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Learn More About Your Insurance
If you have health insurance, your health insurer pays some or all of your healthcare costs in exchange for a premium (the amount you pay for your health insurance every month).
In the US, health insurance is generally divided into two different categories: private/commercial or government.
Commercial health insurance, also known as private health insurance, is issued by a private company or entity. Commercial insurance is usually purchased through your work, but you can also buy commercial health insurance through other sources like the Affordable Care Act (ACA) marketplace. Private/commercial health insurance cannot be issued by government entities such as Medicare or Medicaid.
You may have Medicare, Medicaid, or both.
Medicare is a federal health insurance program for:
- People aged 65 years or older
- Certain younger people with disabilities
- People of any age with end-stage renal disease (ESRD), which refers to permanent kidney failure requiring dialysis or a transplant
There are 4 parts of Medicare: A, B, C, and D.
- Medicare Part A: hospital insurance
- Medicare Part B: medical insurance
- Medicare Advantage (MA), also known as Medicare Part C
- Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. MA plans offer Part A and Part B coverage, in addition to vision, hearing, and dental services, as well as prescription drug coverage (Part D)
- Medicare Part D: prescription drug coverage
- Medicare coverage that helps with the cost of prescription drugs, including shots and vaccines
You can choose to get coverage either through Original Medicare (Parts A and B) or Medicare Advantage (Part C).
Medigap, also known as Medicare Supplement Insurance, is extra insurance you can buy from a private (also known as commercial) health insurer to help with costs in Original Medicare (Medicare A and B).
Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. Medicaid offers benefits not normally covered by Medicare, like nursing home care and personal care services. People who get both Medicare and Medicaid are known as dual-eligible. The rules around who’s eligible for Medicaid are different in each state.
Appeal
A request for your health insurer or plan to review a decision or a grievance again.
Benefit period
A specific time frame during which an insurance plan provides coverage for medical services.
Coinsurance
An amount you may have to pay as your share of the cost for services after you pay any deductibles, usually as a percentage (for example, 20%).
Copayment
An amount you may have to pay as your share of the cost for benefits, after you pay any deductibles, usually a fixed amount, like $30.
Coverage gap
The Medicare coverage gap was phased out in 2020 and referred to a period of time in which Medicare patients had to pay higher cost sharing for prescription drugs until they spent enough to qualify for catastrophic coverage. The coverage gap (also called the “donut hole”) started when the Medicare patient and their plan paid a set dollar amount for prescription drugs during that year.
Deductible
The amount you must pay for healthcare or prescriptions before your insurance begins to pay.
Formulary
A list of prescription drugs covered by an insurance plan offering prescription drug benefits. Also called a drug list.
Healthcare provider
A person or organization that's licensed to give healthcare. Doctors, nurses, and hospitals are examples of healthcare providers.
Low-Income Subsidy (LIS) (also known as Extra Help)
A Medicare Part D program that helps people with limited income and resources pay their premiums, deductibles, coinsurance, and other costs.
Medicaid
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 healthcare costs are covered if you qualify for both Medicare and Medicaid.
Medicare Advantage (MA), also known as Medicare Part C
A type of Medicare-approved health plan from a private company that you can choose to cover most of your Part A and Part B benefits instead of Original Medicare. It usually also includes drug coverage (Part D).
Medicare Savings Program
State-run programs that help people with limited income and resources pay some or all of their premiums, deductibles, and coinsurance for Original Medicare.
Network
The facilities, providers, and suppliers your health insurer or plan has contracted with to provide healthcare services.
Out-of-pocket costs
Health or prescription drug costs that you must pay on your own because they are not covered by Medicare or any other insurance. These include deductibles, coinsurance, and copayments for covered services, plus all costs for services that are not covered.
Premium
The periodic payment that an insurance company or a healthcare plan (including Medicare) requires for health or prescription drug coverage.
Prior authorization (PA)
A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called preauthorization, prior approval, or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization does not guarantee that your health insurance or plan will cover the cost.
State Health Insurance Assistance Program (SHIP)
A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.
Tiers
Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.
Call 1-855-2-INPEFA
(1-855-246-7332)(1-855-246-7332), Monday to Friday 8 AM to 8 PM ET, with any questions or to learn more.