This glossary defines words used by Medicare and KelseyCare Advantage. While it is very helpful, it is not a complete dictionary of Medicare or health care terms. If you have questions or comments, call us 713-442-CARE or toll free at
Allowed AmountThe total sum the plan considers reasonable and necessary for a covered service. At the HMO (in-network) coverage level, this is an amount agreed upon between the Plan and our contracted providers. At the POS (out-of-network) coverage level, this the amount approved by Medicare as payment in full for the covered service. The allowed amount includes the copayment or co-insurance owed by you plus what the plan reimburses the provider for covered services.
AppealAn appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services and/or prescription drugs or payment for services and/or prescription drugs you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn’t pay for a drug/item/service you think you should be able to receive.
(See also, Appeals, Grievances and Coverage Determinations.).
Balance BillingWhen a provider bills you for the difference between the amount charged and the amount allowed by the plan. When you use your POS (out-of-network) benefit, you may be subject to balance billing by providers who do not accept the amount approved by Medicare as payment in full.
Benefit PeriodFor both our plan and the Original Medicare plan, a benefit period is used to determine coverage for some inpatient stays in hospitals and skilled nursing facilities. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or a skilled nursing facility. The benefit period ends when you haven’t been an inpatient at any hospital or SNF for 60 days in a row. If you go to the hospital (or SNF) after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. The type of care that is covered depends on whether you are considered an inpatient for hospital and SNF stays. You must be admitted to the hospital as an inpatient, not just under observation. You are an inpatient in a SNF only if your care in the SNF meets certain standards for skilled level of care. Specifically, in order to be an inpatient in a SNF, you must need daily skilled nursing or skilled-rehabilitation care, or both.
Brand-Name DrugA prescription drug that is manufactured and sold by the 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 CoverageThe phase in the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,950 in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS)The Federal agency that runs the Medicare program.
CoinsuranceAn amount you may be required to pay for services. In the Original Medicare Plan, this is a percentage (such as 10% or 20%) of the Medicare-approved amount. For Medicare Prescription Drug Plan, the coinsurance will vary and will depend on how much you have spent on Part D drugs.
Compound Medication/CompoundingIn general, compounding is a practice in which a licensed pharmacist, a licensed physician, or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist, combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.
CopaymentAn amount you pay in some Medicare health and prescription drug plans, for each medical service, like a doctor’s visit, or prescription. A copayment is usually a set amount, rather than a percentage. For example, you could pay $15 for a doctor’s visit or $30 for a prescription. Copayments are lower for people with Medicaid and people who qualify for extra help. Copayments are also used for some hospital outpatient and inpatient services.
Cost-sharingCost-sharing refers to amounts that a member has to pay when drugs/services are received. It includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before drugs/services are covered; (2) any fixed “copayment” amounts that a plan may require be paid when specific drugs/services are received; or (3) any “coinsurance” amount that must be paid as a percentage of the total amount paid for a drug/service.
Coverage DeterminationA decision from your Medicare drug plan about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage if you disagree.
Covered DrugsThe term we use to mean all of the prescription drugs covered by our plan.
Covered servicesThe general term we use to mean all of the health care services and supplies that are covered by our plan.
Creditable Prescription Drug CoverageCoverage (for example, from an employer or union) that is at least as good as Medicare’s prescription drug coverage.
Custodial careCare for personal needs rather than medically necessary needs. Custodial care is care that can be provided by people who don’t have professional skills or training. This care includes help with walking, dressing, bathing, eating, preparation of special diets, and taking medication. Medicare does not cover custodial care unless it is provided as other care you are getting in addition to daily skilled nursing care and/or skilled rehabilitation services.
DeductibleThe amount you must pay for health care or prescriptions before our plan begins to pay.
Disenroll or DisenrollmentThe process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).
Durable medical equipmentCertain medical equipment that is ordered by your doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds.
A medical emergency is when you, or any other prudent layperson 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 careCovered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate or stabilize an emergency medical condition.
Evidence of Coverage (EOC) and Disclosure InformationThese documents, explain your coverage, what we must do, your rights, and what you have to do as a member of our plan.2017 Essential (HMO) Evidence of Coverage2017 Essential+Choice (HMO POS) Evidence of Coverage2017 Rx (HMO) Evidence of Coverage2017 Rx+Choice (HMO POS) Evidence of Coverage
ExceptionA type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor's formulary (a formulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor 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 HelpA Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premium, deductibles, and coinsurance.
FormularyA list of covered drugs provided by the plan.
Generic DrugA 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.
GrievanceA type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. For more information regarding appeals and grievances,
Home health aideA home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.
Home health careSkilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury. Please see the Evidence of Coverage for your plan for further coverage information.
Hospice careA special way of caring for people who are terminally ill and providing counseling for their families. Hospice care is physical care and counseling that is given by a team of people who are part of a Medicare-certified public agency or private company. Depending on the situation, this care may be given in the home, a hospice facility, a hospital, or a nursing home. Care from a hospice is meant to help patients in the last months of life by giving comfort and relief from pain. The focus is on care, not cure. For more information on hospice care visit
www.medicare.gov and under “Search Tools” choose “Find a Medicare Publication” to view or download the publication “Medicare Hospice Benefits.” Or, call 1-800-MEDICARE (1-800-633-4227. TTY users should call
Inpatient CareHealth care that you get when you are admitted to a hospital.
