Glossary of Medicare and Medicare Advantage Terms

Medicare Advantage Terms and What they Mean

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Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care if they are furnished to a member whose medical condition is such that other means of transportation are contraindicated (could endanger the person’s health) or if authorized by the plan.

A facility, typically a building that is not attached to a hospital, where simpler surgeries are performed for patients who aren't expected to need more than 24 hours of care.

The amount you must pay for your healthcare or prescription drugs before Original Medicare, your prescription drug plan, your Medicare Advantage plan, or your other insurance begins to pay.

Medicare sets aside this period for enrollment in Medicare Advantage (MA) and Medicare Prescription Drug Plans (PDP). From October 15th to December 7th you have the opportunity to enroll in an MA or PDP plan, switch from your current plan or return to Original Medicare for coverage effective on January 1 of the following year.

Screening for glaucoma once a year for people who are at high risk of glaucoma, such as people with a family history of glaucoma, people with diabetes, and African-Americans who are age 50 and older.

Diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.

The amount you pay every year for your Medicare Advantage plan.

An appeal is something you do if you disagree with a decision to deny a request for healthcare services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn't pay for a drug, item, or service you think you should be able to receive.

The process of obtaining approval from the health plan or health insurance company to ensure that it will pay for the services you want or need to receive.

A way to pay your monthly premium by allowing your plan to automatically withdraw money from your bank account. If you decide to switch to Automatic Bank Withdraw or move from Automatic Bank Withdraw to a monthly premium bill, it could take up to three months for it to take effect and you are responsible for paying those premiums during that time.

The third phase of Medicare Part D coverage that, depending on the plan, is where you pay a low copayment or coinsurance for your drugs.

The federal agency that runs the Medicare program.

A formal request to the health plan asking for payment for services you received.

A percentage of the cost you pay when your plan does not cover 100% of the cost. For example, a plan may cover 80% of the cost of your medicine or your hospital visit; the other 20% is your coinsurance.

Coverage as follows when provided by a general dentist (i.e. not an oral surgeon): Periodontal scaling and root planning, Full mouth debridement, Surgical removal of erupted tooth requiring removal of bone and/or section of tooth, Anterior resin-based composite, Posterior resin-based composite. See the plan Evidence of Coverage for further details.

A dollar amount or percentage that you pay when your plan does not cover 100% of the cost of your medicines or your medical care. For example, if you pay a certain pre-determined amount for a medicine, or for a visit to the doctor, that amount is your copay.

The second stage of Medicare Prescription Drug Coverage (following the Initial Coverage stage). For more information, please visit the Medicare Coverage Gap page.

Prescription drug coverage that is at least as good as Medicare Prescription Drug Coverage. If you go without Creditable Prescription Drug Coverage for a period of <63> consecutive days or longer you may have to pay a Late Enrollment Penalty.

A dollar amount that you may be required to pay out-of-pocket before your plan begins to provide coverage for healthcare costs that are covered by the plan.

Diabetes supplies can include: Blood sugar (glucose) test strips, Blood sugar testing monitors, Lancet devices and lancets. See the plan Evidence of Coverage for further details.

A medical test that does not require the use of imaging to diagnose the body. Examples include: urine collection, diagnostic colonoscopy, and cardiac stress test

A request to end your healthcare coverage with a health plan.

Medically necessary healthcare equipment prescribed by a healthcare provider to be used by a member in the home, such as hospital beds and wheelchairs. Durable medical equipment includes items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a provider for use in the home.

Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical condition.

Permanent kidney failure requiring kidney dialysis or a transplant.

A document you receive each year from your health plan that gives you information about what benefits the plan will cover, how much you pay, and more.

A type of coverage decision that, if approved, allows you to get a drug that is not on the Medicare Advantage Prescription Drug plans 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 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).

A statement you receive for each month you use your Medicare Advantage or Medicare Advantage Prescription Drug Plan benefits. This statement is from your plan and provides complete information about the health or prescription drug services you've received, payments made, and any costs you are responsible for paying. It is important to remember that the EOB is not a bill. This information is only provided for your convenience.

The program run by the Social Security Administration that helps with the costs of Medicare Prescription Drug Coverage (Part D). If you qualify, Social Security will enroll you in the program. The amount of assistance you receive will depend on your financial situation and income.

A list of generic and brand-name prescription drugs that are covered by a Medicare Advantage Prescription Drug plan.

The second phase of Medicare Part D coverage that, depending on the plan, starts after the initial coverage stage.

Generic drugs have 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.

A formal complaint about how a Medicare Advantage or Medicare Prescription Drug plan is providing your care. If you want to request coverage for a prescription drug or service, you should request a coverage determination instead of filing a grievance.

HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. HIPAA does the following:

  • Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs;
  • Reduces healthcare fraud and abuse;
  • Mandates industry-wide standards for healthcare information on electronic billing and other processes; and
  • Requires the protection and confidential handling of protected health information.

Sometimes called "managed care organizations," HMOs contract with doctors and hospitals who agree to accept their payments. In an HMO, you typically receive your care from the doctors, hospitals, and other providers who contract with the HMO.

