Medicare Health Insurance Glossary

  • Annual Notification of Change (ANOC): Lists changes to plan benefits. This document is mailed to members once a year.
  • Centers for Medicare & Medicaid Services (CMS): The Federal agency that administers the Medicare and Medicaid programs.
  • Evidence of Coverage: This contract is mailed to members annually. It contains a detailed description of the benefits included in your plan.
  • Income Related Monthly Adjustment Amount (IRMAA): Some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). This penalty is referred to as IRMAA.
  • Medicaid: Medicaid helps with medical costs for some people with low incomes and limited resources. Medicaid is a joint Federal and state program and can vary from state to state.
  • Medicare (aka Original Medicare): Medicare is a health insurance program for those 65 years of age or older, under age 65 with certain disabilities, or those with End-Stage Renal Disease. The term Original Medicare typically refers to Medicare Part A and Part B.
  • Medicare Part A (Hospital Coverage): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.
  • Medicare Part B (Medical Coverage): Coverage for doctors' services, outpatient care, medical supplies and some preventive services. There is a monthly premium for Part B that is typically deducted from your social security.
  • Medicare Part C (Medicare Advantage): Insurance offered by a private company like Excellus BlueCross BlueShield. Medicare Advantage plans cover all Part A, Part B and often include Part D benefits. They may also offer extra benefits such as eyewear or dental. These are typically managed care plans (e.g., HMO or PPO). Copayments/coinsurance may apply.
  • Medicare Part D: Prescription drug benefits offered by a private insurance company like Excellus BlueCross BlueShield. Coverage can be purchased as a stand-alone Prescription Drug Plan or can be included in a Medicare Advantage plan.
  • Medicare Supplement (Medigap): Insurance offered by a private company like Excellus BlueCross BlueShield to fill in the gaps in Original Medicare. These plans are medical coverage only. Typically there are no copayment/coinsurance associated with these plans.
  • TDD/TTY: A Telecommunications device for the deaf (TDD) or a teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or speech-impaired. When calling a TTY phone number, you are connected with operators who are available to send and interpret TTY messages.
  • Allowance: An amount an insurance plan provides for a specific purpose such as purchase of eyeglasses or contacts. Typically you receive an allowance per calendar year.
  • Balance Billing: When an out-of-network doctor or hospital bills a patient more than the insurance plan’s allowed cost-sharing amount. Medicare does not allow providers to balance bill or otherwise charge you more than the cost-sharing your plan says you must pay.
  • Claim: A bill that asks for payment for services you received. You may be asked to pay a portion of the bill (see cost sharing below) and Excellus BlueCross BlueShield will pay the remaining covered charges.
  • Coinsurance: A percentage you will pay out-of-pocket (e.g., 20%)
  • Copayment: A set amount you will pay out-of-pocket (e.g., $20)
  • Cost Sharing: An amount you may be required to pay out-of-pocket as your share of the cost of services. This can be in the form of a coinsurance, copayment, or deductible.
  • Deductible: The amount you may be asked to pay out-of-pocket before your health plan will begin to pay.
  • Explanation of Benefits (Health Statement): A monthly report to help you understand and keep track of the benefits you have used.
  • Health Maintenance Organization (HMO): With HMO plans you must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from Out-of-Network providers, you may be responsible for the costs.
  • Maximum Out-of-Pocket: When your total payment of copayments or coinsurance reaches an annual in-network amount, Excellus BlueCross BlueShield will pay the remaining covered charges for the rest of the year. PPO plans also include a combined out-of-pocket maximum, which is a limit to your expenses for medical services received from both in- and out-of-network providers.
  • 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.
  • Out-of-Pocket Costs: The portion of the cost you will pay for goods or services received.
  • Point of Service (POS): A Health Maintenance Organization Plan option that lets members use doctors and hospitals outside the plan for an additional cost. There is a coinsurance and a maximum plan coverage dollar limit per calendar year.
  • Preferred Provider Organization (PPO): With PPO plans you have access to both In- and Out-of-Network providers. However, your out-of-pocket costs may be higher when you use an Out-of-Network provider, except in limited cases such as emergencies and urgently needed care.
  • Premium: A periodic payment for health or prescription drug insurance. This can be paid to Medicare or a private company like Excellus BlueCross BlueShield.
  • Preventive care: Certain services such as physical exams, preventive mammograms, and immunizations that prevent illness and promote health and wellness.
  • Prior Authorization (PA): Approval in advance to get covered services. Some medical services or prescription drugs are covered only if your doctor or other provider gets "prior authorization" from our plan.
  • Protected Health Information (PHI): Federal privacy laws prohibit health insurers from disclosing your protected health information to another person or organization without your written authorization (with some exceptions, like your physician). If you wish to designate another individual to receive information related to your health insurance, please complete an authorization form.
  • Providers: Refers to 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 In-network providers when they have an agreement with our plan to accept our payment as payment in full. Out-of-network providers are providers who are not contracted with Excellus BlueCross BlueShield.
  • Primary Care Physician (PCP): Generally family practice, general practice or internal medicine doctors trained to give you routine or basic medical care and help arrange or coordinate other covered services you get as a member of our plan.
  • Specialist: A doctor who provides health care services for a specific disease or part of the body. For example, an oncologist cares for patients with cancer.
