AHIP Medicare key terms

The federal fee-for-service health program made up of Part A hospital insurance and Part B medical insurance, administered by CMS and available to people who qualify by age or disability.

The hospital insurance portion of Medicare, covering inpatient hospital stays, skilled nursing facility care after a hospital stay, hospice, and some home health services, generally without a monthly premium for those with sufficient work history.

The medical insurance portion of Medicare, covering physician services, outpatient care, durable medical equipment, and preventive services, funded by enrollee premiums and general federal revenue.

The monthly amount most Part B enrollees pay, set annually by CMS; higher-income beneficiaries pay an income-related surcharge, and late enrollment can add a permanent penalty.

A spell of illness measured from inpatient admission until the patient has been out of a hospital or skilled nursing facility for 60 consecutive days, after which a new deductible applies under Original Medicare.

The seven-month window around a person's 65th birthday, beginning three months before the birthday month and ending three months after it, during which most people first enroll in Medicare.

The yearly window, generally October 15 through December 7, when Medicare beneficiaries may join, switch, or drop Medicare Advantage and Part D plans, with coverage effective January 1.

A January 1 through March 31 window in which a person already enrolled in Medicare Advantage may switch to another MA plan or return to Original Medicare, with one change permitted.

A time outside standard enrollment windows when a person may enroll or change plans because of a qualifying event such as moving, losing employer coverage, or a plan leaving the area.

A January 1 through March 31 window each year when people who missed their Initial Enrollment Period can sign up for Part A and Part B, with coverage starting the month after enrollment.

A private plan approved by CMS to deliver Part A and Part B benefits, often with extra benefits, in place of Original Medicare; most are health maintenance organizations or preferred provider organizations.

The group of doctors, hospitals, and other clinicians contracted with a Medicare Advantage or Part D plan; using in-network providers usually costs less, and out-of-network care may not be covered.

A health maintenance organization Medicare Advantage plan that generally requires members to use network providers and obtain referrals for specialists, except in emergencies or for out-of-area urgent care.

A preferred provider organization Medicare Advantage plan that lets members see out-of-network providers at a higher cost share and generally does not require referrals for specialist care.

A Medicare Advantage plan limited to specific groups such as people in institutions, people eligible for both Medicare and Medicaid, or people with certain chronic conditions, and tailored to their needs.

A person entitled to both Medicare and Medicaid, often qualifying for a special needs plan or a Medicare Savings Program that helps pay Medicare premiums and cost sharing.

Private supplemental insurance sold to people with Original Medicare that helps pay Part A and Part B deductibles, coinsurance, and other cost sharing; it cannot be combined with a Medicare Advantage plan.

Federal protections that let a person buy certain Medigap policies without medical underwriting in specified situations, such as losing employer coverage or a Medicare Advantage plan ending service.

The optional Medicare prescription drug benefit delivered through private stand-alone drug plans or through Medicare Advantage plans that include drug coverage.

A plan's list of covered prescription drugs, organized into cost-sharing tiers; plans may change it annually, and members generally must use drugs on the list or request an exception.

A cost-sharing level within a drug plan's formulary; lower tiers usually hold generic drugs with small copayments, while higher tiers hold brand or specialty drugs with larger cost sharing.

The phase of the Part D benefit, sometimes called the donut hole, in which the enrollee pays a larger share of drug costs until reaching the annual out-of-pocket threshold.

The final phase of the Part D benefit, entered after an enrollee's out-of-pocket spending reaches the annual threshold, in which the plan pays most of the remaining drug costs.

True out-of-pocket costs: the amount an enrollee has paid toward Part D drug costs, counting certain payments such as copayments and brand discounts, which determines progression through benefit phases.

Prescription drug coverage from another source, such as an employer or union plan, that is at least as good as standard Part D; having it can excuse a person from the Part D late enrollment penalty.

A permanent surcharge added to premiums when a person goes without Part B or creditable Part D coverage for a continuous period after first becoming eligible, unless an exception applies.

The federal Low-Income Subsidy that reduces Part D premiums, deductibles, and copayments for people with limited income and resources who meet eligibility rules.

A requirement that a plan approve certain services or drugs before they are provided; without approval, the plan may deny payment, though the member can appeal.

A Medicare Advantage or Part D plan's decision about whether it will cover or pay for a requested item or service, which the enrollee may appeal if dissatisfied.

A complaint about the quality of care or the way a plan or provider operates, rather than a dispute about coverage; plans must respond within set timeframes.

A formal request to a plan or to an independent reviewer to reconsider a coverage denial or payment decision, filed within deadlines and following the levels set by Medicare rules.

The Centers for Medicare & Medicaid Services, the federal agency that administers Medicare, approves plan offerings and marketing materials, and enforces program rules.

Any printed or electronic materials a plan or agent uses to advertise or explain plan benefits; they must be submitted to CMS for review and must avoid misleading or inaccurate statements.

Outreach such as cold calls, door-to-door visits, or unexpected emails that Medicare marketing rules generally prohibit; plans and agents may not contact beneficiaries without their prior request or permission.

A form documenting the product types a beneficiary has agreed to discuss during a sales meeting, which agents must complete before the appointment and may not exceed.

A beneficiary's documented agreement that a plan or agent may follow up by phone or in person, required before most marketing contacts and revocable at any time.

Fraud is intentional deception for gain, waste is careless spending without gain, and abuse is misuse that may be improper or unnecessary; all three harm Medicare and must be reported.

A federal law making it a crime to knowingly offer, pay, solicit, or receive anything of value to induce referrals or business paid by federal health programs.

A federal law imposing liability on people or entities that knowingly submit or cause the submission of false claims to Medicare, and providing for whistleblower suits and penalties.

A set of internal policies, training, monitoring, and reporting channels a plan or provider adopts to prevent and detect violations of Medicare rules and to correct problems promptly.