Terms Glossary
At Brooks Insurance Group, educating our clients is at the core of what we do. Use this glossary to brush up on important terms.
Enrollment Periods
Oct 15–Dec 7 annually; time to join, switch, or drop Medicare Advantage or Part D plans.
A 6-month period starting when you turn 65 and enroll in Part B. You can buy a Medigap policy with no medical underwriting.
Jan 1–Mar 31; allows those in a Medicare Advantage plan to switch MA plans or return to Original Medicare.
January 1 to March 31 annually. For those who missed enrolling in Medicare Part A and/or Part B when first eligible. Coverage begins July 1, and penalties may apply.
Allows changes to Medicare plans outside standard periods due to life events like moving, loss of coverage, or gaining Medicaid eligibility.
A type of Medicare Advantage plan for people with chronic conditions, institutional care needs, or dual eligibility.
Your first chance to enroll in a Medicare Advantage (Part C) plan. It usually coincides with your IEP but ends the month before your Part B coverage starts if you delay enrolling in Part B.
Penalties and Premium Adjustments
Fees for enrolling late in Part A (if not free), Part B, or Part D, unless you had creditable coverage.
A higher premium for Part B and Part D based on income.
Creditable coverage means your current insurance is as good as Medicare.
Part B: Employer coverage (from active employment) is creditable if the employer has 20+ employees. It lets you delay Part B without penalty.
Part D: Drug coverage (e.g. from employer, VA, or union) is creditable if it’s expected to pay as much as Medicare’s standard drug plan. Without it, a late penalty may apply if you go 63+ days without coverage.
Medicare Parts and Plan Types
Consists of Part A (hospital) and Part B (medical).
Covers inpatient hospital care, skilled nursing, hospice, and some home health care.
Covers outpatient care, doctor visits, preventive services, and medical supplies.
Offered by private companies; includes Parts A and B, often Part D and extras like dental/vision.
Stand-alone prescription drug coverage or part of a Medicare Advantage plan.
Another name for Part C; includes medical and often drug coverage.
Private insurance that helps pay for costs not covered by Original Medicare (e.g., coinsurance, deductibles).
Costs and Coverage Terms
The monthly amount paid for Medicare coverage.
A fixed amount paid for a service (e.g., $20 per doctor visit).
The amount you must pay before coverage begins.
A percentage of costs you pay after meeting the deductible.
General term for the insured’s share of costs (copays, coinsurance, deductibles).
The most you’ll pay in a year for covered services in Medicare Advantage.
The amount Medicare agrees to pay for a covered service.
Services or supplies needed to diagnose or treat a condition per accepted standards.
Plan Structures and Care Access
The main physician for regular care and referrals.
Requires use of network providers and referrals for specialists.
Offers more provider flexibility, including out-of-network care (often at a higher cost).
Group of doctors, hospitals, and providers contracted with a Medicare plan.
Pharmacies with lower cost-sharing in your Part D or Advantage plan.
Low-Income and State Assistance
Joint federal/state program offering health coverage to low-income individuals, including some Medicare beneficiaries (dual eligible).
State programs that help pay Medicare drug plan costs.
Free counseling and assistance with Medicare choices and issues.
Prescription Drug Plan Structure
You pay 100% until your deductible is met.
Your plan pays a portion of drug costs, and you pay the rest (copay or coinsurance).
After reaching a set limit, you pay a higher share for drugs (gradually closing).
You pay reduced amounts once total out-of-pocket costs reach a set limit.
The list of prescription drugs covered by a plan.
Classification of drugs (usually 1–5); lower tiers cost less.
Offers the lowest copay or coinsurance for covered drugs.
Restrictions on how much of a drug you can receive.
Must try less expensive drugs before coverage for costlier alternatives.
Option to spread Medicare drug costs over time.
A program that helps low-income beneficiaries with Part D costs.
Types of Care and Facilities
Short-term rehab or medical care provided by trained professionals after hospitalization.
Provides intensive rehab for serious injuries or illnesses.
Non-medical care for chronic conditions; generally not covered by Medicare.
Care focused on comfort for those with a terminal illness, covered under Part A.
Outpatient facilities for same-day surgeries.
CMS and Medicare Oversight
Federal agency that runs Medicare and Medicaid.
Quality ratings (1–5 stars) for Medicare Advantage and Part D plans based on performance.
Geographic area where a plan is available and provides coverage.
Annual Notices and Documentation
Sent by Medicare plans each fall to explain changes for the next year.
When doctors agree to accept Medicare’s approved amount as full payment.
Starts when admitted to hospital/skilled nursing and ends after 60 days without care.
60 extra hospital days available after regular Part A benefits are used.
Screenings, vaccines, and check-ups covered by Medicare to prevent illness.
Special Conditions and Eligibility
A person enrolled in Medicare.
Qualifies for automatic Medicare enrollment upon diagnosis.
Kidney failure requiring dialysis or transplant; qualifies for Medicare.
Appeals and Protections
Request to confirm if a service/item will be covered before you receive it.
Request to review and change a denied coverage or payment decision.
For more information, contact the Centers for Medicare & Medicaid Services.
Complaint about a plan’s services, not related to a denial.
Right to buy Medigap without medical underwriting in specific situations.
Insurer cannot cancel your policy if you pay premiums.
Review of health status and preexisting conditions before issuing a Medigap policy (not allowed in some situations).
Legal document appointing someone to make health/financial decisions if you're unable.