MEDICARE AND HUMANA

Monthly Premium (for people who pay a premium)
$407 each month

Late Enrollment Penalty
-If you don’t buy it when you are 1st eligible your monthly premium goes up 10% (you will have to pay the higher premium for twice the number of years you could have had Part A but you didn’t sign up).
-Enrollment January 1 to March 31 to enroll in Part B
-Coverage will start July 1 of that year.

Home Health Care
$0 home health care services
20% of the Medicare-approved amount for durable medical equipment.

Hospice Care
$0 for Hospice Care
-You may need to pay a co-payment of no more than $5 for each prescription drug and other similar products form pain relief and symptom control while you are at home.
-In rare case it is not covered, Medicare Drug Plan could see if it is covered under Part D.
-You may need to pay 5% of the Medicare-Approved amount for inpatient respite care.
-Medicare doesn’t cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).

Hospital In-patient Stay
$1,260 deductible for each benefit period.
-Days 1 -60 $0 coinsurance for each benefit period.
-Days 61 -90 $315 coinsurance per day of each benefit period.
-Days 91 and beyond $630 coinsurance per each “lifetime reserve day.”
-After day 90 for each benefit period (up to 60 days over your lifetime).
-Beyond lifetime reserve days all costs.

Mental Health Policy
-$1,260 deductible for each benefit period.
-Days 1-60 $0 coinsurance per day of each benefit period.
-Days 61-90 $315 per each day (up to 60 days over lifetime.)
-Days 91 and beyond $630 coinsurance per “lifetime reserve day”. After day 90 for each benefit period (up to 60 days over your lifetime).
-Beyond lifetime reserve days: all costs.
-20% of the Medicare-approved amount for mental health services you get from doctors and other providers while you are a hospital in-patient.
-*There’s NO limit to the number of benefit periods you can have when you get mental healthy care in general hospital. You can also have multiple benefit when you get care in a psychiatric hospital.
-*Lifetime limit to 90 days*

Skilled Nursing Facility Stay
-Days 1-20 = $0 for each benefit period.
-Days 21-100 = $157.50 coinsurance per day of each benefit period.
-Days 101 and beyond = all costs.

Medicare Part B (Medical Insurance)
Monthly Premium
-Most people pay the Part B premium $104.90 each month if you sign up when you are first eligible.
However, if your modified adjusted gross income is reported on your IRS TAX RETURN from 2 years ago, is above a certain amount, you may pay more.

Medicare Part B costs if you have Original Medicare
*All Medicare Advantage Plans must cover these services. If you are in a Medicare Advantage Plan, costs vary by plan and may be either higher or lower than those in Original Medicare.

Medicare Part B Annual Deductible
-You pay $147 per year for your Part B deductible.

Clinical Laboratory Services
-You pay $0 for Medicare-Approved Services
-20% of the Medicare-Approved amount for durable equipment.

Home Health Services
You pay $0 for Home Health Care Services
20% of the Medicare-Approved

Medical & other services
-You pay 20% of the Medicare-Approved amount for most doctor services while you are a hospital in-patient), outpatient therapy and durable medical equipment.

Outpatient Mental Health Services
-You pay nothing for yearly depression screening if your doctor or health care provider accepts assignment.
20% of the Medicare-Approved amount for visits to a doctor or other health care provider to diagnose or treat your condition. The Part B deductible applies.
-If you get your services in a hospital, outpatient clinic or hospital outpatient department, you may have to pay an additional copayment or coinsurance amount to the hospital. This amount will vary depending on the service provided, but will be between 20-40% of the Medicare-Approved amount.

Partial Hospitalization Mental Health Services
-You pay a % percentage of the Medicare-Approved amount for each service you get from a doctor or certain other qualified mental health professionals. If your health care professional accepts assignment.
-You also pay coinsurance for each day of partial hospitalization services provided in a hospital outpatient setting or community mental health center, and the Part B deductible applies.

Outpatient Hospital Services
-You generally pay 20% of the Medicare-Approved amount for the doctor or other health care provider’s services and the Part B deductible applies.
-For all other services, you also generally pay a copayment for each service you get in an outpatient hospital setting. You may pay more for services you get in a hospital outpatient setting than you would pay for the same care in a doctor’s office.
-For some screenings and preventative services, coinsurance, copayments, and the Part B deductible, don’t apply. (so you pay nothing).

Medicare Part C (Medicare Advantage)
Monthly Premium
-The Part C monthly premium varies by plan.
-Deductibles, copayments & coinsurance, they also vary by plan.

Medicare Part D (Medicare Prescription Drug Coverage)
Monthly Premium
-The Part D monthly premium varies by plan (Higher income consumers may pay more).
-Late Enrollment Penalty = The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.
-You may owe a late enrollment penalty if you go without Part D or creditable prescription drug coverage for any continuous period of 63 days or m ore after your initial enrollment period is over.
-In general, you’ll have to pay this penalty for as long as you have a Medicare Drug Plan.
-Deductibles , copayments, & coinsurance. The amo9unt you pay for Part D deductibles, copayments, and or coinsurance varies by plan.

MEDICARE PART A
-Hospital Care
-Skilled Nursing Facility Care
-Nursing Home Care (as long as custodial care you need).
-Hospice
-Home Health Services

Main Factors of Medicare Coverage
-Medicare coverage is based on 3 main factores:
1. Federal and State Laws
2. National coverage decisions made by Medicare about whether something is covered.
3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should in their area.

MEDICARE PART B
-Medicare Part B covers services (like lab tests, surgeries, doctor visits, supplies, like wheelchairs and walkers) considered medically necessary to treat a disease condition.
-Medicare Part B covers 2 types of services:
1. Medically necessary services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
2. Preventive Services = Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.
*You pay nothing for most services if you get the services from a health care provider who accepts assignment.
-Medicare Part B covers things like:
*Clinical Research
*Ambulance Services
*Durable Medical Equipment (DME)
*Mental Health
>Inpatient
>Outpatient
>Partial Hospitalization
_Getting a second opinion before surgery.
-Limited outpatient prescription drugs.

How to find out if Medicare covers what you need?
-There are 2 ways to find out if Medicare covers what you need:
1. Talk to your doctor or health care provider about why you need certain services.
2. Ask if Medicare will cover those services.

Medicare Drug Plans Coverage
-Each Medicare Prescription Drug Plan has its own list of covered drugs (called a FORMULARY).
-Many drug plans place drugs into different ‘tiers” on their formularies.
-Drugs in each tier have a different cost.
-A drug in a lower tier will cost you less than a drug in a higher tier.
-If your drug is in a higher tier and your prescriber thinks you need that drug instead of a similar drug or a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.

How to find out about Prescription Drug coverage
-There are 2 ways to find out about Prescription Drug coverage.
1. Medicare Prescription Drug Plan (Part D)
*Sometimes called (PDP), add coverage to Original Medicare. Some Medicare private fee-for-service (PFFS) plans. Medicare Medical Savings Accounts (MSA) plans.
2. Medicare Advantage Plan (Part C)
*Like an HMO or PPO or other Medicare Health Plan that offers Medicare prescription drug coverage, you get all of your Medicare Part A, Part B and prescription drug Part D through these Plans.
Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PD’s” .
*You must have PART A and PART B to join Medicare Advantage Plan.

Supplement and other Insurance
-If you have Medicare and other health insurance or coverage, each type of coverage is called a “payer”. When there is more than one payer, “coordination of benefits” rules decide which one pays first.
-The “primary payer” pays what it owes on your bills first and then sends the rest to the “secondary payer”.
-In some cases, there may also be a “third payer”.

What is a PRIMARY/SECONDARY PAYER?
-The insurance that pays first is the “Primary Payer” and pays up to the limits of coverage.
-The one that pays second is the “Secondary Payer” and only pays if there are costs the primary insurer didn’t cover.
-The secondary payer (which may be Medicare) may NOT pay all of the uncovered costs.
_If your employer insurances is the secondary payer, you may need to enroll in Medicare Part B, before your insurance will pay.
-If the insurance company doesn’t pay the claim promptly (usually within 120 days), your doctor or other provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then, later recover any payments the primary should have made.

CONDITIONAL PAYMENT
-It is a payment Medicare makes for services another payer may be responsible for. Medicare makes this “conditional payment”, because it must be repaid to Medicare when a settlement, judgment, award, or other payment is made.
-If Medicare makes a conditional payment for an item or service and you get a settlement, judgment, award or other payment for that item or service from an insurance company later, the conditional payment must be repaid to Medicare.
-You are responsible for making sure Medicare gets repaid for those conditional payments.
-Medicare recovers a conditional payment, by you or your representative calling the Benefits Coordination & Recovery Center (BCRC).

