Medicare glossary for North Carolina

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70/30 Plan (State Health Plan)

The State Health Plan option that, for retirees on Medicare, pays after Original Medicare instead of replacing it. Retirees whose Parts A and B aren't in effect, and retirees who join an outside Medicare Advantage or Part D plan, are placed on the 70/30 Plan; if you don't have Part B, it pays as if Part B had paid. See State Health Plan retirees and Medicare.

ABN (Advance Beneficiary Notice of Noncoverage)

A form a doctor, lab or supplier with Original Medicare gives you before a service when they think Medicare may not pay for it. If you sign it and get the service, you may have to pay if Medicare denies the claim. You can still ask them to bill Medicare so you keep your right to appeal.

AEP (Annual Enrollment Period)

October 15 to December 7 each year, also called Open Enrollment. You can join, switch or drop a Medicare Advantage or Part D plan, and changes start January 1. For 2027 coverage it runs October 15 to December 7, 2026. The State Health Plan has its own, earlier open enrollment for its retirees. See Medicare Open Enrollment in North Carolina.

ANOC (Annual Notice of Change)

A notice your Medicare Advantage or Part D plan sends by September 30 explaining what changes next year: premiums, costs, drug list, network and benefits. If your plan is ending instead, you get a non-renewal letter; see plans ending in 2027.

Appeal

A formal request to change a coverage or payment decision by Medicare or your plan. There are five levels, and deadlines start from the date on your notice. See Medicare appeals in North Carolina.

Area agency on aging

A regional agency that connects older adults and caregivers to local services such as in-home help, meals, caregiver support and the long-term care ombudsman. North Carolina has 16 area agencies on aging, each housed in a regional council of government and overseen by the NCDHHS Division of Aging. See how to find your area agency on aging.

Assignment

An agreement by a doctor or supplier to accept the Medicare-approved amount as full payment for a covered service. With assignment, you pay only your deductible and coinsurance.

Benefit period

How Part A measures hospital and skilled nursing facility use. It starts the day you're admitted as an inpatient and ends when you've been out of the hospital or skilled care for 60 days in a row. The Part A deductible applies to each benefit period ($1,736 in 2026; CMS publishes the 2027 amount each fall).

BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization)

The organization Medicare pays to handle fast appeals when a hospital stay or other covered care is ending, and complaints about quality of care. For North Carolina it is Acentra Health, 1-888-317-0751, TTY 711.

CAP/DA (Community Alternatives Program for Disabled Adults)

An NC Medicaid waiver that pays for home and community services, such as in-home aide help, adult day health and respite, for adults 18 and older who need a nursing-facility level of care but want to stay at home. Participants must be in NC Medicaid Direct, and since February 2024 new applicants may be placed on a statewide waitlist. See the CAP/DA waiver in North Carolina.

CMS (Centers for Medicare & Medicaid Services)

The federal agency that runs Medicare and works with states such as North Carolina on Medicaid. CMS sets the yearly Medicare amounts and approves Medicare Advantage and Part D plans.

Coinsurance

Your share of a covered cost, as a percentage. After the Part B deductible, you usually pay 20% of the Medicare-approved amount for doctor visits and outpatient care.

Coordination-only D-SNP

A D-SNP that covers your Medicare benefits and coordinates with your Medicaid, which still comes from the state. CMS's 2027 plan data show that every D-SNP in North Carolina is coordination-only: none is a fully or highly integrated plan that also covers Medicaid benefits. See dual eligible special needs plans in North Carolina.

Copayment

A set dollar amount you pay for a covered service or drug, such as a doctor visit or a prescription. Amounts vary by plan.

County Department of Social Services (county DSS)

Each of North Carolina's 100 counties has a Department of Social Services that takes and decides applications for NC Medicaid, the MQB programs and Special Assistance. You can apply in person, by phone, by mail or online through ePASS, the state's benefits website; the NC Medicaid Contact Center, 1-888-245-0179, can help you find your DSS.

Coverage determination

A decision by your Part D plan about whether it will cover a drug, and how much you pay. Asking for an exception, such as covering a drug that isn't on the plan's list, starts with a coverage determination.

Creditable coverage

Other drug coverage that is expected to pay at least as much as standard Part D, such as many employer, union, VA and TRICARE plans, and care from the Indian Health Service or a tribal health program. Having it lets you delay Part D without a late penalty. Your plan tells you each year whether its coverage is creditable.

