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The Annual Election Period (AEP) is the period that runs from October 15 – December 7 each year. Medicare beneficiaries can enroll in, change, or disenroll from a Medicare Advantage plan or Part D drug plan. 

The Annual Notice of Change (ANOC) letter is a notice that Medicare Advantage and Part D plan carriers must send their members each September that outlines the changes to their plan for the coming year. It may include increases or decreases to benefits, premiums, copays, and more. It may also include additions or deletions from the plan’s drug formulary for the following year. 

An appeal can be used when a you disagree with a decision on a payment or coverage of a service. An appeal can be made to Medicare directly and/or the private carrier you have your Medicare plan(s) through. 

When a provider accepts “Medicare assignment” or “Medicare’s assigned rates,” it means he or she has agreed to accept Medicare’s approved rate for your healthcare service as full payment. No balance billing is allowed. 

Attained-Age Rating is a rating class in which a Medigap insurance company determines the rate based on your current age (the age you’ve “attained”). Your premiums tend to go up as you get older. 

Balance billing is a practice in which doctors or other health care providers bill you for charges that exceed the amount that will be reimbursed by Medicare for a particular service 

 Under Medicare Part A, a benefit period begins with the day you are admitted into the hospital and lasts until you have been discharged from the hospital or facility for at least 60 consecutive days.  

Under Medicare Part D, the Catastrophic Coverage Limit kicks in after a Medicare beneficiary, and the Part D plan has spent a specific dollar amount for the year. Once you have reached the Catastrophic coverage level of your Part D plan, the plan must pay 95% of the cost of your covered medications for the remainder of the year. 

A claim is a request for direct payment or reimbursement from Medicare or another health insurance provider for covered medical services. 

Consolidated Omnibus Budget Reconciliation Act (COBRA) insurance offers retirees an opportunity to extend their former employer’s health coverage for a number of months after they have retired, usually at their own expense. 

A coinsurance is a percentage that you must pay toward your own covered healthcare services. For example, Medicare Part B covers 80% of your costs for approved services (after you meet your deductible), and you’re responsible for a 20% coinsurance. 

Community-rating is a type of Medigap rate that is based on your zip code. Everyone on the same Medigap plan from the same carrier in the same location has the same premium. 

A copay is a set dollar amount that you must pay toward the cost of your covered health-care services. For example, it’s common for insurance companies to require a copay when you visit the doctor or fill a prescription. 

 Cost-sharing is the amount of money that you are required to pay as your share of the cost of a medical service. Deductibles, copays, and coinsurance are all examples of cost-sharing. 

Sometimes called the “Donut Hole”, the Coverage Gap occurs when your total cost of prescription medications reaches a certain dollar limit that is set by Medicare each year. During the Coverage Gap, the cost that you pay toward your medications may change. You continue paying the new cost until your total out-of-pocket drug spending reached the Part D catastrophic coverage limit.  

Creditable coverage is insurance coverage that is equal to or better than your coverage from another source. For example, employer coverage from a large employer with 20 or more employees is considered creditable coverage for Medicare and allows you to delay enrollment without penalty. 

Custodial care is non-skilled medical care designed to help a person with activities of daily living like eating, dressing, bathing, transferring, and toileting. 

A deductible is the amount of money that you must pay out-of-pocket toward your covered medical expenses before the insurance plan begins to pay benefits. 

Medications on a Part D drug formulary are grouped into drug tiers that determine your portion of the drug cost. For example, Tier 1 usually includes preferred generic medications. 

To be dual-eligible means to be eligible for both Medicare and Medicaid. 

Durable medical equipment (DME) is medical equipment that is ordered or prescribed by a doctor or other Medicare provider for your use. Examples are crutches, hospital beds, oxygen equipment, canes, walkers, and wheelchairs. 

End-Stage Renal Disease (ESRD) is a chronic kidney disease in which the kidneys fail to filter waste and excess fluid from the blood. People with ESRD usually require dialysis or may need a kidney transplant. 

Evidence of Coverage (EOC) is a list of costs and covered services under your Medicare Advantage or Part D plan. Your insurance company must send you the EOC whenever you enroll in or renew your coverage. 

Under Part B, nonparticipating Medicare providers (providers who accept Medicare but don’t accept Medicare assignment) can charge up to 15% more than what Medicare will pay for a covered service. This 15% charge is called a Part B Excess Charge. 

Also called the Low-Income Subsidy, the Extra Help Part D Program is a federal program to help reduce the costs of medications under Part D for certain low-income Medicare beneficiaries. 

 A formulary is a list of medications that are covered under a Part D plan. 

A formulary exception is a request whereby a Medicare Part D plan member (and his or her doctor) asks the plan to cover a drug that is not on the formulary or to cover a drug without certain restrictions.

