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 - When you (or those paying on your behalf) have spent a set total of out-of-pocket costs within the calendar year, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage. This amount changes annually. Please see your Evidence of Coverage for details.
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 - Every drug on the list of covered drugs is in one of the cost sharing tiers. 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.
Centro de Cuidado para Pacientes Terminales: un miembro a quien le quedan seis meses de vida o menos tiene derecho elegir un centro de cuidado para pacientes terminales. Nosotros, su plan, debemos proporcionarle una lista de centros de cuidado para pacientes terminales en su área geográfica. Si elige un centro de cuidado para pacientes terminales y continúa pagando las primas, sigue siendo miembro de nuestro plan. Aún puede recibir todos los servicios médicamente necesarios, así como los beneficios adicionales que ofrecemos. El centro de cuidado para pacientes terminales le proveerá el tratamiento especial para su estado.
Internación en un Hospital: se trata de una internación en un hospital que ocurre cuando lo hayan admitido formalmente para recibir servicios médicos especializados. Incluso si permanece en el hospital durante toda la noche, se lo puede considerar como un “paciente ambulatorio”.
Asociación de Práctica Independiente (IPA): una asociación de médicos, incluidos PCP y especialistas, y demás proveedores de servicios de salud, como hospitales, que tienen un contrato con una HMO para proveer servicios a los miembros. Algunas IPA tienen círculos formales de remisión del médico. Esto significa que sus proveedores solo remitirán pacientes a otros proveedores que pertenecen a la misma IPA.
Límite de Cobertura Inicial: límite máximo de cobertura según la Etapa de Cobertura Inicial.
Período de Inscripción Inicial: se trata del período en el que se inscribe para la Part A y la Part B de Medicare que ocurre cuando usted se torna elegible para Medicare. Por ejemplo, si usted es elegible cuando cumple 65 años, su Período de Inscripción Inicial es el período de siete meses que comienza tres meses antes al mes en que cumple 65 años. Incluye el mes en el que cumple 65 años y termina tres meses después de que cumple 65 años.
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. A Medicare Advantage plan can be an HMO, PPO, Private Fee-for-Service (PFFS) plan, Special Needs Plan, or a Medicare Medical Savings Account (MSA) plan. 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. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).
Medicare Coverage Gap Discount Program - A program that provides discounts on most covered Part D brand name drugs to Part D enrollees who have reached the Coverage Gap Stage and who are not already receiving Extra Help. Discounts are based on agreements between the Federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted.
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 Health Plan - A Medicare health plan is 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. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-Inclusive Care for the Elderly (PACE).
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 Cost Sharing - Preferred cost sharing means lower cost sharing for certain covered Part D drugs at Express Scripts® Pharmacy.
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.
Preventive services - Health care meant to prevent illness or detect illness at an early stage when treatment is likely to work best. For example, preventive services include screening mammograms and Pap tests.
Prescription Drug Benefit Manager (or PBM) - Companies that contract with Medicare Advantage Prescription Drug Plans to manage pharmacy services.
Primary Care Provider (PCP) - Your primary care provider is the doctor or other provider 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 health plans, you must see your primary care provider before you see any other health care provider.
Prior Authorization - Approval in advance to get services or certain drugs that may or may not be on our formulary. Some in-network medical services are covered only if your doctor or other network provider gets "prior authorization" from our plan. Some drugs are covered only if your doctor or other network provider gets "prior authorization" from us. Covered drugs that need prior authorization are marked in the formulary.
Quality Improvement Organization (QIO) - A group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients.
Quantity Limits - A management tool that is designed to limit the use of selected drugs for quality, safety or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.
Remisión del Médico: una orden escrita de su médico de cuidado primario para que vea a un especialista u obtenga determinados servicios médicos. En muchos planes de Health Maintenance Organizations (HMO), debe obtener una remisión del médico antes de que pueda recibir atención médica de cualquier persona, excepto de su médico de cuidado primario. Si no obtiene una remisión del médico primero, es posible que el plan no pague por los servicios.
Servicios de Rehabilitación: servicios que incluyen fisioterapia, terapia del habla y del lenguaje, y terapia ocupacional.
Área de Servicios: área geográfica en la que un plan de salud acepta miembros si limita su membresía con base en el área de residencia de las personas. Para planes que limitan los médicos y hospitales que puede utilizar, por lo general, también es el área donde puede obtener servicios de rutina (que no tienen carácter de emergencia). El plan puede cancelar su inscripción si usted se muda permanentemente fuera del área de servicios del plan.
Atención en un Centro de Enfermería Especializada (SNF): servicios especializados de enfermería y de rehabilitación prestados de forma continua y cotidiana en un centro de enfermería especializada. Algunos ejemplos de cuidado en un centro de enfermería especializada incluyen fisioterapia o inyecciones intravenosas, la cuales solo un profesional de enfermería certificado o un médico puede administrar.
Período de Inscripción Especial: período establecido durante el cual los miembros pueden cambiar sus planes de salud o de medicamentos o volver a Original Medicare. Algunas situaciones en las que puede ser elegible para un Período de Inscripción Especial son las siguientes: si se muda fuera del área de servicios, si recibe Extra Help con los costos de sus medicamentos con receta, si se muda a un centro de convalecencia o si nosotros violamos el contrato que mantenemos con usted.
Special Needs Plan: tipo especial de Medicare Advantage Plan que ofrece atención de salud más específica para grupos determinados de personas, como aquellas personas que tienen tanto Medicare como Medicaid, que residen en un centro de convalecencia o que padecen ciertas condiciones médicas crónicas.
Standard Cost Sharing - Cost sharing other than preferred cost sharing offered at all network pharmacies except Express Scripts® Pharmacy.
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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