  • Referral: Approval from your primary care doctor for you to see a specialist or get certain medical services. Medicare HMO members are required to get a referral first, or the plan may not pay for certain services.
  • Annual Enrollment Period (AEP): The Annual Enrollment Period is from October 15 until December 7. During this time, members can change their health or drug plans or switch to Original Medicare.
  • Disenroll or Disenrollment: Ending your membership in our plan. This may be voluntary (your own choice) or involuntary (not your own choice).
  • Initial Enrollment Period: This is time when you can sign up for Medicare Part A and Part B when you are first eligible for Medicare. For example, if you’re eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
  • Medicare Advantage Disenrollment Period (MADP): From January 1 until February 14 each year, members in a Medicare Advantage plan can cancel their plan and switch to Original Medicare. They can also choose to enroll in a stand-alone prescription drug plan during this time.
  • Service Area: To enroll in a health plan, you may be required to maintain a permanent residence in a specific geographic area. It is also generally where you can get routine services.
  • Special Enrollment Period (SEP): A set time when members can switch insurance plans. You may qualify if:
    • You move out of your plan's service area
    • Your plan leaves the Medicare program or reduces its service area
    • You leave or lose employer or union coverage
    • You enter, live at, or leave a long-term care facility
    • You lose your Extra Help status (note: you have a continuous SEP if you qualify for Extra Help)
    • You join or switch to a plan that has a 5-star rating
    • You are enrolled in Elderly Pharmaceutical Insurance Coverage (EPIC)
  • Appeal: If you disagree with our decision to deny coverage of health care services or prescription drugs, you may file an appeal. You may also appeal if you disagree with our decision to stop services that you are receiving.
  • Coverage Determination: The decision by Excellus BlueCross BlueShield about your drug benefits. Specifically, whether items or services are covered or how much you have to pay for covered items or services. If you disagree with a coverage determination you can file an appeal.
  • Exception: A type of coverage determination. This may include coverage for a drug not on your plan's drug list, waiving a coverage rule, or charging a lower amount for a drug.
  • Grievance: You would file a grievance if you have any type of problem with Excellus BlueCross BlueShield, a provider of care, or one of our network pharmacies that does not relate to coverage for a prescription drug.
  • Organization Determination: The decision by Excellus BlueCross BlueShield about your medical benefits. Specifically, whether items or services are covered or how much you have to pay for covered items or services. If you disagree with an organizational determination you can file an appeal.
  • Durable Medical Equipment: Certain medical equipment that is ordered by your doctor for medical reasons. Examples are walkers, wheelchairs, compression socks, or hospital beds.
  • Emergency: Severe symptoms that require immediate medical attention. The medical symptoms may be an illness, injury, severe pain, or a medical condition that could reasonably result in serious jeopardy to your health.
  • Hospital Inpatient Stay: When you have been formally admitted as an inpatient to the hospital for medical services. Even if you stay in the hospital overnight, you might still be considered an "outpatient." If you are not sure if you are an inpatient or an outpatient, you should ask the hospital staff. There are different costs associated with each.
  • Outpatient Hospital Services: Care received when you have not been formally admitted to the hospital. This may include services in an emergency department or outpatient clinic, such as observation services or outpatient surgery.
  • Outpatient Surgery: Surgery performed in a hospital or free standing facility, sometimes called an Ambulatory Surgical Center. Typically outpatient surgical services are under 24 hours.
  • Skilled Nursing Facility (SNF): 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.
  • Urgent Care: Treatment for a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgent care is typically less expensive and less time consuming than visiting an emergency room.
  • Coverage Restrictions: Some covered drugs may have additional requirements or limits on coverage. This can include:
    • Prior Authorization (PA): Approval in advance before the plan will cover the prescribed drug.
    • Quantity Limits (QL): Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.
    • Step Therapy (STEP): A coverage rule that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug.
  • Creditable Prescription Drug Coverage: Non-Medicare 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 Part D coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.
  • Elderly Pharmaceutical Insurance Coverage (EPIC): New York State program to help income-eligible individuals 65 years old or older with their out-of-pocket Medicare Part D drug plan costs.
  • 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: A list of Part D prescription drugs covered by an insurance plan offering prescription drug benefits. The formulary is also called a drug list.
  • Generic Drugs: A prescription drug that has the same active-ingredient formula as a brand-name drug, but usually costs less. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as the brand-name drugs.
  • Part B Drugs: Covered under your medical benefits, Part B drugs are typically injected or infused drugs that are self-administered by the patient. This includes certain oral anti-cancer drugs. You are usually responsible for a 20% coinsurance for Part B drugs.
  • Deductible: The amount you may be asked to pay out-of-pocket before your plan will begin to pay.
  • Initial coverage limit: You pay a copayment or coinsurance for each covered drug until you reach your plan's initial coverage limit. You'll then enter your plan's coverage gap (also called the "donut hole").
  • Coverage gap: A period of time in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap starts when you and your plan have paid a set dollar amount for prescription drugs during that year.
  • Catastrophic Coverage: Catastrophic coverage begins after you have spent a pre-determined amount on your prescription drugs. You will only pay five percent of the cost of each prescription drug or a low copayment for your drugs during this phase.
Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. .
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