AHIP Medicare flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Part A coverage

Hospital insurance covering inpatient hospital stays, skilled nursing facility care, hospice, and some home health. Most people pay no premium after 40 quarters of Medicare-taxed work.

Part B coverage

Medical insurance covering physician services, outpatient care, durable medical equipment, and preventive services. Premiums are income-related and usually deducted from Social Security.

Initial Enrollment Period

A seven-month window beginning three months before the month a person turns 65, including the birthday month and the three months after it.

Annual Election Period

The Medicare open enrollment window from October 15 through December 7 each year, during which beneficiaries may change Part D or Medicare Advantage coverage effective January 1.

General Enrollment Period

Runs January 1 through March 31 for those who missed initial enrollment. Coverage generally begins the first day of the month after enrollment.

Part B late penalty

A permanent premium increase of 10% for each full 12-month period a person went without Part B after becoming eligible, unless creditable coverage applied.

Original Medicare

Fee-for-service coverage combining Part A and Part B, allowing beneficiaries to see any provider that accepts Medicare assignment nationwide.

Medicare Advantage (Part C)

Private plan option approved by CMS that delivers all Part A and Part B benefits except hospice, often with extra benefits and network rules.

HMO plan network rules

Health Maintenance Organization plans generally require care from in-network providers, except for emergencies and out-of-area urgent care situations.

PPO plan network rules

Preferred Provider Organization plans allow beneficiaries to see out-of-network providers at higher cost sharing while offering lower costs in network.

Special Needs Plans

Medicare Advantage plans limited to three groups: institutionalized beneficiaries, dually eligible Medicare-Medicaid beneficiaries, and people with specific chronic conditions.

MA-PD plan

A Medicare Advantage plan that includes Medicare Part D prescription drug coverage, combining medical and drug benefits in a single plan.

5-star special enrollment

A period allowing beneficiaries to switch once per year to a five-star rated Medicare Advantage plan or Prescription Drug Plan, from December 8 through November 30.

Hospice and MA plans

Beneficiaries generally cannot enroll in a Medicare Advantage plan while receiving hospice care; hospice remains covered under Original Medicare Part A.

MA maximum cost sharing

Medicare Advantage plans cannot charge more than Original Medicare for certain services, including chemotherapy, renal dialysis, and skilled nursing facility care.

Part D program purpose

Optional outpatient prescription drug coverage delivered through standalone Prescription Drug Plans or through Medicare Advantage plans that include drug coverage.

Protected drug classes

Six classes plans must cover all drugs in: antipsychotics, antidepressants, antiretrovirals, antineoplastics, immunosuppressants, and anticonvulsants.

Part D late penalty

One percent of the national base beneficiary premium multiplied by the number of full months without creditable drug coverage, added to the monthly plan premium.

Extra Help (LIS)

The Low-Income Subsidy reduces or eliminates Part D premiums, deductibles, and copayments for beneficiaries who meet income and resource limits.

Part D out-of-pocket cap

Under the Inflation Reduction Act, annual out-of-pocket spending on Part D drugs is capped at $2,000 starting in 2025.

Formulary exception process

A request that a plan cover a non-formulary drug or place a drug on a lower tier, with appeal rights if the plan denies it.

Insulin cost sharing cap

Under the Inflation Reduction Act, covered insulin is limited to $35 per month per prescription, with no deductible applied.

Scope of appointment

A documented agreement obtained before a personal marketing appointment that specifies which product types the beneficiary agreed to discuss.

Unsolicited contact rule

CMS prohibits cold-calling, door-to-door solicitation, and approaching beneficiaries in common areas such as parking lots or pharmacies.

Marketing material review

Plan marketing materials must be submitted to CMS for review, generally 45 days before intended use, and approved before distribution.

Call recording retention

Telephonic enrollments must be recorded with permission, and the recordings must be retained for ten years for compliance review.

Prohibited marketing practices

Marketing may not be misleading, high-pressure, or discriminatory, and may not imply endorsement by Medicare or use the Medicare name deceptively.

Fraud definition

Intentional deception or misrepresentation that the person knows or should know could result in an unauthorized benefit to themselves or another.

Waste definition

Overutilization or misuse of resources that results in unnecessary costs, often without intent to deceive, such as duplicative testing.

Anti-Kickback Statute

Prohibits offering, paying, soliciting, or receiving remuneration to induce referrals for items or services covered by federal health care programs.

False Claims Act

Imposes liability for knowingly submitting false claims to federal programs and includes qui tam provisions allowing whistleblowers to bring suits.

Stark Law

Prohibits physician self-referral for designated health services when a financial relationship exists, unless a specific exception applies.