Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.
Medicare prescription drug coverage (Part D)
This Medicare coverage is optional and comes at an additional charge for Medicare patients. It provides benefits for prescription drugs available to Medicare patients, and is offered by Medicare-approved insurance and/or private companies.
Medicare Prescription Drug Plan (Part D)
This Medicare coverage is an add-on to other plans, supplementing those plans with prescription drug coverage. The types of plans that may accept this supplement include Original Medicare, Medicare Medical Savings Account Plans, some Medicare Private-Fee-for-Service Plans and some Medicare Cost Plans. This coverage is offered by Medicare-approved insurance and/or private companies.
This type of provider has been approved by Medicare to offer their services, such as home health care, hospital care, nursing home care or dialysis, to Medicare patients. To become certified by Medicare, providers must pass a state government inspection for approval. Patients enrolled in Medicare are only able to receive coverage for services from certified providers.
Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.
“Medigap” (Medicare supplement insurance) policy
Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)
Member (member of our plan, or “plan member”)
A person with Medicare who is eligible to get covered services, who has enrolled in our plan, and whose enrollment has been confirmed by the Centers for Medicare & Medi-Cal Services (CMS).