Medicare and Medicaid Terminology
Healthcare coverage comes with its own vocabulary. This guide defines the terms you are most likely to encounter when exploring D-SNPs and dual eligibility.
Educational information only. SubsidyCheck does not determine eligibility, enroll you in a plan, or act as a government agency. Final decisions are made by Medicare, your state Medicaid agency, and licensed plan administrators.
Dual Eligibility Terms
Dual eligible: A person who qualifies for both Medicare and Medicaid. Dual Eligible Special Needs Plan (D-SNP): A Medicare Advantage plan for dual-eligible individuals. Full-benefit dual: Someone who receives full Medicaid benefits plus Medicare. Partial dual: Someone who receives limited Medicaid help, often through a Medicare Savings Program.
These categories affect which D-SNPs you may join and what costs you pay. Your state Medicaid agency determines your specific category.
Medicare Parts and Programs
Part A: Hospital insurance covering inpatient stays, skilled nursing, hospice, and some home health. Part B: Medical insurance for doctor visits, outpatient care, and preventive services. Part C: Medicare Advantage—an alternative to Original Medicare offered by private plans. Part D: Prescription drug coverage.
Medicare Savings Program (MSP): State Medicaid programs that help pay Medicare premiums and cost-sharing. Levels include QMB, SLMB, QI, and QDWI. Extra Help (LIS): Federal subsidy reducing Part D drug costs.
Plan and Enrollment Terms
Annual Enrollment Period (AEP): October 15–December 7, when most people can change Medicare Advantage plans. Special Enrollment Period (SEP): A window triggered by qualifying life events. Evidence of Coverage (EOC): The official document listing everything a plan covers.
Formulary: The list of drugs a plan covers. Prior authorization: A requirement to get plan approval before a service or drug is covered. Network: The group of providers who have agreed to treat plan members.
Care and Coverage Terms
Care coordination: Services that help members manage appointments, medications, and transitions between care settings. Chronic condition: An ongoing health issue such as diabetes, heart disease, or COPD that may require ongoing management.
Cost-sharing: Out-of-pocket costs including premiums, deductibles, copayments, and coinsurance. For full-benefit dual members in D-SNPs, federal law limits Medicare cost-sharing.
Using This Glossary
When you encounter an unfamiliar term in plan documents or counselor conversations, refer back to this guide. Official definitions may also appear in your plan's EOC or on Medicare.gov.
SubsidyCheck uses these terms educationally. For definitions specific to your plan or state, consult official plan documents and agency resources.
Frequently asked questions
What is the difference between dual eligible and D-SNP member?
Dual eligible describes your status having both Medicare and Medicaid. D-SNP member means you enrolled in a specific plan type designed for dual-eligible individuals.
What does QMB Plus mean?
QMB Plus (or QMB+) typically refers to someone in the QMB program who also receives full Medicaid benefits beyond what QMB alone provides.
What is a formulary tier?
Drug tiers classify medications by cost. Tier 1 is usually generic drugs with the lowest copay; higher tiers cost more. Formulary structures vary by plan.
Sources & official references
Related D-SNP guides
Curious whether a D-SNP may fit your situation?
Take our educational eligibility check. It does not enroll you in a plan or guarantee benefits.