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Chapter 1. So What The Heck Is Medicare Anyway?

  • Medicare has four parts: Part A covers hospitals, Part B covers doctors and outpatient care, Part C is Medicare Advantage (a private alternative), and Part D covers prescriptions. Parts A and B together are Original Medicare, the baseline everything else builds on.
  • → DO THIS: Go to Medicare.gov and set up your online account before you need it. Bookmark 1-800-633-4227 as a backup.
  • Two agencies run Medicare: CMS and Social Security. They do not share a phone number or a website.

Chapter 2. Part A, The Hospital Part

  • → DO THIS: The moment you or a family member is admitted to a hospital, ask in writing: ’Am I admitted as an inpatient or placed under observation status?’ Observation days do not count toward the 3-day inpatient requirement for skilled nursing facility coverage. The answer to that question could save you $300 or more per day.
  • → The Part A deductible is per benefit period, not per calendar year. A benefit period resets after you have been out of the hospital for 60 consecutive days. You can hit the deductible multiple times in one year. There is no annual out-of-pocket cap under Original Medicare alone.
  • → DON’T: Assume Medicare covers the nursing home stay after your hospital visit. Part A covers skilled nursing care only after a qualifying 3-consecutive-midnight inpatient stay. It does not cover custodial care, meaning help with bathing, dressing, or eating. Those are very different things, and the distinction is expensive.

Chapter 3. Part B, The Doctor Part

  • → The 20 percent with no out-of-pocket maximum is the single biggest financial risk in Original Medicare. A serious illness can generate $50,000 or more in cost-sharing in one year. Get a supplement.
  • → DO THIS: Use your free Annual Wellness Visit every year for the preventive review. Save new symptoms for a separate visit. Evaluating a symptom during the AWV converts it into a regular billed visit. Exception: anything urgent, mention it anyway. Your health beats a copay.
  • → DON’T: Assume Part B covers everything medical. Routine dental, hearing aids, routine vision, and long-term care are all excluded. Budget for those separately or find coverage that fills the gap.

Chapter 4. The Gaps, What Original Medicare Doesn’t Cover

  • → Original Medicare has no annual out-of-pocket cap. A single serious illness can generate $50,000 or more in personal costs in one year, with no ceiling. That exposure is the reason Medigap and Medicare Advantage exist.
  • → DO THIS: Understand the core distinction before you shop. Medigap fills the gaps in Original Medicare and keeps it as your foundation. Medicare Advantage replaces Original Medicare entirely with a private plan. Confusing these two leads to the wrong purchase.
  • → DON’T: Assume Medicare Advantage dental coverage is full dental insurance. Most plans cap dental at $1,000 to $2,500 per year, with no implants, no orthodontics, and a thin network. One root canal can exhaust the annual benefit. If you need real dental work, price a standalone dental plan separately.

Chapter 5. Your Medicare Personality Test

  • → Five questions, scored 0 to 13, gave you a verdict: Original Medicare + Plan G, the gray zone, or Medicare Advantage.
  • → DO THIS: Write your score and your verdict. You will check it against the next eight chapters.________Total Points All Questions
  • → DON’T: Treat the verdict as final. The book refines it. Your zip code, your doctors, and your drug list still need to confirm.

Chapter 6. How to Buy Medicare Without Getting Screwed

  • → Insurance agents earn the highest commission on Medicare Advantage. That does not make them dishonest; it does mean, you have to verify their recommendation against your actual needs.
  • → DO THIS: Get every recommendation in writing before you sign anything. Forty-eight hours minimum to read it on your own time.
  • → DON’T: NEVER Sign in the agent’s living room on the day of the conversation. There is no Medicare deadline that requires same-day enrollment except IEP, and IEP gives you seven months.

Chapter 7. Medicare Supplement Plans (Medigap)

  • → DO THIS: Buy Medigap during your six-month Open Enrollment Period starting when you are 65 and enrolled in Part B. That is the window (I can’t emphasize this enough; this is the secret sauce) where insurers must sell you any plan at standard rates with no health questions asked.
  • → Plan G is the benchmark. After your $283 Part B deductible, you pay nothing for covered Medicare services for the rest of the year. If you are comparing any other Medigap plan, compare it against Plan G first and price the difference against the out-of-pocket risk you are accepting.
  • → DON’T: Assume the cheapest premium is the best deal. Plan N costs less than Plan G but exposes you to up to $20 office visit copays, $50 ER copays, and Part B excess charges. In states that ban excess charges, that gap shrinks significantly. Know your state’s rules before you decide.

Chapter 8. The High-Deductible Plan G “Secret”

  • → DO THIS: Calculate your expected annual medical costs before choosing between Plan G and HDG. If your premium savings exceed $1,200 per year and you rarely generate major claims, HDG wins on expected value for most years.
  • → The 2026 HDG deductible is $2,950, set by CMS. It adjusts modestly each year. Check your renewal notice every fall and re-run the math. Do not assume last year’s number still applies.
  • → DON’T: Choose HDG if a $2,950 bill in January would cause real hardship or keep you up at night. Peace of mind has a dollar value. Standard Plan G is a rational choice too. The goal is honest math, not the lowest premium.

