Medicare Eligibility, Structure, and Enrollment Notes

Comprehensive review flashcards covering Medicare eligibility criteria, enrollment periods, Original Medicare Parts A and B, assignment and excess charges, Medigap policies, Medicare Advantage, and Part D drug tiers.

Five-Year Residence Requirement

The legal duration an individual must reside in the United States to meet baseline eligibility for Medicare.

Age-Based Medicare Eligibility Criterion

Reaching $65$ years of age or older, which qualifies an individual for Medicare once the residency requirement is fulfilled.

Disability-Based Medicare Eligibility Criterion

Collecting Social Security Disability Income (SSDI) for at least $24\text{ months}$.

Qualifying Medical Conditions for Medicare Eligibility

Specific medical diagnoses, specifically Amyotrophic Lateral Sclerosis (ALS) and End Stage Renal Disease (ESRD), that trigger Medicare eligibility.

Initial Enrollment Period (IEP)

The standard primary enrollment timeframe during which most eligible individuals initially sign up for Medicare.

Immigrant Medicare Eligibility Delay

A waiting delay experienced by legal immigrants (such as green card holders) while waiting to satisfy the mandatory $5\text{-year}$ residency requirement.

Social Security

Monthly federal payments issued to disabled or retired individuals and qualifying dependents, funded through payroll taxes during employment to supply basic retirement income.

Age 64 (Social Security)

The age at which individuals can begin receiving monthly Social Security retirement payments.

Automatic Medicare Enrollment

The automatic enrollment into Medicare Parts A and B for beneficiaries already receiving Social Security payments when turning age $65$.

Social Security Part B Premium Deduction

The automatic deduction of the monthly Part B insurance premium directly from a beneficiary's monthly Social Security check.

Manual Medicare Enrollment

The requirement for individuals not collecting Social Security at age $65$ (e.g., active workers) to manually register for Original Medicare.

Quarterly Part B Billing

The payment schedule for beneficiaries not on Social Security, consisting of paying $3\text{ months}$ of Part B premiums every $4\text{ months}$.

Social Security Administration (SSA)

The federal agency through which beneficiaries enroll in Medicare by telephone, online, or in-person at local field offices.

Centers for Medicare & Medicaid Services (CMS) Enrollment Scope

The federal agency that administers Medicare operations but does not oversee or execute direct beneficiary Medicare enrollment.

Medicare.gov Enrollment Functionality

The federal program website which does not accept enrollments and instead redirects users to the Social Security Administration.

HR1 (Medicare Immigrant Restrictions)

Federal legislation that restricted Medicare access by narrowing eligibility to select groups of lawfully present immigrants.

Immigrant Categories Retaining Eligibility Under HR1

The select lawfully present groups retaining Medicare access: Legal Permanent Residents (green card holders), Cuban-Haitian entrants, and Compacts of Free Association (COFA) migrants.

Refugee Education Assistance Act of 1980

The statutory act defining Cuban-Haitian entrants who remain eligible for Medicare under the passage of HR1.

Compacts of Free Association (COFA) Migrants

A specific legal immigrant classification that retained eligibility for Medicare enrollment following the enactment of HR1.

Immigrant Categories Excluded Under HR1

Lawfully present groups barred from Medicare under HR1, including refugees, asylees, Temporary Protected Status (TPS) holders, and trafficking victims.

July 2025 Immigrant Cutoff Date

The date after which lawfully present immigrants in categories excluded by HR1 were no longer permitted to enroll in Medicare.

January 2027 Immigrant Coverage Termination

The date when Medicare coverage will terminate for existing enrollees belonging to immigrant categories excluded under HR1.

Original Medicare

The federally administered fee-for-service program comprising Medicare Part A (hospital) and Medicare Part B (medical).

1965 Medicare Legislation

The original federal legislation that established Medicare Part A and Medicare Part B.

Medicare Part D

The outpatient prescription drug benefit added to Medicare in the early 2000s under President George W. Bush.

