Glossary

Glossary

Here’s a helpful list of important terms and acronyms along with their definitions.

AARP	AARP is the leading nonprofit, nonpartisan membership organization for people age 50 and over in the United States.
accepting assignment	In Part B, a doctor “accepts assignment” when the client agrees to take payment of the Medicare–approved amount as payment in full for a service. If a doctor accepts assignment, your client’s share of the cost is limited to their co-insurance payment (usually 20 percent of the Medicare–approved amount). See also Medicare–approved amount.
accepts Medicare	Refers to a provider who will take Medicare patients.
actual charge	The amount of money the provider charges for services.
ADL	Activities of Daily Living. Refers to eating, bathing, dressing and toileting.
advocate	A person who gives your client support or protects their rights.
AEP	Annual Election Period. The election period specified by CMS when Medicare beneficiaries can change plans (11/15-12/31 of each year). During this time beneficiaries may change prescription drug plans, change Medicare Advantage Plans, return to original Medicare, or enroll in a Medicare Advantage Plan or Prescription Drug Plan for the first time. Enrollment changes take effect on January 1. NOTE: The Annual Election Period does not apply to Medicare Supplement. Eligible applicants can enroll year round in a Medicare Supplement Plan.
age-ins	Newly Medicare-eligible individuals.
ALJ	Administrative Law Judge. An enrollee who is dissatisfied with the independent review entity (IRE) reconsideration determination has a right to a hearing before an ALJ.
ambulatory surgical center	The following facilities qualify as an Ambulatory Surgical Center: a facility licensed as an ambulatory surgical center by the state in which it is located; or a freestanding facility, other than a clinic or Health Care Practitioner’s office, where surgical and diagnostic services are provided on an ambulatory basis, and which has written agreements with local Hospitals for the immediate acceptance of patients who develop complications or require postoperative confinement.
annual election period	The period from November 15 through December 31 of each year. During the annual election period, your client may enroll in any Medicare Advantage plan or Prescription Drug Plan available to them. NOTE: The annual election period does not apply to Medicare supplement. Eligible applicants can enroll year round in a Medicare supplement plan.
annual enrollment (election) period	For Medicare beneficiaries this is period during which decisions and changes in coverage elections can be made. It is from November 15 through December 31 each year. The effective date of these decisions begin the following January.
ANOC	Annual Notification of Change Letter. Letter that Medicare Advantage and Prescription Drug Plan organizations send out each year notifying their members which benefits and premiums they are changing for the following benefit year. It is a notice required by the Centers for Medicare & Medicaid Services (CMS) and typically arrives in October.
AoA	Administration on Aging. The Older Americans Act (1965) established the AoA, which is an agency of the U.S. Department of Health and Human Services. Its mission is to develop a comprehensive, coordinated and cost-effective system of long-term care that helps elderly individuals to maintain their dignity in their homes and communities.
appeal	An appeal is a special kind of complaint. Your client can file an appeal if they disagree with a decision such as denial of a request for services or for payment of services they already received. Your client may also appeal a decision to stop coverage of services that they are receiving. For example, your client may appeal if a Part D plan doesn’t pay for a prescription your client thinks they should be able to get. Appeals are filed using a specific process. See appeal process.
appeal process	The process your client uses to formally disagree with any decision about their health care services. It allows the initial Medicare plan decision to be reviewed again. Your client’s appeal rights are on the back of the Explanation of Benefits (EOB) sent to them from their plan. The plan must tell your client in writing how to appeal.
Assets	Property your client owns that the government may review when your client applies for assistance. For help with the costs of a Medicare prescription drug plan, the government counts cash or any property that can be turned into cash within 20 days. This includes checking and savings accounts, certificates of deposit, IRAs and 401(k) plans, stocks, bonds, and similar items. It does not include your client’s primary home, or certain property related to burial expenses.
authorized representative	The person designated to assist or handle affairs related to your client’s health care services. This may be someone designated as a Power of Attorney, a family member, friend, caregiver, or it may be an advocate assigned to assist your client with an exception, appeal or grievance.