Chapter 9. Medicare Advantage

  • → DON’T: Choose Medicare Advantage assuming you can switch to Medigap later without consequence. In 41 states, Medigap insurers can medically underwrite you on the way back. If your health has changed, they can deny you, charge you more, or apply waiting periods.
  • → DO THIS: Review your Medicare Advantage plan every fall during Annual Enrollment Period (October 15 to December 7). Networks change, formularies change, premiums change. A plan worth keeping this year may not be worth keeping next year.
  • → If Medicare Advantage denies a claim or prior authorization, appeal it. A meaningful percentage of denials get reversed on appeal. Use every tool available, including AI, to draft that appeal. The insurer is already using it to deny you.

Chapter 10. Part D, Prescription Drug Coverage

  • → DO THIS: Before comparing Part D plans, write down every medication you take by name, dosage, and frequency. Run each drug through Medicare.gov’s Plan Finder using your actual list. A drug that is Tier 2 at one plan may be Tier 4 at the next, and that difference compounds every month.
  • → If your plan requires step therapy and your doctor prescribed something specific, request an exception in writing. The plan must respond within 24 to 72 hours on an expedited basis. Your doctor’s documentation that step therapy is clinically inappropriate is the key. Know this tool exists before you need it.
  • → DON’T: skip Part D enrollment if you are healthy now. The 1 percent per month late penalty applies from the date you were first eligible, not from the date you got sick.

Chapter 11. When the Heck Do I Sign Up?

  • → DO THIS: Mark your IEP on a calendar the day you read this. Seven months total, starting three months before your birthday month. Enroll in the first three months of that window so coverage starts the month you turn 65, not a month or two later.
  • → DON’T: Assume COBRA or an ACA Marketplace plan buys you time. Neither counts as creditable coverage for delaying Part B. If you retire at 65 and go on COBRA, your IEP clock is still running. Miss it and the penalty follows you for life.
  • → Your Medigap Open Enrollment Period is six months, starts the month you are 65 and enrolled in Part B, and does not repeat. During that window insurers must sell you any plan at standard rates with no health questions. After it closes, underwriting applies in most states, and you can be rejected or charged more.

Chapter 12. IRMAA.

  • → IRMAA is triggered by income from two years prior. Your 2026 premium is based on your 2024 tax return. Plan two years ahead, not one. By the time the IRMAA letter arrives, the income that caused it is already locked in.
  • → DO THIS: If your income dropped since that two-year-prior return because you retired, lost a spouse, divorced, or had a one-time event like a home sale, file SSA Form SSA-44 and appeal. Approvals are common. The paperwork is worth it.
  • → DON’T: Trigger IRMAA accidentally through Roth conversions, large IRA distributions, or poorly timed capital gains in the two years before your premium year. One dollar over a bracket threshold costs you hundreds per month for twelve months. Talk to a tax professional who understands Medicare premium implications before you move money.

Chapter 13. Special Situations

  • → VA coverage does not count as creditable coverage for Medicare Part B. Enroll in Part A and Part B at 65 even if the VA covers most of your care. One out-of-network emergency without Part B active can cost six figures.
  • → DO THIS: If you have VA drug coverage, you can delay Part D without penalty. But track the 63-day Special Enrollment Period window. When VA drug coverage ends, changes, or reduces, that window opens and closes fast.
  • → Federal retirees with FEHB: run the actual cost math before skipping Part B. FEHB plus Medicare Part B together often reduces your real out-of-pocket costs to near zero. The $202.90 monthly premium is not a cost. It is an investment with a documented return.

Chapter 14. Your State Matters

  • → DO THIS: If you live in California, Idaho, Illinois, Kentucky, Louisiana, Maryland, Nevada, Oklahoma, or Oregon, calendar your birthday now. Three months before it arrives, pull competitive Medigap quotes. A birthday-rule switch to the same plan with a lower-cost carrier can cut your premium by $600 to $1,200 a year, no health questions asked.
  • → If your state is on the list banning Part B excess charges (Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, or Vermont), Plan N becomes a safer option than it is everywhere else. That changes your cost math at enrollment.
  • → DON’T: skip your state’s drug assistance programs. Eighteen states run them. Most people eligible for them never apply. Search your state insurance commissioner’s website or call SHIP (1-800-MEDICARE can connect you) and ask specifically about state pharmaceutical assistance.

Chapter 15. Your Benefits

  • → DO THIS: If you have chronic low back pain, ask your doctor about Medicare’s acupuncture benefit. Up to 20 sessions per year. Covered under Part B. If you have Plan G, your 20 percent coinsurance is covered. You are paying for it either way.
  • → DO THIS: Use telehealth. Resistance is habit, not preference. A video visit for a medication check or follow-up takes 15 minutes and no parking. Same cost-sharing as in-person. Your doctor’s office can schedule it today.
  • → DON’T: Assume the program doesn’t apply to you without looking it up. If you are pre-diabetic, the Diabetes Prevention Program at cdc.gov/diabetes/prevention is 12 months, free, and reduces Type 2 diabetes risk by 58 percent. That is not a maybe. That is already paid for.

