Medicare Advantage Plans

Healthcare Glossary:

Making Sense of Medicare Terms and Phrases

The glossary below will define some commonly used terms related to Medicare.


ACTUAL CHARGE

The amount of money a physician or supplier charges for a specific medical service or supply. Because 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.

ANNUAL ELECTION PERIOD (AEP)

AEP begins on October 15 and ends on December 7 of every year. During AEP, Medicare beneficiaries can enroll, disenroll, or change your 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.

ANNUAL NOTICE OF CHANGES (ANOC)

The Centers for Medicare & Medicaid Services (CMS) mandated notification of yearly plan benefit changes 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.

BENEFICIARY

A person who is eligible to have health insurance through the Medicare or Medicaid program.

BENEFIT PERIOD

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.

BENEFITS

The care, items, and services covered by an insurance plan.

CATASTROPHIC ILLNESS

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.

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

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.

COINSURANCE

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.

COPAYMENT

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.

DEDUCTIBLE

The total amount you must pay for health care before your health plan begins to pay.

DUAL ELIGIBLES

Individuals who are entitled to Medicare and also qualify for Medicaid.

EFFECTIVE DATE

The date your coverage begins.

EMERGENCY CARE

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.

END-STAGE RENAL DISEASE (ESRD)

Permanent kidney failure requiring dialysis or a kidney transplant.

EVIDENCE OF COVERAGE (EOC)

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.

EXCLUSIONS

Services or items not covered under your benefit plan.

FORMULARY

A list of prescription medications that are approved for coverage by a health plan, also known as Prescription Drug Guides.

FULL BENEFIT DUAL ELIGIBLE (FBDE OR MEDICAID ONLY)

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.

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.

HEALTH MAINTENANCE ORGANIZATION (HMO)

With an HMO, 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.

INITIAL COVERAGE ELECTION PERIOD (ICEP)

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 and individual newly eligibile for Medicare Advantage (MA) may make an initial enrollment request to enroll in an MA plan.

IN-NETWORK PROVIDER

A healthcare provider – such as a physician, hospital, other medical facility, and/or pharmacy – that have contracts with the health plan to provide services at a set rate. Providers on the plan’s network listings are also called participating providers.


LIMITATIONS

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.

LOCK-IN PERIOD

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).


MAXIMUM OUT-OF-POCKET COSTS (MOOP)

The maximum dollar amount you would be required to pay out of your own pocket for health services during a specified period of time.

MAXIMUM PLAN BENEFIT COVERAGE

The maximum dollar amount that a plan will insure per benefit period. Medicare plans have a Maximum Plan Benefit Coverage expenditure limit only for service categories where the plan offers enhanced benefits.

MEDICAID

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.

MEDICARE

The federal health insurance program available to people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD) – permanent kidney failure requiring dialysis or a transplant.

MEDICARE ADVANTAGE DISENROLLMENT PERIOD (MADP)

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. MAPD does not provide an opportunity to join or switch Medicare Advantage plans.

MEDICARE ADVANTAGE ORGANIZATION

Medicare Advantage is a United States health insurance program 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.

MEDICARE SAVINGS PROGRAMS

There are programs that help millions of people with Medicare save money each year. States have programs for people with limited incomes and resources that pay Medicare premiums. Some programs may also pay your Medicare deductibles and coinsurance.

MEDICARE-APPROVED AMOUNT

This is 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 (HOSPITAL INSURANCE)

Medicare Part A provides payments for inpatient hospital, hospice and skilled nursing services, excluding those of physicians and surgeons.

MEDICARE PART B (MEDICAL INSURANCE)

Part B provides payments to physicians and surgeons, 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.

MEDICARE PART C (MEDICARE ADVANTAGE PLANS)

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.

MEDICARE PART D (PRESCRIPTION DRUG COVERAGE)

Coverage to help with the costs of prescription drugs offered through private companies and organizations. 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.

MEDICARE SUPPLEMENT INSURANCE

A Medicare Supplement insurance policy or Medigap plan is health insurance sold by private insurance companies to 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.

NETWORK

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.

NON-FORMULARY DRUGS

Drugs not included on a plan-approved list.

ORIGINAL MEDICARE

A 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 accepts 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.

OUT-OF-NETWORK BENEFITS

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.

OUT-OF-POCKET COSTS

Healthcare costs that you must pay on your own because they are not covered by Medicare or other insurance.

OUTPATIENT CARE

Medical or surgical care that does not include an overnight hospital stay.

PRIMARY CARE PHYSICIAN (PCP)

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.

PROVIDER

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.

QUALIFYING INDIVIDUAL (QI)

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 MEDICARE BENEFICIARIES (QMB ONLY)

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 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.

QUALIFIED MEDICARE BENEFICIARIES PLUS (QMB PLUS)

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. Entitled to all benefits available to the QMB, as well as all benefits available under the State Medicaid plan. These individuals 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.

REFERRAL

A written request from your primary care physician for you to see a specialist or to receive certain services.

SERVICE PLAN COVERAGE AREA

The specific county/ZIP code/state that a member actually resides in, 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 ID card to find out if the service area is affected.

SPECIAL ELECTION PERIOD (SEP)

A period, outside of the usual 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

  • The organization does not renew its contract with CMS
  • You are turning or recently turned 65
  • You recently moved to the plan coverage area
  • You have Medicare and Medicaid
  • You are disenrolling from an Employer or Union health coverage

Other exceptional conditions may exist, as determined by CMS. These are only examples.

SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES (SLMB ONLY)

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.

SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES PLUS (SLMB PLUS)

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.

SUMMARY OF BENEFITS (SB)

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.

URGENTLY NEEDED CARE

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.

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