What is BCRC?
-BCRC is the Benefits Coordination & Recovery Center
*The BCRC gathers information about any conditional payments, Medicare made related to your pending settlement, judgment, award or other payment.
*The BCRC gets the final repayment amount, on your case and issues a letter requesting repayment.

MEDIGAP
-You must have Medicare Part A and Part B.
-If you have Medicare Advantage Plan you can apply for a Medigap policy, make sure you can leave the MAP before your policy begins.
-You pay the private insurance company a monthly premium for your Medigap policy in addition to the monthly Part B premium that you pay to Medicare.
-A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you will each have to buy separate policies.
-You can buy Medigap policy from any insurance company that is licensed in your state to sell one.
-Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company cant cancel your Medigap policy as long as you pay the premium.
-Some Medigap policies sold in the past cover prescription drugs, but Medigap policies sold after Jan. 1, 2006 aren’t allowed to include prescription drug coverage. You have to join Part D to get prescription drug coverage.
-It is illegal for anyone to sell you a Medigap policy if you have a Medicare Medical Savings Account Plan (MSA).

What MEDIGAP POLICIES don’t cover?
-Long Term Care, vision or dental care, hearing aids, eyeglasses or private-duty nursing.

Insurance Plans that are NOT MEDIGAP
-Medicare Advantage Plans (HMO, PPO, or Private Fee-for-Service Plan)
-Medicare Prescription Drug Plans
-Medicaid
-Employer or union plans, including Federal Employers Health
-TRICARE
-Veteran’s benefits
-Long Term Care insurance policies
-Indian Health Service, Tribal and Urban Indian Health Plans

HUMANA GOLD PLUS
-HMO plans
-You choose a doctor from our broad network of physicians to coordinate your care. These plans have affordable, fixed costs, and offer all the benefits of Original Medicare, plus some added features.
$0 coverage for most annual screenings.
-Choice of a primary care physician in the plan network.
-More predictable out-of-pocket costs that make it easier to budget.
-You and your doctor coordinate all of your care.
-Hospitalization coverage.
-Emergency coverage when you travel outside the united states.
-Prescription drug coverage (some plans do not include drug coverage).

HUMANA CHOICE (PPO)
-Freedom to choose any doctor or hospital that accepts Medicare, but you pay less for services received from
in-network providers.
-Referral-free visits to any doctor nationwide.
-Choose any doctor or hospital (with most plans).
-Affordable monthly plan premiums for most plans.
-Prescription drug coverage equal to or better than the standard requirement for a Medicare Part D plan.
-Emergency coverage anywhere in the world.
-$0 coverage for most annual screenings.
-Your out-of-pocket costs are lower when you choose a provider from Humana’s list of in-network-providers.

HUMANA GOLD CHOICE (PFFS) PLANS
-You are free to visit any doctor who accepts Humana’s terms and conditions of payment. Many Humana Gold Choice Plans combine all the benefits of Original Medicare with prescription drug coverage and more.
-Affordable monthly plan premium
40 coverage for most annual screenings.
-Humana Gold Choice is a Medicare Advantage Private Fee for service (PFFS) plan.
-Prescription drug coverage equal to or better than the standard requirements for a Medicare Part D plan.
-Hospitalization coverage.
-Emergency coverage when you travel outside the U.S.

HUMANA MEDICARE ADVANTAGE SPECIAL NEEDS
-Special Needs plans are a type of Medicare Advantage plan that combines all the benefits of Original Medicare (Part A and Part B) with prescription drug coverage (Part D).
-Special Needs plans provide personalized guidance and resources that help members get the right care and information.
-Unlike other Medicare Advantage plans, Special Needs plans are only available to people with specific conditions who qualify.
-Many of Humana Special Needs plans have a $0 or low monthly premium. Depending on the specific plan, benefits may also include routine dental, vision, hearing, non emergency, transportation, fitness membership, over the counter items and more.

SPECIAL NEEDS PLANS
-Chronic Condition Special Needs
Plans for individuals with one or more of the following conditions: diabetes mellitus, cardiovascular disorders, chronic heart failure, chronic lung disorders
-Humana’s Chronic Condition Special Needs
Offer specialized care by tailoring benefits to help meet the needs of people with conditions like yours and by offering provider choices and drug formularies.
-Dual Eligible Special Needs
For individuals who are entitled to Medicare and who are eligible for some level of assistance from the State Medicaid Program.

STATES THAT OFFER SPECIAL NEEDS PLANS
Alabama, Arkansas, California, Florida, Georgia, Illinois, Kentucky, Louisiana, Maine, Mississippi, Missouri,
New York, North Carolina, Ohio, Puerto Rico, Tennessee, Texas, Virginia and Washington

STATES THAT OFFER CHRONIC CONDITION SPECIAL NEEDS PLANS
Arizona, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Missouri, Mississippi, North Carolina, Nevada, Ohio, Texas and Virginia

Who can enroll in a Special Needs plan?
Anyone who meets the specific eligibility requirements of the plan, lives in the plan’s service area and is enrolled in both Part A and Part B through age or disability.

STATES THAT COVER CARDIOVASCULAR DISORDERS
ARIZONA, FLORIDA, GEORGIA, ILLINOIS, INDIANA, KENTUCKY, LOUISIANA, NORTH CAROLINA, NEVADA, OHIO, VIRGINIA

STATES THAT COVER HEART FAILURE
ARIZONA, FLORIDA, GEORGIA, ILLINOIS, INDIANA, KENTUCKY, LOUISIANA, MISSOURI, NORTH CAROLINA, NEVADA, OHIO, TEXAS, VIRGINIA

STATES THAT COVER DIABETES MELLITUS
ARIZONA, FLORIDA, GEORGIA, ILLINOIS, INDIANA, KENTUCKY, LOUISIANA, MISSOURI, MISSISSIPI, NORTH CAROLINA, OHIO, TEXAS, VIRGINIA

STATES THE COVER LUNG DISORDERS
NEVADA

STATES THAT COVER ESRD (END STAGE RENAL DISEASE)
NEVADA

Accelerated Death Benefit
-This rider provides early access to life insurance in case of a terminal illness. Living benefits are paid to the insured for the medical expenses before death. Benefits paid decrease the benefit payable to beneficiaries, after the insured’s death.

Accepting Assignment
-Refers to those instances when a provider agrees to accept the TRICARE allowable charge (s).

Access
Refers to your ability to obtain medical care.

Access Fee
This is a fee you pay directly to a provider for a service related to a treatment covered by your insurance provider. Some Humana plans have access fees for specific services. These fees are separate from deductibles, coinsurance, or copayment charges. For example, *there is an emergency room access fee that must be paid each time you visit an Emergency Room. The emergency room access fee is waived if you are admitted to the hospital.

Accidental Death Benefit Rider
An additional cash benefit paid in addition to other benefits. When a death is a result of an accident.

Account
For spending accounts, this term refers to the particular type of account (FSA,PCA,HSA) the subscriber participates in.

Account Termination Date
The date a spending account was closed.

Accumulation Period
Length of time an individual has to incur covered expenses to satisfy a required deduction and or calendar year of plan year maximum.

Actively-at-work Provision
Life insurance coverage is not available to employees who are not actively at work on the effective date of the employer’s contract with Humana; employees are covered when they return to work.

Actual Charge
The amount of money a doctor or supplier charges for a specific medical service or supply is the actual charge. This is often higher than the approved amount that you and Medicare pay, because Medicare and insurance companies negotiate lower rates for members.

Adjudication
Processing a claim to determine proper payment is referred to adjudication.

Admission
This refers to your entry into a Medical facility as a registered in-patient according to the rules and regulations of the facility. Your admission ends when you are discharged or released from the facility.

Admitting Physician
The doctor responsible for admitting you into a hospital or other in-patient health facility is referred to as the admitting physician.

Advance Coverage Decision
This is a decision on whether a specific service is covered under your Private Fee-for-Service Plan.

Advanced Imaging
Advanced imaging refers to radiology tests that use complex, highly developed, non-invasive technology to view the interior of the body. Examples include CT SCANS, ULTRASOUND, MRA, and MRI tests.

Age In
When a retiree or eligible dependent becomes Medicare eligible , – usually after turning 65 and is eligible to enroll in the group Sponsored Medicare Advantage Plan.

Allowable Charges
Allowable charges are the maximum amount a benefits plan will pay for a procedure.

Allowed Amount
The allowed amount is the maximum charge allowed for a specific covered medical service or supply.

Ambulatory Care
Any health service that does not require an overnight stay is considered ambulatory care.

