Enter your ZIP code to learn about the CarePlus Medicare Advantage plans in your area.
The amount of money a physician or supplier charges for a specific medical service or supply. Since Medicare and insurance companies usually negotiate lower rates for members, the actual charge is often greater than the "approved amount" that you and Medicare actually pay.
AEP begins on October 15 and ends on December 7 of every year. During AEP, Medicare beneficiaries can enroll, disenroll, or change their Medicare Advantage (MA) plan, Prescription Drug plan (PDP) or also return to Original Medicare. Elections made during AEP are effective on January 1 of the following year.
The Centers for Medicare & Medicaid Services (CMS) mandates notification of yearly plan benefit changes be sent to enrolled members. This notification is mailed to enrolled members each year before the Annual Election Period begins. This notice is mailed with the Evidence of Coverage (EOC) and it explains any changes in plan benefits, services and costs for the next calendar year. It also provides instructions and important deadlines for changing plans as well as other helpful information.
A person who is eligible to have health insurance through the Medicare or Medicaid program.
The time during which you are admitted and treated at a hospital or Skilled Nursing Facility (SNF). The benefit period begins the day you go to the facility and ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
The care, items, and services covered by an insurance plan.
A very serious and costly health condition that could be life-threatening or cause life-long disability. The cost of medical services for this type of condition could cause you financial hardship if you are not properly insured.
The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards.
The percentage of billed charges that you may have to pay after you pay any plan deductibles. The coinsurance payment is a percentage of the cost of the service. For instance, your health plan might pay 70 percent of billed charges; this means, your coinsurance payment is the remaining 30 percent.
The flat amount you pay to a healthcare provider or pharmacy at the time of service. Copayments vary depending on your plan and the services you receive. Copayments do not reduce your annual deductible.
The total amount you must pay for health care before your health plan begins to pay.
Dual-eligible beneficiaries (Medicare dual eligibles or "duals") refers to those qualifying for both Medicare and Medicaid benefits.
The date your coverage begins.
Covered services that are 1) administered by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.
Permanent kidney failure requiring dialysis or a kidney transplant.
A document that details and explains a health plan’s benefits and services. Medicare Advantage and Prescription Drug plans are required to issue EOCs to new members upon enrollment and renewing members yearly.
Services or items not covered under your benefit plan.
A list of prescription medications that are approved for coverage by a health plan, also known as Prescription Drug Guides.
An individual who does not meet the income or resource criteria for QMB or SLMB, but is eligible for Medicaid either categorically or through optional coverage groups based on Medically Needy status, special income levels for institutionalized individuals, or home and community-based waivers. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable. Medicaid payment of the Medicare Part A or Medicare Part B premiums may be a Medicaid benefit available to FBDE beneficiaries in certain states.
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.
A Medicare Advantage plan in which you select a primary care physician (PCP) who is in the plan’s network and acts as a “gatekeeper” to direct access to medical services. Your PCP refers you to a specialist in the network when necessary.
This period begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B. The ICEP is the period during which an individual newly eligible for Medicare Advantage (MA) may make an initial enrollment request to enroll in an MA plan.
A healthcare provider – such as a physician, hospital, other medical facility, and/or pharmacy – that is contracted with the health plan to provide services at a set rate. Providers on the plan’s network listings are also called participating providers.
A specific time period or number of visits a health plan covers, or items or services a health plan doesn't cover in some circumstances.
Individuals 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 or choose to switch to a plan with a Plan Performance Rating of 5 stars during the year in which that plan has the 5-star overall rating, provided the individual meets the other requirements to enroll in the plan (e.g., living within the plan’s service area as well as requirements regarding end-stage renal disease).
The maximum dollar amount you would be required to pay out of your own pocket for health services during a specified period of time.
The maximum dollar amount that a plan will insure per plan year. Medicare plans have a Maximum Plan Benefit Coverage limit applicable to service categories for which the plan offers enhanced benefits.
A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.
The federal health insurance program available to people 65 years of age or older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD) – permanent kidney failure requiring dialysis or a transplant.
From January 1 – February 14, Medicare Advantage plan members can disenroll from their Medicare Advantage plan and return to Original Medicare and enroll in a stand-alone Prescription Drug Plan. The MADP period does not provide an opportunity to join or switch Medicare Advantage plans.
Medicare Advantage is a health insurance program offered by private insurance companies of managed health care (preferred provider organization (PPO) or health maintenance organization (HMO)) that serves as a substitute for "Original Medicare" Parts A and B Medicare benefits. Medicare Advantage Organizations can offer one or more Medicare Advantage plans. CarePlus is a Medicare Advantage Organization.
The payment amount that Medicare pays to a physician or supplier for a service or supply. It may be less than the actual amount charged by a physician or supplier. If a provider does not accept Medicare’s approved payment amount as full payment and you are not enrolled in a Medicare Advantage plan or do not follow the plan’s payment rules, you may have to pay the difference between what Medicare allows or the plan pays and what the provider charges.
Medicare Part A helps provide coverage for inpatient hospital, hospice and skilled nursing services, excluding those of physicians and surgeons.
Part B helps provide coverage for physicians and surgeons services, as well as for medically necessary outpatient hospital services (such as ER, laboratory, X-rays and diagnostic tests) and certain durable medical equipment and supplies.
Health benefits coverage offered by a Medicare Advantage Organization. You receive a specific set of health benefits at a set premium and predetermined cost-sharing level. Part C is available to all Medicare beneficiaries residing in a plan's service area.
