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| (CMS) Centers for Medicare and Medicaid Services |
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The federal agency overseeing both the Medicare and Medicaid programs. They were made responsible for carrying out the legislation that put the Part D insurance plans into existence and overseeing how all of the plans conduct business.
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| cancellation |
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Termination of a policy before its normal expiration date.
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| caregiver |
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A person who helps care for someone who is ill, disabled or aged. Some caregivers are relatives or friends who volunteer their help. Some people provide caregiving services for a fee.
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| catastrophic coverage |
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This is the last portion of coverage in a Part D plan in which the plan pays almost the entire drug expense for the remainder of the calendar year. The portion that the beneficiary pays during this step is a very small amount of the drug expenses (approximately five percent).
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| catastrophic limit |
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The catastrophic limit is the highest amount of money you’ll have to pay out of your own pocket in a year for certain covered prescription drug charges.
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| certificate of insurance |
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The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what is covered, what is not, and insurance limits.
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| chronic condition |
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Prolonged conditions or illness, such as heart disease, asthma, diabetes.
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| claim |
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A request by an beneficiary (or their provider) to the insurance company for the insurance company to pay for services obtained from a health care professional.
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| coinsurance |
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The portion of cost belonging to the beneficiary after costs are split on a percentage basis. In a 20/80 plan, the beneficiary would pay 20%.
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| coinsurance out-of-pocket maximum |
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After this maximum is met, the plan pays 100% of covered expenses.
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| copayment or copay |
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When the beneficiary pays a pre-determined, flat amount for each service. A doctor's visit copay is often ten or fifteen dollars.
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| COBRA |
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A Federal law that gives the right to pay for continued group health care coverage for a specified period if the person loses coverage because of reduced work hours or leaving or loss of a job.
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| coordination of benefits |
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This occurs when the insured is covered under more than one plan (for example under a group plan at work, and as a family member on a spouse's plan) the benefits from the plans are coordinated so as to limit the total benefits from all plans. Usually, the benefits from all plans will not exceed 100% of the covered medical expenses.
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| cost sharing |
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The way in which insurance plans share their costs. Examples of cost sharing are co-insurance and co-payments.
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| coverage |
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The benefits package received from an individual insurance plan. Under Part D, prescription drug costs paid by the insurer are the benefits package, also known as coverage.
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| coverage gap |
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The gap in your coverage that spans between ordinary drug coverage and catastrophic drug coverage. In this gap, the Medicare beneficiary pays 100% of their prescription costs. According to the federal government, about 88% of Medicare beneficiaries who enrolled in a Medicare Part D plan do not have Donut Hole (or doughnut hole) coverage. The standard or model Part D coverage begins with a deductible of $275 followed by a co-pay of 25% on the next $2235 (you pay $558.75). Upon reaching the total medication costs of $2510 (with $833.75 out of pocket), coverage ceases and the beneficiary is 100% responsible for all costs during a "blackout period" known as the "Donut Hole" or "Coverage Gap", until a new spending tier, an additional $3216.25 out of pocket, is reached and coverage kicks in again at the "Catastrophic" level. See Doughnut (Donut) Hole.
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| creditable coverage |
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A plan other than a Part D plan that offers Prescription drug coverage and which meets certain Medicare standards.
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