Coinsurance
Other than the deductible, coinsurance, which is usually expressed as a percentage, is the portion of cost that the member will pay for healthcare services.
Community plans
Commercial Medicare plans offered to the general public.
Copay/copayment
A fixed amount that the member pays at the time of service. Generally the copayment is the only cost the member will have for a particular service.
Deductible
Generally applied on a calendar-year basis, the deductible is the amount of money each year that members pay out of their own pocket before the benefit plan begins to pay. Usually expressed as a per-person amount.
Durable medical equipment (DME)
Medicare-approved, medically necessary durable medical equipment is reusable medical equipment such as walkers, wheelchairs, hospital beds, etc.
Employer-sponsored health plan
A plan sponsored by an employer, or by an employer in partnership with a union, that provides medical care to two or more employees.
Evidence Of Coverage (EOC)
Annually your plan will send you an Evidence of Coverage (EOC). This document provides detail about what the plan covers, how much you will pay, and other important information about your health plan’s coverage.
Health Maintenance Organization (HMO)
Covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO’s guidelines and restrictions. Most HMOs require members to select a primary care physician (PCP). Except for a medical emergency, patients need a referral from the PCP in order to see a specialist or other doctor.
Health Savings Account (HSA)
A health savings account is a tax-advantaged account created for individuals who are covered under a high deductible health plan. HSA’s can be used to help pay for qualified expenses before you meet the deductible.
High Deductible Health Plan (HDHP)
A plan with a higher deductible than a traditional health plan. The deductible must be paid before the health plan starts to pay its share (coinsurance). A qualified HDHP may be combined with a health savings account (HSA).
Late enrollment penalty
An amount added to your Medicare Part D monthly premium if you go without Part D or creditable prescription drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period is over.
Maintenance drug
A drug that is appropriate for chronic use as prescribed and is supported by evidence that it is safe and effective when used for a chronic condition. For example, certain drugs for high blood pressure or diabetes are considered maintenance drugs.
Maximum allowable cost
Limits the amount a carrier will pay for a specific service. This designation is generally used in the absence of “participating” or “preferred” contracts. In the case of most carriers, a national data clearinghouse is used. The clearinghouse collects fee data by ZIP code and procedure and then publishes the information. Fees are usually updated every six months.
Maximum out-of-pocket
This is the maximum amount of money that a member is responsible for paying in any one calendar year, when a member uses only PPO or participating providers (depending on the contract).
Medicare Advantage (MA) Plan
Medicare Advantage (MA) plans cover medical and prescription drugs with a single premium. MA plans contract with hospitals and physicians to provide care. When you enroll in any MA plan, that plan becomes the administrator of your Medicare Parts A and B benefits. You will continue to pay the monthly Medicare Part B premium in addition to your PHIP Medicare Advantage premium.
Medicare-approved amount
In the original Medicare Supplement plan, this is the Medicare payment amount for an item or service. This is the amount a doctor or supplier is paid by Medicare, your supplement and/or you for a service or supply. It may be less than the actual amount charged by the doctor or supplier.
Medicare Supplement Plan
Medicare Supplement plan works like a Medigap plan in that if fills in the gaps in Original Medicare. You can choose any physician who is a Medicare participating provider. You can live anywhere in the United States, travel outside the U.S., and still maintain coverage.
Medicare Supplement plan and Original Medicare will each pay its share of covered health care costs. You will continue to pay the monthly Medicare Part B premium in addition to your PHIP Medicare Supplement premium.
Medicare limiting charge
Doctors and providers who do not accept assignment may charge you more than the Medicare-approved amount. The limit on the amount over the Medicare-approved amount these providers can charge is 15 percent. The limiting charge applies only to certain services and doesn’t apply to supplies and equipment. In addition, you may have to pay the entire charge at the time of service.
Medicare Part A
Hospital insurance that covers hospital stays, skilled nursing facility care and hospice.
Medicare Part B
Medical insurance that covers doctors’ services and outpatient hospital care.
Medicare Part D
Medicare prescription drug plan.
Medicare participating provider
A provider who accepts Medicare patients; this provider may or may not accept Medicare assignment.
Medigap
Medicare Supplement insurance that conforms to one of the 10 Medicare-approved plans.
Medsupp
Medicare Supplement insurance.
Nonpar
Nonparticipating provider.
Participating provider
Providers that are contracted to provide services for specific fees. The fees may or may not be discounted, but the providers are bound to not charge the member for anything above the contracted fee even if they would generally charge someone with other coverage more. This is often referred to as “hold harmless” because the member is held harmless for charges over the contracted fee.
Point-Of-Service (POS) plan
POS plans work similar to an HMO plan with a more flexible network allowing care outside of the traditional HMO network. You may have a higher copay or coinsurance for using services outside of the traditional HMO network. A Primary Care Physician (PCP) may be required and often a referral will be necessary to see a specialist.
PPO provider
Preferred Provider Organization (PPO) relates to a panel of doctors. Similar to participating providers, PPO providers sign contracts
and cannot charge members more than the contracted fee. These providers agree to discount their charges.
Preferred Provider Organization (PPO)
PPO plans give you access to a network of health care providers known as preferred (in-network) providers, however it allows you the option of seeing non-preferred (out-of-network) providers at a higher percentage of the bill (co-insurance). Typically, a PPO plan will not require you to select a Primary Care Physician (PCP) and you may access services without receiving a referral
Prior authorization
Prior authorization is a request to determine and approve if a service or supply is medically necessary and/or covered under the plan. Not all services and supplies require prior authorization. Prior authorization is not guaranteed coverage. If a prior authorization is not obtained within a specific timeframe, a penalty may be applied.
Service Area
The geographic area in which your health plan provides coverage. You must permanently reside in the health plan’s service area to enroll in and remain enrolled in a plan.