Glossary of Terms

A

  • Ambulatory Surgical Center

    An entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the center does not exceed 24 hours.

  • Annual Enrollment Period

    A set time each fall when members can change their health or drugs plans or switch to Original Medicare. The Annual Enrollment Period is from October 15 until December 7.

  • Annual Health Assessment (AHA)

    An annual visit in which the primary care physician makes a complete assessment of each patient in order to identify specific clinical conditions and provide for proper management. This evaluation must occur at least once a year. Your physician can provide more information about this face to face intervention and offer more details about the programs and services that you need to better manage your health condition.

  • Appeal

    Something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving. For example, you may ask for an appeal if we don’t pay for a drug, item, or service you think you should be able to receive. Your Evidence of Coverage explains appeals, including the process involved in making an appeal.

  • Appointment of Representative

    A document whereby a member appoints an individual to act as his/her representative in connection with a claim or asserted right under Title XVIII of the Social Security Act (the "Act") and related provisions of Title XI of the Act. The document authorizes this individual to make any request; to present or to elicit evidence; to obtain appeals/grievance information; and to receive any notice in connection with his/her appeal/grievance, wholly instead of him/her. It also authorizes the representative to file and receive any information related to Medical and Prescription Drug Services.

B

  • 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.

C

  • Catastrophic Coverage Stage

    The stage in the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,950 in covered drugs during the covered year.

  • Centers for Medicare & Medicaid Services (CMS)

    The Federal agency that runs Medicare. You can contact Medicare offices through 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call at 1-877-486-2048.

  • Coinsurance

    An amount you may be required to pay as your share of the cost for services or prescription drugs. Coinsurance is usually a percentage.

  • Complaint

    The formal name for “making a complaint” is “filing a grievance.” The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. See also “Grievance,” in this list of definitions.

  • Comprehensive Outpatient Rehabilitation Facility (CORF)

    A facility that mainly provides rehabilitation services after an illness or injury, including physical, respiratory and occupational therapy, social or psychological services, speech-language pathology services and home environment evaluation services.

  • Copayment

    An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is usually a set amount, rather than a percentage.

  • Cost sharing

    Amounts that a member has to pay when services or drugs are received. Cost sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed “copayment” amount that a plan requires when a specific service or drug is received; or (3) any “coinsurance” amount, a percentage of the total amount paid for a service or drug, that a plan requires when a specific service or drug is received. A “daily cost sharing rate” may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copay.

  • Coverage Determination

    A decision about whether a medical service or drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the service or 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 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 Prescription Drug Coverage

    Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

  • Custodial Care

    A type of personal care provided in a nursing home, hospice, or other facility setting when you do not need skilled medical care or skilled nursing care. Custodial care is personal care that can be provided by people who don’t have professional skills or training, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. Medicare doesn’t pay for custodial care.

D

  • Daily Cost-Sharing Rate

    It may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copay. It’s the copay divided by the number of days in a month’s supply. Here is an example: If your copay for a one-month supply of a drug is $30, and a one-month’s supply in your plan is 30 days, then your “daily cost-sharing rate” is $1 per day. This means you pay $1 for each day’s supply when you fill your prescription.

  • Deductible

    The amount you must pay before our plan begins to pay its share of your covered medical services or drugs.

  • Disenroll or Disenrollment

    The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).

  • Dual Eligible

    When a person qualifies for both Medicare and Medicaid.

  • Durable Medical Equipment

    Certain medical equipment that is ordered by your doctor for use in the home. Examples are walkers, wheelchairs and hospital beds.

E

  • Emergency

    A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

  • Emergency Care

    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.

  • Evidence of Coverage (EOC) and Disclosure Information

    A legal document in the form of a manual that, along with your enrollment form, explains your coverage, what we must do, 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, or get a non-preferred drug at the preferred cost-sharing level. 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.

  • Extra Help

    A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.

G

  • Generic Drug

    A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a “generic” drug works the same as a brand name drug and usually costs less.

  • Grievance

    A type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. Read your Evidence of Coverage for more information about grievances.

H

  • Home Health Aide

    A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

  • Hospice

    An enrollee who has 6 months or less to live has the right to elect hospice. We, your plan, must provide you with a list of hospices in your geographic area. If you elect hospice and continue to pay premiums you are still a member of our plan. You can still obtain all medically necessary services as well as the supplemental benefits we offer. The hospice will provide special treatment for your state.

  • Hospital Inpatient Stay

    A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an “outpatient."

I

  • Initial Coverage Limit

    The maximum limit of coverage under the Initial Coverage Stage.

  • Initial Enrollment Period (IEP)

    When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you’re eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

  • Inpatient Care

    Healthcare that you get when you are admitted to a hospital.

  • Institutional Equivalent Special Needs Plan (SNP)

    An institutional Special Needs Plan that enrolls eligible individuals living in the community but requiring an institutional level of care based on the State assessment. The assessment must be performed using the same respective state level of care assessment tool and administered by an entity other than the organization offering the plan. This type of Special Needs Plan may restrict enrollment to individuals that reside in a contracted assisted living facility (ALF) if necessary to ensure uniform delivery of specialized care.

