Medicare, translated.

A group of doctors, hospitals, and other providers that works together to coordinate care for people with Original Medicare.

Worth knowing: An ACO is not a Medicare Advantage plan or an insurance network.

Basic personal tasks such as bathing, dressing, eating, using the toilet, and moving from one place to another. Some long-term care policies and assistance programs use these tasks when evaluating needs.

A written notice a provider may give before an item or service when the provider believes Original Medicare may not pay. It explains why payment may be denied and lets you choose whether to receive the service and accept possible financial responsibility.

The period each fall when people with Medicare can review and change Medicare Advantage and Part D coverage for the following year. Medicare officially calls it Open Enrollment.

Worth knowing: Dates and effective-date rules should always be confirmed on Medicare.gov for the current year.

A notice Medicare Advantage and Part D plans send each fall describing changes to costs, coverage, and service area for the next plan year.

A Part B preventive visit focused on creating or updating a personalized prevention plan. It is not the same as a comprehensive annual physical exam.

A formal request to review a decision about coverage, payment, or the amount you must pay. Appeal steps and deadlines depend on the type of Medicare coverage involved.

An agreement by a provider to accept the Medicare-approved amount as full payment for a covered service under Original Medicare, aside from your applicable deductible and coinsurance.

A person who has Medicare benefits. Government materials may say beneficiary, while a private plan may say member or enrollee.

The way Original Medicare measures your use of inpatient hospital and skilled nursing facility services. A new benefit period can begin after you have been out of inpatient hospital or skilled nursing care for the required time.

The final Part D benefit phase, reached after countable out-of-pocket prescription spending meets the threshold for that plan year.

Worth knowing: The threshold and cost-sharing rules are set for each year; always use current Medicare guidance.

The federal agency that administers Medicare and works with states to administer Medicaid, the Children’s Health Insurance Program, and other health programs.

Documentation showing that prior health or prescription coverage met a required standard. For Part D, a plan or employer generally provides a yearly creditable-coverage notice.

A type of Medicare Advantage Special Needs Plan for people who have one or more qualifying severe or disabling chronic conditions and meet the plan’s eligibility rules.

Worth knowing: Qualifying conditions, service areas, networks, benefits, and availability vary by plan.

A request for Medicare or an insurance plan to pay for a health service, supply, or prescription. Providers usually submit claims, though a member may sometimes need to file one.

Temporary continuation of certain employer or union health coverage after employment or another qualifying event ends.

Worth knowing: COBRA generally does not extend the Medicare Part B Special Enrollment Period, so coordination deserves careful review.

Your share of a covered service, usually expressed as a percentage of the allowed cost after any deductible is met.

The process used to determine which health coverage pays first when a person has Medicare and another kind of insurance.

Worth knowing: Employer size and why you are eligible for Medicare can affect the order of payment.

A fixed dollar amount you may pay for a covered service or prescription, such as an office visit or medication.

A Part D plan’s decision about whether a medication is covered, what tier it is on, whether a coverage rule applies, or how much you must pay.

A former separate phase of the standard Part D benefit that appears in older materials. The standard benefit was redesigned beginning in 2025, so current drug-cost explanations should not rely on old donut-hole guidance.

Worth knowing: Historical term—use current Medicare.gov Part D cost information.

Drug coverage expected to pay, on average, at least as much as standard Medicare prescription drug coverage. Keeping proof can matter if you enroll in Part D later.

Non-skilled help with everyday activities such as bathing, dressing, or eating. Medicare generally does not pay for long-term custodial care when that is the only care needed.

The amount you must pay for covered services or prescriptions before a particular part of Medicare or insurance plan begins paying under its rules.

A person who qualifies for both Medicare and Medicaid. The programs can work together, but benefits and eligibility rules vary by state and by eligibility category.

A type of Medicare Advantage Special Needs Plan designed for people who have both Medicare and Medicaid and meet the plan’s eligibility rules.