balance billing	In Part B, an additional payment your client makes to a doctor who doesn’t accept assignment. The doctor may not bill your client more than an additional 15 percent of the Medicare–approved amount. Some states limit balance billing to a smaller percentage or forbid it entirely. Another name for balance billing is “excess charges.” See accepting assignment.
beneficiary	The name for a person who has health care insurance through the Medicare or Medicaid program.
benefit	Money (reimbursement/copay) or services provided by an insurance policy. Another name for coverage. See coverage.
benefit period	The way that the Original Medicare Plan measures use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day a member goes to a hospital or skilled nursing facility. The benefit period ends when the member hasn’t had any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If one goes into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. The member must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods, although inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.
brand–name drug	A 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. See generic drugs.

calendar year	January through December 31
capacity waiver	Permission from CMS (Center for Medicare and Medicaid Services) for a Medicare Advantage plan to discontinue new enrollments in an area for a certain time period under defined circumstances.
caregiver	A person who helps care for someone who is ill, disabled or aged. Some caregivers are relatives or friends who volunteer their help. Some people provide care giving services for a cost.
catastrophic coverage	The phase in the Part D Drug Benefit where your client pays a low copayment or coinsurance for their drugs after your client or other qualified parties on their behalf have spent $4,350 in covered drugs during the covered year.
claim	A request for payment, for services and benefits received.
CMS	Centers for Medicare & Medicaid Services. The federal agency that runs the Medicare program, and works with the states to manage the Medicaid program. CMS sets standards for Medicare Advantage and Medicare Prescription Drug Plans.
coinsurance	A kind of cost sharing where costs are split on a percentage basis. For example, Part B might pay 80 percent, and your client would pay 20 percent.
complaint	See grievance.
confidentiality	Your client’s right to talk with their health care provider without anyone else finding out what they have said. See HIPAA.
coordinated care	In Part C, health care plans that coordinate your care by the doctors and hospitals your client visits. These plans may have some restrictions on the doctors and hospitals your client can use for their care. You may also hear these plans referred to as “managed care” plans.
copayment or copay	A kind of cost sharing where your client pays a predictable, pre–set amount for each service. In a Medicare Prescription Drug Plan, for example, an enrollee might pay $7 for each prescription they receive and the plan would pay the remaining cost of the drug. See cost sharing.
cost sharing	A term for the way an insurance plan shares its costs with someone. The most common types of cost sharing are coinsurance and copayments. See coinsurance and copayment.
coverage	The benefits an enrollee receives from an insurance plan. In a Medicare Prescription Drug Plan, the prescription drug costs that are paid by the insurance plan are the enrollee’s benefits or coverage.
coverage determination	A decision intended to ensure a medication is appropriate or effective for a particular situation. Certain medications covered by Medicare Part D require a coverage determination in order to receive benefits for these drugs. There are 4 types of coverage determinations: prior authorizations, step therapy, quantity limit and tier exceptions. The coverage determination may be requested by a member, their appointed representative or the prescriber. For a standard exception request, your client will receive an answer 72 hours after United Healthcare receives their physician’s supporting statement. If your client thinks waiting for that long will harm their health, your client can ask for an expedited exception review and get an answer 24 hours after we receive your physician supporting statement. See exception.
coverage gap	A name for the step in a Medicare Prescription Drug Plan in which an enrollee pays all of their expenses for eligible drugs including the discounted cost of their medications. In 2009 the coverage gap begins after the enrollee and the plan together have spent $2,700 in total yearly drug costs. From this point the enrollee will pay 100% of their prescription drug costs until they reach $4,350 in yearly true out–of–pocket (TrOOP) drug costs. Some people call the coverage gap the “doughnut hole.” Once an enrollee reaches $4,350 in TrOOP costs, they will enter the Catastrophic Coverage phase, during which the plan pays nearly all of their drug expenses until the end of the year, with no upper limit. See true out–of–pocket costs or (TrOOP). Some people call this coverage gap the “doughnut hole.”
covered service(s)	Stays or services incurred while coverage is in force and determined by United HealthCare to meet all of the following: (1) the stay or service must meet United States medical standards; (2) the stay or service must be necessary for the prevention, diagnosis, or treatment of a Sickness or Injury; (3) the stay or service must not be primarily for convenience; (4) the stay or service must be certified by a physician, upon United HealthCare’s request, as being appropriate for the diagnosis and treatment of Sickness or Injury; and (5) the stay or service must meet all other applicable terms and conditions of this plan.
creditable coverage	Certain kinds of previous health insurance coverage that can be used to shorten a pre–existing condition waiting period under a Medigap policy. Also, please see ‘creditable drug coverage’ below.
creditable drug coverage	Prescription drug coverage, from a plan other than a Part D stand–alone plan or a Medicare Advantage plan with drug coverage, which meets certain Medicare standards. If your client is currently enrolled in a drug plan that gives them prescription drug coverage, their plan will tell your client if it meets the Medicare standards for creditable drug coverage.
critical access hospital	A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.
current procedural terminology	Current Procedural Terminology (CPT) codes are identifying codes which are used nationwide for reporting medical services and procedures performed. A complete listing, entitled Physicians’ Current Procedural Terminology, is published by the American Medical Association.
custodial care	Care that provides help with the activities of daily life, like eating, bathing, or getting dressed. Most long–term care is custodial care.
custodial nursing	Refers to the traditional nursing home where the patient may spend their remaining years receiving aid with ADLs as primary care over medical maintenance.

