Annual Enrollment Period
The period of time during which people enrolled in Part A and B of Medicare are able to enroll in a Medicare Advantage or Prescription Drug Plan (PDP). Those who are currently on Medicare Advantage or PDP plans may make changes to their plans during this period. This enrollment period runs annually from October 15th through December 7th with coverage beginning on January 1st.
Annual Notice of Changes (ANOC)
A document provided by each Medicare plan to all enrollees, detailing any changes in coverage, costs or service area that will go into effect in January of the approaching plan year. Medicare requires that health plans notify all enrolled members of these changes by mail by either September 30th or 15 days before the start of the Annual Enrollment Period.
An individual who has health insurance coverage through the Medicare or Medicaid program.
A benefit period is the space of time that begins on the day that a beneficiary is admitted to either a hospital or skilled nursing facility and which ends sixty consecutive days after they last received care at either a hospital or skilled nursing facility. Each benefit period has its own inpatient hospital deductible that must be paid. If a beneficiary is admitted to a hospital or skilled nursing facility after a benefit period is closed, a new benefit period begins. There is no limit to the number of benefit periods provided.
The percentage of the cost of healthcare service or prescription drugs that a beneficiary is required to pay after their plan deductible.
A flat rate, out-of-pocket payment that a beneficiary is required to pay for prescription drugs or healthcare services ranging from medical visits to procedures. Copayments are preset and may vary based upon the type of service. Copayments and coinsurance for in-network care go towards your maximum out-of-pocket costs.
The amount that a beneficiary has to pay for medical services or prescription drugs before their healthcare plan, prescription drug plan, or Medicare begins to pay.
Durable Medical Equipment (DME)
Specific medical equipment ordered for use in the home by a physician in response to a medical condition or illness. Durable Medical Equipment is covered as part of home health services under Medicare Part B. Wheelchairs, hospital beds, and walkers are all examples of durable medical equipment.
An “emergency medical condition” is defined by Medicare a “medical condition manifesting itself by acute symptoms of severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual in serious jeopardy; (b) serious impairment of bodily functions; or (c) serious dysfunction of any bodily organ or part of the body.
Evidence of Coverage (EOC)
This is the paperwork that health plans mail each year to both new enrollees and renewing enrollees. It provides details of the plan’s benefit and acts as proof that the individual is enrolled.
Items and services that your healthcare plan does not cover or pay for.
A published list of prescription drugs that a health insurance plan provides payment for. Prescription drug plans and Medicare Advantage publish a new list each year, and are required to have them posted on their websites no later than October 15th of each year. Members are able to get a printed copy upon request. The formulary is also referred to as the Prescription Drug Guide.
Health Maintenance Organization (HMO)
A type of health insurance coverage in which a beneficiary selects a primary care physician (PCP) from within the plan’s network and seeks care from that individual. When specialized care is required, the beneficiary is required to get a referral from their PCP to a specialist within the HMO’s network, and hospital care is also limited to those included in the plan’s network, though exceptions are made for emergencies.
Initial Coverage Election Period (ICEP)
For most people, this period occurs at the same time as their Initial Enrollment Period (IEP) for Original Medicare Parts A and B. For example, if you turn 65 on June 14th, your IEP for Parts A and B will run from March 1st through September 30th and your ICEP for Medicare Advantage will run the same months as your IEP.
If you delay enrollment in Part B and enroll outside of your Initial Enrollment Period, then your ICEP for Medicare Advantage begins the three-month period before your Part B start date and ends the last day of the month before your Part B coverage starts. For example, if your Part B coverage start date is June 1st, your ICEP for Medicare Advantage runs from March 1st through May 31st with coverage beginning on June 1st. You do not have an additional three months after your Part B start date to enroll in a Medicare Advantage plan. If you do not apply for coverage beginning at the same time as your Part B start date, then you will have to wait until the next annual enrollment period. (See Annual Enrollment Period)
Also known as a participating provider, an in-network provider can be a hospital or medical facility, a physician or a pharmacy with whom an individual healthcare plan has contracted for services at an agreed upon rate.
An established endpoint beyond which physicians or other healthcare suppliers that don’t accept assignment are permitted to charge for a covered service. The limiting charge is 15% above the amount that Medicare has approved for a specific service, and paying it is the responsibility of the Medicare beneficiary unless they have purchased a Medigap policy that pays the excess. Only some services have a limiting charge. Equipment and supplies do not have one. The limiting charge does not apply to in-network Medicare Advantage Plan coverage.
A program that is jointly operated through the federal and state governments to cover health care costs for people who are either low income or who have limited resources. Individuals who qualify for both Medicaid and Medicare generally have most of their medical costs covered.
