Aquí encontrará una lista de palabras y frases que se usan comúnmente cuando se habla de Medicare.
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Centro de Cirugía Ambulatoria: una entidad cuyo único propósito es proveer servicios quirúrgicos ambulatorios a los pacientes (1) que no requieren hospitalización y (2) cuya estadía esperada en el centro no supere las 24 horas.
Período de Inscripción Anual: período establecido cada otoño durante el cual los miembros pueden cambiar sus planes de salud o de medicamentos, o cambiarse a Original Medicare. El Período de Inscripción Anual es del 15 de octubre al 7 de diciembre.
Apelación: una apelación es la acción que debe llevar a cabo si no está de acuerdo con nuestra decisión de denegar una solicitud de cobertura de servicios de salud o de medicamentos con receta, así como el pago de servicios o medicamentos que ya recibió. También puede presentar una apelación si no está de acuerdo con nuestra decisión de suspender los servicios que actualmente recibe. Por ejemplo, puede presentar una apelación si no pagamos por un medicamento, artículo o servicio que usted considera que debería poder recibir.
Benefit Period - The way that both our plan and Original Medicare measures your use of skilled nursing facility (SNF) services. A benefit period begins the day you go into a skilled nursing facility. The benefit period ends when you have not received any skilled care in a SNF for 60 days in a row. If you go into a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods.
Brand Name Drug - A prescription drug that is manufactured and sold by the same pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.
Catastrophic Coverage Stage - The phase of Medicare Part D coverage during which your covered Part D drugs no longer have any out-of-pocket costs for the remainder of the year.
Centers for Medicare & Medicaid Services (CMS) - The federal agency that administers Medicare.
Coinsurance - An amount you may be required to pay as your share of the cost for services or prescription drugs. Coinsurance is usually a percentage (for example, 20%).
Co-payment - 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 a prescription drug. A co-payment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription drug.
Cost Sharing - Cost sharing refers to amounts that a member has to pay when services or drugs are received. Cost sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed "co-payment" amount that a plan requires when a specific service or drug is received; or (3) any coinsurance amount that a plan requires when a specific service or drug is received. A daily cost sharing rate may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you are required to pay a co-pay.
Cost Sharing Tier - Different levels within a plan’s drug list (Formulary) that determine how much you pay for your prescription drugs. In general, the higher the cost sharing tier, the higher your cost for the drug.
Coverage Determination - A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the service or prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription is not covered under your plan, that is not a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are also called "coverage decisions."
Covered Drugs - All of the prescription drugs covered by our plan.
Covered Services - All of the health care services and supplies that are covered by our plan.
Creditable Prescription Drug Coverage - Prescription drug coverage (for example, from an employer or union) that is 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 the coverage without paying a penalty if they decide to enroll in Medicare prescription drug coverage later.
Customer Service - A department within our plan that answers your questions about membership, benefits, grievances and appeals.
Daily Cost Sharing Rate - Something that may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you are required to pay a co-pay. A daily cost sharing rate is the one month co-pay divided by the number of days in a month's supply. For example, if your co-pay for a one-month supply of a drug is $30, and a one-month's supply in your plan is 30 days, then your daily cost-sharing rate is $1 per day. This means you pay $1 for each day's supply when you fill your prescription.
Deductible - The amount you must pay for health care or prescriptions before our plan begins to pay.
Disenroll or Disenrollment - The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).
Dual Eligible Individual - A person who qualifies for both Medicare and Medicaid coverage.
Durable Medical Equipment - Certain medical equipment that is ordered by your doctor. Examples are walkers, wheelchairs, or hospital beds.
Emergency - A medical emergency is when you, or any other person with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.
Emergency Care - Covered services that are: (1) rendered by a provider qualified to furnish emergency services; and (2) needed to evaluate or stabilize an emergency medical condition.
Evidence of Coverage (EOC) and Disclosure Information - The document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan.
Exception - A type of coverage determination that, if approved, allows you to get a drug that is not on your plan's formulary (a formulary exception), or get a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if your plan requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).
Extra Help - A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
Formulary or "Drug List" - A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.
Generic Drug - A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a "generic" drug works the same as a brand name drug and usually costs less.
Grievance - A type of complaint you make about the plan or one of the plan's network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
Home Health Aide - A home health aide provides services that do not require the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out prescribed exercises). Home health aides do not have a nursing license or provide therapy.
Hospice - A program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease.