Chapter 16. Mental Health Coverage Under Medicare

  • → The 190-day lifetime limit on inpatient psychiatric care applies ONLY to freestanding psychiatric hospitals. If you are admitted to a psychiatric unit inside a general hospital, those days do not count against the cap. Before any inpatient admission, ask which type of facility you are entering.
  • → DO THIS: Request your free annual depression screening at your next Annual Wellness Visit. It costs $0, takes five minutes, and is already included in a visit you are likely scheduling anyway. If it flags a concern, your doctor can act on it immediately.
  • → DON’T: Assume your therapist does not take Medicare. Since January 2024, licensed marriage and family therapists and licensed mental health counselors are covered under Part B. The provider network expanded significantly. Search Medicare.gov before giving up on a provider.

Chapter 17. Medicare and Chronic Conditions

  • → DO THIS: If you have diabetes and use insulin, confirm your continuous glucose monitor is billed under Part B as durable medical equipment, not Part D. The billing classification determines your cost. Most pharmacies default to the wrong one.
  • → If you have had a heart attack, bypass surgery, or qualifying cardiac event, ask your cardiologist about cardiac rehab. Medicare covers up to 36 sessions. Completers show 20 to 30 percent lower mortality. Most eligible patients never get a referral.
  • → DON’T: assume your cancer drug is covered the same way your infusion is. Oral chemotherapy you take at home runs through Part D, with formulary tiers and deductibles that can reach thousands. Infusion drugs at an outpatient center run through Part B at 20 percent. Same disease, two completely different cost structures.

Chapter 18. When Medicare Says No

  • → DO THIS: File a Level 2 Reconsideration if Level 1 fails. An independent contractor reviews it, not the same plan that denied you. Most people who reach Level 2 get a favorable decision. The insurance company is banking on you stopping at Level 1.
  • → If a hospital says it is time to leave and you disagree, request the QIO review notice before you walk out the door. File while you are still in the building. Leave first and you lose your protection and owe the bill. Ask the discharge planner for the QIO notice the moment you hear ’time to go home.’
  • → DON’T: Ignore your Medicare Summary Notice. Check it every quarter. Billing errors happen. Outright fraud happens. If you see a service you did not receive, call 1-800-MEDICARE immediately and contact your State Senior Medicare Patrol at smpresource.org.

Chapter 19. The Long-Term Care Reality Check

  • → Medicare covers skilled nursing care up to 100 days after a qualifying three-day hospital stay. Days 1 to 20 cost you nothing. Days 21 to 100 cost $217.00 per day in 2026. Day 101 onward, Medicare is done.
  • → DO THIS: If you are between 55 and 65 and in good health, get a quote on long-term care insurance or a hybrid life insurance policy with an LTC rider. Premiums only go up with age and health conditions. Waiting until you need it means you will not qualify.
  • → DON’T: Assume Medicaid is a backup plan you can access in a crisis. Medicaid has a five-year lookback on asset transfers and requires spending down to roughly $2,000 in countable assets in most states. Planning needs to start years before a crisis, not days. If you have significant assets, talk to an elder law attorney now.

Chapter 20. Medicaid, Medicare Savings Programs, and Help Paying Your Costs

  • → DO THIS: Call your state Medicaid office or go to Medicare.gov to apply for a Medicare Savings Program. Start with QMB. If you are near the income limits, apply anyway. Many states use higher limits than the federal floor.
  • → If you are enrolled in QMB, providers are legally prohibited from billing you for Medicare cost-sharing. If a bill arrives, call the provider, state your QMB enrollment, and the bill is extinguished. Keep your QMB notice with your insurance cards.
  • → DON’T: skip the Extra Help application for Part D drugs. It is free to apply, it is separate from the MSP application, and it can reduce your drug costs to a few dollars per prescription. Apply through SSA.gov or call 1-800-772-1213.

Chapter 21. Your Action Plan

  • → DO THIS: Three months before 65, stop HSA contributions, list every medication with dosage and frequency, and get quotes from at least three Medigap carriers for the same plan letter. These tasks cannot wait until your birthday.
  • → Every October 15 through December 7, run the Medicare.gov Part D Plan Finder with your current drug list. Formularies change every year. Last year’s cheapest plan may cost you hundreds more this year.
  • → DON’T: Assume Medicare runs itself after enrollment. Ask inpatient or observation status every hospital admission, review your Medicare Summary Notice every quarter, and appeal every denial starting at Level 1 Redetermination.