Worth knowing: Availability, benefits, and Medicaid coordination vary by location and plan.

Certain reusable medical equipment ordered for use at home, such as walkers, wheelchairs, hospital beds, or oxygen equipment, when Medicare’s coverage conditions are met.

Permanent kidney failure requiring a regular course of dialysis or a kidney transplant. ESRD can qualify a person for Medicare before age 65.

The detailed legal description of a Medicare Advantage or Part D plan’s benefits, costs, coverage rules, and member rights for a plan year.

A request asking a Part D plan to cover a non-formulary drug, waive a coverage rule, or charge a lower cost-sharing tier when the plan’s requirements are met.

A periodic summary from a health or drug plan showing processed services or prescriptions, what the plan paid, and what the member may owe. It is generally not a bill.

Worth knowing: Do not confuse an EOB with the Evidence of Coverage, which explains the plan’s benefits and rules.

A federal program that helps people with limited income and resources pay Medicare Part D premiums, deductibles, and other prescription costs.

Worth knowing: Eligibility limits and cost amounts can change; use SSA or Medicare.gov for current figures.

A payment approach in which Medicare pays providers for each covered service. Original Medicare is often called Medicare Fee-for-Service.

A prescription drug plan’s list of covered medications. Formularies can organize drugs into tiers and may apply rules such as prior authorization, step therapy, or quantity limits.

A yearly enrollment opportunity for people who did not enroll in Part A or Part B when first eligible and who do not qualify for a Special Enrollment Period.

Worth knowing: Coverage timing and possible late penalties should be checked against current Medicare rules.

A medication approved to work the same way as its brand-name counterpart in areas such as active ingredient, strength, dosage form, quality, safety, and intended use.

Worth knowing: Coverage tier and cost still depend on the plan’s current formulary.

A complaint about the quality of care, customer service, waiting times, or another concern that is not primarily a coverage or payment decision.

A protected situation in which an insurance company must sell you certain Medigap policies, cover pre-existing conditions, and cannot charge more because of health problems.

Worth knowing: Federal rights apply in specific circumstances; states may provide additional protections.

A type of Medicare Advantage plan that generally uses a provider network and often requires members to follow plan rules for referrals or out-of-network care, except for emergencies and other protected situations.

A type of HMO plan that may let members use certain out-of-network services for a higher cost under the plan’s point-of-service rules.

Worth knowing: The point-of-service option does not make every out-of-network service covered; check the plan’s current rules.

A tax-advantaged account paired with an eligible high-deductible health plan. Once Medicare coverage begins, a person generally can no longer contribute to an HSA.

Worth knowing: Part A can be retroactive in some situations, so people working past 65 should get tax and benefits guidance before contributing near enrollment.

Certain part-time or intermittent skilled services provided at home when Medicare’s eligibility and certification requirements are met.

Comfort-focused care for a terminal illness when a person meets Medicare’s eligibility rules and elects the hospice benefit.

A provider, facility, or pharmacy that has a contract with a plan. Using network participants may affect whether a service is covered and how much you pay.

An additional amount some people with higher reported income pay with their Part B and Part D premiums. Social Security generally uses tax information from two years earlier and offers an appeal process for certain life-changing events.

The period when a person who is newly eligible for Medicare can first choose a Medicare Advantage plan. Its timing depends on when Part A and Part B begin.

The first window to enroll in Medicare around the time a person becomes eligible, usually based on age or disability eligibility.

Worth knowing: The exact window depends on why and when you become eligible.

A type of Medicare Advantage Special Needs Plan for people who live in an institution, such as a nursing home, or who meet the plan’s requirements for an institutional level of care.

Worth knowing: Eligibility, service areas, networks, benefits, and availability vary by plan.

An amount that may be added to Part B or Part D costs when a person delays enrollment without qualifying coverage or an applicable exception. Part A can also have a penalty for some people who must buy it.

Worth knowing: Penalty rules are different for each part of Medicare and can last for years or longer.

