The Medicare & TFL Glossary

AEP (Oct 15 – Dec 7) is when you can join, switch, or drop MA plans. OEP (Jan 1 – Mar 31) lets you change MA plans once.

October 15 – December 7 each year — the main window to join, switch, or drop a Medicare Advantage or Part D plan, with coverage starting January 1.

A formal request to review and reverse a denial, partial payment, or coverage decision by Medicare, a Medicare plan, TRICARE/TFL, VA, or a drug plan.

A signed form (CMS-1696) that authorizes another person — family member, attorney, or advocate — to file or pursue a Medicare appeal on your behalf.

The practice of a provider billing you for the difference between their charge and what insurance approved.

How DEERS classifies you (active duty, retiree, family member, survivor, etc.) — determines which TRICARE plans and cost shares apply.

The Part A timeframe used to measure hospital deductibles and coinsurance — it resets after 60 days out of the hospital.

Mistakes — accidental or intentional — on Medicare or TFL claims, ranging from duplicate charges to outright fraud.

FDA-approved drugs sold under a manufacturer's proprietary name — middle copay tier on the TRICARE formulary.

A VA health benefit for certain spouses, children, and survivors of permanently and totally disabled or deceased veterans — separate from TRICARE and TFL.

A formal request to an insurer for payment of a covered service.

The formal process for asking Medicare or TFL to reconsider a denied or underpaid claim.

COBRA is not creditable coverage for Part B — using it past 65 instead of enrolling in Medicare causes lifetime late penalties.

Your percentage share of a covered service — typically 20% under Medicare Part B.

A 18- to 36-month temporary TRICARE-like coverage option for those who lose TRICARE eligibility — functionally the military version of COBRA.

The federal and contractual rules that determine which insurer pays first when you have more than one health plan.

A flat dollar amount you pay for a covered service, such as $20 for a doctor visit.

A formal decision by a Medicare Advantage or Part D plan about whether — and how — it will cover a service, item, or prescription.

Non-Medicare coverage that CMS deems at least as good as a standard Medicare Part D plan — TRICARE Pharmacy qualifies, so TFL beneficiaries don't need Part D.

Prescription drug coverage that CMS certifies is at least as good as standard Medicare Part D — including TRICARE Pharmacy and VA Pharmacy.

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

The DoD's master database that determines who is eligible for TRICARE — including TRICARE For Life.

The DoD combat support agency that runs the Military Health System and administers TRICARE, including TRICARE For Life.

A written notice from Medicare, an MA plan, Part D plan, TRICARE/WPS, or VA explaining what was denied, why, and how to appeal.

Dental coverage included with most Medicare Advantage plans — exams, cleanings, fillings, and sometimes crowns and dentures.

Medicare eligibility before age 65 — automatic after 24 months of SSDI, immediately for ALS, and based on dialysis/transplant for ESRD.

A percentage (0–100%) VA assigns to each service-connected condition that determines compensation and, in part, VHA Priority Group.

People enrolled in both Medicare and Medicaid — Medicaid pays Medicare premiums and cost-sharing, and may cover services Medicare does not.

Medically necessary, reusable equipment for home use — covered by Part B at 80% after the deductible.

VA may reimburse emergency care at a non-VA facility under specific eligibility, timing, and notification rules — but coverage is never automatic.

Emergency room care is covered by MA plans nationwide — in or out of network — at the plan's emergency copay.

Active employer group health coverage at age 65 or later allows most retirees to delay Part B without penalty.

A condition (permanent kidney failure requiring dialysis or transplant) that grants Medicare eligibility at any age.

A fast-track appeal for situations where standard timeframes could seriously jeopardize the beneficiary's health or ability to regain function.

A statement from your insurer showing what a provider billed, what the plan paid, and what you may owe.

The pharmacy benefit manager that administers the TRICARE Pharmacy Program, including TFL home-delivery and retail-network prescriptions.

A federal program that helps pay Part D premiums, deductibles, and copays for beneficiaries with limited income and resources.

Optional dental and vision insurance retired military can buy through BENEFEDS — fills the dental/vision gap in Medicare and TFL.

Federal civilian retirees often keep FEHB into retirement and must decide how it coordinates with Medicare and TFL.