Chapter 22. Your First Year on Medicare

  • → Year one on Medicare is twelve months, not one enrollment decision. Treat it like an audit you do four times: week one, month six, month nine, month twelve. (Use the checklist).
  • → DO THIS: Save every Medicare Summary Notice or Explanation of Benefits for at least twelve months. Set up your Medicare.gov online account in week one.
  • → DON’T: Auto-renew your plan in year two without re-reading the Annual Notice of Change and running the cost math on at least one alternative.

Chapter 23. Frequently Asked Questions

  • → DON’T: Accept a Medicare denial as final. File Level 1 Redetermination within 120 days. If denied again, go to Level 2 Reconsideration with the independent reviewer. Many denials reverse at Level 2, and more reverse at the ALJ hearing. The first denial is not the last word.
  • → DO THIS: If you are a veteran or on COBRA at 65, enroll in Part A and Part B during your Initial Enrollment Period anyway. VA coverage and COBRA do not count as creditable coverage for Part B. Skipping it means a permanent late enrollment penalty you will pay every month for the rest of your life.
  • → If you are hospitalized, ask this question before you settle in: am I being admitted as an inpatient or placed under observation? Observation status does not count toward the three-day inpatient requirement for skilled nursing coverage. Four days in a hospital bed under observation status, and Medicare may not cover the nursing facility that follows.

Chapter 24. Medicare and Social Security

  • → DON’T: Assume Medicare and Social Security move together. Delaying Social Security to age 70 to maximize your benefit is smart. Missing your Medicare Initial Enrollment Period at 65 because of that delay costs you a permanent penalty surcharge of 10 percent per year, forever.
  • → DO THIS: If you enroll in Medicare before you claim Social Security, set up automatic quarterly billing at Medicare.gov immediately. At 2026 rates, that is $608.70 per quarter. Ignore those bills and your coverage lapses.
  • → The year you claim Social Security affects your Medicare premiums two years later. Social Security income counts toward IRMAA thresholds, which start at $109,000 for single filers in 2026. Run the numbers with a tax professional before you claim, especially if you are near a threshold.

Chapter 25. Medicare and Travel

  • → If you split time between two states or travel domestically for weeks at a stretch, Original Medicare plus a Medigap supplement is the right structure. A Medicare Advantage HMO is not built to cross state lines for routine care.
  • → DO THIS: For any international trip, buy standalone travel medical insurance. A two-week policy typically runs $100 to $300 and covers medical evacuation and extended hospitalization with no lifetime cap.
  • → DON’T: board a cruise that goes offshore without travel insurance that explicitly covers medical evacuation. Medicare covers you only within roughly 6 miles of the US coast. Once the ship is at sea, you are paying ship-rate billing with no Medicare backstop.

Chapter 26. Major Life Transitions on Medicare

  • → Six major life transitions (widowhood, divorce, remarriage, state move, inheritance, cognitive decline) each trigger specific Medicare rules and windows. Know which one applies to you.
  • → DO THIS: Set up Authorized Representative paperwork on Medicare and on every plan now, before you need it. The form takes 10 minutes per entity.
  • → DON’T: Liquidate an inheritance all in one tax year if you can spread it across multiple years. The IRMAA cliff is sharp and lasts the full year.

Chapter 27. Dental, Vision, and Hearing

  • → DO THIS: If you need major dental work, price a dental discount plan before buying standalone dental insurance. A 40 percent discount on a $4,000 implant saves $1,600 outright. Most insurance annual maximums are $1,500 to $2,000. The math favors discount plans the moment the work gets serious.
  • → DON’T: Enroll in a Medicare Advantage plan primarily for its dental benefit without reading the actual coverage line by line. Most MA dental benefits cover preventive care well and implants poorly, often limiting implant coverage to $1,000 lifetime or excluding them entirely.
  • → If cost is the barrier for dental or vision care, check ada.org for dental schools near you and findahealthcenter.hrsa.gov for Federally Qualified Health Centers. Dental school care runs 40 to 70 percent below market. FQHC vision and dental services use sliding-fee scales based on income. These are real options, not last resorts.

Chapter 28. What People Regret

not in the large print edition
  • → Medicare Advantage is a bet you stay healthy. If you lose that bet after your Medigap Open Enrollment window closes, you can be medically underwritten and denied in most states. The $0 premium is not free. It is deferred cost with no guaranteed exit.
  • → DON’T: Treat COBRA as a substitute for Medicare. COBRA does not count as creditable coverage for Part B. Your Special Enrollment Period clock starts when your employer coverage ends, not when COBRA ends. Missing that window costs you a permanent 10 percent penalty for every 12 months you were late.
  • → DO THIS: Before your 65th birthday, price out both paths, Original Medicare plus Plan G and Medicare Advantage, with your actual doctors, your actual zip code, and a worst-case health scenario in the math. The decision is not about premiums. It is about what happens if things go wrong.

