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.

Medicare Advantage (Part C)

A type of health plan offered by private insurance companies that contracts with Medicare to provide all Part A and Part B benefits. Medicare Advantage plans often include extra benefits, such as vision, dental, and prescription drug coverage.

Network

A group of doctors, hospitals, and other healthcare providers that have agreed to provide care to members of a health insurance plan at negotiated rates. In Medicare Advantage, Medicaid, and ACA plans, enrollees typically pay less for using in-network providers.

Out-of-Pocket Maximum

The maximum amount an individual must pay for covered healthcare services in a plan year before the insurance company covers 100% of the costs. Out-of-pocket maximums apply to ACA Marketplace plans, Medicare Advantage, and some Medicaid programs.

Part C (Medicare Advantage)

A Medicare-approved plan offered by private insurance companies that includes all the benefits of Medicare Part A and Part B, often with additional benefits like dental, vision, and prescription drug coverage.

Primary Care Physician (PCP)

A healthcare provider who acts as the first point of contact for an individual’s healthcare needs and coordinates further specialist care if necessary. Many Medicare Advantage, Medicaid, and ACA plans require enrollees to choose a PCP.

Referral

A written order from a primary care doctor for a patient to see a specialist or receive certain medical services. Many Medicare Advantage, Medicaid, and ACA plans require a referral before seeing a specialist or undergoing specialized tests.

Risk Adjustment

A process used by health insurance companies to adjust payments based on the health status of their enrollees. It ensures that plans enrolling higher-risk individuals (such as those with chronic conditions) are compensated to maintain financial stability. Medicare Advantage and ACA Marketplace plans use risk adjustment.

Special Needs Plan (SNP)

A type of Medicare Advantage (Part C) plan designed for people with specific diseases or characteristics. SNPs tailor their benefits, provider choices, and drug formularies to meet the unique needs of the groups they serve, such as individuals with chronic conditions or those eligible for both Medicare and Medicaid.

Utilization Management

A process used by health insurance providers to evaluate the necessity and efficiency of healthcare services. It includes practices like prior authorization, step therapy, and case reviews to ensure appropriate use of medical resources. Common in Medicare Advantage, Medicaid, and ACA plans.

Urgent Need Care (Medicare)

Immediate medical care required for sudden illnesses or injuries that are not life-threatening but require prompt attention. Medicare Advantage plans typically cover urgent care services, and they may have lower out-of-pocket costs than emergency room visits.

Vision Coverage

Insurance coverage for eye care services, such as routine eye exams, glasses, and contact lenses. Medicaid and CHIP often include vision benefits for children, while vision coverage for adults is limited under Medicare unless purchased through a Medicare Advantage plan.

Voluntary Disenrollment

The process by which an individual chooses to leave a health insurance plan, such as Medicare Advantage, Medicare Part D, or a Medicaid managed care plan. Beneficiaries may disenroll during the appropriate enrollment periods or under special circumstances.

Yearly Out-of-Pocket Maximum

The maximum amount an individual must pay for covered services in a calendar year before their health insurance plan covers 100% of additional costs. This applies to ACA Marketplace, Medicare Advantage, and some Medicaid plans. Once the yearly out-of-pocket maximum is reached, the insurer pays all remaining covered expenses.