Common Health Insurance Terms : (republished from KFF.org)

• Annual Deductible: The amount you must pay out-of-pocket for covered services before your insurance starts paying.

• Annual Election Period AEP

• CMS stands for the Centers for Medicare & Medicaid Services a federal agency within the U.S. Department of Health and Human Services (HHS).

• Co-Pay: A fixed amount you pay for a specific medical service (like a doctor visit or prescription), usually due at the time of service.

• Co-Insurance: The percentage of medical costs you share with your insurance after meeting your deductible. Example: You pay 20%, your insurance pays 80% Gold; 70% / 30 % Silver; 60% / 30% Bronze.

• Doctors Network (Provider Network): A group of doctors, hospitals, and facilities that have agreed to provide services at negotiated rates for your plan. Using in-network providers saves you money.

• Extra Help (LIS) low income subsidy:

• HMO (Health Maintenance Organization): A plan that requires you to choose a primary care doctor and get referrals to see specialists. Generally lower cost, but less flexibility.

• Maximum Out-of-Pocket (Max OOP): The most you’ll pay in a year for covered services. After you reach this limit, your insurance covers 100% of approved costs.

• Medicare: A federal health insurance program for people age 65 and older, and for certain younger individuals with disabilities or specific conditions.

• Medicare Advantage (MA) Part C

• MediGap / Medicare Supplemental

• Medicaid: A state and federally funded program that provides health coverage to eligible low-income individuals and families.

• Medi-Cal: California’s version of Medicaid. It offers free or low-cost health coverage to eligible California residents, including families, seniors, and people with disabilities.

• Medi / Medi: dual eligible

• Medicare Open Enrollment Period, also known as the Annual Election Period (AEP), every year from 10/15 -12/7.

• PACE stands for Program of All-Inclusive Care for the Elderly.

• PCP Primary Care Physician

• PDP Prescription Drug Plan, RX Plan

• PPO (Preferred Provider Organization): A flexible plan that lets you see any doctor, including specialists, without a referral. You can see out-of-network providers, but at a higher cost.

• Star Rating Medicare are quality scores (1 to 5 stars) given to Medicare Advantage (Part C) and Medicare Part D (prescription drug) plans by the Centers for Medicare & Medicaid Services (CMS). They help consumers compare plans based on quality, performance, and customer satisfaction.

• SEP, or Special Enrollment Period, is a time outside of the standard enrollment windows when someone is allowed to enroll in or change their Medicare Advantage (Part C), Part D, or Marketplace/ACA health insurance plan due to certain life events or qualifying circumstances.

• Needs Assessment

• Summary of Benefits is a standardized document that clearly outlines what a health insurance plan covers, including costs, services, and limits. It helps beneficiaries compare plans side by side in a simplified format.

• TRICARE (Veterans) It is managed by the Defense Health Agency (DHA) under the U.S. Department of Defense (DoD) and provides civilian health benefits for military personnel and their dependents.

• 7 Activities of Daily Living