Appeal

The process you follow if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare drug plan.

Annual Enrollment Period (AEP)

The time from October 15 to December 7 each year when you can switch or join Medicare Advantage or Part D prescription drug plans. You can also move between Original Medicare and Medicare Advantage.

Assignment

An agreement where your doctor or provider accepts Medicare’s approved payment amount as full payment, billing you only for deductibles and coinsurance.

Beneficiary

A person who receives Medicare or Medicaid benefits.

Benefit Period

A way Original Medicare measures hospital or skilled nursing facility use. It starts when you're admitted and ends when you've been out of inpatient care for 60 consecutive days. There’s no limit to the number of benefit periods.

Claim

A request for Medicare or health insurance to pay for services or items you received.

Coinsurance

The percentage of the cost you pay for services after meeting your deductible. (Example: 20%)

Copayment

A fixed amount (like $10 or $20) you pay for a medical service or drug.

Coverage Gap ("Donut Hole")

A temporary limit in Part D coverage where you pay more out of pocket until reaching catastrophic coverage.

Creditable Prescription Drug Coverage

Other insurance (like from an employer) that pays at least as much as Medicare’s standard drug coverage.

Critical Access Hospital

A small hospital in a rural area providing limited inpatient and outpatient services.

Custodial Care

Non-medical personal care like bathing, eating, or dressing. Medicare usually doesn’t cover this.

Deductible

The amount you must pay before Medicare or insurance starts covering costs.

Demonstrations

Short-term special Medicare projects ("pilot programs") to test coverage and care improvements.

Dual-eligible

A person who qualifies for both Medicare and Medicaid benefits.

Durable Medical Equipment (DME)

Medical equipment (like wheelchairs or walkers) prescribed for use at home.

Employer or Union Retiree Plans

Health coverage plans offered through a current or former employer.

End-Stage Renal Disease (ESRD)

Permanent kidney failure requiring dialysis or a transplant

Extra Help

A Medicare program that helps pay prescription drug costs for people with limited income and resources.

Fee-for-Service

A payment system where each service provided is billed and paid separately.

Formulary

The list of prescription drugs covered by a health plan.

Generic Drug

A prescription drug with the same ingredients as a brand-name drug but typically costing less.

Home Health Care

Medical services provided at home under a doctor’s supervision.

Hospice

Comprehensive care for terminally ill patients, addressing medical, emotional, and spiritual needs.

In-network

Doctors, hospitals, and providers contracted with a plan to offer discounted rates.

Initial Enrollment Period (IEP)

The 7-month window around your 65th birthday to enroll in Medicare.

Inpatient Rehabilitation Facility

A hospital specializing in intensive rehabilitation therapy for patients.

Lifetime Reserve Days

Extra hospital days Medicare covers after 90 days of hospitalization, limited to 60 days total over your lifetime.

Long-Term Care

Non-medical support for daily living activities, usually not covered by Medicare.

Long-Term Care Hospital

Facilities treating patients requiring extended hospital stays (25+ days).

Medical Underwriting

An insurance company’s process to assess your medical history when offering coverage.

Medically Necessary

Healthcare services or supplies needed to diagnose or treat a medical condition under accepted standards.

Medicare-approved Amount

The maximum amount Medicare will pay a provider who accepts assignment.

Medicare-certified Provider

A healthcare provider approved by Medicare to deliver services.

Medicare Health Plan

Private plans like Medicare Advantage that contract with Medicare to deliver Parts A and B benefits (and often Part D).

Medicare Savings Program

State-run programs helping low-income individuals pay for Medicare premiums and cost-sharing.

Medicare Plan

Any private Medicare coverage alternative to Original Medicare (e.g., Medicare Advantage, Part D plans).

Out-of-Pocket Costs

Expenses you must pay yourself because Medicare or other insurance doesn’t cover them.

Out-of-Pocket Limit

The maximum you have to pay in a year before your health plan pays 100% for covered services.

Penalty

A fee added to your premium if you delay enrollment in Part B or Part D without other creditable coverage.

Pre-existing Condition

A health issue you had before your new health coverage began.

Premium

Monthly payment for Medicare, health, or prescription drug coverage.

Preventive Services

Medical services aimed at disease prevention or early detection, such as vaccines or screenings.

Primary Care Doctor

The doctor you see regularly for most healthcare needs and referrals to specialists.

Prior Authorization

Approval from a Medicare drug plan required before a prescription is filled and covered.

Provider

A doctor, hospital, or organization that delivers healthcare services.

Referral

A required written order from your primary doctor to see a specialist (in many Medicare Advantage plans).

Service Area

The geographic region where a health plan provides coverage and accepts new members.

Skilled Nursing Facility (SNF) Care

Daily skilled nursing or rehabilitation services provided in a certified facility.

Special Enrollment Period (SEP)

A special time outside of regular enrollment periods to join Medicare plans due to qualifying life events.

Step Therapy

A rule requiring you to try less costly drugs before Medicare covers a more expensive drug.

Telemedicine

Healthcare services provided remotely via communication technologies (like video calls).

Tiers

Categories of drugs in a health plan’s formulary, where lower tiers usually mean lower out-of-pocket costs.

Urgently Needed Care

Immediate but non-life-threatening care needed when you’re outside your health plan’s service area.