Coverage to help with the costs of prescription drugs offered through private insurance companies. You can get Part D coverage through a Medicare-approved Stand-alone Prescription Drug plan or a Medicare Advantage HMO, PPO, or PFFS plan that includes drug coverage.
These are state programs that assist individuals with limited income paying with their Medicare costs. The names of these programs may vary by state. The state can help individuals paying for Medicare premiums. In some cases, Medicare Savings Programs may also pay Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) deductibles, coinsurance, and copayments if certain conditions are met.
A Medicare Supplement insurance policy or Medigap plan is health insurance sold by private insurance companies to help fill gaps in Medicare Parts A and B coverage. Medicare Supplement policies can help pay your share (like coinsurance, copayments, or deductibles) of the costs of Medicare-covered services. Some Medicare Supplement policies also cover certain benefits Medicare doesn’t cover like emergency foreign travel expenses. These policies don’t cover your share of the costs under other types of health coverage, including Medicare Advantage Plans, stand-alone Medicare Prescription Drug Plans, employer/union group health coverage, Medicaid, Department of Veterans Affairs (VA) benefits, or TRICARE. Insurance companies generally can’t sell you a Medicare Supplement policy if you have coverage through Medicaid or a Medicare Advantage Plan.
A group of healthcare providers, including pharmacies, who have contracts with a health plan to provide care to the plan's members. Your network choices may vary, depending on your benefit plan and where you live. The provider network may change at any time. You will receive notice when necessary.
Drugs not included on a plan-approved list.
Healthcare insurance provided through the federal government. It is sometimes called "traditional” Medicare or "fee-for-service" Medicare. It provides Medicare eligible individuals with coverage for and access to physicians, hospitals, or other health care providers who accept Medicare. You are responsible for the annual deductible. Medicare pays its share of the Medicare-approved amount, and you pay your member cost-share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). The Centers for Medicare & Medicaid Services (CMS) is the federal agency that runs Medicare.
Generally, out-of-network benefits give you the option to use a physician, specialist, or hospital that is not a part of the plan's contracted network. In some cases, your out-of-pocket costs may be higher for out-of-network benefits, or not covered at all.
Healthcare costs that you must pay on your own because they are not covered by Medicare or other insurance.
Medical or surgical care that does not include an overnight hospital stay.
A healthcare professional that is trained to give you basic care. Your PCP is responsible for providing, authorizing, and coordinating covered services while you are a plan member.
A person or facility that offers healthcare services. Examples include: a physician, hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, End-Stage Renal Disease facility, hospice, non-physician provider, laboratory, supplier, pharmacies, etc. A provider is licensed or certified and practices within the scope of his or her license or certification.
These individuals are entitled to Medicare Part A, have income of 100% Federal Poverty Level (FPL) or less and resources that do not exceed three times the limit for Supplemental Security Income (SSI) eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles, copayments and coinsurance for Medicare services provided by Medicare providers. These beneficiaries do not qualify for any additional Medicaid benefits. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.
These individuals are entitled to Medicare Part A, have income of 100% Federal Poverty Level (FPL) or less and resources that do not exceed three times the limit for Supplemental Security Income (SSI) eligibility, and are not otherwise eligible for full Medicaid, are entitled to all benefits available to the QMB, as well as all benefits available under the state Medicaid plan. They often qualify for full Medicaid benefits by meeting the Medically Necessary standards, or through spending down excess income to the Medically Needy level. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.
An individual entitled to Medicare Part A, with an income at least 120% Federal Poverty Level (FPL) but less than 135% FPL, and resources that do not exceed three times the Supplemental Security Income (SSI) limit, and who is not otherwise eligible for Medicaid benefits. This individual is eligible for Medicaid payment of the Medicare Part B premium. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.
Qualified Disabled and Working Individuals (QDWIs)
QDWI is a less common Medicare Savings Program (MSP) administered by each state's Medicaid program. It pays the Medicare Part A premium for individuals who are under 65, have a disabling impairment, continue to work, and are not otherwise eligible for Medicaid
A written request from your primary care physician for you to see a specialist or to receive certain services.
The specific county/ZIP code/state that a member actually resides. The service area is where you must live for a plan to accept you as its member. If a member moves out of the plan coverage service area, he or she needs to contact the plan using the number listed on the back of their CarePlus member ID card to find out if the service area is affected.
A period, outside of the ICEP, AEP or MADP, when an individual may elect a plan or change his or her current plan election. Some examples of special election situations are:
Other exceptional conditions may exist, as determined by CMS. These are only examples.
These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for Supplemental Security Income (SSI) eligibility, and are not otherwise eligible for Medicaid. Eligible for payment of Medicare Part B premiums only. These beneficiaries do not qualify for any additional Medicaid benefits. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.
These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for Supplemental Security Income (SSI) eligibility, and are eligible for full Medicaid benefits, entitled to all benefits available to an SLMB, as well as all benefits available under the state Medicaid plan. Medicaid does not pay towards out-of pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.
A brief description or outline of your coverage, including the amounts or percentage you pay for certain services, the amounts or percentage your plan pays, and the services for which coverage is limited or excluded.
Care you receive for a sudden illness or injury that needs medical attention right away, but is not life-threatening. The care should generally be provided by your primary care physician or an Urgent Care Center, unless you are out of the service area.