APPEAL - An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services or payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if Medicare doesn’t pay for an item or service you think you should be able to get. Please refer to your Evidence of Coverage for more information about appeals, including the process involved in making an appeal.
BENEFIT PERIOD - For both our Plan and the Original Medicare Plan, a benefit period is used to determine coverage for inpatient stays in hospitals and skilled nursing facilities. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or a skilled nursing facility. The benefit period ends when you haven’t been an inpatient at any hospital or SNF for 60 days in a row. If you go to the hospital (or SNF) after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. The type of care you actually get during the stay determines whether you are considered an inpatient for SNF stays, but not for hospital stays.
BRAND-NAME DRUG - A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.
CATASTROPHIC COVERAGE - The phase in the Part D Drug Benefit where you pay a low co-payment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,050 in covered drugs during the covered year.
CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) - The Federal agency that runs the Medicare program. Section 1 explains how to contact CMS.
COST-SHARING - Cost-sharing refers to amounts that a member has to pay when services are received. It includes any combination of the following three types of payments: (1) any deductible amount the plan may impose before services are covered; (2) any fixed “copayment” amounts that a plan may require be paid when specific services are received; or (3) any “coinsurance” amount that must be paid as a percentage of the total amount paid for a service.
COVERAGE DETERMINATION - The Plan has made a coverage determination when it makes a decision about the benefits you can receive under the Plan, and the amount that you must pay for those benefits; A decision from your Medicare drug plan about whether a drug prescribed for you is covered by the Plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage if you disagree.
COVERED DRUGS - The general term we use to mean all of the prescription drugs covered by our Plan.
COVERED SERVICES - The general term we use to mean all of the health care services and supplies that are covered by our Plan.
CREDITABLE COVERAGE - Coverage that is at least as good as the standard Medicare prescription drug coverage.
CUSTOMER SERVICE - A department within our Plan responsible for answering your questions about your membership, benefits, grievances, and appeals.
DEDUCTIBLE - The amount of money you must first pay for your drugs before the Plan will begin paying for your covered drugs.
DISENROLL OR DISENROLLMENT - The process of ending your membership. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice).
DURABLE MEDICAL EQUIPMENT - Equipment needed for medical reasons, which is sturdy enough to be used many times without wearing out. A person normally needs this kind of equipment only when ill or injured. It can be used in the home. Examples of durable medical equipment are wheelchairs, hospital beds, and equipment that supplies a person with oxygen.
EMERGENCY CARE - Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.
EVIDENCE OF COVERAGE AND DISCLOSURE INFORMATION - The document along with your enrollment form which explains your coverage, and what we must do, and explains your rights and what you have to do as a member of our Plan.
EXCEPTION - A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor's formulary (a formulary exception), or get a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the Plan limits the quantity or dosage of the drug you are requesting (a formulary exception).
FORMULARY - A list of covered drugs provided by the Plan.
GENERIC DRUG - A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.
GRIEVANCE - A type of complaint you make about us or one of our Plan providers, including a complaint concerning the quality of your care. This type of complaint doesn’t involve payment or coverage disputes.
INITIAL COVERAGE LIMIT - The maximum limit of coverage under the initial coverage period.
INITIAL COVERAGE PERIOD - This is the period after you have met your deductible (if you have one) and before your total drug expenses, have reached [$2,040] including amounts you’ve paid and what our Plan has paid on your behalf.
INPATIENT CARE - Health care that you get when you are admitted to a hospital.
MEDICALLY NECESSARY - Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition; are used for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for your convenience or that of your doctor.
MEDICARE - The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with permanent kidney failure (who need dialysis or a kidney transplant).
MEDICARE ADVANTAGE ORGANIZATION - Medicare Advantage Plans are run by private companies. They give you more options, and sometimes, extra benefits. These plans are still part of the Medicare Program and are also called “Part C.” They provide all your Part A (Hospital) and Part B (Medical) coverage. Some may also provide Part D (prescription drug) coverage.
MEDICARE ADVANTAGE PLAN - A benefit package offered by a Medicare Advantage Organization that offers a specific set of health benefits at the same premium and level of cost-sharing to all people with Medicare who live in the service area covered by the Plan. Medicare Advantage Organizations can offer one or more Medicare Advantage Plans (plan in the same service area). We are a Medicare Advantage Organization.
MEDICARE ADVANTAGE PLAN WITH PRESCRIPTION DRUG COVERAGE - A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. In most cases, Medicare Advantage Plans also offer Medicare prescription drug coverage. A Medicare Advantage Plan can be an HMO, PPO, or a Private Fee-for-Service Plan.
