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Important Terminology to Know

Home / Resources / Important Terminology to Know

Many insurance agents try to impress you by using million-dollar insurance words, but that normally just results in confusion and frustration! My Medicare Partners does our best to avoid confusing, technical insurance jargon – but sometimes it’s unavoidable. Here are a few key terms to become familiar with.

Agent

A person who is a representative of insurance carrier(s). We refer to our Agents as “Medicare Agents” since their expertise is in Medicare plans.

Annual Election Period (AEP)

October 15 – December 7. A Medicare beneficiary may sign up for or switch their Medicare Advantage or Prescription Drug Plan during the AEP. Also known as the Medicare Open Enrollment Period. These plans become effective on January 1.

Original Medicare Care Transparent

Benefit Period

The set amount of time during which Medicare Part A will pay for hospitalization and skilled nursing facilities (SNF). The Period begins upon admission to a hospital or SNF. It ends once you have been discharged and remain out of the hospital or SNF for at least 60 days. If readmitted within the 60 day period, you are considered to be in the same Benefit Period. If admitted more than 60 days later, a new Benefit Period is begun, and you are subject to the Part A deductible and co-pays. Medicare supplement greatly reduce, and oftentimes eliminate, these co-pays and deductibles.

Carrier

A fancy term for “insurance company”.

Claim

A bill sent by your provider to get paid for the services provided. A claim may be denied if the individual’s plan does not cover a specific service.

Coinsurance

After the plan’s deductible is met, this is the amount you have to pay out of pocket to cover your share of cost for the services. Coinsurance is typically a percentage.

Co-pay

The amount you pay out of pocket for a covered service, before receiving that service. Typically, co-pays are a set dollar amount.

Deductible

The portion you pay before the insurance begins to cover a majority of expenses.

Donut Hole

Also known as the Coverage Gap. A period during which there is a gap in the coverage Medicare Part D provides for prescription drugs.

Enrollment Periods

Specified times of the year during which you may sign up for or change your health insurance plan. Under Medicare, there are several enrollment periods, including the Annual Election Period, Special Enrollment Periods, and the General Enrollment Period.

Formulary

A list of medications covered by a plan. Also called a “drug list”.

General Enrollment Period

January 1 – March 31. The time during which you may enroll in Original Medicare if you missed your Initial Enrollment Period. Coverage becomes effective on July 1.

Guaranteed Issue

Requirement that an insurance plan accept you as a member, regardless of health issues. Medicare Supplement plans are guaranteed issue when you’re first eligible to enroll in Original Medicare, typically at age 65.

Initial Enrollment Period

The 7 month period during which a newly eligible person can sign up for Medicare Part A and Part B, as well as additional coverage like Part D drug plans, a Medicare Supplement plan, or a Medicare Advantage plan. This Period begins three months before the month you turn 65, the month of your 65th birthday, and the three months after your 65th birthday.

Depending on when in the IEP you enroll will determine when your plan becomes effective. If you do not enroll during your IEP, you will need to enroll during the Annual Election Period or see if you qualify for a Special Enrollment Period.

Maximum Out Of Pocket

The limit on out of pocket costs a beneficiary has for services, tests, hospitalization, etc. Once the MOOP has been met, you no longer pay for medical services covered under your plan.

Medicaid

A program administered by each state that helps people who are indigent (low income) with medical services. A person may qualify for both Medicare and Medicaid.

Medicare

A program administered by the federal government that provides insurance coverage for people 65 and older who qualify. Others may qualify if they are disabled and have been receiving Disability for at least 24 months, or if they have end-stage renal disease (permanent kidney failure) or Lou Gehrig’s disease (ALS).

Medicare Advantage Disenrollment Period

January 1 – February 14. Allows Medicare Advantage beneficiaries to terminate their plan, reverting them back to Original Medicare only. During this time, you can also enroll in a Part D drug plan.

Medicare Part A

Hospitalization, skilled nursing facilities, home health care, and hospice care. Half of Original Medicare.

Original Medicare Only

Medicare Part B

Doctors, services, medication administered by a physician, preventive care, outpatient care, and more. Half of Original Medicare.

Original Medicare Only

Medicare Part C

Also known as Medicare Advantage, these plans are administered by private insurance companies to provide coverage for Part A and Part B. Most Medicare Part C plans also include prescription drug coverage, and oftentimes are referred to as Medicare Advantage with Prescription Drug (MAPD) plans.

Medicare Part D

Medications. Also known as Prescription Drug Plans (PDP).

Medicare Supplement

Also known as MediGap, these policies are administered by private insurance companies to cover the “gaps” in the coverage offered by Original Medicare only. Medicare Supplement plans greatly reduce, or eliminate, deductibles, coinsurance, and co-pays of medicare approved services that you would normally be responsible to pay. Medicare Supplement plans allow you to visit any doctor or facility in the United States that accepts Medicare, and some provide coverage outside of the USA. Medicare Supplement plans also allow you to visit Specialist doctors without requiring a referral first

Medicare Supplement Plans

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Out of Pocket Costs

The portion of health care bills that you, the insured/patient, must pay from your own money. Out of pocket costs can include deductibles, co-pays, and coinsurance.

Part

Medicare is divided into four parts – Part A, Part B, Part C, and Part D. Each part provides coverage of different services. Parts are different from Plans! Read more about the Parts of Medicare here.

Plan

Medicare Supplements, also known as MediGap, are divided into Plans. They are currently ten different Plans available for sale – Plan A, Plan B, Plan C, Plan D, Plan F, Plan G, Plan K, Plan L, Plan M, and Plan N.

Plans of different letters differ from each other in the benefits they cover. However, all Plans of the same letter, within the same state, offer the same standardized benefit. For example, Plan A offers different benefits than Plan F. In Michigan, all Plan A offer the same coverage.

The premium for these plans may vary based on the insurance company providing the coverage. For example, all Plan G in Iowa cover the same benefits, but Insurance Company #1 could charge a different premium than Company #2.

Preexisting Condition

A health problem or illness you have been diagnosed with before health coverage begins.

Premium

The price you pay monthly to the insurance carrier/company in order to receive medical coverage through your plan.

Preventative Care

Health care screenings, tests, and interventions that help prevent illness. Preventive care is usually “regularly-scheduled” screenings physicians recommend you receive every X years.

Special Enrollment Period (SEP)

Certain events in life that allow you to make changes to your Medicare plan, outside of and in addition to the regular enrollment periods. Some SEPs include losing current insurance coverage or moving to a different area. If you qualify for an SEP, you do have a limited amount of time during which you may apply for or change your plans. If you miss your SEP deadline, you will have to wait until the next enrollment period

Special Enrollment Period

 

Underwriting

The questions and parameters insurance companies use to determine if an individual will be accepted into a plan.

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