A limited pool of extra inpatient hospital days Original Medicare can help cover after the regular covered days in a benefit period are used.

A decision by a Medicare Administrative Contractor about whether an item or service is covered in its geographic jurisdiction when national policy does not fully answer the question.

Ongoing services and support for personal-care needs. Medicare is not designed to cover most long-term custodial care.

A joint federal-state program that provides health coverage to eligible people based on state rules. Medicaid may help some people with Medicare costs and services Medicare does not cover.

Worth knowing: NorthReach does not determine Medicaid eligibility; the state Medicaid agency does.

Health-care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

Worth knowing: A service can be medically necessary and still need to meet Medicare or plan coverage rules.

The federal health insurance program primarily for people 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease or ALS who meet eligibility rules.

Worth knowing: Medicare is not only for people over 65.

A Medicare-approved plan from a private company that provides another way to receive Part A and Part B benefits and usually includes Part D coverage. Members remain enrolled in Medicare and must follow the plan’s rules.

A yearly period when someone already enrolled in Medicare Advantage can make one permitted change, such as switching Medicare Advantage plans or returning to Original Medicare and joining a separate Part D plan if needed.

A Medicare Advantage plan that includes Part D prescription drug coverage along with its Part A and Part B benefits.

Worth knowing: Drug lists, pharmacy networks, costs, and coverage rules vary by plan and plan year.

The unique number printed on a Medicare card. It is personal information and should not be entered into a general website contact form.

A Medicare Advantage option combining a high-deductible health plan with a medical savings account funded through the plan. It differs from an employer HSA and generally does not include Part D.

A voluntary option offered by Medicare drug plans that spreads out-of-pocket costs for covered Part D drugs across the remaining months of the calendar year.

Worth knowing: It changes when costs are paid, not the total drug cost.

One of several state-administered programs that can help eligible people pay some Medicare premiums and, depending on the program, certain deductibles and cost sharing.

Private insurance that helps pay certain out-of-pocket costs in Original Medicare. Standardized lettered plans differ from Medicare Advantage and generally do not include prescription drug coverage.

Worth knowing: Availability, pricing, enrollment protections, and underwriting rules can vary by state and timing.

The amount Original Medicare recognizes for a covered service or item. When a provider accepts assignment, Medicare and the patient base their shares on this amount.

A nationwide CMS decision about whether Medicare covers a particular item or service.

A unique identifier assigned to an insurance professional through the national producer licensing system. It is not a Medicare member number or provider number.

A unique identifying number used for covered health-care providers in standard transactions. It is different from an insurance agent’s NPN.

The doctors, hospitals, pharmacies, and other providers a health or drug plan contracts with to deliver covered services under plan rules.

Observation services are outpatient hospital services used while a doctor decides whether to admit or discharge a patient. A Medicare Outpatient Observation Notice explains extended observation status.

Worth knowing: A person may still be an outpatient after an overnight hospital stay, which can affect costs and later skilled-nursing coverage.

The traditional fee-for-service Medicare program administered by the federal government. It includes Part A and Part B; people can add a separate Part D plan and may be able to buy Medigap.

A provider, facility, or pharmacy that does not have the relevant contract with a plan. Coverage and cost can differ or the service may not be covered, subject to emergencies and other protections.

The most a Medicare Advantage member pays in a plan year for covered Part A and Part B services under the plan’s rules. It generally does not include premiums or Part D prescription costs.

The part of Medicare that helps cover inpatient hospital care, qualifying skilled nursing facility care, hospice, and certain home health services.

The part of Medicare that helps cover physician services, outpatient care, preventive services, durable medical equipment, and certain home health services.

Another name for Medicare Advantage, the private-plan pathway for receiving Part A and Part B benefits.

Medicare prescription drug coverage offered through private plans approved by Medicare, either as a stand-alone drug plan or usually as part of a Medicare Advantage plan.