Initial Coverage LimitThe maximum limit of coverage under the initial coverage period.
Initial Coverage PeriodThis is the period before your total drug expenses, have reached $3,700, including amounts you’ve paid and what our plan has paid on your behalf.
Late Enrollment PenaltyAn amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that expects to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions.
Medically necessaryServices, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.
Medicare Advantage (MA) PlanSometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A (Hospital) and Part B (Medical) benefits. A MA plan offers a specific set of health benefits at the same premium and level of cost-sharing to all people with Medicare who live in the service area covered by the Plan. Medicare Advantage Organizations can offer one or more Medicare Advantage plan in the same service area. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) Plan, or a Medicare Medical Savings Account (MSA) plan. 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).
Hospital Insurance that helps cover inpatient care in hospitals, inpatient care in skilled nursing facility (not custodial or long-term care), hospice care services, home health care services and inpatient care in a Religious Nonmedical Health care Institution.
Medicare Part BMedical Insurance that helps cover medically-necessary doctors' services, outpatient care, home health services, durable medical equipment, and other medical services.
Medicare Prescription Drug Coverage (Medicare Part D)Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.
"Medigap” (Medicare supplement insurance) policyMedicare supplement insurance sold by private insurance companies to fill “gaps” in the Original Medicare Plan coverage. Medigap policies only work with the Original Medicare Plan. (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).
Member ServicesA department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals.
Contact us to request a call from Member Services.
Network pharmacyA 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.
National Compound Credentialing Program (NCCP) The National Compound Credentialing Program (NCCP) is a process used to ensure that the same standards required for manufacturing traditional prescriptions are being followed by pharmacy providers creating compound medications.
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 DeterminationThe Medicare Advantage organization has made an organization determination when it, or one of its providers, makes a decision about MA services or payment that you believe you should receive.
Original Medicare Plan (“Traditional Medicare” or “Fee-for-service” Medicare)The Original Medicare plan is the way many people get their health care coverage. It is the national pay-per-visit program that lets you go to any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States.
Out-of-network pharmacyA pharmacy that doesn’t 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 facilityA 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.
Part C – see “Medicare Advantage (MA) Plan”
Part D DrugsDrugs 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.
Part DThe voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)
Point-of-Service (POS) OptionAn added benefits which allows members to use out-of-network providers or certain network providers without authorization. Members can see any willing Medicare provider who agrees to see them. This benefit applies to some but not all covered services, and prior authorization is required for facility services. When using Point-of-Service benefits you are responsible for a higher cost share.
Preferred Cost-SharingPreferred cost-sharing means lower cost-sharing for certain covered Part D drugs at certain network pharmacies.
Preferred Cost-Sharing PharmacyPreferred Cost-Sharing pharmacies are pharmacies in our network where the plan has negotiated lower cost-sharing for members for covered drugs than at Standard Cost-Sharing pharmacies. However, you will still have access to lower drug prices at Standard Cost-Sharing pharmacies than at out-of-network pharmacies. You may go to either of these types of network pharmacies to receive your covered prescription drugs.
PremiumThe periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.
Prescription Drug Benefit Manager A Prescription Drug Benefit Manager (PBM) is a company that administers, or handles, the prescription drug (Part D) benefit.
Primary Care Physician (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 authorizationApproval in advance to get services and certain drugs that may or may not be on our formulary. In a Point of Service plan, some in-network and out-of-network services are covered only if your doctor or other network provider gets “prior authorization” from our plan. You may want to check with your plan before obtaining services from out-of-network provider to confirm that the service is covered by your plan, whether or not you need a prior authorization, and what your cost share responsibility is. 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)Groups of practicing doctors and other health care experts that are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by Medicare Providers.
Quantity LimitsA 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.
Rehabilitation servicesThese services include physical therapy, speech and language therapy, and occupational therapy.
Service areaA 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’s 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) CareA level of care in a SNF ordered by a doctor that must be given or supervised by licensed health care professionals. It may be skilled nursing care, or skilled rehabilitation services, or both. Skilled nursing care includes services that require the skills of a licensed nurse to perform or supervise. Skilled rehabilitation services are physical therapy, speech therapy, and occupational therapy. Physical therapy includes exercise to improve the movement and strength of an area of the body, and training on how to use special equipment, such as how to use a walker or get in and out of a wheelchair. Speech therapy includes exercise to regain and strengthen speech and/or swallowing skills. Occupational therapy helps you learn how to perform usual daily activities, such as eating and dressing by yourself.
Standard Cost-SharingStandard cost-sharing is cost-sharing other than preferred cost-sharing offered at a network pharmacy.
Standard Cost-Sharing Pharmacy or “Other network pharmacy”A network pharmacy that offers covered drugs to members of our plan at higher cost-sharing levels than apply at a preferred Cost-Sharing pharmacy.
Statement of Coinsurance for Out-of-Network ServicesA statement issued by the plan when you use your POS (point of service) benefit. The statement calculates your coinsurance amounts for POS services. If you receive a service or item from a non-plan provider that is not covered by the plan, you will receive a Notice of Denial of Payment under separate cover.
Step TherapyA 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 the Social Security Administration 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.