MEDICARE HEALTH PLAN - A Medicare Advantage Plan (such as an HMO, PPO, or Private Fee-for-Service Plan) or other plan such as a Medicare Cost Plan. Everyone who has Medicare Part A and Part B is eligible to join any Medicare Health Plans that are offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).
MEDICARE MANAGED CARE PLAN - a Medicare Advantage HMO, Medicare Cost Plan or Medicare Advantage PPO.
MEDICARE PRESCRIPTION DRUG COVERAGE - Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part B.
“MEDIGAP” (MEDICARE SUPPLEMENT INSURANCE) POLICY - Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in the Original Medicare Plan coverage. Medigap policies only work with the Original Medicare Plan.
MEMBER (MEMBER OF OUR PLAN, OR “PLAN MEMBER”) - A person with Medicare who is eligible to get covered services, who has enrolled in our Plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).
NETWORK PHARMACY - A network pharmacy is a pharmacy where members of our Plan can get their prescription drug benefits. We call them “network pharmacies” because they contract with our Plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.
NON-PLAN PROVIDER OR NON-PLAN FACILITY - A provider or facility with which we have not arranged to coordinate or provide covered services to members of our Plan. Non-plan providers are providers that are not employed, owned, or operated by our Plan or are not under contract to deliver covered services to you. As explained in this booklet, most services you get from non-plan providers are not covered by our Plan or Original Medicare.
ORGANIZATION DETERMINATION - The MA organization has made an organization determination when it, or one of its providers, makes a decision about MA services or payment that you believe you should receive.
ORIGINAL MEDICARE - Some people call it “traditional Medicare” or “fee-for-service” Medicare. The Original Medicare Plan is the way many people get their health care coverage. It is the national pay-per-visit program that lets you go to any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States.
OUT-OF-NETWORK PHARMACY - A pharmacy that doesn’t have a contract with our Plan to coordinate or provide covered drugs to members of our Plan. As explained in this Evidence of Coverage, most services you get from non-network pharmacies are not covered by our Plan unless certain conditions apply.
PART D - The voluntary Prescription Drug Benefit Program. (For ease of reference, we will refer to the new prescription drug benefit program as Part D.)
PART D DRUGS - Drugs that Congress permitted our Plan to offer as part of a standard Medicare prescription drug benefit. We may or may not offer all Part D drugs, see your formulary for a specific list of covered drugs. Certain categories of drugs, such as benzodiazepines and barbiturates, and over-the-counter drugs were specifically excluded by Congress from the standard prescription drug package. These drugs are not considered Part D drugs.
PLAN PROVIDER - “Provider” is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. We call them “plan providers” when they have an agreement with our Plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our Plan. Our Plan pays plan providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services.
PRIMARY CARE PROVIDER (PCP) - A health care professional you select to coordinate your health care. Your PCP is responsible for providing or authorizing covered services while you are a plan member.
PREFERRED PROVIDER ORGANIZATION PLAN - A Preferred Provider Organization plan is an MA plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they are received from network or non-network providers. Member cost-sharing may be higher when plan benefits are received from non-network providers.
PRIOR AUTHORIZATION - Approval in advance to get services. In an HMO with a referral model and in the network portion of a PPO, some in-network services are covered only if your doctor or other plan provider gets “prior authorization” from our Plan. In a PPO and PFFS plan you do not need prior authorization to obtain out-of-network services. However, you may want to check with your plan before obtaining services out-of-network to confirm that the service is covered by your plan and what your cost share responsibility is. If your plan offers Part D drugs, certain drugs may require prior authorization. Check with your plan.
QUALITY IMPROVEMENT ORGANIZATION (QIO) - Groups of practicing doctors and other health care experts that are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by Medicare Providers.
QUANTITY LIMITS - A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.
REHABILITATION SERVICES - These services include physical therapy, cardiac rehabilitation, speech and language therapy, and occupational therapy that are provided under the direction of a plan provider.
SERVICE AREA - “Service area” is the geographic area approved by the Centers for Medicare & Medicaid Services (CMS) within which an eligible individual may enroll in a Medicare Health Plan.
STEP THERAPY - A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.
SUPPLEMENTAL SECURITY INCOME (SSI) - A monthly benefit paid by the Social Security Administration to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits.
URGENTLY NEEDED CARE - Urgently needed care refers to a non-emergency situation where you are inside the United States, you are temporarily absent from the Plan’s authorized service area, you need medical attention right away for an unforeseen illness, injury, or condition, and it isn’t reasonable given the situation for you to obtain medical care through the Plan’s participating provider network. Under unusual and extraordinary circumstances, care may be considered urgently needed when the member is in the service area, but the provider network of the Plan is temporarily unavailable or inaccessible.