Medicare glossary

A provider agrees to accept Medicare’s approved amount as full payment.

When a provider accepts assignment, they agree to accept the Medicare-approved amount as full payment for covered services. The patient is only responsible for normal cost-sharing, no excess charges.

A span of Medicare coverage used to measure inpatient deductibles.

A benefit period begins the day you are admitted to a hospital or skilled nursing facility and ends when you have been out for 60 consecutive days. The Part A deductible applies per benefit period, so it can apply more than once a year.

A percentage of a covered service you pay.

Coinsurance is your share of the cost of a covered service, expressed as a percentage (for example, Original Medicare Part B generally charges 20% coinsurance for most outpatient services after the deductible).

A fixed dollar amount you pay for a service.

A copayment is a fixed dollar amount you pay at the point of care (for example, a $20 office-visit copay or $50 ER copay). Plan N includes small copays for some Medicare Advantage-like visits within Original Medicare.

Drug coverage at least as good as Medicare’s standard.

Creditable coverage is prescription drug coverage (such as from an employer or union) that is at least as good as Medicare’s standard Part D coverage. Maintaining it lets you delay Part D without a late enrollment penalty.

An amount you pay before coverage begins.

A deductible is the amount you pay for covered services before your plan begins to pay. Medigap plans may cover some or all of Medicare’s Part A and Part B deductibles.

Amounts some non-assigning providers may bill above Medicare’s approved amount.

Part B excess charges occur when a doctor does not accept Medicare assignment and bills up to 15% more than the Medicare-approved amount. Some Medigap plans (e.g., Plan G, Plan F) cover excess charges; others (e.g., Plan N) do not. Most Florida providers accept assignment, so excess charges are uncommon there.

A plan’s list of covered drugs and their cost tiers.

A formulary is a Part D or Medicare Advantage plan’s list of covered prescription drugs, organized into tiers with different cost-sharing. Each plan’s formulary can change annually.

The right to buy a Medigap plan without medical underwriting.

Guaranteed Issue rights let you buy certain Medigap plans without medical underwriting in specific situations, for example, during your Medigap Open Enrollment or when you lose certain coverage. The insurer cannot deny you or charge more for health reasons.

A plan type requiring in-network care and referrals.

A Health Maintenance Organization (HMO) plan requires you to use in-network providers and usually select a primary care doctor who refers you to specialists. Out-of-network care is generally not covered except in emergencies.

Your first 7-month window to sign up for Medicare at 65.

The Initial Enrollment Period (IEP) is the seven-month window around your 65th birthday, three months before, your birthday month, and three months after, when you can first enroll in Medicare Parts A and B.

An income-based premium surcharge on Part B and Part D.

The Income-Related Monthly Adjustment Amount (IRMAA) is a surcharge added to Part B and Part D premiums for higher-income beneficiaries, based on income from two years prior.

Medicare Supplement insurance that fills Original Medicare gaps.

Medigap (Medicare Supplement) is private insurance that helps pay Original Medicare cost-sharing like deductibles, coinsurance, and copays. Plans are standardized by letter (A N) and work alongside Original Medicare, not with Medicare Advantage.

A health review an insurer may require before approving Medigap.

Medical underwriting is a review of your health history. Outside guaranteed-issue situations and your Medigap Open Enrollment, insurers may underwrite Medigap applications and can decline, rate up, or impose waiting periods.

Six months after Part B when you can buy any Medigap plan without underwriting.

Medigap Open Enrollment is the six-month period that begins the month you are both 65 and enrolled in Part B. During it, you have guaranteed access to any Medigap plan regardless of health in most states.

A group of providers contracted with a plan.

A provider network is a group of doctors, hospitals, and other providers contracted with a health plan. Original Medicare has no networks; Medicare Advantage plans typically use HMO or PPO networks.

The federal fee-for-service program: Parts A (hospital) and B (medical).

Original Medicare is the traditional, federal fee-for-service Medicare program, consisting of Part A (hospital insurance) and Part B (medical insurance). You can see any doctor that accepts Medicare nationwide. It does not include an annual out-of-pocket cap unless paired with a Medigap plan.

Hospital insurance under Medicare.

Medicare Part A covers inpatient hospital stays, skilled nursing facility care, hospice, and limited home health care. Most people get premium-free Part A based on 40 quarters of work.

Medical insurance under Medicare.

Medicare Part B covers outpatient medical services: doctor visits, preventive care, durable medical equipment, and some home health. Most people pay a monthly premium for Part B.

Medicare Advantage plans offered by private insurers.

Medicare Part C is the Medicare Advantage program. Private insurers approved by Medicare offer plans that cover all Part A and Part B services, often bundled with Part D and extras like dental and vision. It replaces Original Medicare as the way you receive benefits.

Optional prescription drug coverage.

Medicare Part D is optional prescription drug coverage offered by private insurers. Going without creditable coverage for 63+ days after your Initial Enrollment Period can trigger a permanent late enrollment penalty.

A plan type allowing in- and out-of-network care.

A Preferred Provider Organization (PPO) plan lets you see in-network providers at the lowest cost and out-of-network providers at higher cost, usually without needing referrals.