Chapter 29. If You Are Self-Employed

chapter 28 in the large print edition
  • → DO THIS: Enroll in Medicare Part B during your Initial Enrollment Period at 65, even if your ACA Marketplace plan feels solid. Marketplace coverage is not creditable coverage for delaying Part B. Miss the window and pay a permanent 10 percent surcharge for every 12 months of delay.
  • → If you are self-employed, 100 percent of your Medicare premiums are deductible under IRS Section 162(l). Part B, Part D, and Medigap all count. Ask your accountant specifically about Section 162(l) before your first enrollment year closes.
  • → DON’T: Contribute to your HSA in the six months before your Medicare start date. The IRS applies a retroactive six-month lookback. Contributions made during that window become excess contributions and trigger a 6 percent annual excise tax until you withdraw them.

Chapter 30. When Medicare Comes Early: Disability and ESRD

chapter 29 in the large print edition
  • → DO THIS: If you are on SSDI, count 24 months from the date your SSDI cash benefits started. Not from your disability onset. Not from your application date. From your benefit start date. Get the date wrong and you will either over-enroll or miss the Medicare enrollment window.
  • → If you have an employer health plan when you become ESRD-eligible, you can keep your employer coverage as primary for the first 30 months. Medicare pays secondary during this period. Mark month 30 on your calendar. After month 30, Medicare flips to primary regardless of what your employer plan does.
  • → DON’T: Assume the 24-month wait applies if the diagnosis is ALS. ALS patients become Medicare-eligible the same month SSDI starts. No wait. This was added in 2001 because ALS progresses too fast for the wait to be anything but harmful.

Chapter 31. Caregivers and Medicare

chapter 30 in the large print edition
  • → DO THIS: Set up Authorized Representative status now, before there is a crisis. One form per entity: Medicare, Medigap, Part D, or Medicare. Send it certified mail. This costs nothing and gives you the legal standing to call on your parent’s behalf when it matters.
  • → When the Annual Notice of Change arrives each fall, offer to read it with them, not for them. Formulary changes and network shifts can cost thousands. Your job is to flag what changed. Their job is to decide what to do about it.
  • → DON’T wait for a diagnosis to have the Durable Power of Attorney conversation. The window to set it up without conflict is before anyone needs it. An estate attorney runs $300 to $1,500. Chasing paperwork from a hospital waiting room with no legal standing costs more than that every time.

Chapter 32. Hospice and End-of-Life Care

chapter 31 in the large print edition
  • → Hospice is not a death sentence. It is a Medicare benefit covering comprehensive care at near-zero cost, and patients who enroll often live longer than predicted because symptom management improves. You can revoke it at any time and return to curative treatment.
  • → DO THIS: If a family member has a terminal or serious progressive illness, ask the physician directly about hospice eligibility now, not in the final weeks. Two doctors certify the prognosis, but you have to initiate the conversation. The median stay is 18 days. The benefit allows 180.
  • → DON’T: assume hospice means no treatment. Curative care for unrelated conditions continues under regular Medicare. What stops is aggressive treatment for the terminal illness itself, replaced by symptom control, comfort, and support that most hospital-based care cannot match.
Plain English

The glossary

Acronyms are still a war crime. Here they are anyway.

