Common Terms

Here is a list of useful words and terms to have handy when reviewing your Medicare coverage options.

Annual Coordinated Election Period

The period between November 15 and December 31, when any Medicare beneficiary can enroll in a Medicare Advantage or Medicare Advantage Prescription Drug plan.

Centers for Medicare and Medicaid Services (CMS)

The federal agency that runs the Medicare program.

Co-payment

The fee you pay at the time of service, in accordance with the terms of your coverage.

Formulary

A list of prescription drugs that have been reviewed and selected for medical and cost-effectiveness. Includes brand-name and generic drugs, all of which are FDA (Food and Drug Administration) approved.

Deductible

Dollar amount that an insured person must pay each year before an insurer will assume any liability for the remaining costs of covered services. (Empire Blue Cross Blue Shield does not charge a deductible for Part D Prescription Drug Coverage).

Exclusions

Specific conditions or circumstances that are not covered under your benefit agreement. It is very important to consult your benefit contract to understand what services are not covered benefits.

Medicaid

A joint federal/state medical assistance program established by the Social Security Act for those who meet the income requirement. As a Medicare beneficiary, you may also be eligible for Medicaid. Medicaid can cover all or part of your Medicare premiums and/or deductibles and coinsurance. If you think you qualify, you should inquire about Medicaid and related programs by calling your state Medicaid agency.

Medicare (also called “original” Medicare, “traditional” Medicare or “fee-for-service” Medicare)

A plan that is available to seniors everywhere in the U.S. It is the national pay-per-visit program that lets you go to any doctor, hospital or health care provider who accepts Medicare. Medicare pays its share of the Medicare-approved amount and you pay your share. You must pay the deductible.

Medicare Part A

Medicare's hospital insurance program. Helps pay for inpatient hospital care, skilled nursing care following a hospital stay, home healthcare and hospice care. Part A is financed in part by the Social Security payroll withholding tax and the Self-Employment tax. If you qualify for benefits under the Social Security or Railroad Retirement systems or through government employment, you also qualify for premium-free Part A benefits.

Medicare Part B

Optional supplementary medical insurance that requires a monthly premium. Covers physician services in hospital and non-hospital settings, and services furnished by certain non-physician practitioners. Coverage also includes lab testing, Durable Medical Equipment, diagnostic tests, ambulance services, prescription drugs that can't be self-administered, some self-administered anticancer drugs, and other therapies. Health services and blood services not covered by Medicare Part A.

Medicare Part C

The program that offers Medicare beneficiaries the option of enrolling in a managed care plan to receive their Medicare benefits (both medical and drug coverage). The program replaces the Medicare + Choice (M+C) program under Part C in Medicare and is also referred to as Medicare Advantage.

Open Enrollment Period

A limited time period when enrollment applications for coverage or changes in your coverage may be made. The open enrollment period is January 1 to March 31.

Provider

The general term used for doctors, other healthcare professionals, hospitals and other healthcare facilities that are licensed or certified by the State to provide healthcare services.

Primary Care Physician (PCP)

The health care professional you select to provide your routine medical care. Your PCP also coordinates other covered services you receive as a plan member, including referrals to specialists, laboratory tests, x-rays, prescription medications, hospital admissions and follow-up care. Using a PCP helps control out-of-pocket medical costs. All members of HMO plans must choose a PCP, who may be a Family Practitioner, General Practitioner or an Internist.