A free gym membership program (SilverSneakers, Renew Active, Silver&Fit, etc.) included with most Medicare Advantage plans.

A once-per-year SEP that lets you switch into a CMS-rated 5-star Medicare Advantage or Part D plan available in your area.

A prepaid debit-style card some Medicare Advantage plans issue for dental, vision, hearing, OTC, or other approved spending.

A VA program that reimburses veterans living or traveling abroad for medical care related to service-connected conditions.

The January 1 – March 31 window each year when you can sign up for Medicare if you missed your IEP and don't qualify for an SEP.

Chemically identical, FDA-approved equivalents of brand-name drugs — the lowest copay tier under TRICARE Pharmacy.

A Reserve or Guard retiree between drilling retirement and age 60, eligible for TRICARE Retired Reserve but not regular TRICARE.

Routine hearing exams and a hearing-aid allowance offered by most Medicare Advantage plans.

Two common Medicare Advantage plan structures — HMOs require in-network care, PPOs allow out-of-network at higher cost.

Part-time skilled nursing or therapy delivered at home for homebound beneficiaries — covered by Medicare with no cost-sharing.

End-of-life comfort care covered 100% by Medicare Part A when a doctor certifies a terminal prognosis of 6 months or less.

A doctor, hospital, or facility contracted with your MA plan at negotiated rates and lower cost-sharing.

The 7-month window around your 65th birthday when you first sign up for Medicare Parts A and B without penalty.

The billing distinction between formal hospital admission (Part A) and outpatient hospital services (Part B), with major cost and coverage consequences.

An income-based surcharge added to your Medicare Part B and Part D premiums when your modified adjusted gross income exceeds CMS thresholds.

A permanent monthly surcharge added to your Part B (10% per 12 months delayed) or Part D (1% per month delayed) premium for as long as you have Medicare.

The maximum a non-participating Medicare provider may charge — 115% of the Medicare non-PAR approved amount.

A documented clinical justification that a non-formulary or restricted drug is required — allowing TRICARE to cover it at a lower tier.

An appeal arguing that a denied service, drug, or device is clinically necessary based on the treating provider's documentation.

The federal health insurance program for people 65+, certain younger people with disabilities, and people with ESRD or ALS.

A Medicare Advantage plan design that requires you to use in-network providers and select a primary care physician.

January 1 – March 31 each year — a one-time chance for current Medicare Advantage enrollees to switch MA plans or drop back to Original Medicare.

A Medicare Advantage plan design that lets you see any Medicare provider — in-network at the lowest cost, out-of-network at higher cost.

The five-level Medicare appeals process — Redetermination, Reconsideration (QIC), Administrative Law Judge, Medicare Appeals Council, and federal court review.

A provider's agreement to accept Medicare's approved amount as full payment for a covered service.

U.S. citizens and lawful permanent residents (5+ years) qualify for Medicare at age 65, or earlier with qualifying disability or ESRD/ALS.

The hospital insurance side of Original Medicare — covers inpatient stays, skilled nursing, hospice, and some home health.

The medical insurance side of Original Medicare — covers doctor visits, outpatient care, preventive services, and durable medical equipment.

An optional, all-in-one alternative way to get your Medicare benefits — delivered through a private plan instead of through Original Medicare.

Medicare's optional prescription drug coverage — almost always unnecessary if you have TRICARE For Life.

Why TFL beneficiaries do not need (and usually should not enroll in) a standalone Medicare Part D plan.

State-administered programs that help pay Part B premiums (and sometimes deductibles and copays) for beneficiaries with limited income — including QMB, SLMB, QI, and QDWI.

Medicare's quarterly statement listing every Part A and Part B claim processed for you — Medicare's version of an EOB.

A provider who has signed an agreement to always accept Medicare assignment for every covered service.

The DoD self-service web portal where retirees verify and update DEERS, view TRICARE coverage, and request ID cards.

Pharmacies operated inside Military Treatment Facilities — fills formulary drugs at $0 copay for TFL beneficiaries.

DoD military hospitals and clinics — at 65, retirees can only be seen if appointments aren't needed by active duty or TRICARE Prime enrollees.

The yearly cap on what you'll spend on covered Medicare Advantage services — Original Medicare has no MOOP.

