Health Insurance Glossary
Annual Plan Deductible: The amount of covered medical expenses a member pays per calendar year before a health plan begins covering services.
Annual Maximum: The amount a member pays out-of-pocket for benefits each year before the plan pays at 100%.
Coinsurance: The set amount a member pays (usually a percentage) for a service before the plan begins to pay benefits.
Copayment/Copay: The set amount a member pays for a medical service.
Creditable Coverage: Prescription drug coverage that is on average at least as good as if not better than the standard Medicare Part D prescription drug coverage.
Deductible: The amount a member pays for a service before the plan begins to pay benefits.
Effective Date: The first day plan coverage begins.
Emergency Medical Care: Medical care provided in a hospital emergency room.
Formulary: A list of preferred drugs approved for use by a health insurance plan.
In-Network: Physicians and hospitals that agree to accept an insurance provider’s terms and payments.
IRMAA: Income-Related Monthly Adjustment Amount (IRMAA). An additional amount that must be paid for Medicare Part B and Part D by Medicare beneficiaries who have higher incomes.
Lifetime Reserve Days: Additional days that Original Medicare will pay for hospitalization longer than 90 days. A total of 60 reserve days can be used during a lifetime. Original Medicare pays all covered costs except for daily coinsurance for reserve days. A Group Medicare Advantage plan may cover more inpatient hospital days than Original Medicare.
Medicare (Original): Original Medicare consists of Part A and Part B. It is run by the federal government. Original Medicare pays hospitals and doctors directly for your care. Original Medicare pays some but not all of the cost of your care.
Medicare Advantage: Medicare Advantage plans are also known as Medicare Part C. Medicare Advantage plans combine the services of Part A and Part B. Medicare Advantage plans are offered by private insurance companies and approved by Medicare. Group Medicare Advantage plans may be sponsored by pension funds, retirement systems and other entities who may choose to enhance the level of benefits offered.
Medicare Part D: Medicare Part D is prescription drug coverage offered by private insurance companies. The federal government sets a minimum standard of prescription benefits that must be covered by Part D plans. Group Medicare Part D plans may be sponsored by pension funds, retirement systems and other entities who may choose to enhance the level of benefits offered.
Medigap: Insurance coverage offered by private companies that helps pay the costs that Original Medicare (Parts A and B) doesn’t cover, such as Part A and B deductibles and coinsurance. Original Medicare provides coverage first, then Medigap helps fill in the gaps. The federal government defines standard benefits for Medigap plans. Premiums may vary between health insurance companies offering Medigap plans for identical coverage. Medigap premiums are regulated by each state.
MedPay: CTPF’s program that pays Medicare Parts A, B, & IRMAA Part B for enrolled members who must pay a premium for both Medicare Part A and B.
Open Enrollment: The period when retirees or survivors can enroll in a health insurance plan for the first time, change health insurance plans, or add dependents to a health insurance plan.
Out-of-Network: Physicians and hospitals who do not accept a health insurance provider’s terms and payments. Charges are usually higher than in-network providers.
Out-of-Pocket Maximum: The maximum amount paid out-of-pocket for covered expenses in any plan year. After the out-of-pocket maximum is met, the plan pays at 100% of eligible charges or the Usual and Customary charge as determined by the health plan carrier.
Premium: Periodic payment to maintain health care or prescription drug coverage.
Primary Care Physician (PCP): A physician responsible for a member’s complete health care services. A PCP can make referrals to specialists and other health care providers for services.
Referral: A written order required from a PCP that allows a visit to a specialist or to obtain certain services.
Special Deductible: Emergency room deductible and non-PPO admission deductible. These deductibles are in addition to the annual plan year deductible.
Urgent Medical Care: Medical care provided in an urgent care facility.