President George W. Bush

The United States President under whose administration Medicare Part D prescription drug coverage was established.

Medicare Advantage (Part C)

A private health plan alternative to Original Medicare introduced in the 1990s under President Bill Clinton.

President Bill Clinton

The United States President under whose administration Medicare Part C (Medicare Advantage) was enacted.

Origin of the "C" in Part C

The letter designation derived from the phrase "Medicare plus Choice," creating private health plan alternatives to government-run Medicare.

Medicare Part A

Inpatient hospital insurance that covers inpatient hospital stays, skilled nursing care, home health, hospice care, and blood.

40 Work Credits (Quarters)

The work threshold, equivalent to approximately $10\text{ years}$ of employment history, required to qualify for premium-free Medicare Part A.

Part A Monthly Premium Requirement

A required monthly charge for Part A assessed to beneficiaries who have accumulated fewer than $40$ work credits (quarters).

Medicare Part B

Outpatient medical insurance covering physician care, surgical procedures, lab and diagnostic testing, physical/occupational therapy, DME, and Part B drugs.

Medicare Part B Covered Services

Outpatient services including physician visits, diagnostic tests, surgical care, physical and occupational therapies, durable medical equipment, and Part B medications.

Standard Part B Premium for 2026

The baseline monthly cost of Part B coverage in $2026$, which is $\$202.90$ per month.

Projected Standard Part B Premium for 2027

The anticipated baseline monthly cost of Part B coverage in $2027$, projected at $\$209.50$ per month.

Income-Related Monthly Adjusted Amount (IRMAA)

An additional surcharge added to Part B (and Part D) premiums for individuals and couples with higher incomes.

2024 IRMAA Single Income Threshold

An individual income exceeding $\$109{,}000$ in $2024$ that triggers higher monthly Part B premium payments.

2024 IRMAA Couple Income Threshold

A married couple income exceeding $\$218{,}000$ in $2024$ that triggers higher monthly Part B premium payments.

Seven-Month Hug

A descriptive term for the Initial Enrollment Period (IEP) spanning $3\text{ months}$ before, the month of, and $3\text{ months}$ after an individual's $65\text{th}$ birthday month.

IEP Enrollment in Months 1 through 3

Submitting Medicare enrollment during the $3\text{ months}$ prior to the birthday month, which begins coverage on the first day of the birthday month.

IEP First-of-the-Month Birthday Exception

A rule stating that if an individual's birthday falls on the $1\text{st}$ day of a month, Medicare coverage begins on the first day of the prior month.

IEP Enrollment in Month 4

Enrolling during one's birthday month, which causes Medicare coverage to become effective on the first day of the following month.

2023 IEP Policy Change for Months 5 through 7

A $2023$ revision establishing that individuals enrolling during months $5$ through $7$ of their IEP have coverage start the first day of the next month.

Special Enrollment Period (SEP) for Active Workers

An enrollment window allowing individuals actively working and covered under an employer group health plan to delay Medicare without penalty and enroll upon retirement.

General Enrollment Period (GEP)

An annual $3\text{-month}$ enrollment period running from January through March for individuals who missed their IEP and do not qualify for an SEP.

2023 GEP Effective Date Policy Change

A rule change effective in $2023$ causing GEP Medicare Parts A and B coverage to begin the first day of the next month rather than July $1$.

Assignment

A payment agreement where a healthcare provider agrees to accept Medicare's approved reimbursement amount as payment in full.

Medicare Fee Schedule

The official document outlining the approved payment amounts that Medicare will reimburse providers for Part B services.

Patient Cost Share under Assignment

The maximum coinsurance of $20\%$ owed by the patient, a Medigap plan, or a combination of the two when a provider accepts assignment.

Medicare Advantage General Enrollment Period (GEP)

A $3\text{-month}$ window covering the month of Part B enrollment plus the next $2\text{ months}$ allowing enrollees using the GEP to sign up for a Medicare Advantage plan.

