Annual Enrollment Period (AEP)

A yearly period (October 15 to December 7) when Medicare beneficiaries can make changes to their health and prescription drug coverage, including switching between Medicare Advantage plans or enrolling in Medicare Part D.

Appeal

A formal request to have a health insurance company or government program review a decision regarding coverage or services, such as a denial of payment for a medical service.

Automatic Enrollment

The process by which individuals are automatically enrolled in a health insurance plan, often through programs like Medicare when they reach age 65 or when they begin receiving Social Security benefits.

Balance Billing

The practice of billing a patient for the difference between the provider’s charge and the amount covered by the insurance plan. In Medicare, Medicaid, and CHIP, balance billing may be prohibited or limited.

Benefit Verification

The process of confirming an individual’s eligibility and benefits for health services through Medicaid, Medicare, or private insurance. This ensures coverage and payment for services.

Coinsurance

The percentage of medical costs a patient must pay after meeting their deductible. For example, a Medicare plan might require patients to pay 20% of the cost of services after Medicare has paid its share.

Coordination of Benefits (COB)

A process used when a patient is covered by more than one insurance plan. It determines which insurance plan pays first and helps prevent overpayment for services covered by both policies. COB applies to Medicare, Medicaid, and private insurance.

CMS (Centers for Medicare & Medicaid Services)

A federal agency within the U.S. Department of Health and Human Services (HHS) that administers the nation’s major healthcare programs including Medicare, Medicaid, and CHIP, as well as oversight of the ACA Marketplace.

Disability

A physical or mental condition that limits an individual’s ability to perform daily activities. People with disabilities may qualify for Medicare before age 65 or receive coverage through Medicaid.

Disenrollment

The process of voluntarily or involuntarily terminating coverage under a health insurance plan, such as Medicare, Medicaid, or CHIP. Disenrollment may occur if a beneficiary no longer meets eligibility requirements or chooses to switch plans.

Dual Eligibility

Refers to individuals who qualify for both Medicare and Medicaid coverage. Dual-eligible beneficiaries often have their Medicare premiums and out-of-pocket costs covered by Medicaid.

Durable Medical Equipment (DME)

Equipment prescribed by a healthcare provider that can be used at home to help with medical conditions, such as wheelchairs, crutches, oxygen tanks, and hospital beds. Medicare, Medicaid, and CHIP cover DME when deemed medically necessary.

Disability Insurance

Insurance that provides income protection to individuals who are unable to work due to a disability. Medicare beneficiaries under age 65 often qualify due to a long-term disability.

Eligibility

The criteria that individuals must meet to qualify for healthcare programs such as Medicare, Medicaid, CHIP, or ACA Marketplace plans. Eligibility is typically based on factors such as age, income, residency, and health status.

Emergency Services

Immediate medical care provided for acute, life-threatening conditions. Medicare, Medicaid, CHIP, and ACA-compliant plans all cover emergency services, often without requiring prior authorization.

Exclusions

Services or treatments that are not covered by a health insurance plan. Exclusions vary by plan, and they may include specific treatments, procedures, or prescription drugs that are not considered medically necessary.

End-Stage Renal Disease (ESRD)

A medical condition in which a person’s kidneys stop functioning permanently, requiring dialysis or a kidney transplant. Individuals with ESRD are eligible for Medicare regardless of age.

Enrollee

An individual who is covered by a health insurance plan, such as those offered through Medicare, Medicaid, CHIP, or the ACA Marketplace.

Enrollment Period

The designated time frame during which individuals can sign up for or make changes to their health insurance coverage. Medicare has an Annual Enrollment Period, and the ACA Marketplace has an Open Enrollment Period.

Federally Qualified Health Center (FQHC)

A community-based health clinic that provides comprehensive primary and preventive care services, including dental, mental health, and substance use services. Medicaid, Medicare, and CHIP typically cover services received at FQHCs, which serve low-income, uninsured, and underserved populations.