Critical Access Hospital

A small rural hospital with no more than 25 inpatient beds and 24-hour emergency care, usually more than a 35-mile drive from another hospital, or 15 miles in mountainous terrain or where only secondary roads are available. Medicare pays these hospitals in a special way to help keep them open. CMS lists 20 Critical Access Hospitals in North Carolina (Hospital General Information, November 2026). See what is a Critical Access Hospital in North Carolina?

D-SNP (Dual Eligible Special Needs Plan)

A Medicare Advantage plan only for people who have both Medicare and Medicaid. Each D-SNP must have a contract with NC Medicaid, and for 2027 all of North Carolina's are coordination-only. CMS data show 57 special needs plans of all types in North Carolina for 2027. See dual eligible special needs plans in North Carolina.

Deductible

What you pay before Medicare or your plan starts to pay. In 2026 the Part B deductible is $283 a year and the Part A deductible is $1,736 per benefit period; for 2027, Part D plans can have a deductible of up to $700.

Disaster Special Enrollment Period

A chance to make a Medicare Advantage or Part D change you missed because of a declared emergency or major disaster, such as Hurricane Helene in western North Carolina. It applies only if you lived in the declared area (or rely on someone who does) and were eligible for another enrollment period that the disaster kept you from using; it isn't a new open season for everyone (42 CFR 422.62(b)(18) and 423.38(c)(23)). See hurricanes, floods and Medicare.

Dual eligible

A person who has both Medicare and Medicaid. Full dual eligibles get full NC Medicaid benefits through NC Medicaid Direct; partial dual eligibles get help only through an MQB program. Medicare pays first, then Medicaid. See NC Medicaid and Medicare.

EBCI Tribal Option

An NC Medicaid option run by the Eastern Band of Cherokee Indians' Cherokee Indian Hospital Authority that manages primary care for federally recognized tribal members and others eligible for Indian Health Service care, mainly in the far western counties. It is a Medicaid program, not a Medicare plan. See American Indians and Medicare in North Carolina.

EOB (Explanation of Benefits)

A statement from your Medicare Advantage or Part D plan showing services or drugs it paid for, what it paid and what you owe. It isn't a bill. Check it for charges you don't recognize.

Estate recovery

NC Medicaid's process for recovering certain Medicaid costs from the estate of a person who has died. Under G.S. 108A-70.5 it covers nursing facility care, home and community-based services, hospital care, prescription drugs and personal care received at 55 or older, and care for people of any age in an institution who couldn't be expected to return home. Help from a Medicare Savings Program alone isn't recovered.

Evidence of Coverage (EOC)

Your Medicare Advantage or Part D plan's full rulebook: what it covers, what you pay, how to appeal and your rights. Plans post it online and must send it on request.

Excess charge

An amount, up to 15% above the Medicare-approved amount, that a doctor who doesn't accept assignment can bill you under Original Medicare. Federal limits apply in North Carolina. Medigap Plans F and G cover it.

Extra Help

The federal program, also called the Low-Income Subsidy (LIS), that lowers Part D premiums, deductibles and copays for people with limited income and resources. People with full NC Medicaid, an MQB program or SSI get it automatically; others apply with Social Security. See Extra Help in North Carolina.

Formulary

A plan's list of covered drugs, usually in tiers. Each Part D and Medicare Advantage plan has its own, and it can change from year to year.

Free look period

The 30 days after a Medigap policy is delivered when you can return it for a full refund of the premium if you're not satisfied for any reason. North Carolina law requires the notice on the first page of the policy (G.S. 58-54-30).

GEP (General Enrollment Period)

January 1 to March 31 each year, for people who missed their Initial Enrollment Period and don't qualify for a Special Enrollment Period. Coverage starts the month after you sign up, and late enrollment penalties may apply.

Guaranteed issue rights

Situations in which a Medigap company must sell you certain policies without health questions, such as when your Medicare Advantage plan leaves your area or ends. Most windows last 63 days after the other coverage ends. North Carolina follows the federal list, and its law gives people under 65 with Medicare because of a disability the right to buy Plan A, D or G within 63 days when their Medicare Advantage plan ends (G.S. 58-54-45). See Medigap in North Carolina.

HMO (Health Maintenance Organization)

A type of Medicare Advantage plan that generally covers care only from doctors and hospitals in its network, except emergencies and urgently needed care, and may require referrals to see specialists.

IEP (Initial Enrollment Period)

Your first chance to sign up for Medicare: 7 months that start 3 months before the month you turn 65 and end 3 months after. See turning 65 in North Carolina.

