Original Medicare = Part A + Part B, any provider that takes Medicare, no yearly out-of-pocket limit.

Medicare Advantage: need A and B, keep paying the Part B premium; has a yearly out-of-pocket limit.

Medigap works only with Original Medicare.

SSDI: Medicare starts in the 25th month of disability benefits.

ALS: first month of disability benefits. ESRD: 1st day of the 3rd month after dialysis starts.

Lawful permanent resident: 5 years of continuous U.S. residence.

40 credits = free Part A; 30–39 = reduced premium; 0–29 = full premium (and must have Part B).

Part A penalty: 10% for twice the number of years missed.

Part B penalty: 10% per full 12 months, generally for as long as you have Part B.

Part A pays the hospital, not the surgeon (Part B).

Benefit period ends after 60 days in a row with no inpatient hospital or SNF care.

Days 61–90 = ¼ of the deductible per day; 60 lifetime reserve days = ½ per day, never renewed.

Freestanding psychiatric hospital: 190-day lifetime limit.

IEP = 7 months: 3 before, the month of, 3 after.

SEP = 8 months after current-employment group coverage ends.

GEP = Jan 1–Mar 31; coverage starts the month after you enroll.

Part B: monthly premium (IRMAA for high income), deductible once a year, then 80/20.

No yearly out-of-pocket maximum in Original Medicare.

Limiting charge = approved amount + 15%.

Medigap fills Original Medicare's gaps; no drug coverage; never pays Medicare Advantage costs.

Core (Plan A): Part A coinsurance + 365 extra days, 3 pints of blood, Part B coinsurance, hospice cost sharing.

The Part A deductible is NOT core.

Excess charges: only F, high deductible F and G.

Newly eligible on or after 1/1/2020: no C or F; G is the top choice still sold.

K = 50%, L = 75% until the yearly out-of-pocket limit, then 100%.

Plan N: up to $20 office / $50 ER (waived if admitted). Foreign travel: first 60 days, 80% after $250, $50,000 lifetime.

Outline: insurers must offer Plan A plus Plan C or F (D or G for the newly eligible since 2020).

Medicare Select = Medigap with a restricted network; emergencies still paid.

Open enrollment: 6 months from the first month you are 65+ AND in Part B.

Birthday rule: 60+ days from the birthday, equal or lesser benefits only. Preexisting exclusion: max 6 months.

Medicare Advantage plan ends: guaranteed issue ends 63 days after coverage terminates.

Trial right: leave a first Medicare Advantage plan within 12 months, get the old Medigap back (or a listed plan).

First-year commission ≤ 200% of year 2; renewals equal year 2 for at least 5 years.

Banned: twisting, high pressure tactics, cold lead advertising.

Knowingly selling a second Medigap policy is unlawful; the application asks about other policies.

Outline of coverage: "Neither this company nor any of its agents are connected with Medicare."

Replacement: keep the old policy until sure; 30-day right to return. Rate guide: Department, HICAP or Department website.

HMO: network only (except emergencies), primary doctor and referrals. PPO: out of network allowed at higher cost.

PFFS: the provider decides at each visit. Every SNP must include Part D.

D-SNP coordinates Medicare and Medi-Cal (Medi-Medi Plans); C-SNP covers conditions such as ESRD.

Outline: joining a stand-alone PDP ends Medicare Advantage enrollment. Plans cover all of A and B, have a yearly out-of-pocket limit, may add extras.

PDP = stand-alone, with Original Medicare; MAPD = built into Medicare Advantage. Eligible with Part A OR Part B.

AEP: Oct 15–Dec 7, effective Jan 1.

Penalty: 1% of the national base beneficiary premium per full uncovered month, after a gap of 63+ days.

Creditable = actuarial value at least equal to standard Part D.

Premium = monthly; copayment = fixed amount; coinsurance = percentage.

Deductible: varies by plan (some none), capped yearly; resets every January.

Outline order: deductible, initial coverage, coverage gap, catastrophic. Current: no gap; $0 after the yearly limit.

Formulary: at least 2 drugs per category and class, not every drug; lower tier usually costs less.

The provider or supplier files the claim, within 12 months of the service.

Assignment = approved amount is payment in full; non-assignment = up to 15% more in many cases.

MSN is a notice, not a bill. Hearing aids, routine eye exams, most dental and cosmetic surgery are excluded.

5 appeal levels; start with a written redetermination within 120 days.

HICAP: free, unbiased Medicare counseling; sells nothing; federal SHIP plus state funding.

Education, counseling, informal advocacy, referral or legal representation, but no lawsuits against private insurers.

Run by the Department of Aging through Area Agencies on Aging; 1-800-434-0222.

TPMO disclaimer: said verbally before discussing benefits. Calls recorded and kept 6 years.

No cold calls; a business reply card asking for contact is permission.

SOA: written for in-person meetings, valid 12 months; no 48-hour wait since the 2026 final rule.

Nominal gifts only, no meals, no cross-selling; no applications at educational events.