Improve your health literacy with these 11 Medicare key terms

Apex Blog - Improve your health literacy with these 11 Medicare key terms

October is Health Literacy Month. According to, personal health literacy is “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.” This means the ability to not just understand health information, but use it to make better, well-informed decisions about your health.

At ApexHealth, we want to make health care, particularly Medicare, simple and easier to understand. This includes translating “health care speak” into simple language and giving you convenient access to the information you need. When it comes to health literacy and Medicare education, there are a number of Medicare key terms you’ll need to know, especially as you navigate through this fall’s open enrollment period.  

1. Coinsurance

Coinsurance is the amount you may be required to pay as your share of the cost for services or prescription drugs after you pay any plan deductibles. For example, with Original Medicare, this is a percentage – usually 20 percent – of the Medicare approved amount. Medicare Advantage plans may feature coinsurance of their own, and Medicare Part D prescription drug plans may feature coinsurance amounts that vary depending on the type of drug and what tier that drug is in.

2. Copayment (copay)

Copays are a fixed amount you pay for each covered medical service, such as a doctor’s visit, or prescription drug after you’ve paid your deductible. The difference between copays and coinsurance is that coinsurance involves a percentage of the total bill while a copay is a flat fee.  

3. Cost sharing

Cost sharing refers to the amount you pay for health care services and/or prescription drugs. This amount includes any combination of coinsurance, copays and/or deductibles.

4. Coverage gap

The coverage gap, also known as the “donut hole” is known as the gap in coverage that happens when someone with Medicare Part D coverage goes beyond the initial prescription drug coverage limit. If this happens, you are then responsible for more of the cost of prescription drugs until your expenses reach the catastrophic coverage threshold. Once this happens, you’ll pay a small coinsurance or a small copay (depending on your plan) for covered prescription drug costs until the end of the plan year.

5. Deductible

A deductible is the amount you must pay for health care or prescription drugs, before Original Medicare, your prescription drug plan, or other insurance begins to pay. For example, in Original Medicare, you pay a new deductible for each benefit period for Part A, and each year for Part B. These amounts can change every year. Not all Medicare Advantage plans have a deductible.

6. Formulary

A formulary is a list of prescription drugs covered by a Medicare plan. Different Medicare plans offer different types of coverage with different cost share. Find out if ApexHealth covers your prescriptions by visiting our formulary search tool.

7. Maximum Out-of-pocket

The most you pay for copays, coinsurance, and deductibles for medical services for the year. Once you reach the maximum out-of-pocket, your health plan pays 100% of covered medical services. Your premium and prescription drugs don’t count toward the maximum out-of-pocket. Original Medicare does not have a maximum out-of-pocket. Some, but not all, Medigap plans have a maximum out-of-pocket limits. All Medicare Advantage plans have limits on your out-of-pocket costs. The Centers for Medicare & Medicaid Services (CMS) sets a maximum out-of-pocket limit (MOOP) for Medicare Advantage plans for combined in and out of network expenses each year; however, some plans may set lower limits.

8. Premium

A premium is a monthly payment to Medicare or a health insurance plan for health care or prescription drug coverage. The standard Medicare Part B premium is set each year by CMS, and you’ll pay that amount monthly (and it’s usually deducted from your Social Security check). If you purchase a Medigap plan, you’ll have to pay your monthly Part B premium plus an additional (and often higher) premium for your Medigap plan. Monthly premiums vary by Medicare Advantage plan, with some plans offering $0 premiums. You’ll also need to pay your monthly Part B premium.

9. Preventive services

Preventive services are health care services to keep you healthy or to help prevent illness. Medicare covers many preventive services at no cost to your patients. Learn more from CMS. Medicare Advantage plans will cover any preventive services approved by Medicare during the contract year. Just remember that there are some items not covered at a $0 cost. Also remember that preventive services help prevent and find diseases early when treatment works best.

10. Primary care provider (PCP)

A primary care provider (PCP) is a doctor or other provider trained to give you basic care. Your PCP is the provider you see first for most health problems and makes sure that you get the care that you need to keep you healthy. Your PCP will also coordinate with other doctors, health care providers and specialists to coordinate your care and refer you to them. In many Medicare health plans, you’ll need to see your PCP before you can see any other health care provider or specialist.

11. Provider network

Many Medicare Advantage plans have networks of health care providers which include doctors, other health care providers, hospitals, facilities and pharmacies. With most Health Maintenance Organization (HMO) Medicare Advantage plans, you can only go to a specific network of doctors, providers, specialists, or hospitals that are part of a plan’s network, except in cases of emergency. Search for doctors/providers, hospitals/facilities, dentists, and hearing providers that are part of ApexHealth’s provider network.

Of course, we’ve only scratched the surface on Medicare 101 and Medicare education. The good news is, we have a great team of ApexAssistants available to simplify Medicare and help you out! Questions? Give us a call at (844) 279-0508 (TTY: 711). Our hours of operation are Monday through Friday 8 a.m. – 8 p.m. (local time) from Apr. 1 through Sept. 30 and seven days a week 8 a.m. – 8 p.m. (local time) from Oct. 1 through Mar. 31.


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