Indian Health Service (IHS)

The federal agency that provides or pays for health care for members of federally recognized tribes, directly or through tribal health programs such as the Eastern Band of Cherokee Indians' Cherokee Indian Hospital. IHS and tribal care counts as creditable drug coverage, so you won't pay a Part D penalty if you join a Medicare drug plan later.

Inpatient

Formally admitted to a hospital on a doctor's order. Staying overnight doesn't make you an inpatient; ask whether you're admitted or under observation, because it changes what you pay.

IRMAA (Income-Related Monthly Adjustment Amount)

An extra amount added to Part B and Part D premiums if your income from two years earlier was above a limit. For 2026 premiums the first limit is $109,000 for an individual and $218,000 for a couple filing jointly; CMS publishes the 2027 brackets each fall. The brackets are cliffs, and Social Security decides it. See our IRMAA calculator.

Late enrollment penalty

A lasting addition to your premium if you sign up for Part B or Part D late without other qualifying coverage. The Part B penalty is 10% for each full 12-month period you could have had Part B but didn't. See our penalty calculator.

LGERS (Local Governmental Employees' Retirement System)

The pension system for employees of North Carolina cities, counties and other local governments, run by the Retirement Systems Division of the Department of State Treasurer. An LGERS pension doesn't come with State Health Plan coverage: retiree health coverage, if any, depends on your former employer.

Look-back period

The 60 months before you apply for Medicaid long-term care, such as nursing home care or CAP/DA, during which Medicaid reviews gifts and other transfers of assets for less than their value. Federal law sets the 60-month look-back (Social Security Act section 1917(c)), and a transfer in that window can delay coverage. Your county DSS explains how it applies to you.

Long-term care ombudsman

An advocate for people who live in nursing homes and adult care homes. North Carolina's Office of the State Long-Term Care Ombudsman, in the NCDHHS Division of Aging, works with regional ombudsmen at the 16 area agencies on aging.

MA OEP (Medicare Advantage Open Enrollment Period)

January 1 to March 31 each year. If you're in a Medicare Advantage plan, you can switch to another one or go back to Original Medicare (and join a Part D plan) once during this period.

Medicaid (NC Medicaid)

The joint federal and state program that pays for health care and long-term care for people with limited income and resources. In North Carolina, NCDHHS runs it as NC Medicaid, and county DSS offices handle applications. Medicaid expansion, since December 1, 2023, covers adults 19 to 64 who don't have Medicare. See NC Medicaid and Medicare.

Medicare Advantage (Part C)

A plan from a private company approved by Medicare that covers Part A and Part B services, usually with Part D drug coverage. Medicare Advantage plans may offer extra benefits such as dental, vision, hearing or fitness. Extra benefits vary by plan and county, may have limits and costs, and not every plan offers them. Check a plan's Summary of Benefits or Evidence of Coverage. For 2027, CMS data show 106 Medicare Advantage plans open to everyone in North Carolina. See Medicare Advantage in North Carolina.

Medicare Prescription Payment Plan

An option in every Part D plan that spreads your out-of-pocket drug costs into monthly payments over the year instead of paying at the pharmacy. It doesn't lower your total cost. The 2027 Part D out-of-pocket cap is $2,400.

Medigap (Medicare Supplement Insurance)

A policy from a private company that helps pay costs Original Medicare leaves to you, such as deductibles and coinsurance. Plans are standardized by letter, and North Carolina regulates them under Chapter 58, Article 54 of the General Statutes. North Carolina has no birthday rule or yearly switching right. See Medigap in North Carolina.

Medigap open enrollment period

The 6 months that start the first month you're 65 or older and enrolled in Part B. During it, companies must sell you any Medigap policy they offer, regardless of your health. North Carolinians under 65 with Medicare because of a disability have their own 6-month window, starting with Part B, for Plan A (and Plan D or G if the company sells them to people 65 and older).

MOOP (maximum out-of-pocket limit)

The most you pay in a year for covered Part A and Part B services in a Medicare Advantage plan. For 2027, Medicare allows in-network limits of up to $9,850; each plan sets its own limit at or below that. Original Medicare has no yearly limit unless you add Medigap.