Medicare Advantage (see Medicare Part C)
This is a type of Medicare benefits plan that is offered through private insurance companies rather than through the federal government. They can be offered in a variety of formats, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Medical Savings Accounts (MSAs), Special Needs Plans (SNPs), and Private Fee-for-Service (PFFS) plans. Medicare Advantage plans are contracted and approved by Medicare, and are required to offer the same benefits as provided by Original Medicare, Part A, and Part B. Because they are private plans, they are able to do so using their own coverage restrictions, rules, and costs as approved by Medicare. In many cases Medicare Advantage plans will incorporate additional coverage such as for prescription drugs, routine vision or dental care, hearing checkups, and wellness programs. To opt into a Medicare Advantage plan, individuals must first have Original Medicare Part A and Part B. They also cannot have end-stage renal disease and must live in the service area where the Medicare Advantage plan is offered.
Medicare Part A
Medicare is a federal health insurance program administered by the Centers for Medicare and Medicaid Services, with enrollment handled by Social Security. It benefits those who are 65 or older, as well as for people with end-stage renal disease and some young people with disabilities. Part A refers to the coverage it provides for inpatient hospital stays, as well as hospice care, skilled nursing facility care, and some home health care.
Medicare Part B
Medicare is a federal health insurance program administered by the Centers for Medicare and Medicaid Services with enrollment handled by Social Security . It benefits those who are 65 or older, as well as for people with end-stage renal disease and some young people with disabilities. Part B refers to the coverage it provides for physician’s services, as well as medical supplies, preventive services, and outpatient hospital care.
Medicare Part C
Medicare is a federal health insurance program administered by the Centers for Medicare and Medicaid Services. Part C refers to plans that can be purchased from private insurers and are purchased through private insurers approved by Medicare. (See Medicare Advantage)
Medicare Part D
Medicare is a federal health insurance program administered by the Centers for Medicare and Medicaid Services. It benefits those who are 65 or older, as well as for people with end-stage renal disease and some young people with disabilities. Part D refers to optional coverage for prescription drugs that can be purchased from private insurance companies at an additional cost.
Medicare Supplemental Insurance
Also known as a Medigap policy, this is coverage that can be purchased from private insurance companies at an additional cost to provide coverage for Medicare-approved services, including deductibles, copays, and coinsurance, that Medicare does not.
Original Medicare describes the federal fee-for-service health insurance program administered by the Centers for Medicare and Medicaid Services. It combines Part A (Hospital Insurance) and Part B (Medical Insurance) and benefits those who are 65 or older, as well as for people with end-stage renal disease (ESRD), amyotrophic lateral sclerosis (ALS), and some young people with disabilities. Every contracted service has a pre-approved amount that Medicare pays, after which the beneficiary pays their share.
These benefits are provided by Medicare Advantage plans for health care services provided by providers outside of the plan’s approved, in-network providers. These services may cost beneficiaries a higher out-of-pocket amount.
Preferred Provider Organization (PPO) Plan
A type of health plan that allows beneficiaries to pay a lower cost for using physicians, hospitals, and providers that are in network but permits them to use out-of-network providers at an additional cost.
The monthly fee that beneficiaries pay to their insurance company, health care plan, or to Medicare for their coverage.
Private Fee-for-Service (PFFS) Plan
A type of health coverage available as a Medicare Advantage plan that permits beneficiaries to seek service from any physician or facility that agrees to the plan’s payment terms and agrees to provide treatment. The amount that a beneficiary pays for service is detailed within its plan documents.
A written order required by some Medicare Advantage health plans for medical services not provided by the beneficiary’s primary care physician. A referral is obtained directly from the primary care physician, and is usually required in order to have the health plan pay for a visit to a specialist or for services such as a vision examination.
Special Enrollment Period for Part B
The special enrollment for Part B period provides the opportunity for enrollment for those who are eligible for Medicare Part B but who did not enroll during the Initial Enrollment Period because they had group health coverage provided by an employer or union, or volunteer internationally for at least 12 months with a qualified service. Employer health plan coverage must be based on your current employment or the current employment of a spouse or family member at the time you first became eligible for Medicare. Coverage must remain continuous with no more than eight consecutive months of lapses from first becoming eligible for Medicare until Medicare enrollment during the SEP; neither COBRA or retirement coverage qualifies.
This special enrollment period lasts for eight months after termination of your employment of loss of employer coverage. However, you can enroll in Medicare Part B at any time you are still covered by a qualified plan based on your current employment.
Special Needs Plan (SNP)
A type of Medicare Advantage plan designed for beneficiaries that have a chronic illness such as diabetes, or who need specialized care (including long-term or institutional level care), or who are entitled to both Medicare and Medicaid. Beneficiaries can be eligible under more than one type of special need.
Urgently Needed Care
Urgently needed care describes care that is needed right away to treat a sudden illness or injury that is not life threatening. If you need this care when you are out of your plan’s area and cannot be seen by your primary care physician then your health plan will pay for it.
The period of time that an enrollee in a Medigap or Medicare Advantage plan is required to wait before their coverage begins. In most cases they are imposed when a beneficiary has a pre-existing condition and has not had creditable coverage for a specified period of time. The time prior to a special enrollment date cannot be counted as part of a waiting period. Waiting period days do not count as a significant break in coverage and they cannot be counted towards creditable coverage unless there is other creditable coverage at that time.