Feeling Overwhelmed by Medicare Lingo? You’re Not Alone.
If you’re about to enroll in Medicare—or even just exploring your options—you’ve probably come across a sea of confusing terms.
Part A, Part B, Advantage, Medigap, formulary… What does it all mean?
Let’s take the mystery out of Medicare by breaking down the key terms you’ll want to understand before enrolling.
The Most Important Medicare Terms (In Plain English)
1. Original Medicare
This refers to Part A and Part B—the traditional government-run Medicare program. It helps cover hospital and medical services.
- Part A = Hospital insurance
- Part B = Medical insurance (like doctor visits and outpatient care)
2. Medicare Advantage (Part C)
A Medicare Advantage plan is offered by private insurance companies approved by Medicare. These plans bundle your Part A and Part B coverage and often include extra benefits.
Important: You still have Medicare when you enroll in a Medicare Advantage plan—it’s just managed by a private carrier instead of the government.
3. Part D (Prescription Drug Coverage)
This is optional coverage that helps pay for your prescription medications. You can get it:
- As a standalone plan (if you have Original Medicare), or
- Included in most Medicare Advantage plans (MAPD)
4. Medicare Supplement (Medigap)
These are additional insurance plans that help pay the “gaps”—like deductibles, coinsurance, and copayments—not covered by Original Medicare. They do not work with Medicare Advantage plans.
You usually need to enroll in Original Medicare to be eligible for Medigap.
5. Network
This refers to the group of doctors, specialists, and hospitals a Medicare Advantage plan works with. Some plans (like HMOs) require you to stay in-network. Others (like PPOs) allow you to go out-of-network for higher costs.
Tip: Always check to see if your doctors are in-network before enrolling in any plan.
6. Formulary
This is a fancy word for a list of covered prescription drugs under a Part D or MAPD plan. Each plan has its own formulary, and it’s categorized by “tiers,” which affect how much you pay.
7. Premium
This is the monthly cost you pay to have coverage.
Example: You’ll usually pay a monthly premium for Part B—even if you choose a $0-premium Medicare Advantage plan.
8. Deductible
This is the amount you pay out of pocket before your plan starts covering costs. Some plans have low or no deductibles for certain services.
9. Copayment and Coinsurance
- Copayment: A fixed dollar amount you pay for a service (e.g., $20 for a doctor visit)
- Coinsurance: A percentage of the cost (e.g., 20% of a hospital bill)
10. Enrollment Periods
There are different times you can enroll or make changes to your coverage:
- Initial Enrollment Period (IEP): Around your 65th birthday
- Annual Enrollment Period (AEP): Oct 15 – Dec 7 each year
- Special Enrollment Periods (SEPs): If you move, lose other coverage, etc.
11. MOOP (Maximum Out-of-Pocket Limit)
This term applies to Medicare Advantage plans. It’s the maximum amount you’ll pay out of pocket in a year for covered services. Once you hit this limit, the plan pays 100% of covered costs.
In Conclusion: Medicare Doesn’t Have to Feel Like a Foreign Language
Understanding Medicare starts with learning the terms.
Once you’ve got the basics down, comparing your options becomes a lot easier—and way less stressful.
Whether you’re just turning 65 or reviewing your current coverage, knowledge is your best tool.
Want help navigating your options?
A licensed agent can walk you through these terms, answer your questions, and help you review plans available in your area—without pressure or obligation.
