Glossary of Terms
Appeal – A type of complaint you make when you want us to reconsider
and change a decision we have made about what services are covered for you or what
we will pay for a service.
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Benefit Period – For both Central Health Medicare Plan and Original
Medicare, 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 skilled nursing facility. The benefit period
ends when you have not been at a skilled nursing facility for 60 days in
a row. If you go to the skilled nursing facility 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 receive during the stay determines whether
you are considered to be an inpatient for skilled nursing facility stays, but not
for hospital stays.
You are an inpatient in a skilled nursing facility only if your care in the skilled
nursing facility meets certain skilled level of care standards. Specifically, in
order to have been an inpatient while in a skilled nursing facility, you must need
daily skilled nursing or skilled rehabilitation care, or both.
Generally, you are an inpatient of a hospital if you are receiving inpatient services
in the hospital (the type of care you actually receive in the hospital does not
determine whether you are considered to be an inpatient in the hospital).
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 not available until after the patent on the brand name drug
has expired.
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Centers for Medicare & Medicaid Services (CMS) – The federal
agency that runs the Medicare program.
Coverage Determination - The plan sponsor has made a coverage determination
when it makes a decision about the prescription drug benefits you can receive under
the plan, and the amount that you must pay for a drug.
Covered Services – The general term we use in this booklet to mean
all of the health care services and supplies that are covered by Central Health
Medicare Plan. Covered services are listed in the Evidence of Coverage.
Creditable Coverage – Coverage that is at least as good as the
standard Medicare prescription drug coverage.
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Disenroll or Disenrollment – The process of ending your membership
in Central Health Medicare Plan. Disenrollment can be voluntary (your own choice)
or involuntary (not your own choice).
Durable Medical Equipment (DME) – 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 include wheelchairs, hospital beds,
or equipment that supplies a person with oxygen.
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Emergency Care – Covered services that are 1) furnished 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
– This document along with your enrollment form which explains your covered services,
defines our obligations, and explains your rights and responsibilities as a member
of the Central Health Medicare Plan.
Exception – A type of coverage determination that, if approved,
allows you to obtain a drug that is not on our formulary (a formulary exception),
or receive a non-preferred drug at the preferred cost-sharing level (a tiering exception).
You may also request an exception if we require 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).
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Formulary – A list of covered drugs provided by the plan.
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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 does not involve payment or coverage disputes.
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Inpatient Care – Health care that you get when you are admitted
to a hospital.
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Late Enrollment Penalty – An amount added to your monthly premium
for Medicare drug coverage if you don’t join a plan when you’re first able. You
pay this higher amount as long as you have Medicare. There are some exceptions.
If you do not have creditable prescription drug coverage, you will have to pay a
penalty in addition to your monthly plan premium.
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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 the convenience
of you or your doctor.
Medicare – The federal health insurance program for people 65 years
of age or older, some people under age 65 with disabilities, and people with End-Stage
Renal Disease (generally those with permanent kidney failure who need dialysis or
a kidney transplant).
Medicare Advantage Organization – A public or private organization
licensed by the State as a risk-bearing entity that is under contract with the
Centers for Medicare & Medicaid
Services (CMS) to provide covered services. Medicare Advantage
Organizations can offer one or more Medicare Advantage Plans. Central Health Medicare
Plan is a Medicare Advantage Organization.
Medicare Advantage Plan – A benefit package offered by a Medicare
Advantage Organization that offers a specific set of health benefits at a uniform
premium and uniform level of cost-sharing to all people with Medicare who live in
the service area covered by the Plan. A Medicare Advantage Organization may offer
more than one plan in the same service area. Central Health Medicare Plan is a Medicare
Advantage Plan.
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 – Many people
who get their Medicare through Original Medicare buy “Medigap” or Medicare supplement
insurance policies to fill “gaps” in Original Medicare coverage.
Member (member of Central Health Medicare Plan, or “plan member”) – A person with
Medicare who is eligible to get covered services, who has enrolled in Central Health
Medicare Plan, and whose enrollment has been confirmed by the Centers
for Medicare & Medicaid Services
(CMS).
Member Services – A department within Central Health Medicare Plan
responsible
for answering your questions about your membership, benefits, grievances, and appeals.
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Network Pharmacy – A network pharmacy is a pharmacy where members
of our Plan can receive covered 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-Preferred Network Pharmacy – A network pharmacy that offers
covered drugs to members of our Plan at higher cost-sharing levels than apply at
a preferred network pharmacy.
Non-plan provider or non-plan facility – A provider or facility
that we have not arranged with to coordinate or provide covered services to members
of Central Health Medicare Plan. Non-plan providers are providers that are not employed,
owned, or operated by Central Health Medicare Plan and are not under contract to
deliver covered services to you. As explained in this booklet, you may pay more
if you see non-plan providers unless it is for an emergency.
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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. Original Medicare is the way most people get their
Medicare Part A and Part B health care. It is the national pay-per-visit program
that lets you go to any doctor, hospital, or other health care provider who 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 we have not arranged
with 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.
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Part D – The voluntary Prescription Drug Benefit Program.
Part D Drugs – Any drug that can be covered under a Medicare Prescription
Drug Plan. Generally, any drug not specifically excluded under Medicare drug coverage
is considered a Part D Drug.
Preferred Network Pharmacy – A network pharmacy that offers covered
drugs to members of our Plan at lower cost-sharing levels than apply at another
network pharmacy.
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 Central Health
Medicare Plan to accept our payment as payment in full, and in some cases to coordinate
as well as provide covered services to members of Central Health Medicare Plan.
Central Health Medicare Plan pays plan providers based on the agreements it has
with the providers.
Primary Care Physician (PCP) – A health
care professional who is trained to give you basic 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. Some
in-network services are covered only if your doctor or other plan provider gets
“prior authorization” from your IPA/Medical Group or Central Health Medicare Plan.
Covered services that need prior authorization are marked in the Benefits Chart.
Prior authorization is not required for out-of-network services. 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.
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Quality Improvement Organization (QIO) – Groups of practicing doctors
and other health care experts who 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 doctors in inpatient hospitals, hospital outpatient
departments, hospital emergency rooms, skilled nursing facilities, home health agencies,
Private fee-for-service plans and ambulatory surgical centers.
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Referral – Your PCP’s “or his/her medical group’s” or “IPA’s”
approval for you to see a certain plan specialist or to receive certain covered
services from plan providers.
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.
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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 particular plan offered by a Medicare health plan.
