Glossary of Terms

Medicare Advantage and Part D plans are required to send an annual notification each September detailing any changes in costs and benefits for the upcoming year.

A request to reconsider a decision made by Medicare or Social Security that you disagree with, aiming to reverse the outcome.

When doctors or healthcare providers agree to treat Medicare patients, they accept the Medicare-approved amount as full payment and cannot charge more.

A benefit period starts when you are admitted to a hospital and ends once you’ve been out of a hospital or skilled nursing facility for 60 consecutive days.

A medication still under patent protection by its manufacturer, typically sold at a higher cost due to exclusive selling rights.

This Part D benefit offers lower-cost drug coverage once you’ve reached a specified out-of-pocket amount on prescriptions within the year, lasting through December 31.

The percentage of service costs you pay after meeting your deductible, representing your share of the total expense.

A set amount you pay for specific medical services or prescriptions, like a doctor’s visit or medication.

A coverage gap where, once your total prescription drug costs reach a certain threshold, you may pay more out-of-pocket until catastrophic coverage begins.

A subsidy for Part D drug coverage that provides lower costs for qualifying individuals based on income.

This document, provided by Medicare Advantage or Part D plans, outlines the plan’s costs, benefits, and your rights and responsibilities upon enrollment or renewal.

A period from January 1 to March 31 each year when individuals who missed their initial Medicare enrollment can sign up, with coverage starting on July 1.

An equivalent to a brand-name drug that has similar clinical effects but typically costs much less.

Your right to purchase a Medigap policy under certain conditions, where insurance companies cannot deny you coverage or charge extra based on health history. You’re also guaranteed yearly renewal as long as premiums are paid.

The second phase of Part D drug coverage, where you pay a set copayment or coinsurance after meeting the deductible for your prescriptions.

A seven-month period surrounding your 65th birthday or disability qualification to sign up for Medicare, beginning three months before and ending three months after your birthday month.

A health assistance program for individuals with limited income, governed by state rules. Those eligible for both Medicare and Medicaid are termed "dual eligibles."

Private insurance options, typically HMOs or PPOs, that provide Medicare Parts A and B benefits in a structure different from Original Medicare, often including Part D coverage as well.

The maximum dollar amount you’ll pay out-of-pocket for deductibles and copayments in a given year.

Covers inpatient hospital stays, skilled nursing facility care, certain home health services, and hospice care.

Provides coverage for outpatient services, doctor visits, preventive care, lab tests, medical equipment, and screenings.

An alternative to Original Medicare, also known as Medicare Advantage, which combines Parts A, B, and sometimes D.

Covers outpatient prescription drugs, available either through standalone Part D plans or Medicare Advantage plans that include drug benefits.

Screenings and tests that detect early signs of diseases, many of which are covered by Medicare without copayment or deductible.

Your main doctor, often a general practitioner or internist, who handles routine medical needs and, in Medicare HMOs, provides referrals to specialists.

A facility, often a nursing home, that provides care such as physical therapy or intravenous drug administration following hospital discharge.

Times outside of the standard enrollment periods when you can join Part B or Part D due to certain life circumstances.

A Medicare Advantage plan designed for individuals living in care institutions, those who have Medicare and Medicaid, or those with specific chronic conditions.

A structure in most Part D plans that categorizes drugs into tiers with varying copayments; lower tiers (often generic drugs) have lower copays, while higher tiers (usually brand-name drugs) have higher costs.