Medicare Terms Glossary
I put this plain-English glossary together to help you quickly understand common Medicare terms. If any term here raises questions about your situation, feel free to reach out—I’m happy to help you make sense of it.
Advance Beneficiary Notice of Noncoverage (ABN)
In Original Medicare, an ABN is a notice a provider may give you before a service or item if they believe Medicare may deny coverage. It explains that you could be responsible for the cost.
Advance Coverage Decision
A notice from a Medicare Advantage plan stating whether a service or procedure will be covered under the plan rules.
Assignment
An agreement by a doctor or supplier to accept Medicare’s approved amount as full payment. You pay your share (deductible/coinsurance), and the provider bills Medicare directly.
Benefit Period
For Original Medicare hospital and skilled nursing facility care: a benefit period starts the day you’re admitted and ends after you’ve been out of those facilities for 60 days in a row. There’s no limit to the number of benefit periods.
Claim
A request for payment submitted to Medicare or another insurer after you receive covered items or services.
Copayment
A fixed dollar amount you pay for a covered service after you’ve met any deductible.
Coverage Determination (Part D)
Your Part D plan’s initial decision about your drug benefits—typically made within 72 hours (24 hours if expedited). Decisions can address:
- whether a drug is covered,
- whether you meet plan rules for that drug,
- how much you’ll pay, and
- whether an exception to plan policy is granted.
Creditable Coverage
Prior health coverage that counts toward reducing a pre-existing condition waiting period under a Medigap policy.
Creditable Prescription Drug Coverage
Drug coverage expected to pay, on average, at least as much as standard Medicare Part D (e.g., certain employer, union, VA, TRICARE, or Indian Health Service plans).
Deductible
The amount you pay for covered health care or prescriptions before your plan begins to pay.
Durable Medical Equipment (DME)
Medical equipment ordered by a provider for use at home—such as walkers, wheelchairs, or hospital beds.
Excess Charge
The difference between a provider’s charge and the Medicare-approved amount if the provider doesn’t accept assignment (Original Medicare only). You may be billed this extra amount up to allowed limits.
Guaranteed Issue Rights (Medigap Protections)
Situations when Medigap insurers must sell you a policy, cover your pre-existing conditions, and can’t charge more because of your health.
Lifetime Reserve Days
Under Original Medicare, up to 60 extra days of hospital coverage you can use over your lifetime for stays longer than 90 days (daily coinsurance applies when used).
Limiting Charge
The maximum amount a non-participating provider can charge for a covered service under Original Medicare (a percentage over the Medicare-approved amount).
Medicare Summary Notice (MSN)
A notice you receive after a provider submits a Part A or Part B claim. It shows what was billed, what Medicare approved and paid, and what you may owe.
Medicare-Approved Amount
The payment amount Original Medicare sets for a covered service or item. If assignment is accepted, Medicare pays its share and you pay your share of this amount.
Medicare-Certified Provider
A facility or supplier (e.g., hospital, nursing home, dialysis facility, home health agency) approved by Medicare after meeting state inspection standards.
Medigap Open Enrollment Period
A one-time, six-month window that starts when you’re 65 or older and enrolled in Part B. During this time, you can buy any Medigap plan sold in your state—no medical underwriting.
Premium
The periodic amount you pay to Medicare or an insurance company for health or drug plan coverage.
Prior Authorization (Part D)
Approval your Part D plan may require before covering certain prescriptions. The plan reviews medical necessity before agreeing to pay for the drug.
Supplemental Security Income (SSI)
A needs-based monthly benefit from Social Security for people with limited income/resources who are 65+ or who are blind or have a disability (different from Social Security retirement or disability benefits).
Urgently Needed Care
Non-life-threatening care needed immediately when you’re temporarily outside your Medicare health plan’s service area. Plans must cover urgently needed care.
Need Help With a Medicare Term?
If a definition here doesn’t quite fit your situation, let’s talk. I’m happy to explain how the rules apply to your doctors, prescriptions, and budget—so you can choose confidently.
Licensed in 48 states and based in Pittsburgh, Pennsylvania.
