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Find an insurance term, expand its explanation, and return to the lesson for the full reasoning and application. These passages come directly from the current course.
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12 terms · A–Z
Medicare is federal health insurance principally for eligible people age 65 or older and certain younger people with disabilities or specified conditions. It is not based solely on having a low income. Qualification for Medicare, entitlement to premium-free Part A, automatic enrollment, and enrollment in a particular plan are different questions.
Part C plans must provide the required Medicare benefit coverage, but networks, referrals, prior authorization, cost sharing, and additional benefits depend on plan type and terms. Compare the person's providers, prescriptions, likely care, and total cost—not just the premium.
A $0 additional plan premium does not ordinarily remove the Part B premium obligation or all service costs. Some plans offer a Part B premium reduction; that is a specific benefit to check, not a universal feature.
Medicare Advantage has an annual limit on the member's out-of-pocket spending for covered Part A and Part B services under the applicable plan rules. That medical limit is separate from Part D drug spending. Premiums and noncovered services are not automatically included.
A benefit period begins with admission as an inpatient to a hospital or skilled nursing facility. It ends after 60 consecutive days without inpatient hospital care or qualifying skilled care in a skilled nursing facility. It is not a calendar year. A new benefit period can bring another Part A deductible.
The hospice benefit generally requires certification of a life expectancy of six months or less if the illness follows its normal course and an election of comfort-focused hospice care rather than curative treatment for the terminal illness and related conditions. Coverage can continue beyond six months with required recertification. Unrelated covered care remains a separate benefit question; hospice does not ordinarily pay permanent room and board.
Medicare Advantage has a hospice payment exception. Once an eligible member elects the Medicare hospice benefit, Original Medicare pays for covered hospice care, even if the member stays enrolled in Medicare Advantage. The MA plan can still provide its extra benefits; covered care and drugs unrelated to the terminal illness have separate payment rules. Do not assume that staying in the plan makes it the payer for the hospice benefit.
For covered inpatient hospital care, the deductible applies to each benefit period. Days 1–60 have no daily hospital coinsurance after that deductible; days 61–90 have daily coinsurance. Beyond day 90, available lifetime reserve days may be used with higher daily coinsurance. There are 60 lifetime reserve days; a new benefit period does not replenish them. Current dollar amounts change, so use the year stated in a calculation.
A covered inpatient hospital admission requires the applicable inpatient order and coverage conditions. Part A helps cover the facility's inpatient services, such as the room, meals, nursing, and covered hospital drugs. The physician's professional services generally fall under Part B.
Part B includes covered physician services, outpatient care, preventive services, durable medical equipment, and certain outpatient drugs. For many services, after the annual deductible, the beneficiary owes 20% of the Medicare-approved amount when the provider accepts assignment. Some benefits have different cost-sharing rules; do not apply 20% automatically to every service.
Part D plans use a formulary, or covered-drug list, with plan-specific tiers and utilization rules. A stand-alone drug plan can accompany Original Medicare. Many Medicare Advantage plans include drug coverage; whether a separate Part D plan is permitted depends on the particular type of health plan.
The Medicare Prescription Payment Plan spreads covered out-of-pocket prescription costs across monthly bills; it does not lower the total cost. Extra Help is different: it assists eligible people with limited income and resources with Part D costs.
Original Medicare's usual qualifying hospital stay is three consecutive inpatient days, counting admission but excluding discharge. Observation and emergency-room time do not count as inpatient time for this requirement. Some approved arrangements, including certain Medicare Advantage plans, can waive the three-day requirement; do not assume every arrangement does.
The beneficiary must meet the other conditions, including a need for qualifying daily skilled services, a Medicare-certified facility, remaining benefit days, and usually admission within 30 days after hospital discharge. Coverage can support improvement or skilled maintenance or prevention of deterioration. A lack of expected improvement alone does not disqualify otherwise covered skilled care.
One hundred days is a maximum, not a promise to pay for every stay that long. Coverage can end earlier when the skilled-care requirements are no longer met. Assistance with bathing or dressing alone does not turn ongoing custodial care into this benefit.
Medicare Supplement insurance, or Medigap, is private insurance that pays specified Original Medicare cost-sharing gaps under the policy. It does not replace Medicare and cannot be used to pay Medicare Advantage cost sharing. The standardized Medigap plan letters are different from Medicare Parts A, B, C, and D.
Original Medicare alone has no single annual out-of-pocket maximum for its covered A/B services. A supplement can address specified gaps; it does not turn every excluded service or unlimited custodial care into a Medicare benefit.
The general federal Medigap open enrollment period lasts six months, beginning with the first month the person is 65 or older and enrolled in Part B. For example, first Part B enrollment on July 1 at age 67 gives a July–December period. It does not repeat during every annual Medicare health/drug enrollment season. Applicable guaranteed-issue and state protections are separate.
Original Medicare delivers Part A and Part B benefits through the federal fee-for-service program. Medicare Advantage delivers Medicare benefits through a private plan under Medicare rules. Both arrangements involve Parts A and B. Therefore, an A-and-B enrollment card does not tell you which arrangement the person uses.
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