Medicare Program Verbiage

• Medicare
  A federal health insurance program primarily for individuals age 65 and older, as well as certain younger individuals with disabilities or qualifying medical conditions.

• Medicare Part A (Hospital Insurance)
  Covers inpatient hospital stays, skilled nursing facility care, hospice care, and limited home health services. Many beneficiaries receive Part A premium-free if they or their spouse worked 40 quarters (10 years) paying Medicare taxes.

• Medicare Part B (Medical Insurance)
  Covers doctor visits, outpatient services, preventive care, diagnostic testing, mental health services, durable medical equipment, and many medically necessary services. Beneficiaries pay a monthly premium that can vary depending on income.

• Medicare Part C (Medicare Advantage)
  Private health plans approved by Medicare that bundle Part A and Part B coverage and often include additional benefits such as dental, vision, hearing, fitness programs, and transportation.

• Medicare Part D (Prescription Drug Coverage)
  Coverage for outpatient prescription medications offered through private insurance companies approved by Medicare.

• Original Medicare
  The traditional Medicare program administered by the federal government, consisting of Part A and Part B coverage.

Medicare Advantage Plan Types

• C-SNP (Chronic Condition Special Needs Plan)
  A Medicare Advantage plan designed for beneficiaries with specific chronic conditions, such as diabetes, heart disease, or COPD. Care coordination focuses on managing the specific condition.

• D-SNP (Dual Eligible Special Needs Plan)
  A Medicare Advantage plan designed for individuals who qualify for both Medicare and Medicaid, coordinating benefits between the two programs and often including additional cost assistance and benefits.

• HMO (Health Maintenance Organization)
  A plan type requiring members to use in-network providers for most services and typically requiring referrals from a Primary Care Provider (PCP) to see specialists.

• HMO-POS (HMO Point of Service)
  A variation of an HMO plan that allows limited out-of-network services, typically at higher out-of-pocket costs.

• I-SNP (Institutional Special Needs Plan)
  A Medicare Advantage plan designed for individuals living in nursing homes or requiring long-term institutional level care.

• MAPD (Medicare Advantage Prescription Drug Plan)
  A Medicare Advantage plan that includes prescription drug coverage (Part D) in addition to medical benefits.

• MA (Medicare Advantage)
  Private insurance plans that replace Original Medicare by providing Part A and Part B coverage through a single coordinated plan.

• MSA (Medical Savings Account)
  A high-deductible Medicare Advantage plan combined with a medical savings account funded by the plan for healthcare expenses.

• PFFS (Private Fee-for-Service)
  A Medicare Advantage plan where the plan determines how much it pays providers and how much the beneficiary must pay. Some plans have networks while others allow broader provider acceptance.

• POS (Point of Service)
  A plan structure that allows members to receive care outside the provider network, usually with higher copays or coinsurance.

• PPO (Preferred Provider Organization)
  A plan type offering greater flexibility, allowing members to visit out-of-network providers without referrals, usually at higher costs.

• SNP (Special Needs Plan)
  Medicare Advantage plans designed for specific groups of beneficiaries, including those with chronic conditions, dual eligibility, or institutional care needs.

Provider Structure & Verbiage

• Network
  The group of doctors, hospitals, pharmacies, and providers contracted with a health plan to provide services at negotiated rates.

• PCP (Primary Care Provider)
  The main doctor responsible for coordinating a beneficiary’s healthcare, managing overall treatment and providing referrals to specialists in certain plan types.

• Referral
  A formal authorization from a Primary Care Provider allowing a patient to see a specialist, required in many HMO-style plans.

• Urgent Care
  Non-emergency medical care needed quickly, typically for conditions such as minor injuries, infections, or illnesses.

Prescription Drug Coverage & Formularies

• Formulary
  The list of prescription drugs covered by a Medicare Part D or MAPD plan. Each plan’s formulary determines which medications are covered and what tier they fall under.