MQB (MQB-Q, MQB-B and MQB-E)

North Carolina's names for the Medicare Savings Programs, run by NC Medicaid. MQB-Q is the federal QMB (income up to about 100% of the federal poverty level; pays Part A and B premiums, deductibles and coinsurance), MQB-B is SLMB (about 100% to 120%; pays the Part B premium) and MQB-E is QI (about 120% to 135%; pays the Part B premium). There is also a resource limit; see what is MQB in North Carolina?

MSN (Medicare Summary Notice)

The statement Original Medicare mails every four months if you had services, also available in your Medicare.gov account. It lists claims, what Medicare paid and what you may owe, and explains how to appeal.

MSP (Medicare Savings Program)

The federal name for the state programs that help pay Medicare premiums and cost sharing: QMB, SLMB, QI and QDWI. In North Carolina they're called MQB. See Medicare Savings Programs in North Carolina.

NC Medicaid Direct

North Carolina's fee-for-service Medicaid, paid by the state instead of through a managed care health plan. It covers people who have both Medicare and Medicaid, people on the CAP/DA waiver or in PACE, and people in the medically needy program, among others.

NCDOI (North Carolina Department of Insurance)

The state agency that licenses insurance companies and agents and regulates Medigap policies in North Carolina. It takes complaints through its online assistance and complaint page but can't change a Medicare coverage decision. See how to file a complaint about an insurance agent.

Network

The doctors, hospitals, pharmacies and other providers a plan contracts with. Most Medicare Advantage plans use networks; Original Medicare and Medigap work with any provider nationwide that accepts Medicare.

Observation status

Hospital care as an outpatient while doctors decide whether to admit you. Part B covers it, so you may pay coinsurance for each service, and observation days don't count toward the 3 inpatient days needed for skilled nursing facility coverage. The hospital must give you a Medicare Outpatient Observation Notice after 24 hours.

Original Medicare

Part A (hospital) and Part B (medical) run by the federal government. You can see any provider in the country that accepts Medicare. Many people add a Medigap policy and a Part D plan.

PACE (Program of All-Inclusive Care for the Elderly)

A program for people 55 and older who need a nursing-home level of care but can live safely at home, run by local PACE organizations that provide and coordinate all their care. NC Medicaid says 11 PACE organizations operate in 14 locations in North Carolina, and PACE members are in NC Medicaid Direct.

Part A (hospital insurance)

Covers inpatient hospital care, skilled nursing facility care after a qualifying stay, hospice and some home health care. Most people pay no Part A premium because they or a spouse paid Medicare taxes for about 10 years. See Medicare Part A.

Part B (medical insurance)

Covers doctor visits, outpatient care, preventive services, durable medical equipment and some drugs given in a doctor's office. Most people pay the standard monthly premium, $202.90 in 2026. See Medicare Part B.

Part D (drug coverage)

Prescription drug coverage from private plans, either a standalone drug plan or built into a Medicare Advantage plan. In 2027, your yearly out-of-pocket cost for covered drugs is capped at $2,400, and the old gap in coverage between phases no longer exists. North Carolina is its own Part D region (PDP Region 08), with 11 standalone drug plans for 2027. See Medicare Part D in North Carolina.

PPO (Preferred Provider Organization)

A type of Medicare Advantage plan with a network, where you can also see out-of-network providers, usually at a higher cost. The State Health Plan's Base Plan and Enhanced Plan are group Medicare Advantage PPOs.

Prior authorization

Approval you or your provider must get from a plan before a service or drug is covered. Medicare Advantage and Part D plans use it for some services and drugs.

Rural Emergency Hospital

A Medicare provider type, available since 2023, for small rural hospitals that keep 24-hour emergency, observation and outpatient care but stop inpatient care, with an average stay of no more than 24 hours. CMS's November 2026 hospital data list no Rural Emergency Hospitals in North Carolina. See what is a Rural Emergency Hospital?

Senior Medicare Patrol (SMP)

A federally funded program in every state that helps people with Medicare prevent, detect and report fraud, errors and abuse. You can reach it through the national SMP Resource Center at 1-877-808-2468. See Medicare fraud in North Carolina.

SEP (Special Enrollment Period)

A time outside the usual periods when you can sign up or change plans because of a life event, such as moving, losing employer coverage, or your plan ending. If your Medicare Advantage or Part D plan doesn't renew for 2027, you have until February 28, 2027 to choose new coverage. See Medicare enrollment periods.

SNF (Skilled Nursing Facility)

A facility that gives skilled nursing or rehabilitation care. Part A covers up to 100 days per benefit period after a qualifying inpatient hospital stay of at least 3 days, with coinsurance from day 21. Long-term custodial care in a nursing home isn't covered by Medicare.

