Glossary

Ambulatory Care—All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are hospitalized.

Appeal—An appeal is a special kind of complaint you make if you disagree with a determination 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 determination 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. Please visit: How to File an Appeal for more information on appeals, including the process involved in making an appeal.

Beneficiary—An individual participating in the federal Medicare program.

Benefits—Covered services as defined by the contract or policy.

Benefits Advisor—A telephone representative who assists members with enrolling in an Elderplan plan.

Capitation—A per-member, per-month (PMPM) payment to a health care provider or health plan for each member enrolled, regardless of the amount of care a member requires.

Care Manager—A nurse, doctor or social worker who works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care.

Centers for Medicare and Medicaid Services (CMS)—The federal agency that oversees all aspects of financing and regulation for the Medicare program, including Medicare Advantage and Part D plans.

Coordination of Benefits (COB)—A term used when a member has medical coverage from two different sources and both parties share the cost. The COB department handles all insurance matters.

Co-insurance—The portion of the bill or contracted charge for which you (the member) are responsible. For example, a 25% co-insurance for specialty tier 4 drugs means you pay 25% of the costs for that prescription, and Elderplan pays 75% of the cost.

Co-payment—The fee you pay at the time of medical services in accordance with Elderplan. For example, a $0 co-payment (or co-pay) to see your regular doctor means you pay nothing.

Coverage—The services or benefits provided.

Customer Service Representative (CSR)—An individual whose primary responsibility is to help members, physicians and interested Medicare beneficiaries with Elderplan questions or issues.

Deductible—A specified amount of money a member must pay before insurance benefits begin. Usually expressed in terms of an “annual” amount. In many for-profit Medicare plans, that means you will pay out-of-pocket expenses before your coverage begins.

Dual-Eligible—Individuals who qualify for both Medicare and Medicaid.

Effective Date of Enrollment—The date that is shown on the Elderplan identification card is the date the membership in Elderplan begins. The effective date is always the first day of the month.

Emergency Medical Condition—A medical condition brought on by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect that not getting immediate medical attention could result in 1) serious jeopardy to the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child); 2) serious impairment to bodily functions; or 3) serious dysfunction of any bodily organ or part.

Emergency Services—Covered services that are 1) furnished by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.

Exclusion—A health care service or medication not reimbursable through an insurance plan or HMO (e.g., elective cosmetic surgery, etc.).

Fee-for-Service (FFS)—A payment system by which doctors, hospitals and other providers are paid a specific amount for each service performed as it is rendered and identified by a claim for payment.

Formulary—A list of covered drugs provided by the plan.

Group Practice—A formal association of a group of physicians usually having shared space, equipment and support services.

Health Education—Educational process or program designed for the improvement and maintenance of health.

Health Insurance—Term used to describe all types of insurance indemnifying or reimbursing costs for health care services.

HMO (Health Maintenance Organization)—Health plans that contract with medical groups to provide a full range of health services for their enrollees for a fixed pre-arranged fee.

Hospice—A Medicare-certified organization or agency that is primarily engaged in providing pain relief, symptom management and support services to terminally ill people and their families.

Inpatient Services—Treatment obtained while hospitalized.

Independent Practice Association (IPA)—IPAs contract with groups of independent physicians who work in their own offices. These independent practitioners contract with an HMO to provide services to enrollees, but they often see patients from other HMOs and non-HMO patients.

Lock-in Period—The time period during which Medicare beneficiaries may not switch plans. The duration and dates of the “lock-in” period may vary according to special needs and eligibility.

Lock-in—Under Medicare, for HMOs, this generally refers to the requirement that enrollees use network providers except for emergency or urgent care and out-of-area dialysis.

Low Income Subsidy (LIS)—Medicare beneficiaries who have limited income and resources may qualify for Extra Help to pay for prescription drugs costs. This low-income subsidy from Medicare provides financial assistance for beneficiaries who have limited income and resources. Those who are eligible for this low-income subsidy will get help paying for their monthly premium, yearly deductible, prescription coinsurance and co-payments and will have no gap in coverage.

Managed Long-Term Care Plan—A plan designed for dual eligible individuals with long-term needs who prefer to live in their own homes yet require assistance with day-to-day health activities.

Medicaid—A joint federal and state program that provides health insurance to people who have incomes and resources below certain limits.

Medicaid Advantage Plan—A plan for people who have both Medicare and Medicaid.

Medicaid Surplus/Spenddown—The amount of income NYS Medicaid or NYC Department of Human Resources (HRA) determines an individual may be required to pay on a monthly basis to meet Medicaid eligibility requirements to continue their Medicaid coverage. HomeFirst is required to bill such enrollees for surplus charges if they are determined to incur a surplus by HRA.

Medical Necessity—Covered services that are necessary to prevent, diagnose, correct or cure conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person’s capacity for normal activity or threaten some significant handicap.

Medicare—The federal government’s health insurance program established by Title XVIII of the Social Security Act. Medicare has three (3) parts: Part A, hospital insurance; Part B, medical insurance; and Part D, prescription drug coverage.

Medicare Advantage—A Medicare program that gives you more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease.

Medicare Advantage Organization—A public or private organization licensed by the state as a risk-bearing entity that is under contract with CMS to provide covered services. Medicare Advantage Organizations can offer one or more Medicare Advantage plans. Elderplan is a Medicare Advantage Organization with a contract with Medicare.

Medicare Advantage Plan—A health plan, such as a Medicare managed care plan or Private Fee-for-Service plan, offered by a private company and approved by Medicare. An alternative to the Original Medicare plan.

