Anyone can make changes to their coverage and enroll in a Medicare plan each year, from October 15 to December 7. During this time you can:

• Switch to a Medicare Advantage plan (Part C) from Original Medicare (Parts A and B) — or vice versa.
• Switch from a Medicare Advantage plan (Part C) with prescription drug coverage to one without — or vice versa.
• Join or drop a Medicare prescription drug plan (Part D).
• Update your coverage by switching to a new plan from your current insurer or switching to a new insurer.

If you choose to make a change during the Annual Enrollment Period, your new coverage will begin on January 1.

An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. You can appeal if Medicare or your plan denies one of these:

• Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
• Your request for payment for a health care service, supply, item, or prescription drug you already got
• Your request to change the amount you must pay for a health care service, supply, item or prescription drug.

You can also appeal if Medicare or your plan stops providing or paying for all or part of a service, supply, item, or prescription drug you think you still need.

An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

How Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you’re admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Once you’ve spent $2,000 out-of-pocket in 2025 (down from $8,000 in 2024), you’re out of the coverage gap. Once you get out of the Medicare prescription drug coverage gap, you automatically get ‘catastrophic coverage’. Beginning in 2024, when you have catastrophic coverage, you won’t need to pay any coinsurance or copayments for covered drugs for the rest of the year.

U.S. Centers for Medicare & Medicaid Services

An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.

The first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits, including:

• Whether a particular drug is covered
• Whether you have met all the requirements for getting a requested drug
• How much you’re required to pay for a drug
• Whether to make an exception to a plan rule when you request it

The drug plan must give you a prompt decision (72 hours for standard requests, 24 hours for expedited requests). If you disagree with the plan’s coverage determination, the next step is an appeal.

Previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medicare Supplement Insurance (Medigap) policy.

Prescription drug coverage (for example, from an employer or union) that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.

Certain medical equipment, like a walker, wheelchair, or hospital bed, that’s ordered by your doctor for use in the home.

An effective date is the date in which your insurance coverage begins. Insurance providers will not pay for benefits incurred before the effective date

Care needed immediately because of a medical condition of sudden and unexpected onset.

Explanation of benefits statements are a document you will receive from your insurance company outlines the cost of the medical care your received. It outlines what costs will be covered by your insurance provider and what costs, if any that you are responsible for paying.

A type of Medicare prescription drug coverage determination. A formulary exception is a drug plan’s decision to cover a drug that’s not on its drug list or to waive a coverage rule. A tiering exception is a drug plan’s decision to charge a lower amount for a drug that’s on its non-preferred drug tier. You or your prescriber must request an exception, and your doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.

If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.

A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles and coinsurance.A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles and coinsurance.

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.

Also called ‘Medigap protections’. Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medicare Supplement policy, nor place conditions on a policy (such as exclusions for pre-existing conditions), and can’t charge you more for a policy because of a past or present health problem.

An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable.

Health care services and supplies a doctor decides you may get in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.

A discount that some states allow that provides a reduction of Medicare supplement premiums if the policyholder resides with another adult or spouse. There are state requirements that must be met in order to qualify for this discount. Policyholders should review their outline for details and restrictions.

Specific to prescription drug plans, once you’ve met your deductible, you will pay for a portion of each medication through a copay or coinsurance based on which tier the drug falls into. Tiers include Preferred Generic, which typically has the lowest copay, and Specialty Drugs, which typically has the highest. The initial coverage limit is set annually by Medicare, for 2025 the limit is $2,000 (down from $5,030 in 2024).

This seven-month period begins three months prior to the month you turn 65, includes your birthday month, and ends three months after your birthday month. During this time, you can:

• Enroll in Original Medicare (Parts A and B)
• Enroll in a Medicare prescription drug plan (Part D)
• Enroll in a Medicare Advantage plan (Part C)

Enrolling during your Initial Enrollment Period can help you avoid potential penalties.

The process that an insurance company uses to decide, based on your medical history, whether to take your application for insurance, whether to add a waiting period for pre-existing conditions (if your state law allows it), and how much to charge you for that insurance.

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.

Medicare is the federal health insurance program for:

People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

People who are 65 or older

Certain younger people with disabilities

A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits, excluding hospice. Medicare Advantage Plans include:

• Health Maintenance Organizations
• Preferred Provider Organizations
• Private Fee-for-Service (PFFS) Plans
• Special Needs Plans
• Medicare Medical Savings Account Plans

If you’re enrolled in a Medicare Advantage Plan:

Most Medicare Advantage Plans offer prescription drug coverage.

Most Medicare services are covered through the plan

Medicare services aren’t paid for by Original Medicare

Part D adds prescription drug coverage to:

• Original Medicare
• Some Medicare Cost Plans
• Some Medicare Private-Fee-for-Service Plans
• Medicare Medical Savings Account Plans

These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare drug plans.

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.

Medigap is Medicare Supplement Insurance that helps fill “gaps” in Original Medicare and is sold by private companies. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like:

Deductibles

Copayments

Coinsurance

In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.

A health care provider (like a home health agency, hospital, nursing home, or dialysis facility) that’s been approved by Medicare. Providers are approved or “certified” by Medicare if they’ve passed an inspection conducted by a state government agency. Medicare only covers care given by providers who are certified.

A one-time only, 6-month period when federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.

Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage

Newly eligible for Medicare occurs when you turn 65. You may also be eligible due to a disability or end-stage renal disease (ESRD).

From October 15 – December 7 each year, you can join, switch or drop a plan. Your coverage will begin on January 1 (as long as the plan gets your request by December 7).

Medicare Advantage and Medicare Prescription Drug Plans policyholders only. Medicare Supplement policyholders may switch year round, but may have to answer health questions. Additional special and state enrollment periods may apply.

Health or prescription drug costs that you must pay on your own because they aren’t covered by Medicare or other insurance.

An amount added to your monthly premium for Part B or a Medicare drug plan (Part D) if you don’t join when you’re first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.

The date your coverage starts under this policy.

The date your policy’s premium is due. The frequency of the policy renewal date will vary depending on whether you pay premiums monthly, quarterly, semiannually, or annually.

A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a health care proxy, appointment of health care agent, or a durable power of attorney for health care.

A health problem you had before the date that new health coverage starts.

The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms). Dental services to care for your gums and teeth to keep them healthy and include oral exams, teeth cleanings and x-rays.

The doctor you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.

Approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered by your plan. Your Medicare drug plan may require prior authorization for certain drugs. This is a restriction on certain medications which requires permission from your doctor before the prescription can be filled.

This is a restriction on certain Medicare prescription drug plans which restricts the amount of a drug that will be covered for a single copay or within a predefined period of time.

Health care services that help you keep, get back, or improve skills and functioning for daily living that you’ve lost or have been impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

You’ll pay this until you hit your deductible.

The insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.

A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

Skilled nursing care and rehabilitation services provided on a daily basis, in a skilled nursing facility (SNF). Examples of SNF care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. These chances to make changes are called Special Enrollment Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP.

A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug. This is a restriction on certain Medicare prescription drug plans which requires that you try safe, effective, lower cost drugs before the plan covers a more costly drug.

A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 or older. SSI benefits aren’t the same as Social Security retirement or disability benefits.

Medical or other health services given to a patient using a communications system (like a computer, phone, or television) by a practitioner in a location different than the patients.

Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.

If you’ve had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly “Wellness” visit once every 12 months to develop or update a personalized prevention plan to help prevent disease and disability, based on your current health and risk factors. Your provider may also perform a cognitive impairment assessment.