Medicare Glossary

Terms and Definitions

Here are definitions to some common terms you'll see when reading about Medicare coverage.

Catastrophic coverage
A coverage stage within the Medicare Part D prescription drug benefit. This coverage applies after you have reached your plan's annual out-of-pocket cost limit for covered drugs in a calendar year.
 
Coinsurance
A percentage amount you pay for a covered service or prescription. For example, you might pay 20% of the cost of your doctor office visit each time you see your doctor.

Copayment, copay
A fixed dollar amount you pay for a covered service or prescription. For example, you might pay a $20 copay each time you see your doctor.

Coverage gap
A coverage stage within the Medicare Part D prescription drug benefit. The coverage gap applies after your drug costs have reached a certain amount during the calendar year. This amount includes both what you've paid and what your plan has paid. During the coverage gap you have less coverage and pay more for your drugs. After you've paid a certain amount out of pocket, including the value of any brand-name drug discounts you receive while in the coverage gap, you qualify for catastrophic coverage.

Deductible
An amount you must pay out of pocket before your plan begins covering costs for most services or prescriptions. Not all plans have deductibles.

Drug cost, total drug cost
In the Medicare Part D prescription drug benefit, this is the full price of a drug, or the amount you pay and the amount your plan pays for a drug, added together.  
If you get extra help paying your drug costs, the coverage gap does not apply to you.

Formulary
A list of drugs that a plan covers. 

Health maintenance organization (HMO)
A managed care-type of Medicare health plan. Medicare HMO plans must cover all Medicare Part A and Part B services. With most HMO plans, you can only go to doctors, specialists, or hospitals in the plan's network, except in an urgent or emergency situation.

In network
Doctors, hospitals, pharmacies, and other health care providers that have agreed to provide members of a health plan with services and supplies at a discounted price. With some health plans, your care is covered only if you get it from in-network providers.

Initial coverage
A coverage stage within the Medicare Part D prescription drug benefit. This coverage applies from the beginning of the calendar year and continues until your drug costs reach a certain amount. During the initial coverage stage, you typically pay a copay or coinsurance for your drugs. 

Medicare Part A
Federally funded insurance for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B
Federally funded insurance that helps pay for certain doctors' services, outpatient hospital care, durable medical equipment, and some medical services that aren't covered by Part A.

Medicare Part C
Part C refers to Medicare Advantage plans, which combine your benefits from Parts A, B, and sometimes D (prescription drugs) in a single plan. Medicare Advantage plans are offered through private companies and must be approved by Medicare.

Medicare Part D
Federally funded insurance for prescription drugs that is available through private companies as stand-alone drug coverage or as part of a Medicare Advantage plan that includes Part D.

Out of network
If a plan offers an out-of-network benefit, you have the option to seek plan services outside of the plan's contracted network of providers. Out-of-pocket costs may be higher for out-of-network services.

Out-of-pocket cost
Any cost you pay for covered services or prescriptions. Deductibles, copayments, and coinsurance are all out-of-pocket costs.

Out-of-pocket maximum
The most you will have to pay out of pocket for services or prescriptions in a calendar year. Plans may have different maximum amounts for medical and drug expenses.

Preferred provider organization (PPO)
A type of Medicare Advantage plan where you pay less if you use doctors, hospitals, and providers that are part of the plan's preferred network. Typically, you can use doctors, hospitals, and providers outside of the network for an additional cost.

Tier, drug tier
A classification used to identify what cost share you pay for a drug. More commonly used and less expensive drugs are in lower tiers (for example, tier 1 or tier 2) and have lower cost shares. Specialty or higher-cost drugs are classified in higher tiers (for example, tier 5) and have higher cost shares.

Get a free info kit right now

Questions? Call Us:

Prospective members
8 a.m. - 8 p.m., Monday - Friday
1-800-446-8882
TTY WA Relay 1-800-833-6388 or 711

Extended hours Oct. 1 - Feb. 14
8 a.m. - 8 p.m., 7 days a week

Current members
CUSTOMER SERVICE
8 a.m. - 8 p.m., Monday - Friday
1-888-901-4600
TTY WA Relay 1-800-833-6388 or 711

Extended hours Oct. 1 - Feb. 14
8 a.m. - 8 p.m., 7 days a week

NCQA Excellent Accreditation

Group Health Cooperative Medicare (HMO) was rated 4.5 out of 5 in the National Committee for Quality Assurance (NCQA) Medicare Health Insurance Plan rankings 2015-2016.