How a permanent move affects Medicare, Medicare Advantage, Part D, and TRICARE For Life coverage.

Drugs not on the TRICARE preferred list — highest copay tier, often requires Medical Necessity approval.

A civilian pharmacy that is NOT contracted with Express Scripts — highest cost and usually requires you to pay up front and file a claim.

A provider who treats Medicare patients but has not agreed to always accept assignment — and may charge up to 15% above Medicare's approved amount.

Any care delivered outside a VA facility — whether through VA Community Care, Medicare + TFL, or an MA plan.

A hospital classification that treats your stay as outpatient — even if you're admitted overnight — with major coverage implications.

A Medicare Advantage plan's initial decision about whether it will pay for or authorize a medical service.

Medicare Parts A and B together — the fee-for-service version of Medicare run directly by the federal government.

An over-the-counter allowance most MA plans give members for buying eligible health items at retailers or online.

A provider not contracted with your MA plan — covered at higher cost (PPO) or generally not covered (HMO).

What you actually pay yourself — premiums, deductibles, coinsurance, and copays — after insurance.

How TFL beneficiaries fill prescriptions outside the US — usually pay up front and file for reimbursement.

How Medicare, TRICARE For Life, and VA care work when a retiree lives outside the United States.

A Medicare Advantage plan benefit that reimburses part of your Part B premium, increasing your Social Security check.

The monthly premium for Medicare Part B — the single most important ongoing Medicare cost for TFL beneficiaries, since TFL requires Part B to remain active.

The flat dollar amount a TFL beneficiary pays per prescription — varies by drug tier and access point.

A pre-approval requirement Express Scripts imposes on certain drugs before TRICARE Pharmacy will pay.

Most people pay no monthly premium for Medicare Part A because they (or a spouse) paid Medicare taxes for at least 40 quarters (10 years) of work.

A request asking a Part D or MA-PD plan to cover a non-formulary drug, lower the tier, or waive a quantity limit — based on medical need.

The insurance plan that pays first on a claim, before any other coverage is considered.

A plan's requirement that a provider get approval before delivering certain services or medications.

An appeal of a denial that occurred when a plan refused to pre-approve a service, procedure, or drug.

Whether a specific provider agrees to bill Medicare and/or TFL — and under what terms.

The list of doctors, hospitals, and facilities that contract with an insurance plan.

An MSP that pays the Part A premium for working disabled individuals under 65 who lost premium-free Part A due to returning to work.

A Medicare Savings Program that pays your Part A and Part B premiums, deductibles, coinsurance, and copays for very low-income beneficiaries.

An MSP that pays the Part B premium for beneficiaries with income slightly above the SLMB threshold — funded on a first-come, first-served basis.

A complaint filed with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) about the quality of medical care you received.

TRICARE Pharmacy caps on how much of a drug can be filled per fill or per time period.

An appeal-level review — Level 1 in Medicare Advantage and Part D, or Level 2 in Original Medicare (handled by a Qualified Independent Contractor).

The first level of appeal in Original Medicare — filed with the Medicare Administrative Contractor (MAC) that handled the claim.

A formal approval from your primary care physician required by some Medicare Advantage plans before you can see a specialist.

Reserve and Guard members who retire from drilling but are not yet drawing retired pay — they typically lose TRICARE until age 60.

The insurance plan that pays after the primary plan, covering remaining eligible cost-shares.

A medical condition VA has determined was caused or aggravated by military service — receives priority care at the VA at no cost to the veteran.

Short-term skilled care after a qualifying inpatient hospital stay — up to 100 days per benefit period under Medicare Part A.

Retirees who live in two states seasonally and must structure Medicare coverage so providers are available in both locations.

The Social Security Administration handles Medicare enrollment, premium collection, and IRMAA determinations — even though Medicare itself is run by CMS.

An enrollment window triggered by qualifying life events — TRICARE and VA care do NOT trigger one.

Medicare Advantage plans designed for beneficiaries with specific chronic conditions, dual Medicare-Medicaid eligibility, or institutional residence.

High-cost, complex medications — typically biologics or injectables — that require special handling, storage, or administration.

An MSP that pays the Part B premium for beneficiaries with income slightly above the QMB threshold.