deductible	A deductible is a dollar amount an enrollee must pay before their benefit plan will begin to contribute to their medical costs. A kind of cost sharing where your client will pay a pre–set, fixed amount first, before Medicare or other insurance starts to pay. In Part B in 2007, for example, your client must pay a deductible of $131 for the year. The deductible is $135 for 2008.
deeming	Applies to Private Fee–For–Service. Providers are deemed when enrollees present their ID cards, inform providers of plan membership and provider agrees to bill the enrollee’s plan, not Medicare, and accept 100% of the plan’s rate as payment in full. (The provider has agreed to accept the Plan’s Terms, Conditions, and payment rates.)
disenroll	Ending health care coverage with a health plan. An enrollee may choose to disenroll, or the plan may disenroll them under specific circumstances.
DME	Durable Medical Equipment. Medical equipment that is ordered by a doctor (or, if Medicare allows, a nurse practitioner, physician assistant, or clinical nurse specialist) for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part A & B for home health services.
doughnut hole	The step in a Medicare Prescription Drug Plan in which an enrollee pays all of their expenses for eligible drugs. Another name for the coverage gap. See Coverage gap.
dual eligible beneficiaries	People who are eligible for both Medicare and Medicaid.

educational event	An educational event is specifically advertised or promoted as “educational” or would lead the attendees to believe that it is solely educational.
EGHP	Employer Group Health Plan.
eligible drugs	Drugs that are covered by a prescription drug plan. In a Medicare Prescription Drug Plan or Medicare Advantage plan with drug coverage, eligible drugs are listed on the plan’s Formulary. See Formulary.
emergency	A medical condition manifesting itself by acute symptoms of sufficient severity (including sever pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (1) serious jeopardy to the health of the individual; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part.
enroll	To join a health plan.
enrollment period	A specific time period when people with Medicare can join a Medicare health plan if it is open and accepting new members. If a health plan chooses to be open, it must allow all eligible people with Medicare to join.
EOB	Explanation of Benefits. A document that shows a member a summary of costs for a particular service. It lists what services are covered, the full cost of those services, any required reduction in that cost, how much the plan will pay and member out–of–pocket cost.
ESRD	End–Stage Renal Disease. Refers to the last stage of kidney disease (less than 5% of kidney function.) This is usually terminal and it is very expensive to provide care during this phase of the illness.
evidence of coverage	The Evidence of Coverage (EOC) is provided to members once they enroll in a Medicare Advantage or a Part D plan and includes important information, including: how to use the plan, details about benefits and how to access them; definition of the Formulary (if applicable); exclusions and limitations; the plan’s service area; quality assurance information; how to file appeals and grievances and how people with limited incomes can get extra financial help.
exception	A request that plan rules be waived for a particular circumstance. In a Medicare Part D plan, exceptions may be requested for: drug limits, coverage for drugs not included in the Formulary and tier pricing. To be approved for coverage, a request for an exception must include information from a doctor about the medical necessity of the change. See coverage determination.
excess charges	If the member is in the Original Medicare Plan, this is the difference between a doctor’s or other health care provider’s actual charge (which may be limited by Medicare or the state) and the Medicare–approved payment amount.
exclusions	Items that are not covered by an insurance policy such as Medicare Prescription Drug Plans which have two types of exclusions. The first type is drugs that Medicare has excluded from coverage under Medicare prescription drug coverage, such as weight–loss drugs. The second type is drugs that are excluded from a plan’s list of covered drugs, or Formulary. See eligible drugs and Formulary.
experimental or investigational	Medical, surgical, diagnostic, psychiatric, substance abuse, or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time United HealthCare makes a determination regarding coverage in a particular case, are determined to be any of the following: (1) not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use; (2) subject to review and approval by any institutional review board for the proposed use; or (3) the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2, or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight.

