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Admission - A registered patient, usually admitted for at least 24 hours to a hospital, skilled nursing facility or other health care facility.

Advance Directive - A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a living will and a durable power of attorney for health care.

Aftercare or Follow-Up Care - Individualized patient services following hospitalization or rehabilitation. Aftercare gradually phases the patient out of treatment while providing follow-up attention to prevent relapse.

Age-Band Ratio -The difference an older person pays in health insurance premiums compared to what a younger person pays. With health care reform, age bands are limited to a 3:1 ratio.

Allowed Amount - The fee doctors can charge for their services.

Ancillary Care - Additional services performed relating to a specific incident of care, for example, home health care, lab work, radiology and anesthesia.

Annual Enrollment Period (AEP) - The time each year when Medicare beneficiaries can join, switch or make changes to their plans.

Annual Notice of Change (ANOC) - Each fall Medicare members get a document explaining any changes that will go into effect on January 1.

Annual Out-of-Pocket Maximum - The total, maximum amount, not including monthly premiums, that your health insurance plan requires you to pay during the year toward the cost of your health care services. This is also called the maximum out-of-pocket. 

Appeal - If your plan does not pay a claim and you think they should, you can request that they reconsider their decision.

Authorization - When you have to get written approval to see another doctor, or have a service or treatment. Authorization can also refer to the approval needed by a hospital or office that wants to give out or get your personal information.

Authorized Representative - An individual authorized by you to act on your behalf in pursuing payment of a claim, obtaining a referral/prior authorization or dealing with any level of the grievance process.

Behavioral Health Care - Assessment and treatment of mental and/or substance abuse disorders.

Beneficiary - A person designated by an insuring organization or Medicare as eligible to receive insurance benefits.

Benefit Period - The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you're admitted as an inpatient in a hospital or skilled nursing facility. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods.

Board Certified - A physician who has completed an approved residency, passed an examination given by a medical specialty board, and who has been certified as a specialist in that medical area.

Brand Name Drug -A drug that can only be sold or produced by the company holding the drug's patent.

Calendar Year - A 12 month period of time beginning on January 1 and ending on December 31.

Case Management - The process of identifying patients with specific health care needs. Case managers then work with the patients and their physician(s) to determine and coordinate the most effective treatment plan.

Case Manager - A registered nurse or social worker who works with members, health care providers, physicians and insurers to determine and coordinate a plan of medically necessary and appropriate health care. Also referred to as a care coordinator.

Catastrophic Coverage - Refers to the final period of your Medicare Part D drug coverage. During catastrophic coverage, your health plan pays for most of your drug costs. Catastrophic coverage ends December 31 of each year.

Centers for Medicare and Medicaid Services (CMS) - The federal agency responsible for administering Medicare and overseeing states' administration of Medicaid.

Chronic Condition - A long-term health problem that requires frequent or ongoing medical care.

Claim - What gets sent to the insurance company asking them to pay for care, medications or medical equipment.

Coinsurance - The amount you pay for specific services, according to your plan. For example, an insurance company may cover 80 percent of a service. The remaining 20 percent is the coinsurance, the amount you pay.

Complaint - A verbal expression of any dissatisfaction with administration, claims practices, or provision of services, expressed by you or an authorized representative. Also called a grievance.

Copayment - A fixed fee you pay for some covered services, usually at a doctor visit or for a prescription.

Cost Sharing - An amount you are required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or prescription drug. This amount can include copayments, coinsurance and/or deductibles.

Coverage Determination (Part D) - The first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits, including the following:

  • Whether a particular drug is covered
  • Whether you've met all the requirements for getting a requested drug
  • How much you're required to pay for a drug
  • Whether to make an exception to a plan rule when you request it

If you disagree with the coverage determination, the next step is an appeal.

Coverage Gap (Medicare Prescription Drug Coverage) - A period of time in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap (also called the "donut") starts when you and your plan have paid a certain amount for prescription drugs during that year. The amount may vary from year to year. 

Covered Services - All services covered by your health plan.

Creditable Prescription Drug Coverage - Prescription drug coverage (for example, from an employer or union) that's 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, which they would have to do if they decide to enroll in Medicare prescription drug coverage later and had not had other creditable prescription drug coverage.

Custodial Care - Medical or non-medical services that do not seek to cure, are provided when the medical condition of the patient is not changing, or do not require continued administration by medical personnel. An example is assistance in the activities of daily living.