Medicare Advantage Prescription Drug (MA-PD) Plan—A Medicare Advantage plan, such as Elderplan, that includes Medicare’s Part D Prescription Drug Coverage benefit. With Elderplan, that means you get ALL the parts of Medicare plus prescription coverage and much more. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease.

Medicare Options—The beneficiaries’ option to choose from several alternatives to Original Medicare.

Medicare Supplement Insurance (or Medigap)—Private health insurance that pays certain costs not covered by Fee-for-Service Medicare, such as Medicare co-insurance and deductibles.

MLTC PLAN (Applicable to Homefirst Users)—For NYS Medicaid insured, an MLTC Plan is defined as: A plan available to Medicaid recipients, which provides health and long-term care services to adults with chronic illness or disabilities to better address their needs and to prevent or delay nursing home placement. (EP glossary states MLTC is for “dual-eligibles.”) Services include, but are not limited to, home health care, nursing, physical therapy, occupational therapy, speech pathology, and ancillary and ambulatory services, including dentistry and medical equipment and supplies, podiatry, optometry, respiratory therapy, medical transportation, and social day care. Enrollees get services from their primary care physicians and inpatient hospital services using their Medicaid and/or Medicare cards.

Multi-Specialty Group—Physicians representing various medical specialties working together in a group setting.

Network—A group of health care providers under contract with Elderplan that is licensed and/or certified by Medicare with the purpose of delivering or furnishing health care services. Generally, members must receive routine services within their designated network in order to be covered by Elderplan.

Network (Applicable to HomeFirst Users)—MLTCP Contract defines “network” as those providers contracted with an MLTC plan to provide covered services. However, per Medicaid and MLTCP contract, there is not a requirement for a network vendor to be “licensed or certified by Medicare,” as defined in EP Glossary.

Out-of-Area—Outside of the geographical area defined by the plan’s service area.

Outpatient Services—Nonhospitalized treatment at a hospital, clinic or dispensary.

Over the Counter (OTC) Medication—Over the Counter medicines are medicines you can buy at a pharmacy or store without a prescription or an order from your doctor. Examples include cold medicine, medicines for stomach pain or pain relievers.

Over the Counter (OTC) Value Added Program—Non-prescription drug program offering everyday products to be purchased using a debit card at authorized retailers. The benefit period is either a month or a quarter depending on the plan. The benefit does not carry over from one quarter to the next or one month to another depending on the plan.

Plan Premium—The monthly/quarterly payment to a health care organization that entitles you to the covered services. However, a Medicare Advantage Organization is not required to charge you a plan premium. Refer to your Summary of Benefits (SOB) for details on your plan’s premium. To qualify for our services, the beneficiary must continue to pay the monthly Medicare Part B premium and, if applicable, Medicare Part A premiums.

Point of Service (POS)—A Medicare Advantage plan that offers the option to choose to go outside the network for treatment for some of the covered services. A member is free to see any specialist they choose without first consulting their primary care physician (PCP). Higher cost sharing applies.

Preferred Provider Organization (PPO)—A managed care organization in which you use doctors, hospitals and providers that belong to the network. You can use doctors, hospitals and providers outside of the network for an additional cost.

Preventive Care—An approach to health care that emphasizes taking care of small conditions before they become big conditions that can become very costly. Preventive care measures include: diagnostic tests (e.g., Pap tests), immunizations and more.

Primary Care Physician (PCP)—These physicians provide a full range of basic health services to their patients. General practitioners, pediatricians, family practice physicians and internists are recognized by health plans as Primary Care Physicians, and some plans, such as Elderplan, include obstetrician/gynecologists in this category.

Prospective Member—An individual who is qualified to join Elderplan.

Prospective “Member” (Applicable to HomeFirst Users)—2011 MLTCP Contract changed the word “member” to “enrollee.”

Qualified Medicare Beneficiary (QMB)—An individual who is eligible for Medicare and partial New York State Medicaid benefits.

Qualified Medicare Beneficiary Plus (QMB)—An individual who is eligible for Medicare and full New York State Medicaid benefits (sometimes called QMB plus or QMB Medicaid).

Referral—Written permission from your Primary Care Physician allowing you to see a certain specialist or to receive certain covered services. With Elderplan, you can visit a specialist with no referral.

Service Authorization—HomeFirst’s review to determine whether health care services that have been provided, are being provided or are requested for an enrollee are medically necessary.

Special Needs Plan (SNP)—An SNP is a specialized Medicare health plan designed to offer coverage to individuals with specialized needs. These individuals are defined by three categories: 1) institutionalized individuals; 2) dual eligibles; or 3) individuals with severe or disabling chronic conditions.

Specialist—A doctor who provides health care services for a specific disease or part of the body. Examples include oncologists (care for cancer patients), cardiologists (care for the heart) and orthopedists (care for bones).

Urgent Care—Urgent care is needed when your medical condition does not place you in serious jeopardy but could get worse, and care is immediately needed. If you are in the Elderplan service area and need urgent care, call your PCP.

Urgent Care (Applicable to HomeFirst Users)—Definition per HF Member Handbook: An urgent care need is an illness or medical problem that needs attention by your physician or other health care provider before your next routine office visit.

Usually, urgent care is provided when you are outside the Elderplan service area. You may visit a walk-in clinic or regular doctor’s office for urgent care. You do not pay the co-payment if you are admitted to the hospital within one day for the same condition.

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