FDA	Food and Drug Administration. The FDA oversees approval and regulation of all prescription drugs, both brand–name and generic versions. Its goals include safety, efficacy and quality.
formulary	A list of drugs covered by the Medicare Part D plan. A Formulary may also be referred to as a covered medications list (CML), preferred drug list (PDL), or a select drug list. These drugs are dispensed through participating pharmacies to covered enrollees. Formularies may differ between Part D plans. You and your client will want to carefully weigh the differences in Formularies against the plan costs and other features when choosing a plan that best meets your needs. See PDL/CML.
FPL	Federal Poverty Level. A measure of income that influences eligibility for the low–income subsidy.

generic drugs	Generic drugs are medications that usually cost less and are sold under a generic name for the brand–name drug (usually its chemical name). Because generic drugs are less expensive than their brand–name equivalent, copayments are usually less for these drugs, as well. Generic drugs are approved by the U.S. Food and Drug Administration (FDA). There are two types of generic drugs. A generic equivalent is a generic drug that contains the same active ingredient as its brand–name version and is shown to work the same way in the body. The FDA requires generic equivalents to have the same quality and strength as the brand-name versions. A pharmacist will generally dispense a generic equivalent when one is available. A generic alternative is a generic drug that belongs to the same chemical family as a similar brand–name drug. Generic alternatives may contain different active ingredients than the brand–name counterparts; however, they work by similar mechanisms within the body and can provide similar results. If your client’s doctor agrees that a generic alternative is appropriate, he/she will need to write a new prescription. See brand–name drugs and FDA.
grievance	A formal complaint about the way a Medicare health plan is giving care. For example, your client may file a grievance if they have a problem calling the plan or if they are unhappy with the way a staff person at the plan has behaved toward them. A grievance is not the way to deal with a complaint about a treatment decision or a service that is not covered. See appeal.
guaranteed issue rights	Rights the member has in certain situations when insurance companies are required by law to sell or offer a Medigap policy. In these situations, an insurance company can’t deny the prospect a Medigap policy, or place conditions on a Medigap policy, such as exclusions for pre–existing conditions, and can’t charge the prospect more for a Medigap policy because of past or present health problems.
guaranteed renewable policy	A feature of Medigap policies. A “guaranteed renewable” policy must be renewed by the company automatically each year, so long as your client pays the premium and doesn’t commit any fraud on the insurance company.

health care common procedure coding system (HCPCS) level II national code	A uniform method for health care providers and medical suppliers to report professional services, procedures, and supplies. This coding system was developed and is updated by the Centers for Medicare and Medicaid Services (CMS).
health care practitioner	A licensed physician, physician’s assistant, nurse practitioner, physical therapist, occupational therapist, speech therapist, chiropractor or mental health care provider acting within the scope of his or her license.
health maintenance organization (HMO) plan	In Part C, a type of Medicare Advantage Plan in which your client must use doctors and hospitals in the plan’s network for your client’s care. If your client goes outside the network, they are responsible for paying for their own care.
high deductible medicare advantage plans	A health insurance plan in which your client pays a significant deductible (usually more than $1,000) before the plan begins to help with your client’s costs. See Medical Savings Accounts Plans.
HIPAA	Health Insurance Portability & Accountability Act. A law passed in 1996, also called the “Kassebaum–Kennedy” law. It expands health care coverage if your client has lost their job and protects them and their family from discrimination based on past or present health conditions. HIPAA also: limits how companies can use pre–existing medical conditions to keep an enrollee from getting health insurance coverage; usually gives credit for health coverage an enrollee has had in the past; may give special help with group health coverage when an enrollee loses coverage or has a new dependent; and generally guarantees the right to renew health coverage. HIPAA does not replace the states’ roles as primary regulators of insurance.
home health aide	A person whose main function is to provide personal care services. If state or local licensing or certification is required, the person must be licensed or certified as a home health aide where the service is performed. If licensing or certification is not required, any person who meets the minimum training qualifications recognized by the National Home Caring Council, National League of Nursing, or Centers for Medicare and Medicaid Services will be considered a home health aide, provided that they are employed through a licensed or Medicare certified home health care agency.
home health care	In Part A and Part B skilled nursing care and therapy, such as speech therapy or physical therapy, provided to the homebound on a part–time or intermittent basis.
hospice care	Care for those who are terminally ill. Hospice care typically focuses on controlling symptoms and managing pain. In Part A, hospice care also includes support services for both patient and caregivers. Part A covers both hospice care received at home and care received in a hospice outside the home.
hospital	The following facilities will qualify as a hospital: Medicare Approved Hospitals – An institution which, while members use it, has an agreement as a provider of inpatient hospital services under the Medicare program (i.e., Section 1866 of Title XVIII of the United States Social Security Act as amended). Christian Science Sanitoria – A Sanitorium operated by or certified by the Commission for accreditation of Christian Science Nursing Organizations/Facilities. Other Institutions – An institution or unit thereof, other than those above, which meets fully all of the following requirements: (1) holds a state license as a hospital (if a license is required); (2) operates mainly for the medical care and treatment of sick or injured persons as inpatients; (3) provides on–duty, 24 hour–a–day nursing service by registered or graduate nurses; (4) has a staff of one or more licensed Physicians available at all times; and (5) provides on its premises, or through contractual arrangement with another institution, organized facilities regularly used for diagnosis and major surgery. The unit of the institution in which a member is confined must meet fully all five of these requirements. Note: Institutions or units thereof (by whatever name called), which might otherwise meet these requirements, will NOT be considered a covered hospital when functioning primarily as: (1) a clinic, rest home, convalescent home, home for the aged, or assisted living center; (2) a nursing home unit or a facility or unit providing skilled nursing care, intermediate care, extended care, or custodial care; (3) a domiciliary unit or a facility or unit providing housing or residential care; (4) a hospice; (5) an ambulatory surgical center or dialysis center; (6) a facility or unit providing scheduled classes, training, education, or recreation; or (7) a facility or unit which provides treatment for alcohol, drug, or other substance abuse.
hospital inpatient stay	The continuous period of time that begins on the day a member: 1) enters a hospital as an inpatient, or 2) enters an emergency room or observation room and is admitted to the hospital as an inpatient directly from the emergency room or observation room, and ends when the member has been out of a hospital for at least 24 hours. This applies even if a member moves from one hospital to another.

I/T/U	Indian Health Service, Tribal Health Programs or Urban Indian Health Services. The Indian Health Service (IHS) is an agency within the U.S. Department of Health and Human Services. Federally recognized tribes access health services through the IHS (I), through tribal programs (T) that operate their own health care services and/or through urban Indian health clinics (U).
ICEP	Initial Coverage Election Period. The ICEP is a period during which an individual is first eligible to enroll in an MA plan. It begins three months before the individual’s enrollment in both Part A & B and ends on the later of: (1) The last day of the month preceding entitlement to both Part A & B , or; (2) The last day of his/her Part B initial enrollment period.
initial coverage determination	The first step of the authorization process, issued by the PDP or MAPD.
initial enrollment period (IEP)	A seven–month period that begins three months before the month of your client’s eligibility for Medicare, and ends three months after the month of your client’s eligibility. During your client’s initial enrollment period, your client will be able to sign up for Part D plans that may either be unavailable or cost more if they wait until later to join.
injury	An accidental bodily injury that is the direct result of an accident, independent of disease or bodily infirmity or any other cause and occurs while this plan is in force.
inpatient care	Care your client receives in a hospital when they are admitted for an overnight stay.
inpatient rehabilitation facility	A hospital, or part of a hospital that provides an intensive rehabilitation program.
institution	A facility that meets Medicare’s definition of a long-term care facility, such as a nursing facility or skilled nursing facility, not including assisted or adult living facilities or residential homes.
IRE	Independent Review Entity. An agency contracted by CMS to conduct reconsiderations of adverse coverage determinations made by Medicare Advantage or Prescription Drug plans.

