Medicare terms in plain language

A person licensed by your state to help you compare Medicare plans and enroll. Agents are paid by the insurance company when you enroll, so there is no fee to you and your premium is the same either way.

See also: Broker, Captive agent, Field Marketing Organization, National Producer Number. Read the guide: Is it free to meet with a Medicare agent? →

The agent your plan has on file as the one who enrolled you. That agent, and their office, can service your plan; a different agent generally cannot. Your plan’s member services line can tell you who it is.

See also: Agent. Read the guide: I’m already enrolled. Who do I call for help? →

October 15 to December 7 every year. You can join, switch or drop a Medicare Advantage or Part D plan, and the change takes effect January 1.

See also: Medicare Advantage Open Enrollment Period, Special Enrollment Period, Annual Notice of Change. Read the guide: When can I enroll in Medicare or change my plan? →

A letter your Medicare Advantage or Part D plan sends each September listing what changes next year: premium, copays, the drug list and the provider network. Read it before Annual Enrollment so you know whether to stay or switch.

See also: Annual Enrollment Period, Formulary, Evidence of Coverage. Read the guide: What is the Annual Notice of Change, and what should I look for? →

A yearly Part B visit to update your prevention plan, review medications and screen for memory and fall risks. It is covered at no cost when the provider accepts assignment, but it is not a head-to-toe physical, and any extra tests can be billed separately.

See also: Welcome to Medicare visit, Preventive services.

A formal request asking your plan or Medicare to reconsider a decision to deny coverage or payment. Your denial notice explains how and by when to appeal; there are several levels if the first answer is no.

See also: Grievance, Prior authorization.

When a doctor or supplier agrees to accept the Medicare-approved amount as full payment. Providers who accept assignment cannot bill you more than your deductible and coinsurance.

See also: Excess charges, Original Medicare.

How Original Medicare measures a hospital or skilled nursing stay. It starts the day you are admitted and ends once you have gone 60 days in a row without inpatient care. You pay the Part A deductible for each benefit period, so it can apply more than once a year.

See also: Part A, Skilled nursing facility (SNF) care.

An independent agent who represents several insurance companies instead of one, so they can compare plans from different carriers. Most agents at the offices listed here are brokers.

See also: Agent, Captive agent. Read the guide: Medicare agent, broker, or SHIP counselor: who should I talk to? →

An agent who works for a single insurance company and can only sell that company’s plans. Ask any agent which companies they represent.

See also: Broker, Agent.

The last phase of Part D coverage each year. Once what you have paid out of pocket for covered drugs reaches the yearly cap, you pay nothing more for covered drugs for the rest of the year.

See also: Part D, Out-of-pocket maximum.

The federal agency that runs Medicare and sets the rules insurance companies and agents must follow, including the marketing rules that require the disclaimers you see on this site.

See also: Third-party marketing organization, Scope of Appointment.

Your share of a cost expressed as a percentage. Under Part B, for example, you usually pay 20 percent of the Medicare-approved amount after the deductible.

See also: Copayment, Deductible, Cost sharing.

The rules that decide which coverage pays first when you have Medicare and other insurance, such as an employer plan, retiree coverage or VA benefits. The one that pays first is the primary payer.

See also: Creditable coverage.

A fixed dollar amount you pay for a service or prescription, such as a set amount for each doctor visit. Plans list copays by service type and drug tier.

See also: Coinsurance, Tier.

The umbrella term for what you pay when you use care: deductibles, copayments and coinsurance. Premiums are not cost sharing; you pay those whether or not you use care.

See also: Deductible, Copayment, Coinsurance, Premium.

Drug coverage, usually from an employer or union, that is at least as good as standard Part D. If you have it, you can delay Part D without a late enrollment penalty. Your plan must tell you each year whether your coverage is creditable.

See also: Late enrollment penalty, Part D.

The amount you pay for covered care before your coverage starts paying. Original Medicare has separate Part A and Part B deductibles; Medicare Advantage and Part D plans set their own.

See also: Cost sharing, Benefit period.

Someone who qualifies for both Medicare and Medicaid. Medicaid can pay Medicare premiums and cost sharing, and special Medicare Advantage plans exist for people in this situation.