L

  • Late Enrollment Penalty

    An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that expects to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. If this is your case, you pay this higher amount as long as you have a Medicare drug plan. There are some exceptions.

  • List of Covered Drugs (Formulary or “Drug List”)

    A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.

  • Lock-In Period

    People with a Medicare Advantage plan are “locked-in,” meaning they can only switch Medicare plans during certain times of the year unless they qualify for special circumstances.

M

  • 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).

  • Member Services

    A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals. To contact Member Services, please call: 787-620-2397 (Metro Area), 1-866-333-5470 (toll free) or 1-866-333-5469 TTY (hearing impaired), Monday through Sunday from 8:00 a.m. to 8:00 p.m.

  • Medicaid

    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 health care costs are covered if you qualify for both Medicare and Medicaid.

  • Medically Accepted Indication

    A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. Read Chapter 5, Section 3 of your Evidence of Coverage for more information about a medically accepted indication.

  • Medically Necessary

    Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.

  • 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 End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare or a Medicare Advantage Plan.

  • Medicare Advantage (MA) Plan

    Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

  • Medicare Covered Services

    Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.

  • Medicare Coverage Gap Discount Program

    A program that provides discounts on most covered Part D brand name drugs to Part D enrollees who have reached the Coverage Gap Stage and who are not already receiving “Extra Help.” Discounts are based on agreements between the Federal Government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted.

  • Medicare Advantage Disenrollment Period (MADP)

    January 1 - February 14. A beneficiary can cancel his/her Medicare Advantage enrollment and switch to Original Medicare. If the beneficiary chooses to switch to Original Medicare, he/she may also choose a separate Medicare prescription drug plan at the same time. NOTE: During this period, you can no longer switch to another Medicare Advantage plan. 

  • Medicare Prescription Drug Coverage (Medicare Part D)

    Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.

  • Medigap (Medicare Supplement Insurance) Policy

    Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original Medicare. A Medicare Advantage plan is not a Medigap policy.

N

  • Network Pharmacy

    Is a pharmacy where members of our plan can get their prescription drugs. We call them “network pharmacies” because they contract with our plan.

  • Network Provider

    A “provider” is the term we use to name physicians, other healthcare professionals, hospitals and other healthcare facilities that are authorized or certified by Medicare and the State to provide health-related services. “Network” providers have an agreement with our plan, accept our payment as total payment, and in some cases, coordinate or provide covered services to our Members. Our plan will pay to providers in base of agreements, if they accept to provide services covered by the plan.

O

  • Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare)

    Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by Congress. You can see 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.

  • Organization Determination

    The Medicare Advantage plan has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. The Medicare Advantage plan’s network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service.

  • 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 drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.

  • Out-of-network Provider or Out-of-network Facility

    A provider or facility with which we have not arranged to coordinate or provide covered services to members of our plan. Out-of-network providers are providers that are not employed, owned, or operated by our plan or are not under contract to deliver covered services to you. Using out-of-network providers or facilities is explained in your EOC.

  • Out-of-pocket Costs

    A member’s cost-sharing requirement to pay for a portion of services or drugs received.

P

  • Part C

    A Medicare Advantage plan. Look for “Medicare Advantage Plan” under letter “M”.

  • Part D

    The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)

  • Part D Drugs

    Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.

  • Preauthorization

    Approval in advance to get services or certain drugs that may or may not be on our formulary. Some in-network medical services are covered only if your doctor or other network provider gets “prior authorization” from our plan. Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4. Some drugs are covered only if your doctor or other network provider gets “prior authorization” from us. Covered drugs that need prior authorization are marked in the formulary.

  • Preferred Provider Organization Plan (PPO)

    A Preferred Provider Organization plan is a Medicare Advantage 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 out-of-network providers. Member cost sharing will generally be higher when plan benefits are received from out-of-network providers. PPO plans have an annual limit on your out-of-pocket costs for services received from network (preferred) providers and a higher limit on your total combined out-of-pocket costs for services from both in-network (preferred) and out-of-network (non-preferred) providers.

  • Premium

    Your primary care provider is the doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare health plans, you must see your primary care provider before you see any other health care provider.

  • Primary Care Physician (PCP)

    Your primary care provider is the doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare health plans, you must see your primary care provider before you see any other health care provider.

  • PHI Authorization

    Is a form or the registry of a verbal authorization to disclose Protected Health Information to an individual. Examples of this information include name, medical condition, prescribed medications, date of birth, and any other information that allows a person to be identified.

Q

  • Quality Improvement Organization (QIO)

    A group of practicing doctors and other health care experts paid by the Federal Government to check and improve the care given to Medicare patients. Your Evidence of Coverage includes information about how to contact the QIO for your state.

  • Quantity Limits

    An administrative 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.

R

  • Rehabilitation Services

    These services include physical, speech, language and occupational therapy.

S

  • Service Area

    A geographic area where a health plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you permanently move out of the plan’s service area.

  • Skilled Nursing Facility Care (SNF)

    Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

  • Special Enrollment Period

    A set time when members can change their health or drugs plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting “Extra Help” with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you.

  • Special Needs Plan

    A special type of Medicare Advantage Plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.

  • 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 Social Security 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.

U-Z

  • Urgently Needed Care

    Is care provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed care may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.