Medicare FAQs

When you’re eligible to sign up for Medicare Part A or Part B for the first time.

Original Medicare is the traditional fee-for-service program offered by the federal government, which pays directly for your healthcare. You can see any doctor who takes Medicare, anywhere in the country.

A type of health plan. Generally, a primary care provider arranges your healthcare in the plan’s provider network.

This type of health plan gives you the freedom to choose your own doctors and hospitals. Your
out-of-pocket costs may be lower if you choose healthcare providers
in the plan’s provider network.

Plan requires the member to find doctors, hospitals and other types of providers that accept Medicare and the plan’s payment terms. Some PFFS plans have a network of providers. You can still see out-of-network providers that accept the plan’s payment terms, although you may pay more. A PFFS plan is not for Medicare Supplement insurance. Providers who do not contract with the PFFS plan are not required to see plan members except in
an emergency.

Plans that may offer benefits, providers and Drug Lists designed to meet the specific needs of the groups they serve. People with chronic conditions, like diabetes or heart conditions, or who have both Medicare and Medicaid, may benefit from this type of plan.

A percentage of your medical and drug costs that you pay out of your pocket. Some plans may require that you pay a deductible first.

The fixed dollar amount some plans require you to pay when you receive medical services or have a prescription filled.

The amount you pay for medical services or prescriptions before your plan pays for your benefits.

Also called a Drug List, the formulary lists the drugs your plan covers. It’s often divided into sections, or tiers, based on the amount your plan will pay for the drugs in that group.

These pharmacies allow you to order your medicines and supplies (like diabetes test strips) and have them mailed to you. Many mail-delivery pharmacies will allow you to fill many maintenance medications for up to a 90-day supply and provide regular refill reminders. Some medications may only be filled for a
30-day supply.

Medicare defines this as services or supplies needed for the diagnosis or treatment of a medical condition. These services and supplies must meet the standards of good medical practice in the local area and cannot be mainly for the convenience of you or your doctor.

A group of healthcare providers who have agreed to provide care based on a plan’s terms and conditions. These providers include doctors, hospitals and other healthcare professionals and facilities.

Anything you are required to pay for medical care, prescriptions and other healthcare services. These include coinsurance, copayments and deductibles.

A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

A state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.

A state agency that regulates insurance and can provide information about Medigap policies and other private health insurance.

If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called excess charge.

Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, such as exclusions for pre-existing conditions, and can’t charge you more for a Medigap policy because of a past or present health problem.

An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable.

The process that an insurance company uses to decide, based on your medical history, whether or not to take your application for insurance, whether or not to add a waiting period for pre-existing conditions (if your state law allows it), and how much to charge you for that insurance.

In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.

A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

A one-time-only, 6-month period when federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first and month that you’re covered under Medicare Part B, you’re 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional Open Enrollment rights under state law.

The periodic payment to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage.