Accountable Care Organizations
Accountable Care Organizations (ACOs) are a group of healthcare providers who work together with the goal of coordinating care. Their goal is to make sure each provider you see is up to date on what’s going on with your health. For instance, every provider you see knows what tests you’ve had and conditions you’ve been treated for.
Actual Charge
Actual charge is 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.
Annual Election Period (AEP)
Annual Election (or Enrollment) Period (AEP) begins October 15 and ends December 7 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 January 1 of the following year.
Annual Notice of Change (ANOC)
The Annual Notice of Change (ANOC)—which is required by Centers for Medicare & Medicaid Services (CMS)—explains any changes in plan benefits, services, and costs for the next calendar year; the information also provides instructions and important deadlines for changing plans and other helpful information. HealthTeam Advantage mails this information to our enrolled members each year before the Annual Election Period (AEP) begins.
Appeal
An appeal is a request you make if you disagree with our decision to deny an authorization request for services to be received (pre-service), discontinue or stop services being received, deny services already received (claims), or if you disagree with the amount of copayment or coinsurance you are required to pay for services already received (claims). Learn more about Appeals & Grievances here.
Attest/Attestation
When you apply for health coverage you’re required to agree (or attest) to the truth of the information provided by signing the application.
Authorized Representative
An authorized representative is someone you choose to act on your behalf with the plan, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf. To designate an authorized representative you’ll need to fill out an AOR form (Appointment of Representative) [Click here to go to the AOR form]
Beneficiary
A beneficiary is a person eligible for health insurance through the Medicare or Medicaid program.
Benefits
Benefits are the care, items, and services that a health plan covers.
Benefit Period
A benefit period is the time during which you’re 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.
Carrier
Your carrier is the private insurance company (HealthTeam Advantage) that has a contract with Medicare to pay your physician and most other Medicare Part B bills.
Catastrophic Coverage Stage
Catastrophic coverage is your prescription coverage once your out-of-pocket costs reach $6,550 (2021). During this stage in HealthTeam Advantage plans, the plan will pay most of the cost of your drugs for the remainder of the year. You pay only a small copay or coinsurance for each filled prescription (see the Evidence of Coverage for details). The plan and Medicare pay the rest until the end of the calendar year. [Click here to go to Drug Payment Stage page and Evidence of Coverage page]
Catastrophic Illness
Catastrophic illness is any 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 U.S. 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. Link to CMS https://www.cms.gov/
Certificate of Creditable Coverage
A certificate of creditable coverage is a written certificate issued by a group health plan or health insurance issuer (including an HMO), that states the period of time you were covered by your health plan.
COBRA
COBRA (Consolidated Omnibus Budget Reconciliation Act) is the federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the share the employer used to pay, plus a small administrative fee.
Coinsurance
Coinsurance is the amount you may be required to pay for services after you pay any plan deductibles. In Original Medicare, this is a percentage (like 20 percent) of the Medicare approved amount. You must pay this amount after you pay the deductible for Part A and/or Part B. In a Medicare prescription drug plan, the coinsurance will vary depending on how much you have spent.
Comprehensive Outpatient Rehabilitation Facility (CORF)
A Comprehensive Outpatient Rehabilitation Facility (CORF) mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physician’s services, physical therapy, social or psychological services, and outpatient rehabilitation.
Copayment (or Copay)
The copay is 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, if you have one.
Coverage Gap Stage/Donut Hole
The coverage gap, also known as the donut hole, is a gap in coverage that occurs when you go beyond the initial prescription drug coverage limit. During this stage in HealthTeam Advantage plans, you pay 25 percent of the total cost for brand name drugs and 25 percent of the total cost for generic drugs PLUS a portion of the dispensing fee. Tier 1 generics are covered at same copay as in the initial coverage stage. Once your out-of-pocket costs reach $6,550 (2021), you move to catastrophic coverage. (see Evidence of Coverage for details). [Click here to go to Drug Payment Stage page and Evidence of Coverage page]
Creditable Coverage
Creditable coverage is the health coverage you have had in the past, such as group health plan (including COBRA), an HMO, an individual health insurance policy, Medicare or Medicaid, which was not interrupted by a significant break in coverage. The time period of this prior coverage must be applied toward any pre-existing condition exclusion imposed by a new health plan. Creditable coverage may be proven by a certificate of creditable coverage or by other documents showing an individual had health coverage, such as a health insurance ID card.
Creditable Prescription Drug Coverage
Prescription drug coverage (for example, from an employer or union), that pays out, on average, as much as or more than Medicare’s standard prescription drug coverage.
Custodial Care
Non-skilled personal care to help with activities of daily living, such as bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care; HealthTeam Advantage does. Click here to learn more about Custodial Care.
Deductible
The amount you must pay for healthcare or prescriptions before your health plan, prescription drug plan, or Original Medicare begins to pay is the deductible. HealthTeam Advantage plans do not have a deductible for medical services or prescription drugs.
Donut Hole/Coverage Gap
The donut hole, or coverage gap, is a gap in coverage that occurs when you go beyond the initial prescription drug coverage limit. During this stage in HealthTeam Advantage plans, you pay 25 percent of the total cost for brand name drugs and 25 percent of the total cost for generic drugs PLUS a portion of the dispensing fee. Tier 1 generics are covered at same copay as in the initial coverage stage. Once your out-of-pocket costs reach $6,550 (2021), you move to catastrophic coverage. (see Evidence of Coverage for details). [Click here to go to Drug Payment Stage page and Evidence of Coverage page]
Drug List
A list of drugs (medications/prescriptions) covered by a plan. This list is also called a formulary.
Durable Medical Equipment (DME)
Certain medical equipment ordered by a doctor for use in the home; for example, walkers, wheelchairs, or hospital beds, are called durable medical equipment (DME). DME is paid for under both Medicare Part A and Part B for home health services.
Durable Power of Attorney
Durable power of attorney is a type of advance medical directive in which legal documents provide the power of attorney to another person in the case of an incapacitating medical condition. A general power of attorney ends the moment you become incapacitated. Durable power of attorney has language within the document which states an agent’s authority continues to apply if you become incapacitated. You should consult an attorney for this document.
Effective Date
The date your coverage begins.
Emergency Care
Covered services a provider qualified to furnish emergency services administers to evaluate and/or stabilize an emergency medical condition.
End Stage Renal Disease (ESRD)
End Stage Renal Disease (ESRD) is permanent kidney failure requiring dialysis or a kidney transplant.
Evidence of Coverage (EOC)
The Evidence of Coverage (EOC) is 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 October 15 each year and provide printed copies to members upon request. (Link to EOC)
Excess Charges
If you are in Original Medicare, this is the difference between a doctor’s or other healthcare provider’s actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.
Exclusions
Services or items not covered under your benefit plan.
Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a document to keep you informed of the healthcare claims that have been submitted on your behalf. It shows what your health plan has paid to the provider, what the health plan has reimbursed to you (if applicable), any financial responsibility you may have for services provided, and if services were not paid for by your health plan. Please note, this is not a bill.
Extra Help
Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug costs, such as premiums, deductibles, and coinsurance. See also Low Income Subsidy (LIS).
Federal Employee Health Benefits Plan (FEHB)
The Federal Employee Health Benefits Plan (FEHB) program offers health coverage for current and retired federal employees. If you’re covered under an FEBH plan, you will get information during the open season about your prescription drug coverage and whether it is creditable prescription drug coverage. Read this information carefully. Contact your FEBH insurer before making any changes. It will almost always be to your advantage to keep your current coverage without any changes. For most people, unless you qualify for Extra Help, it is not cost effective to join a Medicare drug plan. Caution: you cannot drop FEHB drug coverage without also dropping FEBH plan coverage for hospital and medical services, which may mean higher costs for these services.
Federal Poverty Level (FPL)
The Federal Poverty Level is the set minimum income a family needs for food, clothing, transportation, and shelter. The government decides this level. It depends on the size of your family. For more information on the Federal Poverty Level, visit healthcare.gov.
Formulary
A list of prescription medications that a health plan covers. Also known as prescription drug guide. Medicare Advantage and prescription drug plans are required to post copies of their drug guides to their websites by October 15 each year and provide printed copies to members upon request. Link to formulary
Generic Drug
A generic drug is 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 Insurance Portability and Accountability Act (HIPAA) of 1996
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that allows individuals to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title ii, subtitle f, of HIPAA gives the Department of Health and Human Services (HHS) the authority to mandate the use of standards for the electronic exchange of healthcare data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for healthcare patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable healthcare information.
Healthcare Concierge (HCC)
Your HealthTeam Advantage Healthcare Concierge (HCC) is your personal member service representative. Whatever your question or concern—from information about your plan’s benefits and services to help finding providers and scheduling appointments—your Healthcare Concierge can help. Learn more about your Healthcare Concierge here.
Health Maintenance Organization (HMO) Plan
In most Health Maintenance Organizations (HMO) plans, you can only go to doctors, other healthcare providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). You may also need to get a referral from your primary care doctor.
Health Risk Assessment (HRA)
A Health Risk Assessment (HRA) is a questionnaire members complete and return to HealthTeam Advantage that helps identify and understand their health risks and monitor health status over time. The HRA includes questions about demographics, lifestyle behavior, physical and emotional health, screenings, etc.
Home Health Care
Limited, part-time, or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language pathology services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
Hospice Care
Hospice Care is a special way of caring for people who are terminally ill. It 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. Hospice care is covered under Medicare Part A (hospital insurance).
Initial Enrollment Period (IEP)
Your Initial Enrollment Period (IEP) is a seven-month period that begins three months immediately before the month of your first entitlement to Medicare Part A and Part B and ends on the last day of the third month following the entitlement month. The IEP is the period during which newly eligible beneficiaries (generally the 65th birthday) may make an initial enrollment request to enroll in an MA plan. Learn more about enrollment periods.
Initial Coverage Stage
During this stage, you pay a flat fee (copay) or a percentage of a drug’s total cost (coinsurance) for each prescription you fill. The plan pays the rest until your total drug costs (paid by you and the plan) reach $4,130 (2021). Link to drug payment stages
In-network Benefits
In-network healthcare providers have contracted with an insurance company to accept certain negotiated (i.e., discounted) rates. You typically pay less when you visit an in-network provider.
In-network Provider
A healthcare provider—such as: a physician, hospital, other medical facility, and/or pharmacy—that’s contracted with the health plan to provide services at a set rate. Providers on the plan’s network listings are also called participating providers. Link to Provider page
Inpatient Care
Healthcare you receive when you are admitted to a hospital or skilled nursing facility.
Inpatient Rehabilitation Facility
A hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients.
KEPRO
The Quality Improvement Organization (QIO) Program (known as KEPRO) helps the Medicare program make the quality of care and health outcomes better. KEPRO is the Beneficiary and Family Centered Care QIO (BFCC-QIO) for 29 states. As a BFCC-QIO, KEPRO helps people who are on Medicare, and their families and caregivers file quality of care complaints and hospital discharge and skilled service termination appeals. If offers Immediate Advocacy, which can be useful in specific situations. Click here for information about KEPRO in North Carolina.
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 generally are locked-in, which means they can switch Medicare plans only during certain times of the year, such as Annual Enrollment Period (AEP) or Open Enrollment Period (OEP). Medicare recipients with special circumstances may be able to switch plans, and Medicare recipients in an area where a plan received a 5 out of 5 plan performance rating from the Centers for Medicare & Medicaid Services (CMS) can or choose to switch to that plan during the year in which that plan has the overall 5-star rating. The Medicare recipients must meet requirements to enroll in the plan (i.e., living within the plan’s service area and requirements regarding end-stage renal disease).
Long-term Care
A variety of services that help people with health or personal needs and activities of daily living 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. Most long-term care is custodial care. Medicare does not pay for this type of care if this is the only kind of care you need.
Long-term Care Hospital
Acute care hospitals that provide treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.
Low Income Subsidy (LIS)
The Low Income Subsidy helps Medicare beneficiaries who qualify pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage.
Maximum Out-of-pocket Costs (MOOP)
The maximum dollar amount you would be required to pay 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.
Medically Necessary
Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and are not mainly for the convenience of you or your doctor.
Medicare
Medicare is the federal health insurance program designed for people who are age 65 or older, people under age 65 with certain disabilities, and people of any age with end stage renal disease (ESRD, permanent kidney failure requiring dialysis or a kidney transplant). Medicare Part A (hospital insurance) helps cover inpatient care in hospitals, and skilled nursing facilities, hospice, and home health care. Medicare part B (medical insurance) helps cover doctors’ services, outpatient care, and home health care, some preventive services to help maintain your health and to keep certain illnesses from getting worse. Link to Simple Guide to Medicare
Medicare Advantage Plan (MA)
A plan offered by a private insurance company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage plans are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), or private fee-for-service plans. If you are enrolled in a Medicare Advantage plan, Medicare services are covered through the plans, and are not paid for under Original Medicare.
Medicare Advantage Open Enrollment Period (MA OEP)
During the Medicare Advantage Open Enrollment Period (January 1-March 31), Medicare Advantage plan enrollees may enroll in another Medicare Advantage plan or disenroll from their Medicare Advantage plan and return to Original Medicare.
Medicare-approved Amount
The payment amount that Medicare pays to a physician or supplier for a service or supply. This amount 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 Coordinated Care Plan
A Medicare Advantage Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) plan.
Medicare Part A (Hospital Insurance)
Coverage for inpatient hospital, hospice, and skilled nursing services, excluding services from physicians and surgeons.
Medicare Part B (Medical Insurance)
Coverage for physician and surgeon services; medically necessary outpatient hospital services (such as emergency room visits, X-rays, and laboratory and diagnostic tests); and certain durable medical equipment and supplies.
Medicare Part C (Medicare Advantage Plans)
Coverage offered by a Medicare Advantage organization. Enrolled members get a specific set of health benefits at a set premium and at a 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 offered through private insurance companies to help with prescription drug costs. 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 Plan
Refers to any way other than Original Medicare that you can get your Medicare health or prescription drug coverage. This term includes all Medicare health plans and Medicare prescription drug plans.
Medicare Prescription Drug Coverage
Optional coverage available to all people with Medicare through insurance companies and other private companies.
Medicare Summary Notice (MSN)
A notice you get after the doctor or provider files a claim for Part A and Part B services in Original Medicare. It explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.
Medicare Savings Programs
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 also may pay Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) deductibles, coinsurance, and copayments if you meet certain conditions.
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. For a Pharmacy directory click here. To find a Provider click here.
Non-formulary Drugs
Brand name or generic prescription drugs not included on a health plan’s list of approved prescription drugs. Link to formulary
Original Medicare
Healthcare insurance provided through the federal government, sometimes called Traditional Medicare or Fee-for-Service Medicare. Original Medicare provides Medicare eligible individuals with coverage for and access to physicians, hospitals, and 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, and hospital that is not a part of a 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-network Provider (OON)
A doctor, dentist, hospital or other practitioner who is not contracted with that particular health plan.
Out-of-pocket Costs
Healthcare costs that you must pay on your own, because Medicare or other insurance does not cover the costs.
Out-of-pocket Maximum
The maximum dollar amount, (also called maximum out-of-pocket/MOOP) including deductibles and copayments, that you pay in any calendar year toward the cost of covered medical care. Your out-of-pocket (OOP) costs in a Medicare Advantage plan depend on whether the plan charges a monthly premium in addition to your Part B premium; whether the plan pays any of the monthly Part B premium; whether the plan has a yearly deductible or any additional deductibles; how much you pay for each visit or service (copayments); the type of healthcare services you need and how often you get them; whether you follow the plan’s rules, like using network providers; whether you need extra coverage and what the plan charges for it; whether the plan has a yearly limit on your out-of-pocket costs for all medical services.
Outpatient Care
Medical or surgical care that does not include an overnight hospital stay.
Outpatient Hospital Care
Medical or surgical care furnished by a hospital to you if you have not been admitted as an inpatient but are registered on hospital records as an outpatient. If a doctor orders that you must be placed under observation, it may be considered outpatient care, even if you stay under observation overnight.
Outpatient Medical Services and Supplies
Certain medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds. Durable medical equipment (DME) is paid for under both Medicare Part B and Part A for home health services.
Penalty
An amount added to your monthly premium for Medicare Part B, or for a Medicare prescription drug plan, if you don’t join when you’re first able to. You pay this higher amount as long as you have Medicare. There are some exceptions.
Plan Administrator
The person who is responsible for the management of the plan. The plan administrator is a person specifically designated by the terms of the plan. If the plan does not make such a designation, then the plan sponsor is generally the plan administrator.
Plan Sponsor
Generally, the employer, the employee organization, (such as a union), or other entity that establishes or maintains an employee benefit plan, including a group health plan.
Pre-existing Condition
A health problem you had before the date that a new insurance policy starts.
Premium
The periodic payment to Medicare, an insurance company, or a healthcare plan for healthcare or prescription drug coverage. HealthTeam Advantage has no-premium plan options.
Preferred Provider Organization (PPO) plans
A Medicare Preferred Provider Organization (PPO) plan is a type of Medicare advantage plan (Part C) offered by a private insurance company, like HealthTeam Advantage. In a PPO plan, you pay less if you use in-network providers. You don’t need a referral for specialists, hospitals, or providers.
Preventive Services
Healthcare to keep you healthy or to prevent illness; for example, annual wellness checkups, flu shots, screenings (blood pressure, colorectal cancer, breast cancer), falls prevention, etc.
Primary Care Provider (PCP)
A primary care provider (PCP) is the doctor you see first for most health problems. PCPs make sure 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 provider 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 (QMB)
Individuals entitled to Medicare Part A, have income of 100% Federal Poverty Level (FPL) or less, 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 the individuals’ 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 individuals do not qualify for additional Medicaid benefits. Medicaid does not pay toward 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)
Individuals are entitled to Medicare Part A, have income of 100% Federal Poverty Level (FPL) or less, resources that do not exceed three times the limit for Supplemental Security Income (SSI) eligibility, are not otherwise eligible for full Medicaid, and are entitled to all benefits available to the Qualified Medicare Beneficiary and 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 toward out-of-pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.
Qualifying Individuals (QI)
Individuals entitled to Medicare Part A, with an income at least 120% Federal Poverty Level (FPL) but less than 135% FPL, resources that do not exceed three times the Supplemental Security Income (SSI) limit, and who are not otherwise eligible for Medicaid benefits. These individuals are eligible for Medicaid payment of the Medicare Part B premium. Medicaid does not pay toward out-of-pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.
Referral
A written order from your primary care provider for you to see a specialist or get certain services. In many HMOs, you need to get a referral before you can get care from anyone except your primary care doctor. If you do not get a referral first, the plan may not pay for your care.
Rehabilitation
Rehabilitation services are ordered by your doctor to help you recover from an illness or injury. These services are provided 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.
Retiree
An individual who is provided coverage under a group health plan after that individual has retired.
Risk Adjustment
A statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their healthcare outcomes or healthcare costs.
Second Opinion
A second opinion refers to an additional doctor giving their view about what you have and how it should be treated.
Secondary Payer
An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation.
Self-Administered Drugs
Medicare defines self-administered drugs as medications you take yourself; examples include (but are not limited to) blood pressure, cholesterol, or diabetes medications.
Service Area
The area in which a health plan accepts members; for plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan’s service area.
Significant Break in Coverage
Generally, a significant break in coverage is a period of 63 consecutive days during which an individual has no creditable coverage. In some states, the period is longer if the individual’s coverage is provided through an insurance policy or HMO. Days in a waiting period during which you had no other health coverage cannot be counted toward determining a significant break in coverage.
Skilled Nursing Care
A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).
Skilled Nursing Facility (SNF)
A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.
Skilled Nursing Facility Care
This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff and that, as a practical matter, cannot be provided on an outpatient basis. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all your care needs in the facility, including assistance with activities of daily living.
Special Enrollment Period (SEP)
There are specific circumstances that make you eligible to enroll in a Medicare Advantage plan at any time of the year if you did not take Medicare Part B during the Initial Enrollment Period. If eligible, you qualify for a Special Enrollment Period. The special circumstances that qualify you for an SEP include (but are not limited to) loss of job, change in qualifications to Medicaid, entrance or exit from long-term care facility, a move outside of a plan’s service area, eligible for a Special Needs Plan, or termination of plan contract.
Specified Low-income Medicare Beneficiaries (SLMBS only)
Individuals entitled to Medicare Part A, have income of greater than 100% Federal Poverty Level (FPL) but less than 120% FPL, resources that do not exceed twice the limit for Supplemental Security Income (SSI) eligibility, and are not otherwise eligible for Medicaid. These individuals are eligible for payment of Medicare Part B premiums only and do not qualify for additional Medicaid benefits. Medicaid does not pay toward 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)
Individuals entitled to Medicare Part A, have income of greater than 100% Federal Poverty Level (FPL) but less than 120% FPL, 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 Specified Low-income Medicare Beneficiary (SLMB), and benefits available under the state Medicaid plan. Medicaid does not pay toward out-of-pocket (OOP) costs for the deductible, premium, coinsurance, or copayments for Medicare Part D prescription drug coverage, if applicable.
Special Needs Plan (SNP)
A special type of plan that provides more focused healthcare for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions. The special needs plan will provide a primary provider or care coordinator to manage your care, and services are provided within the plan’s network. Prescription drug coverage is included. Learn about HealthTeam Advantage’s Diabetes & Heart Care HMO CSNP here.
Specialist
A doctor who treats only certain parts of the body, certain health problems, or certain age groups. Click here to see our provider directory.
Step Therapy
It’s a prior authorization process that encourages the use of the most cost-effective and safest medication therapy before progressing (if necessary) to more costly or risky options. Step therapy—It’s a prior authorization process that encourages the use of the most cost-effective and safest medication therapy before progressing (if necessary) to more costly or risky options.
Summary of Benefits (SBs)
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. Click here to learn more about your PPO summary of benefits or your HMO CSNP summary of benefits.
Telehealth
Telehealth, or virtual visits, are remote visits with healthcare providers that take place either by phone or computer. Learn more about HealthTeam Advantage’s telehealth visits here. Link to Telehealth PDF.
Tiers
To have lower costs, many plans place prescription drugs into different tiers, which cost different amounts. Each plan can form their tiers in different ways. Here is an example of how a plan might form its tiers. HealthTeam Advantage has five tiers for its PPO plans and six tiers for its HMO CSNP plan. Learn more about our tiers here. Click here to visit the pharmacy page w/ drug tiers.
Treatment
Something done to help with a health problem; for example, medicine and surgery are treatments.
Tricare
A healthcare program for active duty and retired uniformed services members and their families.
Tricare for Life (TFL)
Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.
TTY (teletypewriter)
A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who do not have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.
Urgently Needed Care
Care that you receive for a sudden illness or injury that needs medical care right away but is not life threatening. Your primary care doctor generally provides urgently needed care if you are in a Medicare health plan other than Original Medicare. If you are out of your plan’s service area for a short time and cannot wait until you return home, the health plan must pay for urgently needed care.
Veterans Administration (VA) Medical Benefits
Healthcare coverage for veterans and individuals who served in the U.S. military. You may be able to get prescription drug coverage through the U.S. Department of Veterans Affairs (VA) program. You may join a Medicare drug plan, but if you do, you cannot use both types of coverage for the same prescription. For more information, call the VA at 800-827-1000, or visit Va.gov. TTY users call 800-829-4833.