The General Enrollment Period (GEP) runs from January 1 to March 31 each year. It is a time when you can sign up for Medicare Part A and/or Part B if you missed your Initial Enrollment Period. Your coverage will begin on the 1st of the following month after you apply. 

When you have guaranteed renewable insurance coverage, your coverage cannot be terminated or rated-up by the insurance company due to any new health conditions that you may experience. For example, a Medigap plan is guaranteed renewable. The carrier may only cancel your policy if you fail to pay your premiums beyond the grace period. 

A Health Maintenance Organization (HMO) is a type of managed care network that is commonly found in Medicare Advantage plans. Most HMO plans will require you to designate a primary care physician and you may need referrals to see a specialist. 

Home health care are services delivered to you in your own home. This may include skilled-nursing care, physical therapy, speech therapy, and home health aide services, among other things. Certain conditions must be met to qualify for most home health care under Medicare. 

Home health care are services delivered to you in your own home. This may include skilled-nursing care, physical therapy, speech therapy, and home health aide services, among other things. Certain conditions must be met to qualify for most home health care under Medicare. 

Hospice care is end-of-life care that focuses on quality of life and pain management of symptoms. Medicare covers hospice care under Part A when a doctor certifies that you are terminally ill with a life expectancy of no more than six months. 

An Individual Health Insurance Plan is health insurance coverage that an individual under age 65 can purchase for him or herself or his or her family through the ACA Marketplace or health-care exchange. 

Under Medicare Part D, the Initial Coverage Phase is the coverage phase that follows the annual deductible phase. During initial coverage, you will pay copays or coinsurance for your covered medications as set by the insurance company providing the drug coverage. 

The Initial Enrollment Period (IEP) is a seven-month window during which individuals newly eligible for Medicare can sign up for Medicare Parts A, B, C, or D. Your IEP begins three months before your 65th birthday months and ends three months after (unless your birthday is on the 1st). 

Inpatient care is medical care that you receive after being admitted to a hospital or skilled-nursing facility. 

The Income Related Monthly Adjustment Amount (IRMAA) is an additional monthly charge that people with certain high-income levels must pay on top of their Medicare Part B and D premiums. 

Issue-Age Rating is a rating class in which a Medigap insurance company determines the rate based on the age at which you purchase your policy. 

A late-enrollment penalty is a fee that is added to your monthly Medicare premium for failing to enroll in Medicare when you were first eligible. Once incurred, the fee lasts as long as you are enrolling in Medicare, which is usually the rest of your life. 

Lifetime reserve days is a bank of 60 inpatient hospital days that you can use only once per lifetime. Under Medicare Part A, you would use your lifetime reserve days for any hospital coverage beyond the first 90 days in a given benefit period. 

Long-term care is non-medical services provided to someone who is unable to manage his or her own basic activities of daily living such as eating, dressing, bathing, and toileting. This care can be provided in your own home or at a long-term care facility such as an assisted-living home or nursing home. Medicare does not cover long-term care expenses. 

The maximum out-of-pocket (MOOP) is the most that you will need to pay towards covered Part A and B services in any one calendar year while enrolled in a Medicare Advantage plan. It includes any deductible spending, copays, and coinsurance that you spend. It does not include monthly premiums or Part D drug costs. 

Medicaid is a joint state and federal program to provide health care for low-income individuals. People who qualify for Medicaid may get assistance with paying their Parts B and D premiums, deductibles, copays, and coinsurance. 

A Medicare Medical Savings plan is a type of Medicare Advantage plan that combines a high-deductible health plan with a medical savings account. These plans have networks of providers but do not include Part D drug coverage. 

Healthcare services are medically necessary when they are needed to diagnose or treat an injury, illness, or disease under Medicare’s guidelines. 

Also known as Part C, the Medicare Advantage program is a form of managed care that allows Medicare beneficiaries to get their Parts A and B benefits through a private insurance plan and its network of providers. Many Medicare Advantage plans offer a built-in Part D drug plan. 

 A Medicare Cost plan is a type of Medicare health plan that offers its members both a network of doctors and hospitals as well as the ability to seek treatment with non-network providers under Original Medicare. 

Medicare Part A covers inpatient hospital stays, blood transfusions, skilled nursing, home health services, and hospice care. 

Medicare Part B covers outpatient medical services, including preventative care, visits to your doctors, lab testing, and more. 

Also known as Medicare Advantage, the Part C program is a form of managed care that allows Medicare beneficiaries to get their Parts A and B benefits through a private insurance plan and its network of providers. Many Part C plans offer a built-in Part D drug plan. 

Medicare Part D is voluntary prescription drug coverage that is available either through a Medicare Advantage plan or through a standalone Part D plan. 

Medicare Savings Programs are state programs that use Medicaid funds to help eligible low-income individuals pay for some or all of their out-of-pocket expenses under Medicare. 

A Medicare SELECT plan is a type of Medigap plan that operates a network of hospitals. Policyholders must see treatment at these hospitals for their care to be covered

A Medicare Summary Notice (MSN) is a quarterly explanation of benefits statement that Medicare provides to show you the healthcare services received and what Medicare paid toward them. You should review your MSN to determine if you owe any balances that are due. 

A medical power of attorney, also known as a health care proxy, allows you to choose someone you trust to make decision about your medical care in case you are unable to. 

Also known as a PPO plan, a Preferred Provider Organization is another type of managed care network that is commonly operated by Medicare Addvantage plans. PPO plans have flexible networks, meaning that you can see out-of-network providers at an additional cost to you. 

A premium is a monthly expense that you pay to an insurance carrier in exchange for coverage of your health risk. 

A prescription drug is a medicine that is prescribed by a doctor and is generally not available over the counter. 

Preventive care is screening tests and other care that is provided to prevent illness or disease. Many of Medicare’s preventive care services are covered at 100%. 

A primary care physician (PCP) is a family care doctor or internist that you select to be your primary physician when you enroll in certain Medicare Advantage plans. Under a Medicare HMO plan, this doctor must write a referral for you to see a specialist. 

Primary coverage is the health insurance coverage that pays first when you have more than one type of medical coverage. 

Prior authorization is an approval that you must get from your Part D insurance company before it will cover a medication. This usually involves additional paperwork that the insurance company will ask of your doctor as to why you need this medication. 

A Medicare Private Fee for Service Plan (PFFS) is a type of Medicare Advantage plan that allows you to be treated by any doctor who is willing to accept the plan’s terms and bill the plan for your treatment. PFFS plans are not typically found in areas where two or more network Medicare Advantage plans operate, so they can be hard to find. 

Secondary coverage is the health insurance coverage that pays after the primary coverage first pays when you have more than one type of coverage.  

A service area is an area in which a Medicare Advantage plan offers its network coverage. You must live in a Medicare Advantage plan service area to be eligible to enroll. 

A skilled-nursing facility (SNF) is an inpatient rehabilitation center where Medicare beneficiaries can go for continuing health care, usually after a hospital stay. An SNF is staffed with a variety of medical professionals to aid in the recovery of its patients. 

Special Election Periods are certain times when a Medicare beneficiary is allowed an exception to enroll or disenroll in a Medicare Advantage or Prescription Drug plan outside the Initial Enrollment Period or Annual Election Period. 

Special Enrollment Periods are certain times when a Medicare beneficiary is allowed an exception to enroll in Medicare outside of the normal Initial Enrollment Period. 

A Special Needs Plan is a type of Medicare Advantage plan that is designed to assist beneficiaries who have a specific qualifying chronic illness or who have both Medicare and Medicaid. Special Needs Plans also exist for people who live in institutions. 

A standalone Part D plan is drug coverage that you can purchase to go alongside your Original Medicare and Medicare Supplement benefits. 

Step therapy is a restriction that an insurance company places on a medication that requires the patient to first try an alternative and less expensive medication before the plan will cover the more expensive medication. 

A Summary of Benefits is a document that gives a breakdown of the details specific to your plan. Every Medicare Advantage and Part D plan have a Summary of Benefits. The Summary of Benefits goes over what healthcare services your plan will cover and your cost-sharing expenses. This helps the beneficiary know their costs before they receive a service or pick up a prescription. 

Special Election Periods are certain times when a Medicare beneficiary is allowed an exception to enroll or disenroll in a Medicare Advantage or Prescription Drug plan outside the Initial Enrollment Period or Annual Election Period. 

Telemedicine is a medical or health service that allows beneficiaries to communicate with a practitioner in a separate location by either using a computer, phone, or television. 

Under a Medicare Advantage plan, you have a one-time Trial Right to leave your coverage during the first 12 months and return to Medicare and/or your prior Medigap company. Your Trial Rights allow you to enroll or re-enroll in a Medigap plan without medical underwriting. 

TRICARE for Life (TFL) is health insurance coverage that pays secondary to Medicare for eligible retired service members and their family members. TFL functions as a wraparound or supplemental coverage to Medicare.  

True out-of-pocket (TrOOP) is the total out-of-pocket costs that you spend during a calendar year on covered medications that are listed in your Part D plan’s formulary. Once you reach your TrOOP, you will move into the catastrophic coverage phase of your plan. 

Underwriting is a process used by insurance companies to assess the financial risk of taking you on as an insured member. Underwriters will review your answers to medical questions as well as your medical records to determine whether the company will offer you coverage.