Diagnostic hearing and balance evaluations performed by your PCP to determine if you need medical treatment

Diagnostic hearing and balance evaluations performed by a specialist, such as an audiologist, to determine if you need medical treatment

Health care services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.

The first phase of Medicare Part D coverage that, depending on the plan, starts after you meet your yearly deductible for Part D.

The Initial Coverage Election Period (ICEP) is the period during which an individual newly eligible for a Medicare Advantage (MA) plan may make an initial enrollment request to enroll in an MA plan. This period begins three months immediately before the individual's first entitlement to both Medicare Part A and Part B and ends on the later of:

1. The last day of the month preceding entitlement to both Part A and Part B, or;

2. The last day of the individual’s Part B initial enrollment period.

The initial enrollment period for Part B is the seven (7) month period that begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends 3 months after the month of eligibility.

Once an ICEP enrollment request is made and enrollment takes effect, the ICEP election has been used.

The first phase of Medicare Part D coverage that, depending on the plan, starts after you meet your deductible.

The period in which you are first eligible to enroll in a Medicare Prescription Drug plan (Part D). For most people, the Initial Enrollment Period begins three months before the month of your 65th birthday, during your birthday month, and up to three months after.

Treatment you get in an acute care hospital, critical access hospital, inpatient rehabilitation facility, long-term care hospital, inpatient care as part of a qualifying research study, and mental health care when you have been admitted as a patient.

Medical procedures that involve testing samples of blood, urine, tissue, or any substance of the body.

The amount added to your monthly premium for Medicare Part B or Medicare Part D coverage if you did not enroll when you were first eligible and did not have other coverage.

Primary Care Physicians are grouped together with Specialty Care Physicians by both geographical location and practice referral patterns. These physician groups are individually referred to as a "Local Physician Organization" or "LPO".

Mail-order service provides up to <90>-day refills for many of your regular, maintenance prescription drugs for a low copay through the mail. Standard shipping is free.

Because you are enrolled in a Medicare Advantage Plan, there is a limit to how much you have to pay out-of-pocket each year for in-network medical services that are covered under Medicare Part A and Part B. The amounts you pay for in-network covered services count toward this maximum out-of-pocket amount. (The amounts you pay for your Part D prescription drugs do not count toward your maximum out-of-pocket amount.) In addition, amounts you pay for some services do not count toward your maximum out-of-pocket amount. If you reach the maximum out-of-pocket amount you will not have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services. However, you must continue to pay the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). See the plan Evidence of Coverage for further details.

A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.

Medicare is a Federal health insurance program for people age 65 or older, under age 65 with certain disabilities, and any age with permanent kidney failure (called End-Stage Renal Disease).

Medicare Advantage Plans are health plan options offered by private insurance companies that are approved by Medicare. If you join one of these plans, you generally get all of your Medicare-covered healthcare through that plan. Medicare Advantage Plans (called MA Plans) combine Part A (hospital insurance) and Part B (medical insurance) together in one plan, and they can also be combined with Part D prescription drug coverage (called MA-PD Plans).

From January 1 through February 14, you may disenroll from a Medicare Advantage plan and return to Original Medicare. Requests to disenroll will be effective on the first day of the month following your disenrollment request.

Provides coverage for inpatient hospital care, inpatient stays in most skilled nursing facilities, and hospice and home health services.

Provides coverage for doctor and clinical lab services, outpatient and preventive care, screenings, surgical fees and supplies, and physical and occupational therapy.

Medicare Advantage Plans are health plan options offered by private insurance companies that are approved by Medicare. If you join one of these plans, you generally get all of your Medicare-covered healthcare through that plan. Medicare Advantage Plans (called MA Plans) combine Part A (hospital insurance) and Part B (medical insurance) together in one plan, and they can also be combined with Part D prescription drug coverage (called MA-PD Plans).

Medicare Prescription Drug Coverage available through either a Medicare-approved stand-alone Prescription Drug Plan or as coverage added to a Medicare Advantage plan (also called MA-PD plans).

People with Medicare who have limited income and resources may get help paying for their out-of-pocket medical expenses from their state Medicaid program. There are various benefits available to "dual eligibles" who are entitled to Medicare and are eligible for some type of Medicaid benefit. These benefits are sometimes also called "Medicare Savings Programs."

Network PFFS plans are a type of Medicare Advantage plan that includes all Medicare Part A (hospital insurance) and Part B (medical insurance) benefits. These plans have a network of providers (that is, providers who have signed contracts with the plan) for all services covered under Original Medicare. These providers have already agreed to see members of the plan. If a provider is not one of the network providers, then the provider is not required to agree to accept the plan's terms and conditions of payment, and they may choose not to provide healthcare services to plan members, except in emergencies.

A doctor, hospital, or other healthcare provider that has agreed to be part of a plan's network. Members usually pay less for their care when they use a network provider, depending on the plan.

Doctors, hospitals, pharmacies, and other healthcare professionals or suppliers who do not belong to a health plan's provider network.