Deductible - The amount of money you must pay (not including premiums) before the insurance company begins paying for services. It's different and separate from a copay, which is a fee paid at office visits or the pharmacy.

Department of Health and Human Services (HHS) - A Federal agency that administers programs for protecting the health of all Americans, including Medicare, Medicaid and Children's Health Insurance Programs.

Disability - Any condition resulting in functional limitations that interfere with an individual's ability to perform his or her customary work and results in substantial limitation of one or more major life activities.

Disenrollment - A person can be disenrolled from their plan if certain changes occur, such as losing their Medicare entitlement or moving out of the service area of the health care plan.

Durable Medical Equipment (DME) - Certain medical equipment, such as a walker, wheelchair, or hospital bed, that's ordered by your doctor for use in the home.

Effective Date - When your health insurance policy takes effect, also referred to as the "start date."

Emergency Care - When you believe you have an injury or illness that requires immediate medical attention to prevent a disability or death.

End-Stage Renal Disease (ESRD) - Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

Evidence of Coverage (EOC) - The document describing the details of a Medicare Advantage Plan.

Exception - A type of Medicare prescription drug coverage determination. A formulary exception is a drug plan's decision to cover a drug that's not on its drug list or to waive a coverage rule. A tiering exception is a drug plan's decision to charge a lower amount for a drug that's on its non-preferred drug tier. You must request an exception, and your doctor or other prescriber must send a supporting statement explaining the medical reason for the exception.

Exclusions - Specific conditions or circumstances listed in the contract for which the plan will not provide coverage or reimbursement.

Expedite - To speed something up. This can refer to hurrying up the processing of a claim, how fast you get care or how fast an appeal is processed.

Explanation of Benefits (EOB) - This is not a bill. It's a form you get in the mail after you've been to a doctor or hospital that lists what services you received. Usually, the charges will be listed on the EOB, too. 

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.

Exclusion - Services, conditions, drugs or equipment not covered by your plan.

Facility - A physical location where health care/services are provided, such as a hospital, clinic, emergency room or ambulatory care center.

Formulary - A list of prescription medications preferred for use by the health plan and dispensed through contracted pharmacies to covered persons. This list is subject to periodic review and modification by the health plan. Also known as preferred drug list.

Generic Drug - Approved by the U.S. Food and Drug Administration (FDA) as having the same active ingredient as a brand name drug, but usually costs less.

Grievance - A complaint about the way your Medicare health plan or Medicare drug plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you're unhappy with the way a staff person at the plan has behaved towards you. However, if you have a complaint about a plan's refusal to cover a service, supply or prescription, you file an appeal.

Health Care Concierge - Our Medicare customer service representatives are called health care concierges. 

Health Insurance Exchange - Part of health care reform, an exchange is an organized marketplace for the purchase of health insurance. In Wisconsin, the federal government will operate the exchange.

Health Insurance Tax - A tax on all health insurance companies based on their premiums. 

Health Insurance Portability and Accountability Act of 1996 (HIPAA) - The Standard for Privacy of Individually Identifiable Health Information ("Privacy Rule") of HIPPA assures your health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being.

Home Health Care - Health care services and supplies a doctor decides you may receive in your home under an established care plan. Medicare only covers home health care on a limited basis as ordered by your doctor.

Hospice - A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient's family or caregiver as well.

Inpatient Hospital Care - Treatment you get in an acute care hospital, critical access hospital, inpatient rehabilitation facility, long-term care hospital, inpatient care as part of a qualifying research study and mental health care.

Identification Card (ID Card) - After enrolling with the health plan, you will receive a member identification (ID) card. This card identifies you (the subscriber). When you receive your card, be sure to verify that your name and other information printed on the card is correct. If any part is incorrect or you need more cards, please contact us. Show your card when you receive any healthcare services or fill a prescription. Your ID card is valid only as long as you are enrolled with our health plan.

In-Network Provider - Doctors, hospitals, pharmacies, and other health care providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. In some insurance plans, your care is only covered if you get it from in-network doctors, hospitals, pharmacies, and other health care providers.

Independent Review - A review process that provides you with an opportunity to have medical professionals, who have no connection with the health plan, review your dispute.

Individual Mandate - A provision of the health care reform law that requires citizens to have health insurance coverage.

Initial Coverage Period - Refers to the first period of your Medicare Part D drug coverage. During this period you will pay the copayment for the drug cost and your health plan pays the rest. 

Initial Enrollment Period (IEP) - The seven-month period when anyone turning 65 (and therefore newly eligible) can enroll in Medicare.