laboratory/pathology services	Only those procedures designated as “Pathology and Laboratory” in the Physicians’ Current Procedural Terminology (CPT).
late enrollment penalty	An amount added to the monthly premium for Medicare Part A and/or Part B, or for a Medicare drug plan (Part D), if a person doesn’t join when they are first eligible. When a person is assigned a late enrollment penalty, they will pay this higher amount as long as they have Medicare. There are some exceptions. See creditable coverage.
lifetime reserve days	Medicare will pay for an additional 60 days impatient care when the patient is in the hospital for more than 90 days. These 60 reserve days can be used only once during an individual’s lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance ($512 per lifetime reserve day in 2008).
limiting charge	The maximum amount of money a patient can be charged for a covered service provided by a doctor or health care provider who doesn’t accept assignment. The limit is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment.
LIS	Low Income Subsidy. A Medicare program to help people with limited income and resources pay prescription drug costs. The amount of assistance depends on income and resources. Your client must join a standalone Medicare prescription drug program or a Medicare Advantage plan with drug coverage in order to receive this help. Apply through the Social Security Administration or your State Medical Assistance Office.
lock–in	Limitations on open enrollment and disenrollment choices (4/1-11/14 of each year).
lock–in provision	An arrangement that all covered services (with the exception of emergency services, urgently needed services, or out–of–area and routine travel dialysis) must be provided or authorized by the contracting medical group or the contracting primary care physician. Services provided “out of the contracting network” and not authorized by the contracting provider would not be paid.
long–term care	Care that gives help with the activities of daily life, like eating, dressing, and bathing, over a long period of time. Most long–term care is custodial care. See custodial care.