See also: Medicaid, Dual Special Needs Plan, Medicare Savings Programs.

A Medicare Advantage plan designed for people who have both Medicare and Medicaid. It coordinates the two programs and often adds benefits such as dental, transportation or an allowance for over-the-counter items.

See also: Dual eligible, Special Needs Plan, Medicare Advantage.

Reusable medical equipment prescribed for use at home, such as walkers, wheelchairs, hospital beds, oxygen and CPAP machines. Covered under Part B when a Medicare-enrolled supplier provides it.

See also: Part B.

The full legal description of what your Medicare Advantage or Part D plan covers, what you pay, and how to file an appeal. Plans send or post it every fall; it is the document to check when a question is not answered by the summary.

See also: Annual Notice of Change.

Under Original Medicare, a doctor who does not accept assignment may charge up to 15 percent more than the Medicare-approved amount. Some Medigap plans cover excess charges; a few states do not allow them at all.

See also: Assignment, Medigap.

A statement from your plan, not a bill, showing what the provider billed, what the plan paid and what you may owe. Check it against the bills you receive. In Original Medicare the equivalent is the Medicare Summary Notice.

See also: Medicare Summary Notice.

A federal program that lowers Part D premiums, deductibles and copays for people with limited income and resources. You apply through Social Security, and people with Medicaid or a Medicare Savings Program get it automatically.

See also: Part D, Medicare Savings Programs, Medicaid.

A company that supports independent agents with carrier contracts, training and compliance. Agents’ commissions come from the insurance company, often through the FMO. Benefits Life, which operates this directory, is one.

See also: Agent, Broker, Third-party marketing organization.

The list of prescription drugs a Part D or Medicare Advantage plan covers, organized into tiers that set your copay. Plans can change the formulary during the year with notice. Check that every drug you take is on it before you enroll.

See also: Tier, Prior authorization, Step therapy.

January 1 to March 31 each year, for people who missed their Initial Enrollment Period and do not qualify for a Special Enrollment Period. Coverage starts the month after you sign up, and a late enrollment penalty may apply.

See also: Initial Enrollment Period, Special Enrollment Period, Late enrollment penalty. Read the guide: When can I enroll in Medicare or change my plan? →

A complaint to your plan about the quality of service or care, such as rude staff or long waits. It is different from an appeal, which challenges a coverage or payment decision.

See also: Appeal.

A situation in which a Medigap insurer must sell you a policy without asking health questions or charging more for your health. The most common is when your Medicare Advantage plan leaves your area; you usually have 63 days to act.

See also: Medigap, Underwriting, Special Enrollment Period. Read the guide: My Medicare Advantage plan is ending or leaving my area. What do I do? →

A Medicare Advantage plan type that usually requires you to use the plan’s network of doctors and hospitals and to get referrals from a primary care provider. Premiums are often lower in exchange for the narrower choice.

See also: PPO, Network, Referral, Medicare Advantage.

Comfort-focused care for people with a terminal illness who choose not to pursue a cure. Part A covers it, and you keep that coverage even if you are in a Medicare Advantage plan.

See also: Part A.

In-network providers have a contract with your plan and cost you less. Out-of-network providers do not; an HMO may not cover them at all, and a PPO covers them at a higher cost.

See also: Network, HMO, PPO.

Your first chance to sign up for Medicare: a seven-month window that starts three months before the month you turn 65 and ends three months after it. Enrolling early in the window avoids a gap in coverage.

See also: General Enrollment Period, Special Enrollment Period, Late enrollment penalty. Read the guide: I’m turning 65. When and how do I sign up for Medicare? →

An extra amount added to your Part B and Part D premiums if your income is above certain levels, based on your tax return from two years earlier. If your income has dropped because of a life change such as retirement, you can ask Social Security to reconsider.

See also: Premium, Part B, Part D.

A permanent increase to your Part B or Part D premium for signing up late without other creditable coverage. It grows the longer you wait, so people who delay should make sure their other coverage counts.

See also: Creditable coverage, Initial Enrollment Period, General Enrollment Period.

Sixty extra hospital days Original Medicare covers once in your lifetime, used after you have been in the hospital more than 90 days in one benefit period. You pay a daily coinsurance for each one.