Ambulatory Surgical Center
Also know as an in-and-out center, this is a non-hospital location where outpatient surgery is performed. You might stay at an ambulatory surgical center for a few hours after surgery or up to one night following the procedure.

Americans with Disabilities Act (ADA)
The 190 Federal Law prohibits discrimination against people who are disabled and formally describes “disability”

Amount Charged
The amount billed for a specific service.

Amount plan pays
This is the amount you must pay your providers

Amount repaid
On the Expenses Requiring Verification Table, this is the amount deposited back into your spending account because you sent repayment for a non-qualified expense.

Analgesia
Is a reduction or elimination of pain.

Ancillary Services
Services, other than those provider performs, are ancillary services. These might include: x-rays and anesthesia

Anesthesia
Intravenous or non intravenous sedation

Annual Deductible
The amount of covered expenses you must pay in one year before your insurance plan pays any benefits, is your annual deductible. For Medicare Part B, Medicare begins to pay 100% of certain covered expenses as soon as you have met the deductible for the year. Part A and Part B the deductibles are not based on annual cycle but individual benefit periods.

Annual Election
The total amount of FSA or PCA funds the employee selects for the play year. In some cases, the employer determines the FSA or PCA amount.

Annual Maximum
The total amount you will spend between your plan effective date and the end of your plan year.

Annual Election Period
You can enroll in Medicare for the 1st time whenever you become eligible. To change your coverage, though, you need to wait for the annual election period, which runs from Oct. 15 through December 07 of each year.
This is when you can join a Medicare Advantage Plan. You can enroll in Medicare Supplement Plans, however, at anytime if you meet the eligibility requirements.

Advance Beneficiary Notice (ABN)
A provider who thinks that procedure will not be covered by Medicare because it will be deemed not reasonable and necessary, must notify the patient before the treatments, using a standard ABN from CMS.

Carriers (Medicare contractors)
Insurance companies that process claims for physicians, suppliers, and providers for Medicare Part B.

Except for exception of this Medicaid is payor of last resort
Bureau for Children with Medical Handicaps

Fiscal Intermediaries (Medicare contractors)
Insurance organization that processes claims for hospitals, skilled nursing facilities, intermediate care facilities, long term care facilities and home health care agencies for Medicare Part A

IM FORM AND SIGNED 3 TIMES
1. REGISTRATION
2. ARRIVAL ON THE FLOOR
3. DATE OF DISCHARGE

Limiting Charge for a Non Par
115% of the physician fee schedule amount (Medicare fee schedule). The beneficiary is not responsible for billed amounts in excess of the limiting charge for a covered service.

Medical Savings Accoount (MSA)
This a type of Medicare Advantage plan that combines a high-deductible health plan with a medical savings account.

Medicare Modernization Act (MMA)
Short name for Medicare Prescription Drug. Improvement and modernization Act of 2003

Medicare Remittance Notice (MRN)
Remittance advice from Medicare providers that explains how payments for Medicare claims were determined.

MSP Questionnaire
Medicare secondary payer. Federal law that requests private papers to be completed (10 questions) who provide health insurance to Medicare beneficiaries to be the primary payer. Completed on every visit. Used to determine medical billing priority.

Medicare Summary Notice (MSN)
Type of remittance advice from Medicare to plan beneficiaries to explain how their benefits were determined.

NonPar Medicare Providers
Providers who choose not to participate in the Medicare program but who accepts assignment on a claim are paid 5% less for their service than a PAR Provider.

Notice of Exclusions from Medicare Benefits (NEBM)
CMS form that can be used by participating providers to give Medicare patients, before providing an uncovered service such as screening test, written notification that Medicare will not pay an estimated charge for which the patient will be responsible for.

Advance coverage decision
A notice you get from a Medicare Advantage Plan letting you know in advance whether it will cover a particular service.

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.

ALS
Amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease.

Angina pectoris
Chest pain.

Angioplasty
A medical procedure used to open a blocked artery.

Appeal
An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan.

You have the right to appeal if Medicare, your Medicare health plan, or your Medicare drug plan denies one of these:
A request for a health care service, supply, item, or prescription drug that you think you should be able to get
A request for payment of a health care service, supply, item, or prescription drug you already got
A request to change the amount you must pay for a health care service, supply, item, or prescription drug

You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need.

Assignment
An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)
A type of QIO (an organization of doctors and other health care experts under contract with Medicare) that uses doctors and other health care experts to review complaints and quality of care for people with Medicare. The BFCC-QIO makes sure there is consistency in the case review process while taking into consideration local factors and local needs, including general quality of care and medical necessity.

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 SNF. 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 SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Benefits
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents.

Benefits Coordination & Recovery Center
The company that acts on behalf of Medicare to collect and manage information on other types of insurance or coverage that a person with Medicare may have, and determine whether the coverage pays before or after Medicare. This company also acts on behalf of Medicare to obtain repayment when Medicare makes a conditional payment, and the other payer is determined to be primary.

CHAMPVA
A health care benefit for dependents of qualifying veterans.

Children’s Health Insurance Program (CHIP)
Insurance program jointly funded by state and federal government that provides health coverage to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but can’t afford to purchase private health insurance coverage.

Claim
A request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered.

Clinical breast exam
An exam by your doctor or other health care provider to check for breast cancer by feeling and looking at your breasts. This exam isn’t the same as a mammogram and is usually done in the doctor’s office during your Pap test and pelvic exam.

Coinsurance
An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

Comprehensive outpatient rehabilitation facility
A facility that provides a variety of services on an outpatient basis, including physicians’ services, physical therapy, social or psychological services, and rehabilitation.

Coordination of benefits
A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.

Copayment
An amount you may be 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. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.

Coronary stent
A device used to keep an artery open.

Cost sharing
An amount you may be 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:
Whether a particular drug is covered
Whether you have 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

The drug plan must give you a prompt decision (72 hours for standard requests, 24 hours for expedited requests). If you disagree with the plan’s 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 hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year.

Creditable coverage (Medigap)
Previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy.

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, if they decide to enroll in Medicare prescription drug coverage later.

Critical access hospital (CAH)
A small facility that provides outpatient services, as well as inpatient services on a limited basis, to people in rural areas.

Custodial care
Non-skilled personal care, like help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.

Deemed status
A provider or supplier earns this when they have been accredited by a national accreditation program (approved by the Centers for Medicare & Medicaid Services) that they demonstrate compliance with certain conditions.

Demonstrations
Special projects, sometimes called “pilot programs” or “research studies,” that test improvements in Medicare coverage, payment, and quality of care. They usually operate only for a limited time, for a specific group of people, and in specific areas.

Dental coverage
Benefits that help pay for the cost of visits to a dentist for basic or preventive services, like teeth cleaning, X-rays, and fillings.

Department of Health and Human Services (HHS)
The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP).

Diagnostic mammogram
An X-ray exam of the breast in a woman who either has a breast problem or has had a change show up on a screening mammogram.

Diethylstilbestrol (DES)
A drug given to pregnant women from the early 1940s until 1971 to help with common problems during pregnancy. The drug has been linked to cancer of the cervix or vagina in women whose mother took the drug while pregnant.

DME Medicare Administrative Contractor (MAC)
A private company that contracts with Medicare to pay bills for durable medical equipment.

Drug list
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. This list is also called a formulary.

Durable medical equipment
Certain medical equipment, like a walker, wheelchair, or hospital bed, that’s ordered by your doctor for use in the home.

Durable power of attorney
A legal document that names someone else to make health care decisions for you. This is helpful if you become unable to make your own decisions.

Employer or union retiree plans
Plans that give health and/or drug coverage to employees, former employees, and their families. These plans are offered to people through their (or a spouse’s) current or former employer or employee organization.

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 or your prescriber must request an exception, and your doctor or other prescriber must provide a written supporting statement explaining the medical reason for the exception.

Excess charge
If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.

Extra Help
A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.

Federally qualified health center
Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally qualified health centers provide primary care services even if you can’t afford it. Services are provided on a sliding scale fee based on your ability to pay.

Formulary
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.

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. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.

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.

Group health plan
In general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.

Guaranteed issue rights (also called “Medigap protections”)
Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, like exclusions for pre-existing conditions, and can’t charge you more for a Medigap policy because of a past or present health problem.

Guaranteed renewable policy
An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable.

Health care provider
A person or organization that’s licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.

Health coverage
Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment, or a government program like Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).

Health Insurance Marketplace
A resource where individuals, families, and small businesses can learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Marketplace, and information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace encourages competition among private health plans, and is accessible through websites, call centers, and in-person assistance. In some states, the Marketplace is run by the state. In others it’s run by the federal government.

Health Insurance Portability and Accountability Act of 1996 (HIPAA
The “Standard for Privacy of Individually Identifiable Health Information (also called the “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.

High-deductible Medigap policy
A type of Medigap policy that has a high deductible but a lower premium. You must pay the deductible before the Medigap policy pays anything. The deductible amount can change each year.

Homebound
To be homebound means:
You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury, or
Leaving your home isn’t recommended because of your condition, and you’re normally unable to leave your home because it’s a major effort

You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.

Home health agency
An organization that provides home health care.

Home health care
Health care services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. 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.

Hospital outpatient setting
A part of a hospital where you get outpatient services, like an emergency department, observation unit, surgery center, or pain clinic.

Hospital-related medical condition
Any condition that was treated during your qualifying 3-day inpatient hospital stay, even if it wasn’t the reason you were admitted to the hospital.

Independent reviewer
An organization (sometimes called an Independent Review Entity or IRE) that has no connection to your Medicare health plan or Medicare Prescription Drug Plan. Medicare contracts with the IRE to review your case if you appeal your plan’s payment or coverage decision or if your plan doesn’t make a timely appeals decision.

Initial coverage limit
Once you’ve met your yearly deductible, you’ll pay a copayment or coinsurance for each covered drug until you reach your plan’s out-of-pocket maximum (or initial coverage limit). You’ll then enter your plan’s coverage gap (also called the “donut hole”).

In-network
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.

Inpatient care
Health care that you get when you’re admitted to a health care facility, like a hospital or skilled nursing facility.

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.

Inpatient hospital services
Services you get when you’re admitted to a hospital, including bed and board, nursing services, diagnostic or therapeutic services, and medical or surgical services.

Inpatient prospective payment system (IPPS)
Hospitals that have contracted with Medicare to provide acute inpatient care and accept a predetermined rate as payment in full.

Inpatient rehabilitation facility
A hospital, or part of a hospital, that provides an intensive rehabilitation program to inpatients.

Large group health plan
In general, a group health plan that covers employees of either an employer or employee organization that has at least 100 employees.

Lifetime reserve days
In Original Medicare, these are additional days that Medicare will pay for when you’re in a hospital for more than 90 days. You have a total of 60 reserve days that can be used during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.

Limiting charge
In Original Medicare, the highest amount of money you can be charged for a covered service by doctors and other health care suppliers who don’t accept assignment. The limiting charge is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment.

Living will
A written legal document, also called a “medical directive” or “advance directive.” It shows what type of treatments you want or don’t want in case you can’t speak for yourself, like whether you want life support. Usually, this document only comes into effect if you’re unconscious.

Long-term care
Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living, like dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living, or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.

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.

Long-term Care Ombudsman
Long-Term Care Ombudsman are advocates for residents of nursing homes, board and care homes, assisted living facilities, and similar
adult care facilities. They work to resolve problems of individual residents and to bring about changes at the local, state, and national
levels that will improve residents’ care and quality of life. They may be able to provide information about home health agencies in your area.

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.

Medicaid-certified provider
A health care provider (like a home health agency, hospital, nursing home, or dialysis facility) that’s been approved by Medicaid. Providers are approved or “certified” if they’ve passed an inspection conducted by a state government agency.

Medicaid office
A state or local agency that can give information about, and assist with applications for, Medicaid programs that help pay medical bills for people with limited income and resources.

Medical emergency
When you believe you have an injury or illness that requires immediate medical attention to prevent a disability or death.

Medically necessary
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

Medical underwriting
The process that an insurance company uses to decide, based on your medical history, whether to take your application for insurance, whether to add a waiting period for pre-existing conditions (if your state law allows it), and how much to charge you for that insurance.

Medicare
Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Medicare Administrative Contractor (MAC)
A company that processes claims for Medicare.

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, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most 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-approved amount
In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.

Medicare-approved supplier
A company, person, or agency that’s been certified by Medicare to give you a medical item or service, except when you’re an inpatient in a hospital or skilled nursing facility.

Medicare-certified provider
A health care provider (like a home health agency, hospital, nursing home, or dialysis facility) that’s been approved by Medicare. Providers are approved or “certified” by Medicare if they’ve passed an inspection conducted by a state government agency. Medicare only covers care given by providers who are certified

Medicare Cost Plan
A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services or urgently needed services).

Medicare Health Maintenance Organization (HMO) Plan
A type of Medicare Advantage Plan (Part C) available in some areas of the country. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Most HMOs also require you to get a referral from your primary care physician.

Medicare health plan
Generally, a plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs. Programs of All-inclusive Care for the Elderly (PACE) organizations are special types of Medicare health plans that can be offered by public or private entities and provide Part D and other benefits in addition to Part A and Part B benefits

Medicare Medical Savings Account (MSA) Plan
MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins.

Medicare Part A (Hospital Insurance)
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)
Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services

Medicare plan
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 Preferred Provider Organization (PPO) Plan
A type of Medicare Advantage Plan (Part C) available in some areas of the country 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 for an additional cost.

Medicare 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

Medicare Prescription Drug Plan (Part D)
Part D 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.

Medicare Private Fee-For-Service (PFFS) Plan
A type of Medicare Advantage Plan (Part C) in which you can generally go to any doctor or hospital you could go to if you had Original Medicare, if the doctor or hospital agrees to treat you. The plan determines how much it will pay doctors and hospitals, and how much you must pay when you get care. A Private Fee-For-Service Plan is very different than Original Medicare, and you must follow the plan rules carefully when you go for health care services. When you’re in a Private Fee-For-Service Plan, you may pay more or less for Medicare-covered benefits than in Original Medicare.

Medicare Savings Program
A Medicaid program that helps people with limited income and resources pay some or all of their Medicare premiums, deductibles, and coinsurance.

Medicare SELECT
A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

Medicare 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, like those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic medical conditions.

Medicare Summary Notice (MSN)
A notice you get after the doctor, other health care provider, or supplier files a claim for Part A or Part B services in Original Medicare. It explains what the doctor, other health care provider, or supplier billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.

Medigap basic benefits
Benefits that all Medigap policies must cover, including Part A and Part B coinsurance amounts, blood, and additional hospital benefits not covered by Original Medicare.

Medigap Open Enrollment Period
A one-time-only, 6-month period when federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.

Medigap policy
Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage.

Multi-employer plan
In general, a group health plan that’s sponsored jointly by 2 or more employers.

Network
The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.

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-preferred 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.

Occupational therapy
Treatment that helps you return to your usual activities (like bathing, preparing meals, and housekeeping) after an illness

Optional supplemental benefits
Services that Medicare doesn’t cover, but that a Medicare health plan may choose to offer. If you enroll in a plan with these services, you may choose to buy the services. If you choose to buy these benefits, you’ll pay for them directly, usually as a premium, copayment, and/or coinsurance. These services may be offered individually or as a group of services, and they may be different for each Medicare health plan.

Original Medicare
Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).

Out-of-network
A benefit that may be provided by your Medicare Advantage plan. Generally, this benefit gives you the choice to get plan services from outside of the plan’s network of health care providers. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.

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 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.

Pap test
A test to check for cancer of the cervix, the opening to a woman’s uterus. It’s done by removing cells from the cervix. The cells are then prepared so they can be seen under a microscope.

Patient lifts
A medical device used to lift you from a bed or wheelchair

Pelvic exam
An exam to check if internal female organs are normal by feeling their shape and size.

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.

Podiatrist
Foot doctor

Point-of-service option
In a Health Maintenance Organization (HMO), this option lets you use doctors and hospitals outside the plan for an additional cost.

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. 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.

Pre-existing condition
A health problem you had before the date that new health coverage starts

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 non-preferred pharmacy.

Premium
The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

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 doctor
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. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.

Prior authorization
Approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered by your plan.Your Medicare drug plan may require prior authorization for certain drugs.

Programs of All-inclusive Care for the Elderly (PACE
A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically necessary care and services based on your needs as determined by an interdisciplinary team. PACE serves frail older adults who need nursing home services but are capable of living in the community. PACE combines medical, social, and long-term care services and prescription drug coverage.

Protective sensations
Feeling in the foot or leg that helps warn you that the skin is being injured. Nerve damage caused by diabetes can cause loss of feeling in the foot or leg, also known as “loss of protective sensations (LOPS).” This may result in skin loss, blisters, or ulcers.

Qualified Disabled and Working Individuals (QDWI) Program
A state program that helps pay Part A premiums for people who have Part A and limited income and resources

Qualified Individual (QI) Program
A state program that helps pay Part B premiums for people who have Part A and limited income and resources.

Qualified Medicare Beneficiary (QMB) Program
A state program that helps pay Part A premiums, Part B premiums, and other cost-sharing (like deductibles, coinsurance, and copayments) for people who have Part A and limited income and resources.

Referral
A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

Rehabilitation services
Health care services that help you keep, get back, or improve skills and functioning for daily living that you’ve lost or have been impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Religious nonmedical health care institution
A facility that provides nonmedical health care items and services to people who need hospital or skilled nursing facility care, but for whom that care would be inconsistent with their religious beliefs.

Respite care
Temporary care provided in a nursing home, hospice inpatient facility, or hospital so that a family member or friend who is the patient’s caregiver can rest or take some time off.

Rural health clinic
A federally qualified health center (FQHC) that provides health care services in rural areas where there’s a shortage of health care services.

Screening mammogram
A medical procedure to check for breast cancer before you or a doctor may be able to find it manually.

Secondary payer
The 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.

Service area
A geographic area where a health insurance plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of the plan’s service area.

Skilled nursing care
Care like intravenous injections that can only be given by a registered nurse or doctor.

Skilled nursing facility (SNF)
A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

Skilled nursing facility care
Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility (SNF).

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.

Speech-language therapy (speech-language pathology services)
Treatment that helps you strengthen or regain speech, language, and swallowing skills.

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.

State Insurance Department
A state agency that regulates insurance and can provide information about Medigap policies and other private health insurance.

State Pharmaceutical Assistance Program (SPAP)
A state program that provides help paying for drug coverage based on financial need, age, or medical condition.

State Survey Agency
A state agency that oversees health care facilities that participate in the Medicare and/or Medicaid programs. The State Survey Agency inspects health care facilities and investigates complaints to ensure that health and safety standards are met.

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.

Subluxation
When one or more of the bones of your spine move out of position.

Supplemental Security Income (SSI)
A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 or older. SSI benefits aren’t the same as Social Security retirement or disability benefits.

Supplier
Generally, any company, person, or agency that gives you a medical item or service, except when you’re an inpatient in a hospital or skilled nursing facility.

Telemedicine
Medical or other health services given to a patient using a communications system (like a computer, phone, or television) by a practitioner in a location different than the patient’s.

Tiers
Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.

TRICARE
A health care 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
A TTY (teletypewriter) is a communication device used by people who are deaf, hard-of-hearing, or have severe speech impairment. People who don’t 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 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.

Workers’ compensation
An insurance plan that employers are required to have to cover employees who get sick or injured on the job.

Applied reserve
The amount of Coordination of Benefits (COB) savings from prior claims applied to pay allowable expenses on subsequent claims. This amount is not otherwise paid by the primary other insurance and regular plan benefits.

Appeal (Individual & Family)
An appeal is a written request from the enrolled member or the enrolled member’s authorized representative, a non-network provider, or court- appointed guardian to reconsider our initial adverse determination to deny coverage of service or payment of a claim, including delay in providing, arranging or approving the healthcare service.

Appeal (Medicare)
You can file an appeal if you were denied a request for healthcare services or payment for services you already received. You can also appeal if you disagree with a decision to stop services you are receiving. Medicare Advantage and Medicare prescription drug plan carriers as well as Medicare Parts A and B must follow a specific process when you ask for an appeal.

Authorization for care
This refers to the determination that the requested treatment is medically necessary, delivered in the appropriate setting, a TRICARE benefit, and that the treatment will be cost-shared by the Department of Defense.

Balance billing
This is a condition under Private Fee-for-Service Plans where some physicians can charge and bill you 15% more than the plan’s payment amount for services

Beneficiary (Medicare)
The beneficiary is the person who has health insurance through the Medicare or Medicaid program.

Beneficiary (TRICARE)
A beneficiary is a person who is eligible for TRICARE benefits. Beneficiaries include Active Duty Family Members (ADFMs) and retired service members and their families. Family members include spouses and unmarried children, adopted children, or stepchildren up to the age of 21 (or 23 if full-time student at approved institutions of higher learning and the sponsor provides more than 50% of the financial support). Other beneficiary categories are listed in the TRICARE Eligibility section of your handbook.

Benefit accumulations
This is the amount that has been paid for a covered person during the calendar year or plan year.

Benefit booklet
This is a booklet or pamphlet you receive once you enroll in HumanaDental. It contains a general explanation of the benefits. It is also known as Summary Plan Descriptions.

Benefit plan
A benefit plan covers costs associated with certain dental services. In addition to paying premiums for your benefits, you may be responsible for deductibles, coinsurance, and/or maximums.

Benefit plan document
Generic term for a legal document detailing a member’s or group’s coverage. This document usually is referred to as a Certificate of Coverage, Certificate of Insurance, or Summary Plan Description.

Benefit summary
A brief description or outline of your plan’s coverage, your benefit summary includes the amounts or percentage you pay for certain services, the amounts or percentage your plan pays, and the services for which coverage is limited or excluded.

Benefits
This is the medical — also dental and pharmacy — care for you and your dependents that’s covered by your insurance either directly or through reimbursement.

Benefits maximum
This is the highest dollar amount your health plan will pay toward your medical costs over the course of a plan year.

Billed claims
This is the amount providers bill for the services they provide

Billing provider
Any eligible person, physician, doctor’s office, hospital, dentist or facility licensed to perform services for our members is a billing provider.

Calendar year
The 12-month period that begins on January 1 and ends on December 31 is the calendar year. When you enroll in Medicare, coverage begins on the effective date of your policy and ends on the following December 31.

Capitation
Method of payment for health services in which a dentist or specialist is paid a fixed amount for each person served regardless of the number or nature of services provided to each person, usually associated with a prepaid/HMO.

Catastrophic cap
This is the maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given fiscal year (October 1 to September 30). Point-Of-Service (POS) cost-shares and the POS deductible are not applied to the catastrophic cap.

Catastrophic coverage
Offered with Medicare Part D, catastrophic coverage is designed to prevent you from having to pay very high out-of-pocket expenses. Once you have spent a pre-determined amount on your healthcare within a year, you will pay no more than 5% for each prescription drug. You will still need to pay your monthly premiums for the plan.

Catastrophic illness
A catastrophic illness is a very serious and costly health problem 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.

Certificate of coverage
A description of the benefits included in a benefit insurer’s plan, the certificate of coverage is required by state law and explains the coverage provided under the contract.

Certificate of insurance
This certificate serves as proof of insurance and outlines benefits and provisions

CHAMPUS Maximum Allowable Charge (CMAC)
CMAC is a nationally determined allowable charge level that is adjusted by locality indices and is equal to or greater than the Medicare Fee Scheduled amount. CMAC is the TRICARE-allowable charge for covered services when appropriately applied to services priced under CMAC.

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
CHAMPVA is the federal health benefits program for eligible family members of 100% totally and permanently disabled Veterans. CHAMPVA is administered by the Department of Veterans Affairs and is a separate federal program from the Department of Defense TRICARE program. For questions regarding CHAMPVA, call 1-800-733-8387 or email [email protected]

Claim
A claim is information submitted by a provider or covered person for reimbursement for services or materials

Claim ID
The number that uniquely identifies the claim Customer Care can use this number to track your claim if you have questions.

Claim number
A number assigned by Humana to identify a claim internally

Claim status
The amount of Coordination of Benefits (COB) savings from prior claims applied to pay allowable expenses on subsequent claims. This amount is not otherwise paid by the primary other insurance and regular plan benefits.

Claim type
On the spending account Claim Form, this is the type of expense incurred, such as a healthcare expense for you, a spouse, or a dependent.

Claims review
Review of a claim is done before reimbursement is submitted to the provider or subscriber.

Closed panel
With a closed panel, you can only receive benefits if services are performed by providers who have signed an agreement with Humana to provide treatment to eligible patients.

COBRA
This law requires employers to offer continued benefits coverage to employees who have had their benefits terminated.

Coinsurance
After you pay any plan deductibles, you may still be responsible for a percentage of the billed charges for services you received. This is called coinsurance. For instance, if your health plan pays 70% of billed charges, your coinsurance payment is the remaining 30%.

Continuation
Continuation refers to a state or federal (COBRA) option for a member who no longer qualifies as an active employee but can extend his or her insurance coverage for a specific amount of time. The member is responsible for any premium. This generally applies to medical coverage only, but can include dental depending on legislation and group size. Coverage and premium are the same as the group’s.

Contract fee schedule plan
In this plan, participating providers agree to accept set fees for treatment.

Contract provider
This refers to a provider who agrees to abide by special terms, conditions, and reimbursement arrangements.

Contract types
Types of contracts or plans include Traditional, PPO, or Prepaid/DHMO selected.

Contract year
This is the period of time from the effective date of the contract to the expiration date of the contract.

Coordination of Benefits
If you have multiple benefits plans, the COB determines which plan pays benefits first.

Coordination of benefits (Dental)
Provision in a contract that applies when a person is covered by more than one group dental program, the coordination of benefits requires that all programs coordinate payment of benefits to eliminate overinsurance or duplication of benefits.

Coordination of benefits (Medicare)
If you have more than one health plan or insurance policy that covers the same benefits the coordination of benefits process will be used to determine which plan should pay first. If one of the plans is a Medicare health plan, federal law may decide who pays first. This is also called cross-over.

Copay
Copays are cost-sharing arrangements in which you pay a specified charge at the time for service for example, $15 for an office visit.

Copayment
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 or out-of-pocket maximums.

Cost sharing
Cost sharing is the amount you pay for medical care or prescription drugs yourself. This may include a copayment, coinsurance, or deductible.

Coverage
Coverage refers to the benefits offered as part of your dental plan.

Coverage gap
There is a coverage gap for Medicare Part D in which you will be responsible for 100% of drug costs as your expenses for prescriptions exceed ordinary coverage but don’t yet meet the out-of-pocket threshold. To protect yourself, you should have what is called Donut Hole Coverage.

Covered benefit
A covered benefit is a health service or item your health plan pays for either partially or in full.

Covered entity
Under HIPAA, this is a health plan, a healthcare clearinghouse, or a healthcare provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Covered expenses
These are qualifying costs that you incur and which your plan may pay or reimburse you for in accordance with the terms of your policy.

Covered person
This refers to an individual who meets a health plan’s eligibility requirements and has paid the required premiums for coverage.

Covered services
These are qualifying services performed by your provider and which your plan may pay for or reimburse you for in accordance with the terms of your policy.

Covered services (Medicare)
Services a health plan pays for in part or in full, a covered service is defined and limited by statute. For instance, covered services under Medicare Supplement plans include most doctor services, care in outpatient departments of hospitals, diagnostic tests, durable medical equipment, ambulance services, and other health services that are not covered by Medicare Part A.

Credentialing
This is the process of approving a provider to participate in a benefit plan.

Creditable coverage (prescription drug plans)
This refers to prescription drug coverage (such as plans offered by an employer or union) that pays out, on average, as much as or more than Medicare’s standard prescription drug coverage.

Current amount
On the spending account Expenses Requiring Verification Table, this is the amount remaining that needs to be validated or repaid.

Date of service
This is the date when service was provided.

Date posted
For spending accounts, this is the date the transaction was completed and applied to your account.

Date processed
The date Humana processed a claim. Providers can expect to receive payment in 7-14 days, depending on the provider payment arrangement.

Deadline to verify
On the spending account Expenses Requiring Verification Table, this is last date you are able to verify an expense was eligible for spending account reimbursement.

Decline reason
On the spending account Declined Card Transactions Table, this is why Humana denied payment for a certain amount or transaction.

Deductible
The amount that you — either by yourself or in combination with other covered family members — pay for covered in-network services each year before the plan pays for specified services is your deductible. There is also a separate out-of-network deductible.

Deductible carry-over credit
These charges, applied to the deductible for services during the last months of a calendar year, may be used towards the next year’s deductible.

Defense Enrollment Eligibility Reporting System (DEERS)
A database of uniformed service members (sponsors), family members, and others worldwide who are entitled under law to military benefits, including TRICARE. Beneficiaries are required to keep DEERS updated. Refer to the TRICARE Eligibility section of your handbook for more information.

Dental coverage
Your dental coverage is the benefit that you pay premiums for. Your coverage will pay certain approved costs associated with preventing and treating dental disease.

Dental Health Maintenance Organization (DHMO)
DHMOs accept responsibility and financial risk for providing you with specified dental services during a set period of time at a fixed price. As a member, you receive comprehensive care through designated providers.

Dependent
A dependent is an individual who is eligible for benefits through a spouse, parent, or other family member.

Dependent coverage
Insurance coverage that extends to your dependents, including spouse and dependent children, is known as dependent coverage.

Deposits to date
For spending accounts, this is the total amount contributed to your spending account as of a certain date.

Description
On the spending account Account Activity Tables, this is an explanation of the type of transaction or the type of provider. On the Claim Form, it is the type of service or procedure performed.

Designated Provider (DP)
Under the US Family Health Plan (USFHP), DPs, formerly known as uniformed services treatment facilities, are selected civilian medical facilities around the United States assigned to provide care to eligible and enrolled USFHP beneficiaries — including those who are age 65 and older — who live within the DP area. At these DPs, the USFHP provides TRICARE Prime benefits and cost-shares for eligible persons who enroll in USFHP, including those who are Medicare-eligible

Disability benefit
This benefit is payable under a disability income policy.

Disabled enrollee
An individual under age 65 who has been entitled to disability benefits for at least two years may receive Medicare Part B benefits as a disabled enrollee

Disclosure
This refers to the release of information by an entity to others not affiliated with that entity.

Disenroll
You disenroll when you end your coverage with a health plan.

DOB
This stands for date of birth.

Document number
The nine-digit number assigned by Humana to each document it receives is called the document number

Drug discount program
A discount drug program offers members of that program special savings on medications not covered by their pharmacy benefit plan.

Dual eligibles
People who are entitled to Medicare and eligible for Medicaid are dual eligible

Durable Medical Equipment (DME)
DMEs refer to certain purchased or rented items that are prescribed by a healthcare provider for use in a patient’s home. Examples of durable medical equipment Medicare might cover include hospital beds, iron lungs, oxygen equipment, seat lift equipment, and wheelchairs.

Effective date
This is the date on which your coverage begins

Effective date (HumanaOne)
People who are entitled to Medicare and eligible for Medicaid are dual eligible.

Electronic Data Interchange (EDI)
A method of enrollment where the enrollment information for the retiree is provided by the group benefits administrator to Humana in an electronic file, the EDI includes necessary information such as your HCFA number, geographic data and date of birth

Eligibility
Requirements that you must meet if you wish to be insured are called eligibility requirements.

Eligibility date
This is the date on which you become eligible to apply for benefits under the benefit plan.

Eligibility period
The eligibility period is a specified length of time, following the eligibility date, during which you remain eligible to apply for benefits under a benefit plan without evidence of insurability.

Eligibility: Medicaid
This refers to the process in which the state decides whether or not you are qualified for healthcare coverage through the Medicaid program.

Eligible dependent
This is a dependent, such as a spouse or a child, who qualifies to receive coverage under your insurance plan. As the policy holder, you may need to pay an additional premium to cover an eligible dependent.
In most states, you can enroll children who are between 2 weeks old and 25 years old in a HumanaOne health benefits plan. Qualifications for eligible dependents may vary for Short-Term Medical plans.

Eligible expenses
This is either the maximum allowable charge or a set service fee for dental or vision services and supplies — whichever is lower — that your plan will cover.

Eligible Person
This includes former employees (or their eligible dependents) of a group and its participating affiliates who are eligible to participate in a Medicare Advantage plan

End date
This refers to the date on which your member coverage ends.

Enrollee
This refers to an individual covered by a benefit plan.

Enrollment booklet
This booklet or pamphlet contains a general explanation of your plan’s benefits. It is also known as Summary Plan Descriptions.

Enrollment period
This refers to the range of days during which you can join a Medicare health plan if it is open and accepting new Medicare members. If a health plan chooses to be open for enrollment, it must allow any eligible person with Medicare to join.

EOB
An EOB is the Explanation of Benefits that explains how your plan will pay your claim.

Estimate
An estimate includes details on how benefits would be covered by a member’s plan when a dentist submits an estimate of services.

Estimated retail price
This is the average cost of a drug on the open market. This price is calculated from a national average wholesale price and does not take into account a prescription drug benefit, the actual cost of a specific drug, mail-order savings, or possible reimbursements to the dispensing pharmacy. Pricing may vary by pharmacy and by the specific quantity, strength, and dosage of the medication. You should always contact your pharmacy for details on pricing for specific medications.

Evidence of coverage
This is a complete list of your benefits under a Medicare Advantage plan.

Evidence of Coverage (EOC)
A CMS approved document that details plan benefits and services, the EOC includes CMS mandated amendments that may occur during the year. All Humana Group Medicare enrolled members, will receive a copy of the EOC as well as any amendments that are mandated during the plan year.

Evidence of insurability
Medical information that shows an individual is medically eligible for insurance coverage is known as evidence of insurability. You may or may not need to provide this information, depending on your employer’s contract with Humana.

Excluded amount
The amount that was excluded from payment consideration. For example, if the doctor has a discounted arrangement with Humana, that amount will show up in this space with an explanation below. In such a situation, you are not responsible for this amount.

Exclusions
Services not covered under your benefit plan are referred to as exclusions.

Exclusive Provider Organization (EPO)
If you belong to an EPO, you must receive care from affiliated providers; services rendered by unaffiliated providers are not reimbursed

Expenses requiring verification
For spending accounts, these are expenses that Humana’s systems have not verified. You may need to submit receipts or copies of Explanation of Benefits (EOBs) for these expenses to meet IRS and plan requirements.

Explanation of Benefits (EOB)
The EOB is not a bill. It details how the claim was processed and indicates the portion of the claim paid to the dentist and the portion of the claim you need to pay (if applicable).

Extended Care Health Option (ECHO)
ECHO is a supplemental program to the TRICARE basic program. It provides eligible and enrolled ADFMs with additional benefits for an integrated set of services and supplies designed to assist in the treatment and/or reduction of the disabling effects of the beneficiary’s qualifying condition. Qualifying conditions may include moderate or severe mental retardation, a serious physical disability, or an extraordinary physical or psychological condition such that the beneficiary is homebound.

Family deductible
Deductible that may be satisfied by the combined expenses of all covered family members.

Fee schedule
This is a list of the charges for specific services that a provider agrees to.

Final claims deadline
For spending accounts, this is the last date a claim can be filed and still be reimbursed out of your spending account.

Flexible Spending Account
An employer-sponsored spending account that allows subscribers to contribute, on a pre-tax basis through paycheck deduction, to a Healthcare FSA or Dependent Care FSA. As you incur eligible expenses, outlined by the IRS, you may request reimbursement from the FSA. Any reimbursements you receive from these accounts remain tax-free when they are paid to you.

Flexible Spending Account – dependent care
An employer-sponsored spending account that allows subscribers to contribute funds on a pre-tax basis through paycheck deduction. Employees can use a Dependent Care FSA to pay for IRS-approved dependent care services, such as child day care, adoption-related costs, and adult care.

Flexible Spending Account – healthcare
An employer-sponsored spending account that allows subscribers to contribute funds on a pre-tax basis through paycheck deduction. Employees can use a Healthcare FSA to pay for qualified medical expenses not covered under the health plan.

Formulary
The formulary is a list of medications your plan covers (also known as a drug list). Humana’s Medicare Drug List shows which drugs are covered and which drug tier they are in — Preferred Generic, Preferred Brand, Non-Preferred Brand, or Specialty. See the definition for drug tier.

FSA grace period
Time when you can still incur expenses and pay for them with any remaining dollars from your previous plan year. This feature is not available to all; check with your employer.

Generic prescription drugs
Generic drugs use the chemical name of the drug and are less expensive than brand-name drugs. They’re chemically identical to their name-brand counterparts and meet Food and Drug Administration (FDA) standards for safety, purity, and effectiveness.

Grace period
A specified period following the date a premium payment is due is called a grace period.

Grievance
A grievance is a complaint about the manner of service provided by a healthcare provider. For example, you may file a grievance when a facility you visited was not clean, staff at a facility behaved unprofessionally, or there was a problem related the operating hours. A complaint about a treatment or coverage decision should be filed as an appeal. See the definition for appeal.

Grievance procedure
Through this procedure, a member of a plan or a provider of benefits may express complaints and receive a response.

Group
Used interchangeably with employer, group benefits administrator, and contract holder.

Group certificate
This document shows the benefits provided under the group contract.

Group ID
Number assigned to each case or group when Humana receives the application, this ID identifies the group in Humana’s computer system and remains with the account permanently.

Guaranteed insurability
This is an option that enables you to buy additional life insurance without being required to provide evidence of insurability.

Guaranteed issue amount
This provision allows a certain amount of insurance to be issued without evidence of insurability.

Health Maintenance Organization – HMO (Medicare)
HMOs are a type of Medicare Advantage Plan available in select areas of the country. Plans must cover all Medicare Part A and Part B healthcare. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Your costs may be lower than in Medicare Parts A and B only. Get more information on Humana Gold Plus HMO plans.

Health Maintenance Organization (HMO)
With an HMO, you select a primary care physician (PCP) who’s in the plan’s network. Your PCP tends to most of your health needs and refers you to a specialist in the network when necessary.

Health plan
A health plan provides insurance protection against illnesses or injury. In addition, some health plans cover the costs of preventive care such as routine checkups.
Humana One offers a wide range of health plans for individuals and their families. Benefits of these plans may include coverage for inpatient and outpatient hospital services, preventive care treatment by specialists, and prescription drugs.

Health Savings Account (HSA)
An account that can be established and funded only in conjunction with a High Deductible Health Plan (HDHP) and allows employees to pay qualifying medial expenses not covered under the health plan. Employees, employers, and others can contribute to the HSA.

Healthcare provider
This is a provider of services, such as a dentist.

High-Deductible Health Plan
This specially designed plan has one deductible that combines medical and prescription drug expenses. An HDHP is usually a Preferred Provider Organization (PPO) plan, but it also could be an HMO or Point of Service (POS) plan.

HIPAA
The “Health Insurance Portability and Accountability Act of 1996.” HIPAA includes four key components: Electronic Transactions, Portability, Privacy, and Security

HMO
HMO is short for a Health Maintenance Organization. It’s a type of plan that allows you to choose a primary care physician (PCP) in the plan’s provider network to coordinate your care.

Home healthcare
This refers to skilled nursing care and certain other healthcare you get in your home for the treatment of an illness or injury

Hospice
A special way of caring for people who are terminally ill, hospice care includes physical care for the patient as well as counseling for the patient and the patient’s family. Hospice care is covered under Medicare Part A.

Hospital insurance (Part A)
This is the part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare services

HSA Transaction Block
This feature prevents all reimbursements from your Health Savings Account (HSA). When you enable the transaction block, you enjoy the benefits that come with saving HSA funds – tax-free growth, investment opportunities, and preparation for future expenses. This feature is not available to all.

Identification card
This is a card given to each person covered under a benefit plan.

In area
In-area refers to healthcare providers and services that are available to members within the geographic area that a specific health plan services

In network
These are providers who have contracts with a benefit plan to provide services at a set rate.

In process
Indicates an estimate or a claim has been received but processing is not complete.

Incomplete application
This refers to an application in which one or more of the required elements established by CMS are not complete. For example: the form isn’t signed by the beneficiary or the legal representative, supporting documentation for a representative’s signature isn’t included, necessary elements on the form are not completed, or entitlement to Part A cannot be established.

Incurred claims
Incurred claims equal the claims paid during the policy year plus claim reserves.

Indemnity insurance
This traditional fee-for-service coverage allows providers to be paid according to their service fees

Individual allowance
The amount Humana pays toward the cost of a covered prescription drug is known as individual allowance

Individual deductible
Amount of eligible expense a covered person must pay each year before the dental plan will pay for eligible benefits.

In-force business
Coverage for which premiums are being paid or for which premiums have been fully paid is referred to as in-force business

In-network coverage
In-network coverage refers to the eligible benefits that are offered when you choose an in-network or participating provider

In-network providers
A healthcare provider (such as a doctor, hospital, other medical facility, or pharmacy) is considered an in-network provider if it has agreed to charge a set rate for members of a health benefits plan. Your network choices may vary, depending on your plan and where you live. With PPO and HMO plans, you can reduce your costs by using in-network providers, which are also known as participating providers.

Insured
This refers to someone covered by an insurance benefits plan

Insurer
An insurer is an organization that bears the financial risk for services and material provided to an individual or group.

Lapse
A policy lapses and is terminated if the insured fails to pay the premium.

Last paid
For a spending account, this is the date when funds were most recently taken out of your account to pay expenses.

Late applicant
This refers to you or your eligible dependent who enroll for coverage more than 31 days after the eligibility date. Late applicants may be subject to a waiting period.

Liability
This refers to an obligation an individual or organization has for a specified amount or action.

Lifetime maximum
This is the maximum amount your plan will pay toward eligible expenses while you’re covered under the plan.

Lifetime maximum benefit
This is the total amount a health plan will pay, per covered member, for the lifetime of the coverage.

Lifetime orthodontic services
The maximum amount payable (for each covered person) for eligible charges related to treatment, no further benefits are payable after this maximum is reached.

Limitation and exclusions
Conditions listed in a policy for which benefits are not paid are limitations and exclusions.

Limitations
Limitations are items or services a health plan does not cover

Limiting charge
The highest amount of money you can be charged for a covered service by doctors and other healthcare suppliers who do not accept Medicare assignment, the limiting charge only applies to certain medical services, not to medical supplies or equipment.

Line status
The status of each line item in the claim can be paid, denied, or in process. Each line item may have a different status; however, if the entire claim is pending for review, each line item will indicate “in process.”

Locked-In period
If you have a Medicare Advantage and prescription drug plan, you are “locked-in,” which means (unless you qualify for special circumstances) you can only switch plans during certain times of the year. The lock-in period runs from April 1 to November 14.

Long-term care hospital
A hospital that has an average inpatient length of stay of greater than 25 days is a long-term care hospital.

Lump sum
These proceeds are paid to beneficiaries all at once instead of in installments.

Managed care
This is a healthcare system under which providers are organized into a network in order to manage the cost, quality, and access to healthcare. Managed care organizations include Preferred Provider Organizations (PPOs) and Dental Health Maintenance Organizations (DHMOs).

Managed Care Support Contractor (MCSC)
An MCSC is a civilian health care contractor of the Military Health System that administers TRICARE in one of the TRICARE regions. An MCSC (Humana Military is an MCSC) helps combine the service available at MTFs with those offered by the TRICARE network of civilian hospitals and providers to meet the health care needs of the TRICARE beneficiaries.

Max
This is another term for maximum.

Maximum allowance
The maximum dollar amount a benefits program will pay towards the cost of a service is the maximum allowance. This is specified in the program’s contract provisions, (e.g. Usual, Customary, and Reasonable [UCR] Table of Allowances).

Maximum annual benefit (MAB)
This is the maximum dollar amount a health plan will pay during a plan period. The plan period is usually your effective date through the end of the calendar year.

Maximum benefit
This is the maximum dollar amount a benefit program will pay toward the cost of care for an individual or family within a specific period.

Maximum fee schedule
This refers to an arrangement in which a participating provider agrees to accept a set amount as the total fee for one or more covered services.

Maximum medical out-of-pocket
This is the most money you will be required to pay within a year for deductibles and coinsurance. Regular premiums are not included in calculations of your maximum medical out-of-pocket expenses.

Maximum plan benefit coverage
The maximum dollar amount a health plan will pay during a benefit period is called the maximum plan benefit coverage. Medicare plans usually only set this type of limit on services for which the plan offers enhanced benefits.

Mbr Resp Amt
This abbreviation means member responsible amount.

Member ID
This is your unique identifying number under the dental plan.

Member name
The name of the person for which a claim is submitted.

Monthly premium
This is the monthly payment you make to an insurance company or a healthcare plan for healthcare coverage in addition to your Medicare Part A or Part B premium.

National Provider Identifier (NPI)
The NPI is a 10-digit number used to identify providers in standard electronic transactions. It is a requirement of the Health Insurance Portability and Accountability Act of 1996.

Network
A network is a group of healthcare providers who have agreed to charge a set rate for members of a health benefits plan. Providers on the list of network members are also called participating providers. Your network choices may vary, depending on your plan and where you live.

Network (and in-network provider)
Humana has negotiated lower rates from specific doctors, hospitals, and other providers, so these providers are part of Humana’s networks and are referred to as in-network providers. They are also called participating providers.

Network deal
Financial agreement applied to a specific dentist or dental network.

Network/participating provider
Also known as in-network providers, these include hospitals, healthcare treatment facilities, healthcare practitioners, and other providers who enter into an agreement with an insurer and are, therefore, designated to provide services to anyone covered by that insurance provider.More than 350,000 doctors are members of Humana’s network and provide discounts to Humana health plan members.

Non-contributory
Employee benefit plans paid for by the employer, non contributory plans require that 100% of eligible employees participate.

Non-duplication of benefits
This stipulation in a contract relieves a third-party payer of liability for cost of services in cases where services are covered under another program. Non-duplication of Benefits is distinct from Coordination of Benefits because

Non-participating provider
Any provider who is not a part of the network of a benefit plan is considered a non-participating provider.

Non-preferred brand drug
Higher-cost brands that include drugs with preferred generic or therapeutic alternatives are referred to a non-preferred brand drugs. This may includes some self-administered injectable medications.

Non-preferred pharmacy
This is a network pharmacy that offers covered Part D drugs at negotiated prices but at higher cost-sharing levels than a preferred pharmacy.

Nonqualified amount
For a spending account, this is the amount that is not reimbursable from your account based on plan or IRS rules

Nonqualified expense
For a spending account, this is an expense that is not reimbursable from your account based on plan or IRS rules.

Original amount
For a spending account, this is the amount you requested for reimbursement from the account.

Other insurance paid amount
The amount paid by your other primary insurance.

Out-of-network
This refers to doctors, hospitals, pharmacies, and other healthcare professionals or suppliers who do not belong to a health or drug plan’s provider/pharmacy network. See the definition of network.

Out-of-network benefit
Generally, an out-of-network benefit gives you the option to use a doctor, 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 an out-of-network benefit.

Out-of-network doctor
A primary care physician or specialist who does not belong to a health plan’s provider network is considered an out-of-network doctor. In some cases, your out-of-pocket costs may be higher if you choose to use an out-of-network doctor.

Out-of-network pharmacy
This is a pharmacy that is not under contract with Humana. By choosing an out-of-network pharmacy, you may pay more through coinsurance. These providers may also bill you for costs that are not covered by your insurance plan. In addition, you will need to meet an out-of-network deductible (separate from your in-network deductible) before Humana begins to pay for covered services.

Out-of-network provider
Also called non-participating provider, this term refers to providers who are not part of the Humana network and, therefore, will cost you more.

Out-of-pocket costs
These are healthcare costs that you pay on your own because they are not covered by your Medicare plan or other insurance.

Out-of-pocket maximum
This is the annual limit on your costs. After you meet the maximum out-of-pocket amount, your plan pays 100% for covered services. You may still pay copayments.

Paid claims
This refers to the amounts paid to providers or members for eligible services.

Paid to date
For a spending account, this is the amount taken from your account to pay medical expenses as of a certain date.

Participating provider
Any provider who is a member of a benefit plan’s network is considered a participating provider.

PCA rollover balance
Remaining previous plan year’s PCA balance that you were allowed to carry over for use during your current plan year. This feature is not available to all.

PCD
Primary care dentist.

PCP name
This refers to primary care physician name. In dental insurance for a DHMO, Humana uses PCD (primary care dentist).

PDP
A Prescription Drug Plan, PDP provides seniors and people with disabilities with the first comprehensive prescription drug benefit ever offered under the Medicare program for a monthly premium.

Pended
This term indicates an estimate or a claim that has been received but processing is not complete.

Pended claims
These are claims that have been submitted but not yet paid because additional information is needed

Pending transactions
For a spending account, these are transactions either into or out of your account that have not been completely processed. Transactions may be pending because we need to verify the charge on the Humana Access Visa Debit Card.

Permanent mailing address
This is the address where you currently reside. It is considered your primary residence

Personal Care Account
Personal Care Account – A Health Reimbursement Arrangement (HRA) regulated by the IRS and funded entirely by the employer. You can use PCA funds for qualified medical expenses not covered under the health plan.

Pharmacy coinsurance
This is the percentage of the total cost of your prescription drug that you must pay. When you go to an in-network pharmacy, your coinsurance is based on the Humana-approved charge, which may be less than the original charge.

Pharmacy copayment
The amount you pay for a prescription drug is your pharmacy copayment. A copayment can range from a few dollars to a few hundred dollars depending on the type of drug you receive

Physician Finder Plus
Here’s where you can find out if your doctor is in network. Physician Finder Plus — on Humana.com/members — lets you search for in-network doctors, hospitals, urgent care centers, and other providers of healthcare

Plan pays/paid
The amount Humana will pay or has paid for a specific service

Plan premium
A plan premium is your monthly payment to Humana for healthcare coverage or prescription drug coverage. This cost does not include your Medicare Part A or Part B premiums.

Plan year
The year starting with your plan effective date is known as your plan year.

POA
A Power of Attorney (POA) is a document that’s signed by a member to authorize another party to act on the member’s behalf. The Executor of Estate takes the place of a Power of Attorney after a member is deceased and the Executor is appointed. Power of Attorney and Executor of Estate are legal documentation and must be provided before another party can act on the member’s behalf.

Point-of-service plans
These plans permit you to choose providers outside your plan but still encourage you to use network providers.

Policy term
The period for which a benefits policy provides coverage for eligible employees is the policy term.

Portability (Group)
Portability allows an active eligible employee who leaves the group to continue coverage by paying annual premiums to Humana if he or she is not yet age 70. Only coverage in force or a lesser amount can be ported at termination.

Portability (Voluntary Life)
Humana Voluntary Life is portable subject to plan provisions. An active eligible employee who leaves the group can continue coverage by paying annual premiums to Humana if he or she is not yet age 70. Only coverage in force or a lesser amount can be ported at termination.

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