Excess Charge

An additional fee capped at $15\%$ above the fee schedule rate billed to patients when a provider treats Medicare patients without accepting assignment.

Excess Charge Medicare Coverage

Out-of-pocket charges added by non-participating providers that are entirely excluded from Original Medicare reimbursement.

Medigap Plans Covering Part B Excess Charges

The two standardized supplemental plans, Plan F and Plan G, that cover the $15\%$ Part B excess surcharge.

Medigap Plan F Part B Deductible Coverage

A benefit feature of Plan F that pays the annual Part B deductible, phased out and no longer available to newly eligible beneficiaries.

Medigap Plan C Discontinuation

The statutory phase-out of Plan C that bars newly eligible Medicare beneficiaries from buying it because it covers the Part B deductible.

Medigap Plan G

The most comprehensive supplemental insurance policy currently available to newly eligible enrollees, covering excess charges but excluding the Part B deductible.

Medigap (Medicare Supplement Insurance)

Supplemental health insurance policies sold by private companies to cover Original Medicare out-of-pocket cost-sharing gaps.

Primary Payer under Medigap

Original Medicare, which pays its share of covered clinical claims first before the Medigap policy pays secondary.

Secondary Payer under Medigap

The private Medigap insurance plan, which pays after Original Medicare to cover remaining deductibles, copayments, or coinsurance.

Standardized Medigap Plans (Alphabet Plans)

Supplemental insurance plans designated by letters (A through N) that must provide uniform benefits across all private insurance sellers.

Cause of Medigap Premium Differences

Variations across private insurance carriers and their specific enrollee risk pools, rather than any differences in benefits covered.

Medicare Advantage (Part C) Operational Model

A private health plan contracting directly with CMS to manage, deliver, and reimburse all Medicare benefits for an individual.

Medicare Advantage Managed Care Networks

Private provider network models, primarily Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs), utilized by Part C plans.

Medicare Advantage Extra Benefits

Supplemental coverage options offered by private Part C plans beyond traditional Original Medicare benefits.

Primary Payer Status in Medicare Advantage

The Medicare Advantage plan itself, which acts as the sole payer for all claims while Original Medicare cost-sharing rules cease to apply.

Original Medicare Gaps Comparison Chart

A standardized matrix detailing how Medigap Plans A through N cover inpatient stays, Part B coinsurance, blood, hospice, deductibles, SNF, and excess charges.

Medigap Plan A Core Benefits

The baseline benefit package covering hospital cost sharing after $60\text{ days}$, Part B coinsurance, the first $3\text{ pints of blood}$, and hospice care coinsurance.

Medigap Plan B Coverage

A standardized Medigap policy that covers all foundational Plan A benefits plus $100\%$ of the Hospital (Part A) deductible.

Community Rating in Medicare Advantage

A pricing system where all plan subscribers pay the identical monthly premium regardless of health status, rendering guaranteed issue rules inapplicable.

Medigap Plan K Cost-Sharing Structure

A cost-sharing Medigap option that covers $100\%$ of hospital cost sharing but only $50\%$ of Part B coinsurance, blood, hospice, Part A deductible, and SNF costs.

Medigap Plan L Cost-Sharing Structure

A cost-sharing Medigap option that covers $100\%$ of hospital cost sharing but only $75\%$ of Part B coinsurance, blood, hospice, Part A deductible, and SNF costs.

Medigap Plan M Part A Deductible Benefit

A standardized supplemental policy that specifically pays $50\%$ of the Hospital (Part A) deductible while covering SNF care and Plan A core gaps in full.

Medigap Plan N Cost-Sharing Structure

A supplemental plan covering Part A gaps and Part B coinsurance in full, except for specified copayments required for some doctor visits and emergency room visits.

Hospital Cost Share Gap (Days 61–90)

The statutory daily coinsurance assessed to an Original Medicare inpatient for hospital days $61$ through $90$.