See also: Benefit period, Part A.

A joint federal and state program that pays health costs for people with limited income and resources. It can work alongside Medicare, paying premiums and cost sharing for those who qualify.

See also: Dual eligible, Medicare Savings Programs, Extra Help.

Services or supplies needed to diagnose or treat a condition and that meet accepted standards of medicine. Medicare and plans use this test to decide what to cover.

See also: Prior authorization.

A private plan approved by Medicare that delivers your Part A and Part B benefits, usually with Part D drug coverage built in and often with extras such as dental or vision. Most have a provider network and a yearly out-of-pocket maximum.

See also: HMO, PPO, Out-of-pocket maximum, Original Medicare.

January 1 to March 31. If you are in a Medicare Advantage plan you can make one switch to another Medicare Advantage plan, or go back to Original Medicare and add a Part D plan. You cannot use it to join Medicare Advantage from Original Medicare.

See also: Annual Enrollment Period, Medicare Advantage. Read the guide: When can I enroll in Medicare or change my plan? →

State-run programs that pay the Part B premium, and in some cases deductibles and copays, for people with limited income. Qualifying also gives you Extra Help with drug costs. Apply through your state Medicaid office.

See also: Medicaid, Extra Help.

The statement Original Medicare mails every three months listing the services billed, what Medicare paid and what you may owe. It is not a bill. Review it for services you did not receive.

See also: Explanation of Benefits, Original Medicare.

A private policy that pays some of the costs Original Medicare leaves to you, such as deductibles and coinsurance. Plans are standardized by letter (Plan G, Plan N and so on), so a given letter covers the same things from every company. You cannot have Medigap and Medicare Advantage at the same time.

See also: Original Medicare, Guaranteed issue right, Underwriting, Excess charges.

A unique identification number for every licensed insurance agent. You can use it to confirm an agent’s license with your state’s insurance department. Every agent listed on this site links to a profile showing their NPN.

See also: Agent.

The doctors, hospitals, pharmacies and other providers that have a contract with a plan. Networks change, so check that your doctors are in a plan’s network before you enroll and again each fall.

See also: In-network / out-of-network, HMO, PPO.

Most people mean the Annual Enrollment Period, October 15 to December 7. It is not the same as the Medicare Advantage Open Enrollment Period in January through March, which has narrower rules.

See also: Annual Enrollment Period, Medicare Advantage Open Enrollment Period.

Part A and Part B run directly by the federal government. You can see any doctor or hospital in the country that accepts Medicare, with no network or referrals, but there is no cap on what you pay unless you add a Medigap policy.

See also: Part A, Part B, Medigap, Medicare Advantage.

The most a Medicare Advantage plan can make you pay in a year for covered Part A and Part B services. After you reach it, the plan pays 100 percent for the rest of the year. Original Medicare has no out-of-pocket maximum, which is one reason people add Medigap.

See also: Medicare Advantage, Medigap, Cost sharing.

Covers inpatient hospital stays, skilled nursing facility care after a hospital stay, hospice and some home health care. Most people pay no premium for Part A because they or a spouse paid Medicare taxes while working.

See also: Benefit period, Skilled nursing facility (SNF) care, Hospice.

Covers doctor visits, outpatient care, lab tests, preventive services and durable medical equipment. It has a monthly premium, a yearly deductible and, for most services, 20 percent coinsurance.

See also: Premium, Coinsurance, Durable medical equipment, Preventive services.

Another name for Medicare Advantage: the part of Medicare law that lets private plans deliver your Part A and Part B benefits.

See also: Medicare Advantage.

Prescription drug coverage from private plans approved by Medicare, either as a standalone drug plan added to Original Medicare or built into a Medicare Advantage plan. Each plan has its own formulary, premium and pharmacy network.

See also: Formulary, Tier, Catastrophic coverage, Late enrollment penalty.

A Medicare Advantage plan type that lets you see providers outside the network, usually at a higher cost, and generally does not require referrals. Premiums are often higher than an HMO’s in exchange for the flexibility.

See also: HMO, Network, Medicare Advantage.

