Sometimes also called “case management” or “disease state management,” these services help ensure the best possible care and coordination of care for people who have either chronic or catastrophic conditions.
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.
Commercial Medicare plans offered to the general public.
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.
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.
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.
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.
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.
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).
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 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.
Medicare Supplement insurance that conforms to one of the 10 Medicare-approved plans.
Medicare Supplement insurance.
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
A type of benefit design that requires members to choose a primary care physician to receive in-network benefits. This type of plan also offers lower benefits (or the same benefits, depending on the contract) to members who receive benefits out-of-network.
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) plan
A type of benefit design that includes different levels of benefits depending on whether or not services are received from a preferred provider. These plans have specific service areas where preferred providers are available, although they usually cover wider geographic regions than managed care plans.
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.