AEPAnnual Enrollment Period. October 15 through December 7 each year. Your window to switch Medicare Advantage or Part D plans. Changes take effect January 1.
ALJAdministrative Law Judge. The third level of the Medicare appeals process. Real courtroom, real reversal rates, many denials get overturned here.
ANOCAnnual Notice of Change. The letter your Medicare Advantage or Part D plan must send you by September 30 explaining what changes in the upcoming year. Don’t throw this away.
Benefit PeriodHow Medicare counts a hospital stay. Starts the day you’re admitted as an inpatient. Ends after you’ve been out of the hospital and any skilled nursing facility for 60 consecutive days. The Part A deductible resets with each new benefit period, not each year.
Birthday RuleA state law (available in select states) allowing you to switch to the same or lesser Medigap plan once a year around your birthday without medical underwriting. Check Appendix A for states that have it.
CMSCenters for Medicare and Medicaid Services. The federal agency that actually runs Medicare. Different from Social Security, which handles enrollment. Two agencies, one nightmare.
COBRAContinuation coverage from your former employer. Keeps your old plan going after you leave a job. Critical warning: COBRA does NOT count as creditable coverage for delaying Part B. Your IEP clock runs regardless.
CoinsuranceYour percentage share of a covered service after you’ve met your deductible. Under Original Medicare Part B, you typically pay 20% of the Medicare-approved amount. There’s no cap on that 20% unless you have supplemental coverage.
CopayA fixed dollar amount you pay per service, typically used in Medicare Advantage and Part D plans. $10 for a generic drug. $40 for a specialist visit. Unlike coinsurance, the number doesn’t scale with the bill.
Creditable CoverageDrug or health coverage that’s at least as good as standard Medicare. Having creditable coverage lets you delay Part A, Part B, or Part D enrollment without owing late penalties later. Get this in writing from your employer or insurer.
Custodial CareHelp with daily activities, bathing, dressing, eating, walking. Medicare doesn’t cover this. Not a dollar. This is the coverage gap that catches families completely off guard when a parent or spouse needs long-term support.
DeductibleThe amount you pay out of pocket before Medicare or your plan starts sharing costs. Part A has a per-benefit-period deductible. Part B has an annual deductible. Part D plans may have their own deductible up to the annual maximum.
Dual EligibleA person who qualifies for both Medicare and Medicaid. Dual eligibles often get enhanced coverage, $0 premiums, and automatic Extra Help for drug costs. If you’re in this category, make sure you’re enrolled in everything you qualify for.
Extra HelpA federal program (also called Low Income Subsidy or LIS) that reduces Part D prescription drug costs for lower-income Medicare enrollees. Covers most or all premiums, deductibles, and copays. Millions of people qualify and don’t know it.
FEHBFederal Employees Health Benefits program. If you’re a federal employee or retiree, your FEHB plan coordinates with Medicare in specific ways. Read the “When You Have Medicare” section of your FEHB plan document carefully.
FormularyYour Part D drug plan’s official list of covered medications, organized into tiers by cost. A drug not on the formulary isn’t covered at plan pricing. Formularies change every year. Check yours every October.
GI (Guaranteed Issue)Your legal right to buy a Medigap plan without medical underwriting, meaning the insurer can’t reject you or charge you more based on health conditions. You have GI rights during your 6-month Medigap open enrollment window. Miss it and you may face medical underwriting forever after.
HDGHigh Deductible Plan G. The lowest-premium Medigap plan that still provides comprehensive coverage. You pay all costs until you hit the annual HDG deductible ($2,950 in 2026), then Medigap covers everything. Best for healthy enrollees who want catastrophic protection without high monthly premiums.
IEPInitial Enrollment Period. The 7-month window centered on your 65th birthday: 3 months before, your birthday month, and 3 months after. Your main chance to enroll in Parts A, B, and D without penalties.
IRMAAIncome-Related Monthly Adjustment Amount. Higher Medicare premiums charged to higher-income beneficiaries. Based on your tax return from 2 years prior. Starts at $109,000 for individuals in 2026. Fully appealable if your income has since dropped due to a qualifying life change.
LEPLate Enrollment Penalty. A permanent premium surcharge for missing Medicare enrollment windows without creditable coverage. Part B LEP: 10% per year of delay, forever. Part D LEP: 1% of the national base premium per month of delay, also forever.
LISLow Income Subsidy. Same program as Extra Help. Some documents use one term, some use the other. Same benefit.
MAMedicare Advantage. Also called Part C. A private-plan alternative to Original Medicare, sold by insurers and approved by CMS. Usually includes drug coverage. Often has $0 premium but higher out-of-pocket costs during serious illness. Networks and prior authorizations apply.
MedigapSupplemental insurance that fills the gaps Original Medicare leaves, deductibles, coinsurance, copays. Also called Medicare Supplement. Plans are standardized by letter (A, B, D, G, K, L, M, N). Plan G and High Deductible Plan G are the most popular for new enrollees.
MSNMedicare Summary Notice. A quarterly statement mailed to you showing what was billed to Medicare on your behalf. Review every line. Billing errors and outright fraud show up here. Report anything you don’t recognize to 1-800-MEDICARE.
MSPMedicare Savings Program. State-run programs that help pay for Part B premiums, deductibles, and cost-sharing for qualifying lower-income Medicare enrollees. Four tiers: QMB, SLMB, QI, QDWI. Apply through your state Medicaid office.
