A
AEP (Annual Enrollment Period) October 15 – December 7 each year, when you can switch Medicare Advantage or Part D plans for the following plan year.
Annual Notice of Change (ANOC) A notice sent each fall by Medicare Advantage and Part D plans detailing changes to costs and benefits for the coming plan year. B
Balance Billing When a provider bills a patient for the difference between the provider's charge and the amount the insurance plan allows — restricted for Medicare-participating providers.
Beneficiary A person enrolled in Medicare who receives benefits under the program.
Benefit Period Under Part A, a period that starts when you're admitted to a hospital or skilled nursing facility and ends after 60 consecutive days without inpatient care. C
Catastrophic Coverage The final phase of Part D coverage, reached after hitting the annual out-of-pocket cap, where you pay $0 for covered drugs the rest of the year.
CMS (Centers for Medicare & Medicaid Services) The federal agency that administers the Medicare, Medicaid, and CHIP programs.
Coinsurance A percentage of the cost of a covered service that you pay after meeting your deductible, such as 20% of the Medicare-approved amount.
Coordination of Benefits The process that determines which plan pays first when a person has more than one type of health coverage, such as Medicare and an employer plan.
Copay (Copayment) A fixed dollar amount you pay for a covered service, such as $20 for a doctor visit.
Creditable Coverage Health or drug coverage considered at least as good as Medicare's, allowing you to delay Medicare enrollment without a late penalty.
CSA (Certification of Sales Appointment) Documentation confirming the products discussed and agreed upon during a Medicare sales appointment, related to SOA compliance requirements. D
Deductible The amount you must pay out of pocket for covered services before your plan begins to pay its share.
DME (Durable Medical Equipment) Reusable medical equipment such as wheelchairs, walkers, and oxygen equipment, covered under Medicare Part B when medically necessary.
Donut Hole (Coverage Gap) A former Part D coverage phase with higher cost-sharing; Part D has since been restructured with a simplified benefit design and annual out-of-pocket cap.
Drug Utilization Review A review process plans use to check prescriptions for safety issues, such as harmful interactions or inappropriate dosing.
DSNP (Dual-Eligible Special Needs Plan) A Special Needs Plan designed for people who qualify for both Medicare and Medicaid.
Dual Eligible A person who qualifies for both Medicare and Medicaid coverage. E
EOB (Explanation of Benefits) A statement from your insurance plan explaining what was billed, what the plan paid, and what you may owe for a service.
Evidence of Coverage (EOC) A detailed document from your plan explaining exactly what is and isn't covered, and at what cost.
Excess Charges Additional amounts some providers who don't accept Medicare assignment can legally charge above the Medicare-approved amount, up to a federal limit.
Extra Help (LIS) A federal Low-Income Subsidy program that helps eligible beneficiaries pay for Part D premiums, deductibles, and copays. F
Formulary The list of prescription drugs a Part D or Medicare Advantage plan covers, organized into cost tiers. G
GEP (General Enrollment Period) January 1 – March 31 each year, for people who missed their Initial Enrollment Period and have no Special Enrollment Period.
Guaranteed Issue Right A right that requires an insurer to sell you a Medigap policy without medical underwriting in specific qualifying situations. H
HICN (Health Insurance Claim Number) The older, Social Security-based identifier used on Medicare cards before it was replaced by the MBI.
HMO (Health Maintenance Organization) A plan type that generally requires in-network care and referrals to see specialists, often with lower premiums.
Hospice End-of-life care focused on comfort rather than curative treatment, covered under Medicare Part A for beneficiaries with a terminal diagnosis. I
IEP (Initial Enrollment Period) The 7-month window centered on your 65th birthday during which you first enroll in Medicare.
In-Network A provider or facility that has a contract with your health plan, typically resulting in lower out-of-pocket costs for you.
IRMAA Income-Related Monthly Adjustment Amount — an extra premium charge for Part B and Part D for beneficiaries with higher income. L
LEP (Late Enrollment Penalty) A permanent premium increase applied when you enroll in Part B or Part D after your initial window without qualifying coverage or a Special Enrollment Period. M
MA-PD (Medicare Advantage Prescription Drug Plan) A Medicare Advantage plan that includes Part D prescription drug coverage bundled in.
