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Medicare Insurance Education and Enrollment
Medicare Terms
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The Medicare Annual Election Period (AEP)—also referred to as Open Enrollment—runs every year from October 15 to December 7. During this window, current Medicare beneficiaries can change, drop, or add Medicare Advantage and Prescription Drug (Part D) plans. Changes made during this time go into effect on January 1.
Notices sent each year to beneficiaries by their Part D plans informing them of changes to their plan in the coming year. ANOCs must be received at least two weeks before the October 15 start of the AEP.
A legal proceeding undertaken to reverse a decision by bringing it to a higher authority. For instance, if a Medicare beneficiary receives a notice indicating the physical therapy services in a skilled nursing facility will be discontinued, the beneficiary can appeal to the Quality Improvement Organization. (QIO)
In traditional Medicare, this means the doctor or supplier agrees to accept the Medicare-approved amount as full payment.
Begins the day the beneficiary is admitted as an inpatient to a hospital. The benefit period ends when a beneficiary has had no hospital or skilled nursing facility level of care for 60 consecutive days. For each new benefit period, beneficiaries must pay the inpatient hospital deductible. There is no limit to the number of benefit periods. Also known in Medicare as the "Spell of Illness."
Under the standard Part D benefit, once beneficiaries' total Part D drug costs reach a maximum amount, beneficiaries pay only a small co-insurance or co-payment for covered drug costs until the end of the calendar year.
CMS is the Federal Agency that administers Medicare, Medicaid, and the State Children's Health Insurance Program. It is part of the U.S. Department of Health and Human Services.
A written statement issued by an insurance company that states the period of time the beneficiary had health insurance through that company that is/was at least as good as Medicare Part D coverage.
The amount beneficiaries pay for services after deductibles are met. For instance, in Medicare Part B, this is often a percentage (20%) of the Medicare approved amount.
Process for determining the respective responsibilities of two or more health plans. The telephone number for the COB contractor is 1(800)999-1118.
An amount that beneficiaries pay for each medical service, like a doctor's visit or prescription. It is a set amount rather than a percentage of costs (coinsurance). For instance, it might be $20.00 for each doctor's visit. There are sometimes copayments in Medicare Advantage and Part D plans and for some hospital outpatient services in traditional Medicare.
The amount beneficiaries pay out-of-pocket for health care, services, and prescriptions. Costsharing includes copayments, coinsurance, and deductibles.
Past health coverage that gives beneficiaries certain rights when applying for new coverage.
1. Creditable coverage for purposes of Medigap plans is previous health insurance coverage that can be used to shorten a pre-existing condition waiting period.
2. Creditable coverage for purposes of Medicare Prescription Drug Coverage is prescription drug coverage that is at least actuarially equivalent to or better than the Medicare Part D Standard Benefit.
The amount beneficiaries pay for health care, services, or prescriptions before Medicare pays. For example, in traditional Medicare, beneficiaries pay an annual Part B deductible.
A beneficiary eligible for both Medicare and Medicaid.
Medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, and hospital beds.
Information sent by insurance companies to new and renewing members describing plan benefits and patient rights and responsibilities.
A list of medications covered by a Part D plan. Formularies vary from plan to plan and also change annually.
The duty of a company to offer an insurance plan to all. Some Medicare beneficiaries are protected in this way from discrimination by insurance companies that offer Medigap policies.
A law that requires insurance companies to automatically renew or continue Medigap policies, unless the beneficiary makes untrue statements to the company, commits fraud, or does not pay premiums.
A type of insurance and Medicare Advantage Plan. Members generally must obtain a referral from their primary care physician in order to see a specialist. with some exceptions Medicare HMOs generally must cover all Medicare Part A and Part B health care. Some HMO's offer additional benefits, such as waiving the three-day qualifying hospital stay for skilled nursing facility coverage. In most HMOs, except in emergency or urgent situations, beneficiaries must receive care from the healthcare providers within the Plan's network.
Medical and supportive care provided at home. Medicare covers part-time or intermittent skilled nursing care and home health aide services, physical therapy, speech therapy, occupational therapy, medical social services, durable medical equipment, medical supplies, and other services provided in the home. Beneficiaries must be homebound to obtain Medicare coverage.
Team-oriented approach to care that addresses the medical, physical, social, emotional and spiritual needs of dying patients and their caregivers. Medicare has a comprehensive hospice benefit.
The seven-month period in which individuals are initially eligible to enroll in traditional Medicare, Part B and Part D. For purposes of Part C, this same period is called the Initial Coverage Election Period (ICEP). The seven-month period consists of the three months before, the month of, and the three months after the individual's 65th birthday or 24th month of disability.
