Medicare Advantage Plans

Healthcare Glossary:

Making Sense of 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. 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.

AGENCY FOR HEALTHCARE ADMINISTRATION (AHCA)

The governmental organization that administers the Florida State Medicaid Program.

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 their Medicare Advantage (MA) plan, Medicare Advantage and Prescription Drug plan (MAPD), prescription drug plan (PDP) or 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) 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 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, if applicable, 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 (or COPAY)

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 healthcare before your health plan begins to pay.

DUAL ELIGIBLES or DUALS

Dual-eligible beneficiaries (Medicare dual eligibles or "duals") refers to those qualifying for both Medicare and Medicaid benefits.

EFFECTIVE DATE

The date your coverage begins.

EMERGENCY CARE

Covered services that are administered by a provider qualified to furnish emergency services; and 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 post copies of the EOC to their websites by October15 each year and provide printed copies to members upon request.

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)

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.

INITIAL COVERAGE ELECTION PERIOD (ICEP)

This 7-month period begins three months immediately before the month of the individual’s first entitlement to both Medicare Part A and Part B and ends on the last day of the 3rd month following the entitlement month. The ICEP is the period during which an individual newly eligible for Medicare Advantage (MA) (generally the 65th birthday) 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 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.

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 or prescription drug 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 plan year. Medicare plans have a Maximum Plan Benefit Coverage limit applicable to service categories for which 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, people with certain disabilities, and people with End-Stage Renal Disease (ESRD) – permanent kidney failure requiring dialysis or a transplant.

MEDICARE ADVANTAGE ORGANIZATION

Medicare Advantage is a health insurance program offered by private insurance companies of managed healthcare (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-APPROVED AMOUNT

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 helps provide coverage for inpatient hospital, hospice and skilled nursing services, excluding those of physicians and surgeons.

MEDICARE PART B (MEDICAL INSURANCE)

Part B helps provide coverage for physician and surgeon 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.

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 insurance companies. You can get Part D coverage through a Medicare-approved stand-alone prescription drug plan (PDP) or a Medicare Advantage HMO, PPO, or PFFS plan that includes drug coverage.

MEDICARE SAVINGS PROGRAMS

These are state programs that assist individuals, who have limited income, 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.

MEDICARE SUPPLEMENT INSURANCE

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.

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

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 healthcare 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.

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.

PREFERRED COST-SHARE PHARMACY

Preferred cost-sharing pharmacies are pharmacies in our network where the plan has negotiated lower cost-sharing for members for covered drugs than at standard cost-sharing pharmacies.

PRIMARY CARE PHYSICIAN (PCP)

A PCP is the doctor you see first for most health problems. PCPs make sure that you get the care you need. They may consult with other doctors and healthcare providers about your care and refer you to them. Generally, you must see your primary care physician (PCP) before you see any other healthcare provider.

PROVIDER

A person or facility that offers healthcare services. Providers may include a doctor, 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, etc. Generally, providers are licensed or certified and must practice within the scope of their license or certification.

QUALIFIED MEDICARE BENEFICIARIES (QMBs 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, 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.

QUALIFIED MEDICARE BENEFICIARIES PLUS (QMBs 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, 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.

QUALIFYING INDIVIDUALS (QIs)

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

REFERRAL

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

SERVICE AREA

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’s 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.

SPECIAL ELECTION PERIOD (SEP)

A period, outside of the ICEP or AEP , 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 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 (SLMBs 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 (SLMBs 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.

STANDARD COST-SHARE PHARMACIES

Standard cost-share pharmacies provide prescriptions for our Medicare members at a higher cost-share (e.g., copayments) than preferred cost-share pharmacies.

SUMMARY OF BENEFITS (SB)

A brief description or outline of your coverage, including the amounts or percentage you pay for certain services, and the services for which coverage is limited or excluded.

URGENTLY NEEDED CARE

Care you receive for a sudden illness or injury that, while not life threatening, requires immediate medical attention. The care should generally be provided by your primary care physician (PCP) or an urgent care center, unless you are out of the service area.