Inpatient - When you are a patient staying in the hospital overnight.

Living Will - A legal document also known as a medical directive or advance directive. It states your wishes regarding life-support or other medical treatment in certain circumstances, usually when death is imminent.

Long-Term Care - A variety of services that help people with their medical and non-medical needs over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Medicare doesn't pay for this type of care if this is the only kind of care you need.

Low Income Subsidy (LIS) - Money the government gives to Medicare beneficiaries who can't afford their part of the fee for prescription drugs, copays, coinsurance and deductibles.

Maximum Out-of-Pocket - The limit on total amount you'll pay for health care services in a calendar year. Once you've paid this amount, your plan pays 100 percent for services for the rest of the year.

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

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

Medicare - Government sponsored health insurance for people age 65 and older and others who meet specific requirements.

Medicare Advantage Plan (Part C) - A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you're enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren't paid for under Original Medicare. Many Medicare Advantage plans offer prescription drug coverage.

Medicare Advantage Prescription Drug (MA-PD) Plan - A Medicare Advantage Plan that offers Medicare prescription drug coverage (Part D), Part A, and Part B benefits in one plan.

Medicare Supplement Plan - Additional insurance coverage you purchase to cover health care expenses not totally covered by Medicare. It is also known as Medigap.

Medigap - See Medicare Supplement Plan.

Member - A person who has been enrolled in a health plan during the reporting period. Also known as covered person, plan participant or beneficiary.

Network - A system of contracted physicians, hospitals and ancillary providers that provides health care to members.

Network Pharmacies - Pharmacies that have agreed to provide members of certain Medicare plans with services and supplies at a discounted price. In some Medicare plans, your prescriptions are only covered if you get them filled at network pharmacies.

Non-Covered Services - Services not paid for by your plan.

Notice of Privacy Practices (NPP) - A document that tells patients how their Personal Health Information (PHI) can be used and disclosed by any entity that has access to that information. Every entity that directly provides a healthcare service to the patient must provide in writing a copy of the NPP and obtain the patient's written acknowledgement of receipt of the NPP. 

Occupational Therapy - Treatments that help you return to your usual activities (like bathing, preparing meals, and housekeeping) after an illness.

Office Visit - When you see your doctor or other health care practitioner.

Original Medicare - The original government sponsored health insurance for people age 65 and older and others who meet specific requirements.

Out-of-Network - Doctors, pharmacies or health care facilities that aren't part of your plan. It may cost more to use out-of-network providers.

Out-of-Pocket Costs - Health or prescription drug costs that you must pay on your own because they aren't covered by Medicare or other insurance.

Outpatient - When you go to the hospital for a procedure or service but don't stay overnight.

Outpatient Hospital Care - Medical or surgical care you get from a hospital when your doctor hasn't written an order to admit you to the hospital as an inpatient. Outpatient hospital care may include emergency department services, observation services, outpatient surgery, lab tests, or X-rays. Your care may be considered outpatient hospital care even if you spend the night at the hospital.

Over-the-Counter (OTC) Drugs - Drugs you can buy without a prescription.

Palliative Care - Medical care that focuses on reducing pain for patients with serious illness.

Part A (Medicare Part A) - The part of Medicare that helps pay for hospital stays, nursing home, in-home and hospice care.

Part B (Medicare Part B) - The part of Medicare that helps pay for doctors' visits and outpatient services.

Part C (Medicare Part C) - Like Medicare but offered through a private insurer, these plans can offer additional benefits not included in the original government program. Also called Medicare Advantage.

Part D (Medicare Part D) - The part of Medicare that helps pay for prescription drugs.

Patient Protection and Affordable Care Act (PPACA) - The official name for the health care reform bill signed into law by President Obama on March 23, 2010.

Penalty - An amount added to your monthly premium for Part B or a Medicare drug plan (Part D) if you don't join when you're first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.

Pharmacy Network - Pharmacies that have agreed to provide members of certain Medicare plans with services and supplies at a discounted price. In some Medicare plans, your prescriptions are only covered if you get them filled at network pharmacies.

Physical Therapy - Treatment of an injury or a disease by mechanical means, like exercise, massage, heat and light treatment.

Physician - Any doctor of medicine (MD) or doctor of osteopathy (DO) who is duly licensed and qualified under the law of the jurisdiction in which treatment is received.

Power of Attorney - A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care if you can't. This type of advance directive also may be called a health care proxy, appointment of health care agent or a durable power of attorney for health care.