An amount added to monthly premiums for Medicare Part B or Part D (and Part A for voluntary enrollees) if a Medicare beneficiary fails to enroll during the initial enrollment period and does not qualify for a "good cause" exemption.
In traditional Medicare, a total of 60 extra days that Medicare will pay for when beneficiaries are hospitalized for more than 90 days during a benefit period. Once these 60 days are used, they are exhausted. In other words, they cannot be used again.
The period from January 1 - February 14 each year when individuals in a Medicare Advantage plan may switch back to original Medicare and enroll in a PDP.
A private plan, often an HMO, that provides the benefits of Medicare Part A and Part B (MA plan) or Part A, Part B, and Part D (MA-PD plan). Medicare Advantage Plans include PPOs, HMOs, PFFS plans, MSA plans and SNPs. See the Medicare Supplement vs. Medicare Advantage page for more information.
The component of Medicare that covers inpatient hospital care, skilled nursing (not custodial or long term care), hospice services, and home health care.
The component of Medicare that covers medically necessary doctor's services, outpatient care (laboratory, x-ray, etc), durable medical equipment, ambulance, and many other services, including some preventive services.
The component of the Medicare Act that establishes private "Medicare Advantage" plans to finance services enumerated in Medicare Part A and Part B, and sometimes additional benefits.
The component of Medicare that covers outpatient prescription drugs via private plans.
MediGap (Medicare Supplement Insurance) is a private policy that helps cover the "gaps" in Original Medicare—such as deductibles, copays, and coinsurance. These plans allow you to see any doctor nationwide who accepts Medicare and do not require network referrals.
Medicare Supplement Insurance (Medigap) is private insurance that helps pay your out-of-pocket costs in Original Medicare (e.g., deductibles, copayments, and coinsurance). Because these policies are standardized, the benefits for a specific lettered plan (like Plan G or N) are the exact same no matter which insurance company you buy it from.
Medical or surgical care provided at the hospital without the beneficiary being admitted as an inpatient. This includes emergency room care and, per Medicare policy, care provided on observation status, even ifthe beneficiary remains in the hospital overnight.
Drugs that may be purchased without a medical prescription.
A medical condition that exists prior to enrolling in an insurance policy.
The periodic payment required to keep insurance in effect.
A Part D plan that covers outpatient prescription drug coverage only (no hospital or medical coverage). PDPs are regulated and subsidized by Medicare. They are sometimes referred to as "stand alone" drug plans and are always private plans.
Health care offered for purposes of prevention or early diagnosis. Examples include flu shots and mammograms.
A doctor who provides basic (non-specialized) health care. In many Medicare Advantage plans, beneficiaries must see their primary care physician and obtain a referral before they can see a specialist.
A utilization management tool used by Medicare Advantage and Part D plans to control costs. The beneficiary's physician must obtain approval from the beneficiary's plan before the plan will cover the given service, item or payment for a prescription medication.
One of three utilization management tools used by Part D plans to control costs. The plan places limits on the drug dosages or quantities it will cover.
A written order from a primary care physician to see a specialist. In many Medicare Advantage plans, payment will not be made for specialist care unless the beneficiary first obtains a referral.
An insurance policy, plan, or program that pays second on a claim for medical care.
A licensed facility that has the staff and equipment necessary to provide skilled nursing and rehabilitation. To be covered by Medicare the facility must also be certified by Medicare.
A period triggered by exceptional conditions, as defined by law and CMS policy, during which beneficiaries can enroll or disenroll from their Part C or D plans, outside the normal Annual Election Period. Changes may include leaving Medicare Advantage and returning to traditional Medicare.
A physician who treats only certain parts of the body, certain health problems, or certain age groups. For instance, nephrologists diagnose and manage kidney disease.
The Medicare system as originally designed: a national public program, including coverage under Parts A and B. (Sometimes referred to as the "fee-for-service" program and as "original" Medicare.
Care for a sudden illness or injury that needs medical care right away, but is not life threatening. If a member of a Medicare Advantage plan is out of the plan's service area and requires urgently needed AAA care, the plan must pay for the care.
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BEVERLY KINGSLEY
INSURANCE AGENT / ADVISOR
Business: (561) 701-4030
Fax: (800) 615-3032
Email: BKingsley@65-MediGap.com
Existing Client service issues: Service@65-MediGap.com
Important disclosures about Medicare Plans: Medicare has neither endorsed nor reviewed this information. 65-MediGap Insurance Agency is not connected or affiliated with any United States Government or State agency. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
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