A free, unbiased Medicare counseling program funded by CMS and administered by states.

A TRICARE Pharmacy rule that requires you to try a cheaper or first-line drug before a more expensive alternative is covered.

Benefits offered by Medicare Advantage plans that go beyond Original Medicare — dental, vision, hearing, OTC, fitness, transportation, and more.

A combination of military, VA, and TRICARE programs that protect a surviving spouse's income and health coverage after a retiree's death.

Outside the U.S., TFL becomes the primary payer because Medicare generally doesn't pay overseas.

The Department of Defense's worldwide health-care program for uniformed service members, retirees, and their families.

The TRICARE appeals process for denied claims, factual disputes, and medical necessity reviews — administered by WPS for TFL and escalating to the Defense Health Agency.

The annual limit on what a TRICARE family pays out-of-pocket for covered services — protecting TFL beneficiaries from runaway costs.

The wraparound secondary health coverage for Medicare-eligible military retirees, spouses, and survivors — no premium, no enrollment fee.

The DoD's tiered list of prescription drugs covered by the TRICARE Pharmacy Program — what's covered, at what cost, and with what restrictions.

TRICARE's mail-order pharmacy through Express Scripts — 90-day supplies of maintenance medications at the lowest retail-equivalent copay.

The DHA contractor program that delivers TRICARE benefits — including TFL — outside the U.S. through International SOS.

The DoD prescription drug benefit administered by Express Scripts — your drug coverage if you have TFL.

An MTF-specific primary-care enrollment program at participating military hospitals — not a substitute for TFL or Medicare.

A primary care enrollment program offered at some Military Treatment Facilities (MTFs) based on local capacity — not a separate TRICARE health plan.

TRICARE's managed-care HMO-style plan with a Primary Care Manager and referrals — ends at age 65 for retirees, replaced by TFL.

Civilian pharmacies (chains and independents) contracted with Express Scripts to fill TRICARE prescriptions at network copays.

TRICARE's PPO-style fee-for-service plan — ends at age 65 for retirees and is replaced by TFL.

The DoD-issued ID card that proves uniformed services affiliation — required (with DEERS) to access military health benefits.

Urgently needed non-emergency care — covered by MA plans nationwide at a fixed copay, in or out of network.

A TRICARE Prime option delivered by designated civilian provider networks in specific U.S. regions — Medicare-eligible enrollees disenroll at 65 and move to TFL.

The full set of benefits administered by the Department of Veterans Affairs — healthcare (VHA), disability compensation and pensions (VBA), and burial/memorial benefits (NCA).

A VA program that pays approved non-VA providers to deliver care when VA cannot — under specific eligibility and pre-authorization rules.

A medical facility operated by the Veterans Health Administration — VA medical centers, CBOCs, vet centers, and outpatient clinics.

A separate federal healthcare system run by the Veterans Health Administration for enrolled veterans — it does not coordinate with Medicare or TRICARE For Life.

Prescription drug benefit delivered through the VA — completely separate from TRICARE/Express Scripts and from Medicare Part D.

The 1–8 tier system VA uses to enroll veterans in healthcare — lower numbers get higher priority and generally lower copays.

A VA benefit that reimburses eligible veterans for mileage and other travel costs to and from VA-authorized appointments.

A VA benefit that lets enrolled veterans use approved in-network urgent care clinics without prior authorization — subject to copay rules and an annual visit cap on certain services.

The VA administration responsible for non-healthcare benefits — disability compensation, pensions, education, home loans, and life insurance.

The VA administration that delivers healthcare to enrolled veterans through VA medical centers, clinics, and authorized community care.

The official photo ID card issued by VA to enrolled veterans for accessing VA healthcare services.

Routine eye exams and eyewear allowances offered by most Medicare Advantage plans.

If you (or your spouse) are still working past 65 with employer group health coverage from a 20+ employee company, you can delay Part B penalty-free and keep TRICARE Prime/Select until employment ends.

Wisconsin Physicians Service — the Defense Health Agency contractor that processes TRICARE For Life secondary claims.

The first-level review of a TRICARE For Life claim decision, filed with Wisconsin Physicians Service (WPS), the TFL contractor.