NABIP Medicare key terms

The federal fee-for-service program made of Part A hospital insurance and Part B medical insurance. Beneficiaries may see any provider nationwide who accepts Medicare and pays deductibles and coinsurance unless other coverage applies.

Hospital insurance covering inpatient hospital stays, skilled nursing facility care after a qualifying stay, hospice, and some home health. Most people pay no premium if they or a spouse worked long enough in Medicare-covered employment.

Medical insurance covering physician services, outpatient care, durable medical equipment, preventive services, and some drugs administered in clinical settings. Enrollment is optional but carries a monthly premium based on income.

Optional outpatient prescription drug coverage delivered through standalone drug plans or built into Medicare Advantage plans. Plans vary in formulary, tier structure, premium, and pharmacy network, and all must meet federal minimum standards.

A private plan alternative to Original Medicare, also called Part C, that must provide at least the same benefits as Parts A and B. Most plans include drug coverage and often add dental, vision, or fitness extras.

Privately sold supplemental insurance that pays some or all of the cost sharing left by Original Medicare, such as deductibles and coinsurance. It cannot be combined with a Medicare Advantage plan and does not include drug coverage.

A seven-month window around a person's 65th birthday, beginning three months before the birthday month and ending three months after. Enrolling late can trigger lifetime Part B and Part D penalties.

The fall window, October 15 through December 7, when beneficiaries may join, switch, or drop Medicare Advantage and Part D plans. Elections generally take effect January 1 of the following year.

A January 1 through March 31 window in which someone already in a Medicare Advantage plan may switch to another Advantage plan or return to Original Medicare. Those who return may add a standalone drug plan.

A time outside standard windows when a person may change coverage because of a qualifying event, such as moving, losing employer coverage, or a plan leaving the area. The exact dates and permitted changes depend on the event.

A permanent premium surcharge for delaying Part B or Part D enrollment without other creditable coverage. The Part B penalty adds ten percent per full year of delay; the Part D penalty is calculated from months without coverage.

An income-related monthly adjustment amount added to Part B and Part D premiums for higher-income beneficiaries. It is based on tax returns from two years earlier and can be appealed after a qualifying life-changing event.

Other drug or health coverage at least as good as Medicare's, such as certain employer or retiree plans. Having it can excuse delayed Part B or Part D enrollment from penalties and permit a special enrollment period.

The way Part A measures inpatient hospital use, starting the day of admission and ending after 60 consecutive days without inpatient hospital or skilled nursing care. A new benefit period restarts the deductible.

Part A coverage for short-term skilled care after a qualifying inpatient hospital stay of at least three consecutive days. Medicare pays up to 100 days per benefit period, with daily coinsurance beginning on day 21.

The amount a beneficiary pays before Medicare or a plan begins paying its share for a benefit period or year. Part A uses a per-benefit-period deductible; Part B and Part D use annual deductibles that may vary by plan.

The percentage share of a covered service the beneficiary pays after the deductible, such as 20 percent under Part B. Medigap or employer retiree coverage may pay some or all of this amount.

A plan's list of covered prescription drugs, organized into cost-sharing tiers. Plans must cover certain protected drug classes, and a drug generally must be on the formulary for routine coverage unless an exception is approved.

A cost-sharing level within a drug plan's formulary. Lower tiers usually hold generic drugs with modest copays, while higher tiers hold brand or specialty drugs with greater cost sharing.

The phase of Part D benefits, sometimes called the doughnut hole, in which the beneficiary pays a larger share of drug costs. Federal rules have narrowed this gap over time and require manufacturer discounts on brand drugs.

A requirement that the plan approve a service or drug before it is provided or covered. It is common in Medicare Advantage for certain procedures and drugs, and members have appeal rights when requests are denied.

The contracted doctors, hospitals, and other suppliers a Medicare Advantage plan covers at in-network cost sharing. Using out-of-network providers may cost more or require referral, except in emergencies or urgent situations.

A plan requirement that a primary care provider authorize a member's visit to a specialist. Plans with this rule may deny coverage for specialist care obtained without one, apart from emergencies.

Federal protections that let a person buy certain Medigap policies without medical underwriting during specific situations, such as losing employer coverage or a Medicare Advantage plan ending. State rules may add more protections.

A health review insurers use to decide whether to sell a Medigap policy and at what price. Outside guaranteed issue situations, an insurer may decline an applicant or charge more because of health history.

A state-level Medigap protection allowing policyholders to switch to a different supplement plan around their birthday month without medical underwriting. It exists only in states that have adopted such a rule.

Federal standards governing how Medicare plans and agents may contact and enroll beneficiaries. They restrict unsolicited contact, prohibit misleading claims and gifts over nominal value, and require recorded permission for sales appointments.

A form documenting which product types a beneficiary agreed to discuss before a sales meeting. Agents may not market products outside that scope during the appointment, and the form must be retained as proof.

An outside entity that markets Medicare plans on behalf of a sponsoring plan and must follow the same federal marketing and enrollment rules. Plans remain responsible for the conduct of these entities and their agents.

Three categories of improper conduct in federal health programs: intentional deception for gain, unnecessary spending, and practices that directly or indirectly harm the program. Training and reporting are required of plan staff and agents.

A federal law imposing liability on those who knowingly submit or cause false claims for government payment. Penalties include treble damages and per-claim fines, and private citizens may sue on the government's behalf.

A criminal law prohibiting knowingly offering or receiving anything of value to induce referrals for items or services paid by federal health programs. Marketing gifts and improper agent incentives can violate it.

A lawsuit filed by a private person on behalf of the government alleging fraud under the False Claims Act. The relator may receive a share of any recovery, and retaliation against the relator is prohibited.

Legal safeguards shielding people who report suspected fraud from retaliation such as firing or demotion. Federal law protects employees who raise concerns about false claims, and plans must not discourage good-faith reporting.

An organized set of policies, training, monitoring, and reporting channels a plan or agency uses to prevent and detect violations of Medicare rules. Federal rules require sponsors to maintain an effective program with a compliance officer.

The formal process a beneficiary may use to challenge a denial of coverage or payment. Levels typically begin with a plan reconsideration and may proceed to independent review, an administrative law judge, and federal court.

The licensed agent formally credited with a beneficiary's enrollment and entitled to related compensation. Changing the agent of record generally requires the beneficiary's documented request rather than an agent's unilateral action.