Hospital Inpatient Stay - A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an "outpatient."
Independent Practice Association (IPA) - An association of physicians, including PCPs and specialists, and other health care providers, including hospitals, that contracts with an HMO to provide services to enrollees. Some IPAs have formal referral circles, which means that their providers will only refer patients to other providers belonging to the same IPA.
Initial Coverage Limit - The maximum limit of coverage under the Initial Coverage Stage.
Initial Enrollment Period - When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you are eligible for Medicare when you turn 65, your Initial Enrollment Period is the seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65.
Plan institucional de necesidades especiales (SNP, Special Needs Plan): Un plan de necesidades especiales que inscribe a personas elegibles que residen de forma continua (o se espera que lo hagan) durante 90 días o más en un centro de cuidados a largo plazo (LTC, long-term care). Estos centros LTC pueden incluir un centro de enfermería especializada (SNF, Skilled Nursing Facility); un centro de enfermería (NF, Nursing Facility); (SNF / NF); un centro de atención intermedia para personas con retraso mental (ICF/MR, Intermediate care facility for the mentally retarded); y/o un centro psiquiátrico para pacientes hospitalizados. Un Plan institucional de necesidades especiales que presta servicios para residentes de centros de LTC de Medicare debe tener un acuerdo contractual con (o ser el dueño y encargado del funcionamiento de) el/los centro(s) de LTC específico(s).
Penalización por Inscripción Tardía: Una cantidad que se añade a su prima mensual para la cobertura de medicamentos en Medicare si usted prescinde de cobertura acreditable (cobertura que se espera que pague, en promedio, por lo menos la misma cantidad que la cobertura estándar de Medicare de medicamentos recetados) durante un periodo de por lo menos 63 días consecutivos después de que se convierta en elegible para Medicare. Puede pagar esta cantidad superior, siempre y cuando tenga un plan de medicamentos de Medicare. Existen algunas excepciones. Por ejemplo, si recibe Asistencia Adicional de Medicare para pagar los costos de su plan de medicamentos recetados, no pagará la penalidad por inscripción tardía.
List of Covered Drugs - See Formulary or Drug List.
Low Income Subsidy - See Extra Help.
Maximum Charge - The amount set by an insurance company as the highest amount than can be charged for a particular medical service.
Maximum Out-of-Pocket Amount - Once you have paid out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered in-network Part A and Part B services for the rest of the calendar year. Amounts you pay for your Medicare Part A and Part B premiums, and prescription drugs, do not count toward the maximum out-of-pocket amount.
Medicaid - A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
Medically Necessary - Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.
Medicare - The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare, a Medicare Cost Plan, a PACE plan or a Medicare Advantage plan.
Medicare Advantage Open Enrollment Period - The period from January 1 – March 31 each year when members in a Medicare Advantage Plan can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan).
Medicare Advantage (MA) Plan -Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. When you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage.
Medicare-Covered Services - Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Parts A and B.
Medicare Prescription Drug Coverage (Medicare Part D) - Medicare prescription drug coverage (Part D) helps cover the cost of prescription drugs, including many recommended shots or vaccines. Part D is offered through Medicare-approved private insurance companies as either a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD).
"Medigap" (Medicare Supplement Insurance) Policy - Medicare supplement insurance sold by private insurance companies to fill "gaps" in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)
Member (Member of our Plan, or "Plan Member") - A person with Medicare who is eligible to get covered services, who has enrolled in our plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).
Network Pharmacy - A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them "network pharmacies" because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.
Network Provider - "Provider" is the general term we use for doctors, other health care professionals, hospitals and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. We call them "network providers" when they have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Our plan pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as "plan providers."
Organization Determination - A Medicare Advantage organization's decision about whether items or services are covered or how much you have to pay for covered items or services. The Medicare Advantage organization's network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service. Organization determinations are called "coverage decisions."
Original Medicare ("Traditional Medicare" or "Fee-for-service" Medicare) - Original Medicare is coverage managed by the federal government that includes two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). Under Original Medicare, you usually pay a monthly Part B premium and must meet yearly deductibles. Original Medicare will then cover 80% of the approved amount and you’re responsible for the remaining 20% of the cost. Original Medicare doesn’t cover everything. Items and services like most prescription drugs, hearing aids, and routine dental care are not covered. There’s no yearly limit to what you pay out-of-pocket.
Out-of-Network Pharmacy - A pharmacy that does not have a contract with our plan to coordinate or provide covered drugs to members of our plan. Most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.
