NABIP Medicare flashcards

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

Part A

Hospital insurance that covers inpatient hospital stays, skilled nursing facility care after a qualifying stay, hospice, and some home health care. Most beneficiaries pay no premium with 40 or more work quarters.

Part B

Medical insurance covering physician services, outpatient care, durable medical equipment, and preventive services. It requires a monthly premium and has an annual deductible and 20% coinsurance after the deductible.

Initial Enrollment Period

A seven-month window around age 65 eligibility: the three months before the birthday month, the birthday month, and the three months after. Enrollment timing affects the coverage start date.

Part B Late Enrollment Penalty

A permanent premium increase of 10% of the standard Part B premium for each full 12-month period a beneficiary could have enrolled but did not, lasting for as long as Part B is held.

Medicare Advantage

Part C plans offered by private insurers that provide all Part A and Part B benefits, usually include Part D, and may add extra benefits such as dental, vision, hearing, and fitness.

Medigap Plan F

A standardized Medicare Supplement plan that covered the Part B deductible and most cost-sharing. It is closed to beneficiaries newly eligible for Medicare on or after January 1, 2020.

Special Needs Plan

A Medicare Advantage plan limited to specific groups: dual-eligible beneficiaries (D-SNP), institutionalized beneficiaries (I-SNP), or those with certain chronic conditions (C-SNP).

Part D Late Enrollment Penalty

One percent of the national base beneficiary premium multiplied by the number of full uncovered months, rounded to the nearest ten cents, added to the monthly Part D premium.

Fraud Definition

Intentional deception or misrepresentation that an individual knows or should know could result in an unauthorized benefit to themselves or another person under a health program.

Anti-Kickback Statute

A federal law prohibiting knowingly offering, paying, soliciting, or receiving remuneration to induce referrals for items or services reimbursed by federal health care programs such as Medicare.

False Claims Act

A civil statute imposing liability, including treble damages and per-claim penalties, on persons who knowingly submit or cause the submission of false claims to federal health programs.

Compliance Program Elements

Core elements include written policies, a designated compliance officer, training and education, communication lines, internal monitoring and auditing, and enforcement of standards through discipline.

Annual Enrollment Period

The window from October 15 through December 7 each year when beneficiaries may change Medicare Advantage or Part D coverage; elections take effect January 1 of the following year.

Scope of Appointment

A document completed and signed by the beneficiary before a personal marketing appointment that identifies the plan types to be discussed and must be retained by the agent.

Cold Call Prohibition

CMS marketing rules bar unsolicited contact with beneficiaries, including cold calls and door-to-door solicitation, unless the beneficiary previously gave permission to be contacted.

Nominal Gift Rule

Agents may not offer gifts or incentives conditioned on enrollment; any nominal gift must fall below the CMS value threshold and cannot be tied to a plan selection.

General Enrollment Period

The window from January 1 through March 31 each year when beneficiaries who missed their Initial Enrollment Period may sign up for Part A or Part B, with coverage starting the next month.

Special Enrollment Period

A period triggered by a qualifying event, such as losing employer coverage or moving out of a plan service area, that lets a beneficiary enroll or change plans outside standard windows.

End-Stage Renal Disease

A permanent kidney failure requiring dialysis or transplant that qualifies a person for Medicare regardless of age; such beneficiaries may have access to Medicare Advantage plans under certain conditions.

Medicare Advantage Network Rules

HMO plans generally require in-network providers and referrals, while PPO plans permit out-of-network care at higher cost; plans must cover all medically necessary Part A and Part B services.

Part D Formulary

A plan's list of covered prescription drugs, organized by tiers, that must include at least two drugs in each therapeutic category and class and be approved by CMS.

Annual Notice of Change

A document a Medicare Advantage or Part D plan must send before the plan year begins that describes changes in benefits, premiums, and formularies for the coming year.

Medicare Appeals Process

For Original Medicare, appeals proceed through redetermination, reconsideration, ALJ hearing, Medicare Appeals Council, and judicial review; expedited appeals are available when health is jeopardized.

Quality Improvement Organization

A CMS-contracted entity that reviews appeals of hospital discharges and certain quality-of-care complaints for Medicare beneficiaries.

Medicare Secondary Payer

Rules determining whether Medicare pays first or second when a beneficiary has other coverage, such as employer group health plans, retiree coverage, or workers' compensation.

Working Aged Rule

Employer group health plans with 20 or more employees generally pay first for working beneficiaries aged 65 or older; smaller employer plans generally pay second to Medicare.

Dual-Eligible Beneficiary

A person enrolled in both Medicare and Medicaid; Medicaid may pay Medicare premiums and cost-sharing, while Medicare generally pays first for covered services.

Part D Coverage Gap

A phase after the initial coverage limit is reached in which the beneficiary pays a share of drug costs until spending reaches the catastrophic threshold.

Part D Exception Request

A request that a plan cover a non-formulary drug or waive a utilization rule such as prior authorization or step therapy, which the plan must decide within a set timeframe.

Extra Help

The Low-Income Subsidy that reduces Part D premiums, deductibles, and copays for beneficiaries with limited income and resources who meet eligibility criteria.

Marketing Material Approval

Medicare Advantage and Part D marketing materials must be submitted to CMS or the plan for review before use, and agents may not alter approved materials.

Annual Agent Training

Agents must complete required annual training and testing, including fraud, waste and abuse and Medicare marketing training, before selling during the Annual Enrollment Period.