Learn the Lingo

 

Here’s a list of terms you’ll likely see or hear as you get settled in with your new plan. If you have questions about the information in this Welcome Kit or about your plan, give us a call at HMO: 1-833-854-4766; (TTY: 711) and HMO SNP: 1-833-717-0806; (TTY: 711). We are here to help.

The time frame (October 15 through December 7) when you can choose a new Medicare plan.

The cost shared by you and your insurance plan. Coinsurance is usually a percentage of the total amount due.

The fixed amount you pay each time for certain services, like a doctor visit or prescription drugs.

What you have to pay when you get services or drugs. Cost-sharing includes copayments and coinsurance.

This refers to all the prescription drugs covered by our plan.

The healthcare, long-term services and supports, supplies, prescription and over-the-counter drugs, equipment and other services covered by our plan.

The amount you must pay each year for healthcare or prescriptions before your Medicare plan begins to cover some costs.

Services given by trained emergency service providers to treat a medical emergency.

This document explains what your health plan covers, how it works and how much you will pay for services. 

This shows you the costs of your healthcare services and how much you owe. (For Part D Prescription Drugs, it shows how much you paid.) The EOB is not an invoice, and you do not pay your Medicare plan. It is provided to you for your information. Please note, it is NOT a BILL.

A law in the United States that requires those in the healthcare field to protect your personal health information.

A doctor or pharmacy included in our network.

A list of prescription drugs covered by your health plan. The drug list is divided into tiers to help you see how much— if anything—you have to pay.

A program that subsidizes prescription drug costs for those who qualify. Also known as Extra Help.

The most you will have to pay on deductibles, copayments, and coinsurance for covered services before your health plan pays 100% of the costs of covered benefits.

Your Medicare member ID number shown on your Medicare ID card from the Centers for Medicare and Medicaid Services.

A Medicare plan offered by private insurance companies that are contracted with the Federal Government.Medicare Advantage plans include all of your Medicare Part A and Part B benefits, along with extra benefits not covered by Original Medicare. Many Medicare Advantage plans also include prescription drug coverage (Part D).

The Medicare prescription drug benefit program. Part D covers outpatient prescription drugs, most vaccines and some supplies not covered by Medicare Part A or Part B or Medicaid.

The annual period of time (January 1 to March 31) in which Medicare Advantage enrollees can either switch to Original Medicare (plus the option for a Part D plan) or select a different Medicare Advantage plan. Enrollees are only allowed to make one change during this time period.

The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities and people with end-stage renal disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare or a Medicare Advantage plan.

A doctor or pharmacy not included in our network. If you use an out-of-network provider, you will likely pay more for your care services.

This is what you actually pay for your healthcare services.

Drugs Medications a consumer can get without a prescription.

The amount you pay each month to receive your Medicare Advantage coverage.

Prescription medication coverage, usually included in most Medicare Advantage plans.

Your primary care provider is your main doctor who refers you to other healthcare professionals within your healthcare group when needed. They make sure you get the care you need.

Approval in advance to get services or certain drugs that may or may not be on our list of drugs. Some medical services and drugs are covered only if your doctor gets “prior authorization” from our plan.

The recommendation, usually by your doctor, to see a specialist within your network for specific treatments or examinations.

A special type of Medicare Advantage Plan that provides more focused healthcare for specific groups of people, like those who have both Medicare and Medicaid, who live in a nursing home or who have certain chronic medical conditions.

A doctor who provides healthcare for a specific disease or part of the body.

Expenses that count toward a person’s Medicare drug plan out-of-pocket threshold. 

A temporary supply (up to 30 days at retail and 31 days at Long Term Care) of your drug that your Medicare drug plan must cover when you switch from one plan to another to allow you time to obtain coverage for the drug or change to another drug covered on our drug list.

A facility that provides a quick diagnosis or treatment of a non-life-threatening illness, injury or other medical condition when you are unable to see your doctor. Always check to make sure an urgent care facility is in-network.

Other Resources

Your Evidence of Coverage and Summary of Benefits are great places to learn about your plan benefits and details about how your coverage works.

If you have questions please, contact Member Services.