Out-of-Network Provider or Out-of-Network Facility - A provider or facility with which we have not arranged to coordinate or provide covered services to members of our plan. Out-of-network providers are providers that are not employed, owned, or operated by our plan or are not under contract to deliver covered services to you.
Out-of-Pocket Costs - A member's cost-sharing requirement to pay for a portion of services or drugs received is also referred to as the member's "out-of-pocket" cost requirement.
PACE plan - A PACE (Program of All-Inclusive Care for the Elderly) plan provides medical, social, and long-term care services to elderly people with chronic care needs to help them stay independent and living in their community (instead of moving to a nursing home) as long as possible, while getting the high-quality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid benefits through the plan.
Part C - See Medicare Advantage (MA) Plan.
Part D - See Medicare Prescription Drug Coverage (Medicare Part D)
Part D Drugs - Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.
Point-of-Service - The HMO with a Point-of-Service (POS) option is an additional benefit that covers certain medically necessary services you may get from out-of-network providers. When you use your POS (out-of-network) benefit, you are responsible for more of the cost of care. Always talk to your Primary Care Provider (PCP) before seeking care from an out-of-network provider. Your PCP will notify us by requesting approval from the plan ("prior authorization").
Preferred Provider Organization (PPO) Plan - A Medicare Advantage Plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they are received from network or out-of-network providers. Member cost sharing will generally be higher when plan benefits are received from out-of-network providers. PPO plans have an annual limit on your out-of-pocket costs for services received from network (preferred) providers and a higher limit on your total combined out-of-pocket costs for services from both in-network (preferred) and out-of-network (non-preferred) providers.
Premium - The amount you pay to your Medicare Advantage and/ or Prescription Drug Plan each month in order to receive their coverage.
Servicios Preventivos: atención médica destinada a prevenir enfermedades o a detectar enfermedades en una etapa temprana en la que es probable que el tratamiento funcione mejor. Por ejemplo, los servicios preventivos incluyen mamografías y pruebas de Papanicolaou.
Administrador de Beneficios de Medicamentos Recetados (o PBM): compañías que tienen un contrato con los planes de Medicamentos con Receta de Medicare Advantage para administrar servicios de farmacia.
Proveedor de Cuidado Primario (PCP): el médico u otro proveedor al que usted acude en primer lugar para la mayoría de los problemas de salud. Se asegura de que usted reciba la atención que necesita para conservar su salud. Este médico también puede hablar con otros médicos y proveedores de atención médica sobre su atención y remitirlo a ellos. En muchos planes de salud de Medicare, primero debe ver a su proveedor de cuidado primario antes de ver a otro proveedor de atención médica.
Autorización Previa: aprobación por adelantado para obtener servicios o determinados medicamentos que pueden estar o no en nuestra lista de medicamentos. Algunos de los servicios médicos de la red se cubren solo si su médico u otro proveedor de la red obtienen una “autorización previa” de nuestro plan. Algunos medicamentos se cubren solo si su médico u otro proveedor de la red obtienen una “autorización previa” de nuestra parte. Los medicamentos cubiertos que requieren autorización previa están indicados en la lista de medicamentos.
Organización para el Mejoramiento de la Calidad (QIO): grupo de médicos y otros expertos activos en el campo de la atención médica, a quienes les paga el Gobierno federal para comprobar y mejorar la atención médica que reciben los pacientes de Medicare.
Límites de Cantidad: herramienta administrativa que está diseñada para limitar el uso de medicamentos seleccionados por motivos de calidad, seguridad o utilización. Los límites pueden ser en la cantidad del medicamento que cubrimos por receta o en un período definido.
Referral - A written order from your primary care physician for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs) plans, you need to get a referral before you can get medical care from anyone except your primary care physician. If you don’t get a referral first, the plan may not pay for the services.
Rehabilitation Services - These services include physical therapy, speech and language therapy, and occupational therapy.
Service Area - A geographic area where a health plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it is also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you permanently move out of the plan's service area.
Skilled Nursing Facility (SNF) Care - Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.
Special Enrollment Period - A set time when members can change their health or drug plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting Extra Help with your prescription drug costs, or if you move into a nursing home.
Special Needs Plan - A special type of Medicare Advantage Plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.
Step Therapy - A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.
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 and older. SSI benefits are not the same as Social Security benefits.
Urgently Needed Care - Care provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical care. Urgently needed care may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.
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