MA–PFFS	Medicare Advantage Plan with Private Fee–For–Service coverage.
MAC	Medicare Appeals Council. If an enrollee is dissatisfied with the ALJ hearing decision, they may request that the MAC review the ALJ’s decision.
maintenance medication	Typically a drug taken on a regular basis for a chronic or long–term medical condition.
MAPD	Medicare Advantage Prescription Drug. This is a Medicare Advantage Plan that integrantes Part D Prescription Drug benefits.
Medicaid	A program that pays for medical assistance for certain individuals and families with low incomes and resources. Medicaid is jointly funded by the federal and state governments to assist states in providing long–term care assistance to people who meet certain eligibility criteria.
medical emergency	The sudden and unexpected onset of symptoms, sickness, injury, or a condition that would be deemed, under appropriate United States medical standards, to carry substantial risk of serious medical complication or permanent damage to a member if care or services are delayed or withheld.
medical savings account (MSA) plans	In Part C, a type of Medicare Advantage Plan that combines a special bank savings account for your client’s medical expenses with a high deductible Medicare Advantage Plan. See also high deductible Medicare Advantage Plans.
medical underwriting	The process that an insurance company uses to decide, based on a prospect’s medical history, whether or not to take an application for insurance, whether or not to add a waiting period for pre–existing conditions (if that state law allows it), and how much to charge the prospect for that insurance.
medically necessary care	Services or supplies that are needed to diagnose or treat a medical condition, according to the accepted standards of medical practice.
Medicare	A federal government health insurance program for people (1) age 65 and older, or (2) with certain disabilities, or (3) of all ages with End–Stage Renal Disease (permanent kidney failure requiring dialysis or kidney transplant).
Medicare advantage (MA)	A type of Medicare Plan offered by a private company. In Medicare Advantage Plans, beneficiaries have the option of receiving Part A and Part B benefits through a single managed care plan. Many Medicare Advantage Plans also include prescription drug coverage. Also called “Part C,” Medicare Advantage Plans include HMOs, PPOs, PFFS Plans, SNPs, and Medical Savings Account Plans. Medicare Advantage Plans used to be called Medicare+Choice Plans.
Medicare prescription drug plans	Insurance plans offering prescription drug coverage that meets the standards established by Medicare. Other names for these plans include Part D Prescription Drug Plans, prescription drug plans (PDP), or Medicare Advantage Prescription Drug Plans (MA–PD). However, not all private insurance plans offering prescription drug coverage are Medicare Prescription Drug Plans. You’ll want to pay close attention to whether a plan is a Medicare Prescription Drug Plan approved by CMS.
Medicare savings program	Medicaid program that helps eligible people pay some or all Medicare premiums and deductibles.
Medicare select	A special type of Medigap policy that requires your client to use specific hospitals, and in some cases, specific doctors, to get your client’s full insurance benefits (except in an emergency).
Medicare supplement insurance	Also called Medigap. An insurance policy your client buys from a private insurance company that pays for some or all of the cost sharing, or gaps in coverage, such as deductibles, copayments, and coinsurance, in Medicare Part A and Part B coverage. Medigap policies are available in up to 12 standard types, or “plans”. Each plan is named with a letter of the alphabet. Don’t confuse Plans A, B, C, and D with Part A, B, C, and D of Medicare.
Medicare–approved amount	The amount of money that Medicare has approved as the total amount that a doctor or hospital should be paid for a particular service. The total amount includes what Medicare pays, plus any cost sharing your client pays.
medication therapy management	The term used to describe the type of help that people with multiple prescriptions, chronic diseases, and high drug costs receive to help them manage all of their medications. The purpose of the help is to make sure that all of their drugs work well together.
medigap	See Medicare supplement insurance.
mental illness	Those mental health or psychiatric diagnostic categories that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association.
MIPPA	Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) prohibits certain sales activities of MA plans and Part D drug plans, including door-to-door sales, cold calling, free meals, and cross selling of non health-related products. Also requires the Secretary to establish limitations on activities for sales and marketing involving the scope of marketing appointments, co-branding of network providers on MA plan materials, gifts, and commissions, and requires plans to abide by state appointment laws affecting agents and brokers.
MMA	Medicare Modernization Act. The 2003 MMA legislation provides seniors and people with disabilities with comprehensive prescription drug benefits through Medicare Part D. It is the first program of its kind ever offered under Medicare, and is therefore the most significant improvement to senior health care in nearly 40 years.
multiple source drugs	The originating manufacturer’s brand-name product that has lost its patent and is now available as an FDA–approved chemical equivalent through multiple generic manufacturers.

national average monthly premium	The national average monthly premium (NAP) for 2009 is $30.36. This calculation is based on the weighted average of the actual bids from prescription drug plans. This amount changes from year to year and the late enrollment penalty that is based on this figure will therefore also change.
network	In Part C and D, the group of providers, such as pharmacists, doctors and hospitals, who agree to provide care to the members of a Medicare Advantage coordinated care plan or Prescription Drug Plan. These providers are called “network providers” or “network pharmacies”.
non–Formulary drugs	Drugs not on a plan-approved list.
nurse	For the purpose of the Post–Hospital Benefit, a professional nurse legally designated “RN” (registered nurse) or “LPN” (licensed practical nurse) who, where licensing is required, holds a valid license from the state in which the nursing service is performed. “LPN” shall include a licensed vocational nurse (“LVN”) and any other similarly designated nurse in those jurisdictions in which a professional nurse is designated as other than an “LPN” and for whom licensing is required.