The amount you pay each month to have coverage, whether or not you use it. Part B has a premium; Medicare Advantage, Part D and Medigap plans set their own, and some Medicare Advantage plans charge nothing beyond Part B.

See also: Cost sharing, IRMAA.

Screenings, vaccines and wellness visits that Medicare covers to catch problems early. Many cost you nothing when the provider accepts assignment, though a follow-up test or treatment can be billed normally.

See also: Part B, Annual Wellness Visit.

The doctor or clinic that handles your routine care and coordinates referrals to specialists. HMO plans usually require you to choose one.

See also: Referral, HMO.

Approval your plan requires before it will cover certain services, procedures or drugs. Your doctor usually requests it. If it is denied, you can appeal.

See also: Appeal, Medically necessary, Step therapy.

A change in your situation, such as moving out of your plan’s area, losing employer coverage or moving into a nursing home, that opens a Special Enrollment Period so you can change plans outside the normal windows.

See also: Special Enrollment Period.

Written approval from your primary care provider to see a specialist. HMO plans usually require one; PPO plans and Original Medicare usually do not.

See also: Primary care provider, HMO.

A form you sign before an agent can discuss Medicare Advantage or Part D plans with you. It lists the products you agreed to talk about and keeps the meeting to those. You sign it before that conversation starts, and since October 1, 2026 there is no waiting period, so it can be signed when you arrive.

See also: CMS, Third-party marketing organization, Agent. Read the guide: What is a Scope of Appointment, and why do I have to sign it? →

A program in every state that helps people spot, report and prevent Medicare fraud, errors and abuse. Call it if you see charges on a statement for care you did not receive.

See also: SHIP, Medicare Summary Notice.

Free, unbiased Medicare counseling available in every state and funded by the federal government. Counselors do not sell plans. Each state has its own name for the program; the state pages on this site list the local number.

See also: Agent, Senior Medicare Patrol. Read the guide: Medicare agent, broker, or SHIP counselor: who should I talk to? →

Short-term nursing and rehabilitation care after a qualifying hospital stay of at least three days as an inpatient. Part A covers up to 100 days per benefit period, with daily coinsurance after day 20.

See also: Part A, Benefit period.

A window outside the regular enrollment periods to join or change plans, triggered by a qualifying life event such as moving, losing other coverage or your plan ending. Each SEP has its own length and rules.

See also: Qualifying life event, Annual Enrollment Period, Guaranteed issue right. Read the guide: My Medicare Advantage plan is ending or leaving my area. What do I do? →

A Medicare Advantage plan limited to people in a specific situation: a chronic condition such as diabetes or heart failure, both Medicare and Medicaid, or living in a nursing home. Benefits are tailored to that group.

See also: Dual Special Needs Plan, Medicare Advantage.

Medicare’s one-to-five-star rating of Medicare Advantage and Part D plans on quality, service and member experience, updated every October. If a five-star plan is offered where you live, you can switch to it once during most of the year through a special enrollment period.

See also: Medicare Advantage, Part D, Special Enrollment Period.

A plan rule that requires you to try a lower-cost drug first before it will cover a more expensive one for the same condition. Your doctor can request an exception if the first drug is not appropriate for you.

See also: Formulary, Prior authorization.

The CMS term for agents, brokers, agencies and marketing companies that sell or promote Medicare plans. TPMOs must follow federal marketing rules and display a required disclaimer about the plans they represent. Benefits Life and the agents listed here are TPMOs.

See also: CMS, Field Marketing Organization, Agent.

A grouping on a plan’s formulary that sets how much you pay for a drug. Lower tiers, usually generics, cost the least; specialty drugs sit on the highest tier.

See also: Formulary, Copayment.

A text telephone service for people who are deaf, hard of hearing or have a speech disability. Medicare’s TTY line is 1-877-486-2048, and 711 connects to the relay service from any phone.

An insurer’s review of your health history when you apply for a Medigap policy outside a guaranteed-issue period. Based on it the company can charge more or decline to cover you, which is why timing a Medigap application matters.

See also: Medigap, Guaranteed issue right.

A one-time preventive visit available during your first 12 months with Part B. It reviews your health history and risk factors and sets up a prevention plan. It is not a full physical exam.

See also: Annual Wellness Visit, Preventive services.