Observation StatusAn outpatient designation hospitals use for patients who haven’t been formally admitted. Observation days don’t count toward the 3-day inpatient stay required for Medicare to cover skilled nursing. You can spend 5 days in a hospital room under observation and still owe full skilled nursing costs. Always ask.
OEPOpen Enrollment Period. For Medicare Advantage specifically: January 1 through March 31 each year. Lets you switch MA plans or return to Original Medicare. Doesn’t apply to Medigap.
Original MedicareParts A and B together, run directly by the federal government. Freedom to see any Medicare-accepting doctor nationwide. No prior authorizations. No network restrictions. No out-of-pocket maximum on its own, which is why most people pair it with a Medigap plan.
PACEProgram of All-Inclusive Care for the Elderly. Available in 33 states for people 55+ who are nursing-home eligible but want to stay in the community. One care team handles everything: medical care, meals, transportation, personal care. Can be fully covered for dual-eligible individuals.
Prior AuthorizationAn insurer’s advance approval requirement before certain services or drugs are covered. Common in Medicare Advantage, not in Original Medicare. If your MA plan denies a prior auth, appeal immediately, especially for urgent care.
PSHBPostal Service Health Benefits. The replacement for FEHB coverage for postal workers, effective 2025. Postal retirees must enroll in Part B to keep PSHB benefits.
SEPSpecial Enrollment Period. A time-limited window triggered by qualifying life events, leaving employer coverage, moving out of a plan’s service area, becoming dual-eligible, etc. SEPs let you change coverage outside normal enrollment windows. Each SEP has its own rules and deadlines.
SHIPState Health Insurance Assistance Program. Free, unbiased Medicare counseling provided by trained volunteers in every state. They have no financial stake in what you choose. Find your local SHIP counselor at shiphelp.org. Use them.
SNFSkilled Nursing Facility. Medicare covers up to 100 days of SNF care after a qualifying 3-day inpatient hospital stay. Days 1-20 are fully covered. Days 21-100 require daily coinsurance ($217.00 in 2026). Day 101 and beyond: you pay everything.
SNPSpecial Needs Plan. A type of Medicare Advantage designed for specific populations: people with certain chronic conditions, dual-eligible individuals, or people in institutions. Usually has enhanced benefits relevant to the specific condition.
SPAPState Pharmaceutical Assistance Program. Some states run their own programs to help with drug costs beyond federal Extra Help. Availability, eligibility, and benefits vary by state. Ask your SHIP counselor whether your state has one.
SSASocial Security Administration. The agency that handles Medicare enrollment, separate from CMS, which runs the program. You enroll at ssa.gov or at a local SSA office. SSA and CMS don’t automatically share information, which is exactly as helpful as it sounds.
Accountable Care Organization (ACO)Group of doctors and hospitals that coordinate care for Medicare patients to improve quality and reduce cost. You may not even know you are in one. (See Ch 9.)
Advance Beneficiary Notice (ABN)Form your provider gives you when Medicare may not cover a service. You sign it agreeing to pay if Medicare denies. Always read it before signing. (See Ch 18.)
Advance Care PlanningDoctor-led conversation about your treatment preferences if you can no longer speak for yourself. Covered by Medicare at no cost during your Annual Wellness Visit. (See Ch 32.)
Annual Enrollment Period (AEP)October 15 to December 7 each year. Window to switch Medicare Advantage plans or Part D plans for the following year. (See Ch 11.)
Annual Notice of Change (ANOC)Letter your Medicare Advantage or Part D plan sends each fall describing what will change next year (premium, copays, formulary, network). Read it. (See Ch 9.)
Annual Wellness VisitYearly preventive visit with your primary care doctor. Includes depression screening, cognitive assessment, fall risk, advance care planning. No cost to you. (See Ch 3.)
AppealFormal challenge to a Medicare or plan coverage denial. Five levels available. You usually have 60 to 120 days to file depending on the type. (See Ch 18.)
AssignmentProvider agreement to accept the Medicare-approved amount as full payment. If your provider does not accept assignment, you can be charged up to 15 percent more (the ’limiting charge’). (See Ch 3.)
Authorized RepresentativePerson you designate (via Form CMS-1696) to speak with Medicare, your MA plan, or your Part D plan on your behalf. Required for most phone calls if you are not the beneficiary. (See Ch 31.)
Benefit Period (Part A)Begins the day you enter a hospital and ends 60 days after discharge. You can have multiple benefit periods in a year, each with its own deductible. (See Ch 2.)
Birthday Rule (Medigap)State-specific annual window to switch Medigap plans without medical underwriting. See Appendix A for the 10 states that have one. (See Ch 14.)
CoinsurancePercentage of cost you pay after meeting the deductible. Typically 20 percent for Part B. (See Ch 3.)
Coordination of BenefitsRules determining which insurance pays first when you have more than one (Medicare plus employer plan, plus TRICARE, plus VA, etc.). (See Ch 13.)
Copay (Copayment)Fixed dollar amount per visit, service, or prescription. Used by Medicare Advantage and Part D plans more than Original Medicare. (See Ch 9.)
Coverage Gap (Donut Hole)Old phase of Part D between initial coverage and catastrophic coverage. ELIMINATED as of 2025 by the Inflation Reduction Act ($2,000 annual cap in 2025, $2,100 in 2026). (See Ch 10.)
Creditable CoverageInsurance considered as good as Medicare, which allows you to delay Part B or Part D without a late enrollment penalty. Marketplace plans and COBRA do NOT count. (See Ch 11.)
