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Glossary of terms


Annual enrollment period:
October 15 to December 7. Medicare’s annual election period when you can enroll in a plan or change the way you receive coverage.

Benefit period: A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility (SNF). The benefit period ends when you haven’t received any inpatient hospital or SNF care for 60 days in a row.

Catastrophic coverage: Coverage stage when your plan pays most of the cost of your drugs for the remainder of the calendar year.

Coinsurance: An amount you are required to pay as part of your share of the cost for services. For example, if you have Medicare Part B, and you see your doctor because you don’t feel well, you are responsible to pay for 20% of the cost for that doctor office visit.

Copayment: A set dollar amount that you must pay as your share of the cost for services or items covered by your plan.

Coverage gap ("donut hole"): Coverage stage when you pay most of the plan's negotiated price for your drugs and your plan pays a small amount .

Deductible: A set dollar amount that you must pay out of pocket before services are paid by your health insurance carrier.

Extra Help: A Medicare program that helps people with limited income to pay for their prescription drug costs and medications. Costs covered may include premiums, deductibles, copayments and/or coinsurance.

HMO: Health Maintenance Organization plan. Health Maintenance Organization plans are offered by private health insurance companies and offer a specific network of providers from whom their patients can receive care. Members of these plans must choose a primary care provider (PCP) who will coordinate their care and provide referrals when needed.

HMO-POS: Health Maintenance Organization plan with a Point-of-Service option. These plans are offered by private health insurance companies and offer out-of-network coverage for certain services. Members of these plans must choose a PCP.

Premium: The cost you must pay to Medicare and/or a private health insurance plan that provides you coverage. This cost is a set dollar amount and is typically paid on a monthly basis.

PACE: Program of All-Inclusive Care for the Elderly. These plans are voluntary programs offered by private health insurance companies that provide comprehensive medical and social services to members which allow them to continue living in their homes, rather than in a nursing home. Members must be 55 years of age or older and clinically eligible to meet Massachusetts’ standards for nursing home care.

PPO: Preferred Provider Organization plan. Preferred Provider Organization plans are offered by private health insurance companies and allow members to receive care in- or out-of-network. Members of these plans do not have to choose a PCP.

SCO: Senior Care Option plan. Available in Massachusetts, Senior Care Option plans are voluntary coverage plans offered by private health insurance companies. These plans combine social support with health care coverage to those who are 65 and older and are eligible for Medicaid coverage. Members of these plans must choose a PCP.

SNP: Special Needs Plan. A special type of Medicare Advantage plan that is offered by private health insurance companies and provide more focused health care for specific groups of people, such as those who have both Medicare and Medicaid or those who have certain chronic medical conditions. Members of most of these plans must choose a PCP.

Fallon Health is an HMO/HMO-POS plan with a Medicare contract and a contract with the Massachusetts Medicaid program. Enrollment in Fallon Senior Plan and NaviCare depends on contract renewal.


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The information on this page was last updated on 6/24/2015.