MBI (Medicare Beneficiary Identifier) The unique identification number on a Medicare card, replacing the older Social Security number-based HICN.
Medicare Assignment An agreement by a provider to accept the Medicare-approved amount as full payment for covered services.
Medicare Part A Hospital insurance covering inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.
Medicare Part B Medical insurance covering doctor visits, outpatient care, preventive services, and durable medical equipment.
Medicare Part C (Medicare Advantage) An alternative way to receive Medicare Part A and B benefits through a private insurance company, often bundled with Part D and extra benefits.
Medicare Part D Prescription drug coverage offered through private insurers, either standalone or bundled into a Medicare Advantage plan.
Medigap (Medicare Supplement) Private insurance that works alongside Original Medicare to help cover deductibles, coinsurance, and copayments.
MSN (Medicare Summary Notice) A quarterly statement from Original Medicare showing the services billed, what Medicare paid, and what you may owe.
MSP (Medicare Savings Program) A state-run program that helps people with limited income and resources pay Medicare premiums, deductibles, and coinsurance. N
Network The group of doctors, hospitals, and other providers that have contracted with a health plan to provide services, often at negotiated rates. O
OEP (Medicare Advantage Open Enrollment Period) January 1 – March 31 each year, allowing a one-time switch between Medicare Advantage plans or back to Original Medicare.
OOP Maximum (Out-of-Pocket Maximum) The most you'll pay for covered services in a plan year before the plan pays 100% of covered costs; required for Medicare Advantage plans.
Open Enrollment (Medigap) A one-time, 6-month period starting when you're 65 and enrolled in Part B, during which you can buy any Medigap plan without medical underwriting.
Original Medicare The traditional fee-for-service Medicare program consisting of Part A and Part B, administered directly by the federal government.
Out-of-Network A provider that does not have a contract with your health plan, which can mean higher costs or no coverage at all, depending on the plan. P
PCP (Primary Care Physician) The doctor you see for routine care and who often coordinates referrals to specialists, especially important in HMO-style plans.
PDP (Prescription Drug Plan) A standalone Part D plan purchased alongside Original Medicare.
PFFS (Private Fee-for-Service) A Medicare Advantage plan type that sets its own payment terms for providers and cost-sharing for members rather than using a traditional network.
PPO (Preferred Provider Organization) A plan type offering more flexibility to see out-of-network providers, usually at a higher cost, and typically no referral requirement.
Premium The amount you pay, usually monthly, to keep your health insurance coverage active.
Preventive Services Screenings and services aimed at preventing illness or catching it early, many of which Medicare covers at no cost when criteria are met.
Prior Authorization A requirement that your plan approve a medication or service as medically necessary before it will cover it. R
Referral Authorization from your primary care physician to see a specialist, often required by HMO Medicare Advantage plans. S
SEP (Special Enrollment Period) A window to enroll in or change Medicare coverage outside standard periods, triggered by a qualifying life event.
SilverSneakers A fitness program offered as an extra benefit by many Medicare Advantage and some Medigap plans, providing gym access and wellness classes.
SNF (Skilled Nursing Facility) A facility providing skilled nursing or rehabilitation care, covered by Medicare Part A under specific conditions following a qualifying hospital stay.
SNP (Special Needs Plan) A type of Medicare Advantage plan tailored to people with specific chronic conditions, institutional needs, or dual Medicare/Medicaid eligibility.
SOA (Scope of Appointment) A required form documenting which specific Medicare products a beneficiary has agreed to discuss with an agent before a sales appointment.
Star Ratings CMS's 1-to-5-star quality rating system for Medicare Advantage and Part D plans, based on measures like member satisfaction and outcomes.
Step Therapy A requirement to try a lower-cost drug first before the plan covers a more expensive alternative. T
Telehealth Health care services delivered remotely via phone or video, with expanded Medicare coverage in recent years.
TPMO (Third-Party Marketing Organization) An organization, like an independent agency or agent, that markets Medicare Advantage or Part D plans on behalf of insurance carriers.