A pharmacy in a Part D plan’s network where the plan may offer lower cost sharing than at another in-network pharmacy.

A type of Medicare Advantage plan with a provider network that generally allows members to use out-of-network providers for covered services at a higher cost, subject to plan rules.

The regular amount paid for Medicare or insurance coverage, usually monthly. A person may have separate premiums for Part B, Part D, Medicare Advantage, or Medigap.

A stand-alone Medicare-approved private plan that adds Part D drug coverage to Original Medicare and certain other eligible Medicare arrangements.

The doctor or other clinician a person generally sees first for routine care, prevention, and help coordinating care. Some plans require members to choose a PCP.

Worth knowing: Whether a PCP or referral is required depends on the plan.

The primary payer processes a claim first; the secondary payer may then pay some remaining covered amount. Medicare Secondary Payer rules identify situations in which another insurer must pay before Medicare.

Worth knowing: This use of MSP is different from Medicare Savings Programs.

A plan requirement to obtain approval before it will cover certain services, items, or medications under the plan’s rules.

A type of Medicare Advantage plan that determines how much it pays providers and how much members pay, under its terms. Provider participation rules can differ from other plan types.

A Medicare and Medicaid program available in certain areas that coordinates comprehensive medical and social services for eligible people who need nursing-home-level care but can live safely in the community.

A Medicare Savings Program that may help pay the Part A premium for certain working people with disabilities who meet the program’s eligibility requirements.

Worth knowing: Income and resource limits, eligibility, and application decisions are state-administered and can change.

A Medicare Savings Program that can help eligible people pay Part A and Part B premiums and Medicare deductibles, coinsurance, and copayments.

Worth knowing: Eligibility limits are state-administered and change; providers may not bill QMB participants for Medicare-covered cost sharing.

A Medicare Savings Program that helps eligible people pay the Part B premium. Funding and eligibility rules are state-administered.

A Part D coverage rule limiting how much of a medication the plan covers during a defined period unless an exception is approved.

An order or authorization from a primary care provider to see another clinician or specialist. Some plan types require referrals for certain services.

The geographic area where a plan accepts members and provides routine access to its network. Moving in or out of a service area can affect coverage and enrollment rights.

A facility that provides skilled nursing or therapy services. Medicare coverage requires specific conditions and is not the same as long-term custodial nursing-home care.

A period outside a standard enrollment window when a qualifying life event or coverage situation allows a person to enroll in or change Medicare coverage.

Worth knowing: The event controls which changes are allowed and the deadline.

A type of Medicare Advantage plan for people who meet specific eligibility conditions, such as having certain chronic conditions, living in an institution, or having both Medicare and Medicaid.

A Medicare Savings Program that helps eligible people pay the Part B premium.

A state program offering free, unbiased counseling about Medicare. SHIP counselors do not sell insurance.

A coverage rule that generally asks a member to try one medication before a plan covers another medication for the same condition, unless an exception applies.

A notice showing claims submitted to Original Medicare, what Medicare paid, and what the person may owe. It is not a bill.

A concise overview of a plan’s major benefits, cost sharing, and rules. The Evidence of Coverage contains more complete detail.

A Social Security program that provides monthly payments to qualifying people with limited income and resources who are disabled, blind, or age 65 or older. It is different from Social Security retirement benefits.

A level in a Part D formulary used to group covered drugs with different cost-sharing amounts or rules.

A temporary supply a new or changing Part D plan may provide when a medication is not on its formulary or is subject to a new rule, allowing time to discuss alternatives or request an exception.

A limited Medigap guaranteed-issue protection that may apply when someone tries Medicare Advantage for the first time and returns to Original Medicare within the permitted period, or in another qualifying situation.

The Part D costs that count toward reaching the plan’s catastrophic coverage threshold, including certain payments made by the member and qualifying assistance programs.

Coverage rules a plan may use to manage how certain services or drugs are accessed, such as prior authorization, step therapy, or quantity limits.