DeductibleAnnual amount you pay out of pocket before insurance starts paying. Part A and Part B each have their own. (See Ch 3.)
Dual EligibleQualified for both Medicare AND Medicaid. Triggers extra protections including QMB program. (See Ch 20.)
End-Stage Renal Disease (ESRD)Permanent kidney failure requiring dialysis or transplant. Qualifies you for Medicare at any age (not just 65 plus). (See Ch 30.)
Explanation of Benefits (EOB)Notice from your Medicare Advantage or Part D plan showing what was billed, what the plan paid, and what you owe. Different from a bill. (See Ch 18.)
Extra Help (Low-Income Subsidy or LIS)Federal program that helps pay Part D premiums, deductibles, and copays for lower-income beneficiaries. Apply at ssa.gov/extrahelp. (See Ch 20.)
FormularyList of prescription drugs your Part D or Medicare Advantage plan covers, organized into tiers. Plans can change formulary year to year. (See Ch 10.)
Formulary ExceptionRequest your plan cover a non-formulary drug, or waive a quantity limit or prior authorization. Your doctor must support the request. (See Ch 10.)
General Enrollment Period (GEP)January 1 to March 31 each year. Window for people who missed their Initial Enrollment Period to enroll in Part B. Coverage starts the following month. Late enrollment penalty applies. (See Ch 11.)
Guaranteed Issue RightPeriod when Medigap insurers must sell you a policy without medical underwriting. Triggered by specific qualifying events. (See Ch 7.)
High Deductible Plan G (HDG)Medigap plan with low monthly premium ($40 to $80 typical) but $2,950 annual deductible in 2026. Good for healthy buyers who can absorb the deductible. (See Ch 8.)
Initial Enrollment Period (IEP)7-month window centered on your 65th birthday month. Your first chance to enroll in Medicare. Miss it and you risk lifetime late enrollment penalties. (See Ch 11.)
Late Enrollment PenaltyPermanent premium surcharge for missing your Part B or Part D enrollment window without creditable coverage. Part B: 10 percent per 12 months delayed. Part D: 1 percent of national base per month. (See Ch 11.)
Lifetime Reserve Days60 extra hospital days you can use ONCE in your lifetime after you exhaust day 90 of a benefit period. $868/day in 2026. (See Ch 2.)
MAGI (Modified Adjusted Gross Income)Income calculation used to determine IRMAA bracket. Adds tax-exempt interest back to AGI. (See Ch 12.)
MedicaidJoint federal-state program for low-income individuals. Coordinates with Medicare for dual eligibles. Each state runs its own. (See Ch 20.)
Medicare Advantage (Part C, MA, or MAPD)Private plan that replaces Original Medicare. Usually includes Part D. Often $0 premium but with network restrictions and prior authorizations. (See Ch 9.)
Medicare Savings Program (MSP)State-administered program that helps pay Medicare costs for limited-income beneficiaries. Four levels: QMB, SLMB, QI, QDWI. (See Ch 20.)
Medigap (Medicare Supplement)Private insurance that fills the gaps in Original Medicare. Standardized plans labeled A through N. Plan G is the most common new purchase. (See Ch 7.)
NetworkGroup of providers and facilities your Medicare Advantage or Part D plan contracts with. Going out of network usually costs more or is not covered. (See Ch 9.)
Open Enrollment Period (Medigap)6-month window starting the first month you are 65 AND enrolled in Part B. The ONLY guaranteed window to buy Medigap without medical underwriting in most states. (See Ch 7.)
Original MedicareThe traditional fee-for-service Medicare administered by the federal government. Includes Part A (hospital) and Part B (medical). (See Ch 1.)
Out-of-Pocket Maximum (MOOP)Annual cap on what you pay for covered services. Medicare Advantage plans have one. Original Medicare WITHOUT a Medigap policy does NOT have one. (See Ch 4.)
Part AHospital insurance. Free for most beneficiaries based on payroll history. Covers inpatient hospital, skilled nursing facility, hospice, home health. (See Ch 2.)
Part BMedical insurance. Standard premium $202.90/month in 2026. Covers doctor visits, outpatient services, preventive care, durable medical equipment. (See Ch 3.)
Part DPrescription drug coverage. Sold by private insurers approved by Medicare. New $2,100 annual out-of-pocket cap in 2026. (See Ch 10.)
POLST/MOLSTPhysician (or Medical) Orders for Life-Sustaining Treatment. State-specific medical order form that translates your advance directives into orders EMTs and hospitals must follow. (See Ch 32.)
Prior AuthorizationPlan approval required before certain services or prescriptions. Common in Medicare Advantage. Can delay or block care. You have appeal rights. (See Ch 18.)
ReconsiderationSecond-level Medicare appeal after an initial denial. Handled by a Qualified Independent Contractor (QIC). (See Ch 18.)
Skilled Nursing Facility (SNF)Medicare-covered short-term rehab facility, typically after a qualifying 3-day inpatient hospital stay. Up to 100 days per benefit period. (See Ch 2.)
Social Security Administration (SSA)Federal agency that handles Medicare enrollment, IRMAA determinations and appeals, and Social Security cash benefits. ssa.gov or 1-800-772-1213. (See Ch 24.)
Special Enrollment Period (SEP)Time outside the standard enrollment windows when you can enroll in or change Medicare coverage due to a qualifying event (job loss, move, marriage, etc.). (See Ch 11.)
Special Needs Plan (SNP)Type of Medicare Advantage plan for people with specific situations: Chronic-SNP (specific conditions), Dual-SNP (dual eligible), Institutional-SNP (long-term care residents). (See Ch 9.)
TRICARE for Life (TFL)Health coverage for military retirees age 65 and older that wraps around Medicare as secondary payer. (See Ch 13.)
Tier (Drug Tier)Cost-sharing level for a specific drug in a Part D or MA-PD formulary. Lower tiers (generics) cost less, higher tiers (specialty) cost more. (See Ch 10.)