Preferred Pharmacy - A pharmacy that's part of a Medicare drug plan's network. You pay lower out-of-pocket costs if you get your prescription drugs from a preferred pharmacy instead of a standard pharmacy.

Preferred Provider Organization (PPO) - A specific kind of health insurance plan in which you can see any doctor in or out-of-network. This is a type of Medicare Advantage plan (Part C) in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You can use doctors, hospitals, and providers outside of the network. You can save money by choosing in-network doctors. 

Premium - What you pay (per month, usually) to keep your insurance active.

Prescription Drug Coverage (Part D) - Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.

Prescription Medication - A drug that has been approved by the Food and Drug Administration (FDA) which under federal or state law can only be dispensed according to a prescription order from a duly licensed physician or other practitioner with dispensing authority.

Preventive Services - Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best. For example, preventive services include pap tests, flu shots and screening mammograms.

Primary Care Physician - The doctor 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.

If you’d like to select a primary care physician, please share this information with customer service. If you haven’t or don’t wish to designate a PCP, Network Health relies on claims data to assign PCPs to members. Our system automatically assigns PCPs to members based on doctors you’ve seen the most who are part of your plan, designated as a PCP specialty and accepting new patients. For those who haven’t seen a PCP in two years, our system assigns PCPs based on doctors who are closest to you, part of your plan and accepting new patients. Whether your PCP is selected or assigned, you’ll receive the same high quality care you’ve come to expect.

Prior Authorization - Approval from a Medicare plan that may be required before you have certain procedures done or prescriptions filled to be sure they are covered by your plan.

Provider/Physician/Practitioner - A person or organization that's licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.

Provider Directory - A list of doctors and organizations which are considered in-network.

Provider Network - The group of hospitals and doctors that are in considered in-network.

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 people with Medicare.

Quantity Limit - Your plan may limit the quantity of certain drugs prescribed for you. The limit may impact the number of refills or the amount of drug allowed each time you fill the prescription.

Rehabilitation Services - Services that help you regain abilities, such as speech or walking, that have been impaired by an illness or injury. These services are given by nurses, and physical, occupational and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.

Routine Exams/Routine Examinations - Any physical exam or evaluation done, in accordance with plan guidelines for age and sex. The exam wouldn't normally have been done because there was no indication of illness or injury.

Service Area - The geographic area serviced by the health plan as approved by state and/or federal government(s), regulatory agencies and/or as detailed in the health plan's certificate of authority.

Services - Any type of health care you get, whether it's a check-up, a procedure in the hospital or a follow-up visit at a specialist's office.

Skilled Nursing Care - An intermediate level of care such as intravenous injections , changing of complex wound dressings or tube feedings that can only be done by a registered nurse or doctor but doesn't require inpatient status.

Skilled Nursing Facility (SNF) - Also referred to as a nursing home, but can be a part of a hospital. A place for stable patients who still need nursing care, rehabilitation or other health care services.

Special Enrollment Period (SEP) - The time when people with Medicare can change their benefits because something has changed in their life, such as moving or becoming eligible for Medicaid.

Specialist - A doctor who focuses on one specific disease, part or system of the body.

Special Needs Plan (SNP) - A special type of Medicare Advantage Plan (Part C) that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid. 

Specified Low-Income Medicare Beneficiary (SLMB) Program - A state program that helps pay Part B premiums for people who have Part A and limited income and resources.

Stand Alone Drug Plan - A stand alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost plans, some Medicare Private-Fee-for-Service plans, and Medicare Medical Savings Account plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug plans.

Standard Pharmacy - A pharmacy that's part of a Medicare drug plan's network but isn't a Preferred Pharmacy. You may pay higher out-of-pocket costs if you get your prescription drugs from a non-preferred pharmacy instead of a preferred pharmacy. It was previously referred to as a non-preferred pharmacy. 

State Health Insurance Assistance Program (SHIP) - A state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.

Step Therapy - A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug.

Summary of Benefits (SOB) - The document describing the details of your plan, including deductibles, coinsurance and copayments.

Tier - Groups of drugs that have a different cost for each group. A drug in a lower tier will cost you less than a drug in a higher tier.

Urgent Care - You really need to see a doctor, but it's not "emergency room serious." Examples include ear infections, urinary tract infections and sprains.

Urgently Needed Care - Care that you get outside of your Medicare health plan's service area for a sudden illness or injury that needs medical care right away but isn't life threatening. If it's not safe to wait until you get home to get care from a plan doctor, the health plan must pay for the care.

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