Costs that you may pay for healthcare because they are not covered by your Medicare plan or other insurance.

Medical or surgical care you get from a hospital when your doctor hasn't written an order to admit you to the hospital as an inpatient. Outpatient hospital care may include emergency department services, observation services, outpatient surgery, lab tests, or X-rays. Your care may be considered outpatient hospital care even if you spend the night at the hospital.

Medicines that do not require a prescription.

An HMO-POS is a Medicare Advantage HMO with a Point of Service (POS) option. This type of plan allows the plan member to seek care from providers in and out of the HMO network. The services for out-of-network coverage are typically at a higher copay/co-insurance.

Eyeglasses or contact lenses prescribed after cataract surgery. See the plan Evidence of Coverage for further information.

PPO plans are a type of Medicare Advantage plan that includes all Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) benefits. These plans are designed to reduce the cost of healthcare by contracting with certain doctors, labs, and hospitals to provide care at a discounted rate for members. A PPO plan has a list of physicians and other providers that members may go to (called a "network"). However, members have the flexibility to go to any doctors, specialists, or hospitals that are not on the plan's list for similar or different costs, depending on the plan. Some plan options include the same costs for in and out-of-network benefits.

The amount an individual must pay to Medicare or a health insurance plan for medical coverage and/or prescription drug coverage. It is generally paid on a monthly basis.

The amount you must pay for drugs before the plan begins to pay its share

A Medicare "Part D" Prescription Drug Plan (or PDP) can be a stand-alone plan (not joined with other insurance) or may be combined with a Medicare Advantage plan. A Medicare Advantage plan that includes prescription drug coverage is often referred to as an MA-PD plan.

Coverage for eye glasses (lenses and frames), eye glass lenses and eye glass frames not related to post cataract surgery

Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms).

Preventive Dental Services typically include: Oral exams, Cleanings (does not include periodontal scaling and root planning), Fluoride treatments, Dental X-rays.

A doctor that a member chooses who coordinates his/her healthcare with specialists and other providers. A PCP acts as the manager of your healthcare and can assist you in finding the right specialists when necessary. He or she is available to patients 24 hours a day, 7 days a week through regularly scheduled appointments or by other doctors providing "on-call" back up coverage. Most Health Maintenance Organization (HMO) plans require you to see your PCP before you see any other healthcare provider.

A plan requirement to get approval from the plan before you fill your prescriptions. If you don't get approval, the plan may not cover the drug.

A limit to the amount of a particular medication a Medicare Advantage Prescription Drug plan or Medicare Prescription Drug plan will cover in a period of time.

A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

Special Election Periods allow you to enroll into or change plans outside of Medicare's standard enrollment periods. For example, if you move out of your Medicare Advantage plan's service area, you have a Special Election Period to enroll in a plan that is available in your new location. If you move into, reside in, or move out of a nursing home you may also have a Special Election Period. If you have Medicare and Medicaid, you have a Special Election Period that allows you to change Part D drug plans at any time.

SNPs are types of Medicare Advantage Plans designed for people with certain chronic diseases and conditions or who have special needs (such as people with both Medicare and Medicaid, or people who live in certain institutions). SNPs provide members with all Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance) services, and Medicare prescription drug coverage (Part D).

A doctor who treats specific conditions or parts of the body.

The percentage of the cost you pay for specialty prescriptions, such as injectable drugs and biopharmaceuticals.

A Specialty tier drug is a very high cost or unique prescription drug which may require special handling and/or close monitoring. Specialty drugs typically treat complex, chronic conditions and are often injected.

A state program that provides assistance in paying for drug coverage, based on financial need, age, or medical condition and not based on current or former employment status. These programs are run and funded by the states.

An optional plan requirement to first try certain drugs for treatment of a medical condition before a different drug will be covered for that same condition. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you the plan will then cover Drug B.

This benefit was designed to assist those who are aged, blind, or disabled and who have little or no income, with monetary benefits for basic needs such as food, clothing and shelter.

A system that Medicare Advantage Prescription Drug plans use to classify prescription drugs.

Routine transportation services are covered for up to thirty (30) one-way trips per calendar year within the Plan’s Service Area. See the plan Evidence of Coverage for details.

A yearly calculation of what you have paid for Part D prescription drugs while on a Medicare Advantage Prescription Drug Plan, including any deductibles and copays. When your TrOOP costs reach a specific dollar amount you become eligible for catastrophic coverage, which allows you to get medicines at a lower cost.

Care that you get outside of your Medicare health plan's service area for a sudden illness or injury that needs medical care right away but isn’t life threatening. If it’s not safe to wait until you get home to get care from a plan doctor, the health plan must pay for the care.

Additional features available to you through your Medicare Advantage plan.

Exam to test your vision and provide a prescription, does not include exam for disease

Exam for disease of the eye only – to diagnose and treat conditions of the eye

A photographic or digital image of the internal composition of a part of the body produced by X-rays being passed through it and being absorbed to different degrees by different materials.

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