Hospital Cost Share Gap (Days 91–150)

The daily out-of-pocket coinsurance required under Original Medicare for inpatient hospital days $91$ through $150$.

365 Additional Lifetime Inpatient Days

A core Medigap benefit guaranteeing payment in full for up to $365$ inpatient hospital days beyond Medicare's standard lifetime limits.

First Three Pints of Blood Gap

The cost of the first $3\text{ pints of blood}$ used each calendar year, which is excluded by Original Medicare and covered by Medigap.

Hospice Care Co-Insurance Gap

The coinsurance required under Part A for respite care and related hospice services, covered by Medigap plans.

Hospital (Part A) Deductible Gap

The mandatory inpatient deductible assessed to beneficiaries under Original Medicare in each separate benefit period.

Skilled Nursing Facility (SNF) Daily Co-Insurance Gap

The daily coinsurance fee charged under Part A for skilled nursing facility stays from day $21$ through day $100$ in a benefit period.

2017 Part B Annual Deductible Amount

The Part B deductible amount of $\$183$ in $2017$, referenced in standardized Medigap benefit schedules for Plans C and F.

Part B Excess Charges Gap

The $15\%$ extra charge billed by non-participating providers that accept Medicare patients without agreeing to the Medicare fee schedule.

Formulary

The designated list of covered prescription drugs established by a Medicare Part D or Medicare Advantage prescription plan.

Drug Tiers

Numbered placement levels within a Part D formulary where lower tiers generally correspond to lower out-of-pocket costs for the patient.

Tier 1 Drug

The medication tier designated as "Preferred generic" in both Dr. Irwin's lecture language and the Medicare Plan Finder website.

Tier 2 (Dr. Irwin's Language)

The formulary classification referred to as "Non-preferred generic" in Dr. Irwin's lecture teaching.

Tier 2 (Medicare Plan Finder Website)

The formulary classification officially listed as "Generic" on the federal Medicare Plan Finder website.

Tier 3 Drug

The formulary tier identified as "Preferred brand" in both Dr. Irwin's language and the Medicare Plan Finder website.

Tier 4 (Dr. Irwin's Language)

The formulary tier designated as "Non-preferred brand" in Dr. Irwin's lecture terminology.

Tier 4 (Medicare Plan Finder Website)

The formulary tier designated as "Non preferred drug" on the federal Medicare Plan Finder portal.

Tier 5 Drug

High-cost medications labeled as "Specialty drug" across both Dr. Irwin's framework and the Medicare Plan Finder website.

Tier 6 Drug

An emerging drug tier for low-cost generics treating chronic conditions (such as diabetes and hypertension) offered for $\$0$ copay without deductible.

Part D Drug Tier Nomenclature Crosswalk

A crosswalk table comparing Dr. Irwin's five-tier drug classification framework with the official tier labeling used on the Medicare Plan Finder website.

Medigap Guaranteed Issue (GI) Protection Period

A $6\text{-month}$ protection window beginning upon initial enrollment in Part B during which private insurers cannot deny coverage or alter Medigap premiums.

Medical Underwriting

The evaluation process where insurers review a beneficiary's health status to deny coverage or charge higher premiums when enrolling outside GI protections.

Oregon Birthday Rule

A state Special Enrollment Period providing a $30\text{-day}$ window beginning on a beneficiary's birthday to change Medigap carriers without medical underwriting.

Lateral Transfers and Downgrades under Oregon Birthday Rule

Allowed policy changes under the Oregon Birthday Rule enabling transfers to the same plan letter across companies (e.g., Plan G to G) or to a lower plan (e.g., G to A).

Upgrade Prohibition under Oregon Birthday Rule

The rule barring beneficiaries from using the Oregon Birthday Rule to upgrade their coverage to a more comprehensive Medigap plan.

Medicare Advantage Annual Enrollment Period (AEP)

The annual enrollment window running from October $15$ to December $7$ where beneficiaries can switch Medicare Advantage plans, taking effect on January $1$.