Glossary of Terms

Appeal – A type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for a service.
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Benefit Period – For both Central Health Medicare Plan and Original Medicare, a benefit period is used to determine coverage for inpatient stays in hospitals and skilled nursing facilities. A benefit period begins on the first day you go to a Medicare-covered skilled nursing facility. The benefit period ends when you have not been at a skilled nursing facility for 60 days in a row. If you go to the skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. The type of care you actually receive during the stay determines whether you are considered to be an inpatient for skilled nursing facility stays, but not for hospital stays.

You are an inpatient in a skilled nursing facility only if your care in the skilled nursing facility meets certain skilled level of care standards. Specifically, in order to have been an inpatient while in a skilled nursing facility, you must need daily skilled nursing or skilled rehabilitation care, or both.

Generally, you are an inpatient of a hospital if you are receiving inpatient services in the hospital (the type of care you actually receive in the hospital does not determine whether you are considered to be an inpatient in the hospital).

Brand Name Drug – A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug.  However, generic drugs are manufactured and sold by other drug manufacturers and are not available until after the patent on the brand name drug has expired.
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Centers for Medicare & Medicaid Services (CMS) – The federal agency that runs the Medicare program.

Coverage Determination - The plan sponsor has made a coverage determination when it makes a decision about the prescription drug benefits you can receive under the plan, and the amount that you must pay for a drug.

Covered Services – The general term we use in this booklet to mean all of the health care services and supplies that are covered by Central Health Medicare Plan. Covered services are listed in the Evidence of Coverage.

Creditable Coverage – Coverage that is at least as good as the standard Medicare prescription drug coverage.
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Disenroll or Disenrollment – The process of ending your membership in Central Health Medicare Plan. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice).

Durable Medical Equipment (DME) – Equipment needed for medical reasons, which is sturdy enough to be used many times without wearing out. A person normally needs this kind of equipment only when ill or injured. It can be used in the home. Examples of durable medical equipment include wheelchairs, hospital beds, or equipment that supplies a person with oxygen.
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Emergency Care – Covered services that are  1) furnished by a provider qualified to furnish emergency services; and  2) needed to evaluate or stabilize an emergency medical condition.

Evidence of Coverage and disclosure information – This document along with your enrollment form which explains your covered services, defines our obligations, and explains your rights and responsibilities as a member of the Central Health Medicare Plan.

Exception – A type of coverage determination that, if approved, allows you to obtain a drug that is not on our formulary (a formulary exception), or receive a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if we require you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).
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Formulary – A list of covered drugs provided by the plan.
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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.

Grievance – A type of complaint you make about us or one of our plan providers, including a complaint concerning the quality of your care. This type of complaint does not involve payment or coverage disputes.
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Inpatient Care – Health care that you get when you are admitted to a hospital.
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Late Enrollment Penalty – An amount added to your monthly premium for Medicare drug coverage if you don’t join a plan when you’re first able. You pay this higher amount as long as you have Medicare. There are some exceptions. If you do not have creditable prescription drug coverage, you will have to pay a penalty in addition to your monthly plan premium.
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Medically Necessary – Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition; are used for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for the convenience of you or your doctor.

Medicare – The federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant).

Medicare Advantage Organization – A public or private organization licensed by the State as a risk-bearing entity that is under contract with the Centers for Medicare & Medicaid Services (CMS) to provide covered services. Medicare Advantage Organizations can offer one or more Medicare Advantage Plans. Central Health Medicare Plan is a Medicare Advantage Organization.

Medicare Advantage Plan – A benefit package offered by a Medicare Advantage Organization that offers a specific set of health benefits at a uniform premium and uniform level of cost-sharing to all people with Medicare who live in the service area covered by the Plan. A Medicare Advantage Organization may offer more than one plan in the same service area. Central Health Medicare Plan is a Medicare Advantage Plan.

Medicare Prescription Drug Coverage – Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part B.

“Medigap” (Medicare supplement insurance) policy – Many people who get their Medicare through Original Medicare buy “Medigap” or Medicare supplement insurance policies to fill “gaps” in Original Medicare coverage.

Member (member of Central Health Medicare Plan, or “plan member”) – A person with Medicare who is eligible to get covered services, who has enrolled in Central Health Medicare Plan, and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Member Services – A department within Central Health Medicare Plan responsible for answering your questions about your membership, benefits, grievances, and appeals.
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Network Pharmacy – A network pharmacy is a pharmacy where members of our Plan can receive covered prescription drug benefits. We call them “network pharmacies” because they contract with our Plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

Non-Preferred Network Pharmacy – A network pharmacy that offers covered drugs to members of our Plan at higher cost-sharing levels than apply at a preferred network pharmacy.

Non-plan provider or non-plan facility – A provider or facility that we have not arranged with to coordinate or provide covered services to members of Central Health Medicare Plan. Non-plan providers are providers that are not employed, owned, or operated by Central Health Medicare Plan and are not under contract to deliver covered services to you. As explained in this booklet, you may pay more if you see non-plan providers unless it is for an emergency.
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Organization Determination - The MA organization has made an organization determination when it, or one of its providers, makes a decision about MA services or payment that you believe you should receive.

Original Medicare – Some people call it “traditional Medicare” or “fee-for-service” Medicare. Original Medicare is the way most people get their Medicare Part A and Part B health care. It is the national pay-per-visit program that lets you go to any doctor, hospital, or other health care provider who accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States.

Out-of-Network Pharmacy – A pharmacy that we have not arranged with to coordinate or provide covered drugs to members of our Plan. As explained in this Evidence of Coverage, most services you get from non-network pharmacies are not covered by our Plan unless certain conditions apply.
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Part D – The voluntary Prescription Drug Benefit Program.

Part D Drugs – Any drug that can be covered under a Medicare Prescription Drug Plan. Generally, any drug not specifically excluded under Medicare drug coverage is considered a Part D Drug.

Preferred Network Pharmacy – A network pharmacy that offers covered drugs to members of our Plan at lower cost-sharing levels than apply at another network pharmacy.

Plan Provider – “Provider” is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. We call them “plan providers” when they have an agreement with Central Health Medicare Plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of Central Health Medicare Plan. Central Health Medicare Plan pays plan providers based on the agreements it has with the providers.

Primary Care Physician (PCP) – A health care professional who is trained to give you basic care. Your PCP is responsible for providing or authorizing covered services while you are a plan member.

Preferred Provider Organization Plan – A Preferred Provider Organization plan is an MA plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they are received from network or non-network providers. Member cost sharing may be higher when plan benefits are received from non-network providers.

Prior Authorization – Approval in advance to get services. Some in-network services are covered only if your doctor or other plan provider gets “prior authorization” from your IPA/Medical Group or Central Health Medicare Plan. Covered services that need prior authorization are marked in the Benefits Chart. Prior authorization is not required for out-of-network services. You do not need prior authorization to obtain out-of-network services.  However, you may want to check with your plan before obtaining services out-of-network to confirm that the service is covered by your plan and what your cost share responsibility is.
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Quality Improvement Organization (QIO) – Groups of practicing doctors and other health care experts who are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by doctors in inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private fee-for-service plans and ambulatory surgical centers.
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Referral – Your PCP’s “or his/her medical group’s” or “IPA’s” approval for you to see a certain plan specialist or to receive certain covered services from plan providers.

Rehabilitation Services – These services include physical therapy, cardiac rehabilitation, speech and language therapy, and occupational therapy that are provided under the direction of a plan provider.
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Service Area – “Service area” is the geographic area approved by the Centers for Medicare & Medicaid Services (CMS) within which an eligible individual may enroll in a particular plan offered by a Medicare health plan.