SNP (Special Needs Plan)

A Medicare Advantage plan limited to people with certain chronic conditions (C-SNP), people who live in an institution such as a nursing home (I-SNP), or people with Medicare and Medicaid (D-SNP). See what are special needs plans in North Carolina?

Special Assistance

A North Carolina cash program, paid by the state and counties and run by county DSS offices, that helps low-income adults 65 and older, or 18 to 64 with a disability, who need adult care home (assisted living) level of care. It helps pay for care in an adult care home or, through the Special Assistance In-Home Program, for living expenses at home; NCDHHS says people eligible for the in-home program are automatically eligible for Medicaid. See what is Special Assistance in North Carolina?

Standard Plan

An NC Medicaid managed care health plan that most NC Medicaid members must use. People who have Medicare aren't in Standard Plans: those with full Medicaid get it through NC Medicaid Direct, and North Carolina law permanently excludes people whose Medicaid only helps with Medicare costs (G.S. 108D-40).

State Health Plan

The State Health Plan for Teachers and State Employees, part of the North Carolina Department of State Treasurer. For retirees on Medicare it offers two group Medicare Advantage options, the Base Plan and the Enhanced Plan, and the 70/30 Plan; its open enrollment for 2027 ran October 12 to 30, 2026. See State Health Plan retirees and Medicare.

Tailored Plan

An NC Medicaid managed care plan for people with serious mental illness, a serious substance use disorder, an intellectual or developmental disability or a traumatic brain injury, run by the regional LME/MCOs. People with Medicare and full Medicaid stay in NC Medicaid Direct but may get some behavioral health and disability services through an LME/MCO.

TPMO (Third-Party Marketing Organization)

A company or agent, other than the plan itself, that sells or markets Medicare Advantage or Part D plans for the plans it contracts with. Benefits Life, the publisher of this site, is one. TPMOs must tell you they don't offer every plan in your area.

TRICARE For Life

Coverage for military retirees and their families who have Medicare Part A and Part B. Medicare pays first, then TRICARE For Life, and you must keep Part B to keep it. See military, veterans and TRICARE in North Carolina.

TSERS (Teachers' and State Employees' Retirement System)

The pension system for North Carolina public school employees and state employees, run by the Retirement Systems Division of the Department of State Treasurer. TSERS retirees with at least 5 years of service can get State Health Plan retiree coverage, with a premium share that depends on hire date and service; people first hired on or after January 1, 2021 aren't eligible for retiree health coverage.

Urgently needed care

Care for a sudden illness or injury that isn't an emergency but needs prompt attention. Medicare Advantage plans must cover it even out of network when you're temporarily outside the plan's service area, such as on a trip out of state.

Sources

• Medicare.gov — Glossary
• CMS — Beneficiary and Family Centered Care QIOs
• eCFR — 42 CFR Part 485, Subpart F (Critical Access Hospitals)
• eCFR — 42 CFR Part 485, Subpart E (Rural Emergency Hospitals)
• eCFR — 42 CFR 422.62, Election of coverage (disaster SEP)
• N.C. General Statutes, Chapter 58, Article 54 — Medicare supplement insurance minimum standards
• N.C.G.S. 108D-40 — Populations covered by Medicaid managed care
• Social Security Act section 1917 — Liens, adjustments and recoveries, and transfers of assets (look-back)
• N.C.G.S. 108A-70.5 — Medicaid estate recovery plan
• NCDHHS — MA-2252, Non-MAGI Medicaid income and reserve limits (MQB) (PDF)
• NC Medicaid — Medicaid health plans and programs
• NC Medicaid — Community Alternatives Program for Disabled Adults (CAP/DA)
• NC Medicaid — Program of All-Inclusive Care for the Elderly (PACE)
• NC Medicaid — How to apply
• NCDHHS — State/County Special Assistance In-Home Program brochure, 2026 (PDF)
• NCDHHS Division of Aging — Area agencies on aging map (PDF)
• NCDHHS Division of Aging — Long-term care ombudsman
• State Health Plan — 2027 plan comparison for Medicare-primary members (PDF)
• NC Retirement Systems (ORBIT Help) — Health benefit coverage for eligible retirees
• Medicare.gov — Your Guide to Medicare Drug Coverage (Indian health coverage is creditable) (PDF)
• Acentra Health — Medicare BFCC-QIO
• SMP National Resource Center

Frequently asked questions

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