• Preferred Pharmacy
  Pharmacies within a plan’s network that offer lower prescription copays compared to standard pharmacies.

• Step Therapy
  A cost-management strategy requiring beneficiaries to try lower-cost medications first before a plan covers more expensive alternatives.

Prescription Drug Tier Levels

Prescription medications are categorized into tiers that determine cost sharing:

• Tier 1 – Preferred Generic Drugs
  Lowest cost medications, typically common generic prescriptions.

• Tier 2 – Generic Drugs
  Standard generic medications with slightly higher copays than Tier 1.

• Tier 3 – Preferred Brand Drugs
  Brand-name medications preferred by the plan, with moderate copayments or coinsurance.

• Tier 4 – Non-Preferred Brand Drugs
  Brand-name medications not preferred by the plan, usually with higher out-of-pocket costs.

• Tier 5 – Specialty Drugs
  High-cost medications used to treat complex or rare conditions, such as cancer therapies or specialty biologic medications.

• Tier 6 – Select Care Drugs (Plan-Specific)
  Some plans include a low-cost maintenance medication tier for common chronic condition treatments like blood pressure or cholesterol medications.

Enrollment Periods

• AEP (Annual Enrollment Period)
  Occurs October 15 – December 7 each year. Beneficiaries can join, switch, or drop Medicare Advantage or Part D plans, with changes effective January 1.

• IEP (Initial Enrollment Period)
  The 7-month window surrounding a person’s 65th birthday when they first become eligible to enroll in Medicare.

• OEP (Medicare Advantage Open Enrollment Period)
  Occurs January 1 – March 31 each year and allows individuals already enrolled in a Medicare Advantage plan to switch plans or return to Original Medicare.

• SEP (Special Enrollment Period)
  A period outside normal enrollment windows allowing beneficiaries to change coverage due to qualifying life events, such as moving or losing other coverage.

Costs & Cost-Sharing

• Coinsurance
  The percentage of costs a beneficiary pays after meeting a deductible, such as 20% for many services under Medicare Part B.

• Copayment (Copay)
  A fixed dollar amount paid for a service, such as a doctor visit or prescription medication.

• Deductible
  The amount a beneficiary must pay before insurance begins covering certain services.

• MOOP (Maximum Out-of-Pocket)
  The maximum amount a beneficiary must pay for covered medical services in a Medicare Advantage plan each year. After this limit is reached, the plan pays 100% of covered services.

Medicaid Verbiage

• Extra Help (Low-Income Subsidy – LIS)
  A federal assistance program that helps individuals with limited income pay for Medicare Part D prescription drug costs, including premiums, deductibles, and copays.

• Medicaid
  A state and federally funded program providing healthcare coverage for individuals with limited income and resources. Some people qualify for both Medicare and Medicaid.

Additional Medicare Terminology

• Assignment (Medicare Assignment)
  When a provider accepts the Medicare-approved amount as full payment for services, typically resulting in lower costs for the beneficiary.

• Appeal
  A formal request to reconsider a coverage decision or payment denial made by Medicare or a Medicare plan.

• Coverage Determination
  A decision made by a Part D plan regarding whether a medication is covered and how much the beneficiary must pay.

• DME (Durable Medical Equipment)
  Medically necessary equipment prescribed by a doctor for use in the home, such as walkers, oxygen equipment, or hospital beds.

• Late Enrollment Penalty (LEP)
  A permanent premium increase applied to Part B or Part D if a beneficiary delays enrollment without having other creditable coverage.

• Part B Giveback (Social Security Giveback)
  A benefit offered by some Medicare Advantage plans that reduces a beneficiary’s monthly Part B premium, often increasing their Social Security payment or reducing their billed premium.

• Prior Authorization
  A requirement that certain services, procedures, or medications receive approval from the plan before they are covered.

• Skilled Nursing Facility (SNF)
  A facility providing short-term skilled nursing or rehabilitation care following a hospital stay.