open enrollment period	Your client can switch to another Medicare Advantage plan during the Open Enrollment Period (OEP) from January 1 to March 31 of any year, but they can’t join or drop Medicare Prescription Drug coverage during that time.
original Medicare plan	The Original Medicare Plan has two parts: Part A (Hospital) and Part B (Medical). It is a fee–for–service health plan. Medicare pays its share of the Medicare–approved amount, and the member pays their share (coinsurance and deductibles).
out–of–network benefit	Generally provides a beneficiary with the option to access plan services outside of the contracted provider network. In some cases, a beneficiary’s out-of-pocket costs may be higher for an out–of–network benefit.
out–of–pocket costs	The amounts paid as the enrollee’s share of prescription drug costs in a Medicare Prescription Drug Plan. Out–of–pocket costs include deductibles, coinsurance, and the amounts the enrollee pays in the coverage gap. Premiums are not included as out–of–pocket costs. In a Medicare Prescription Drug Plan, any amounts paid by the enrollee, but for which they are later reimbursed by someone else, such as an employer’s insurance plan, do not count as part of the enrollee’s true out–of–pocket costs. The true out–of–pocket costs paid for which the enrollee is not reimbursed are called their “true out–of–pocket costs,” or “TrOOP.” In 2009, when an enrollee’s “true out–of–pocket costs” exceed $4,350, they are eligible for the catastrophic coverage step of a Medicare Prescription Drug Plan. See catastrophic coverage and coverage gap.
out–of–pocket maximum	A limit that some plans set on the amount of money your client will have to spend out of your clientâ€™s own pocket.
outpatient care	Care your client receives as a hospital patient if your client doesn’t stay overnight, or care your client receives in a free–standing surgery center where your client doesn’t stay overnight.

PA	Prior Authorization or Prior Approval. Some benefit plans requires an enrollee to receive authorization or approval before they will cover a particular prescription or service. For example, sometimes prior authorization may be needed for the plan to ensure your client’s drug is covered by the Medicare Part D benefit. In other cases, prior authorization helps to guide appropriate use of very high–cost drugs. If your client does not get approval, their drug may not be covered by the plan.
PACE	Programs of All–Inclusive Care for the Elderly. PACE combines medical, social, and long-term care services for frail people. PACE is available only in states that have chosen to offer it under Medicaid. The goal of PACE is to help people stay independent and live in their community as long as possible, while getting high quality care they need. To be eligible, your client must: Be at least 55 years old, Live in the service area of the PACE program, Be certified as eligible for nursing home care by the appropriate state agency, and Be able to live safely in the community.
Part A	The part of Original Medicare that provides help with the cost of hospital stays, skilled nursing services following a hospital stay, and some other kinds of skilled care. Don’t confuse this with a Medigap Plan A, which is a type of Medigap policy.
Part B	The part of Original Medicare that provides help with the cost of doctor visits and other medical services that don’t involve overnight hospital stays.
Part C	The part of Medicare that offers plans that combine help with hospital costs with help for doctor’s visits and other medical services. Part C plans are referred to as Medicare Advantage Plans. See also Medicare Advantage.
Part D	The part of Medicare that offers help with the cost of prescription drugs. Your client can get Part D coverage as part of a Medicare Advantage Plan, or as a stand–alone drug plan.
PDF	Portable Document Format. A standard file format created by Adobe Systems to enable seamless document sharing. Documents are accessible to anyone because they are independent of the original file type and operating system.
PDL/CML	Preferred Drug List/Covered Medications List. Another name for the plan Formulary, a list of drugs that are covered by the plan. See Formulary.
PDP	Prescription Drug Plan. A Medicare Advantage or stand alone PDP plan that provides prescription drug benefits.
period of hospital stay	The total number of days of all successive Hospital Inpatient Stays. Such Hospital Inpatient Stays that are separated by more than 90 days are NOT part of the same Period of Hospital Stay. If a member re–enters a Hospital after his/her coverage stops, that Hospital Inpatient Stay is NOT covered.
permission to call	A non-UHC plan member must give the plan permission to make an outbound call. Permission may be obtained by paper BRC or web BRC, lead card, or beneficiary expressly granting it at the close of an inbound call.
physician	A licensed doctor of medicine or osteopathy acting within the scope of his or her license.
point–of–service (POS) plan	In Part C, a type of Health Maintenance Organization (HMO) plan that lets your client use doctors and hospitals outside the plan if your client pays more. See Health Maintenance Organization (HMO) Plan.
pre–existing condition	A health problem a member had before the date that a new insurance policy starts.
preferred mail service	Preferred pharmacies are pharmacies in UnitedHealthcare“s network that offer a lower price for covered prescription drugs. Mail service pharmacies fill prescriptions as any other pharmacy and deliver the medication to your client by mail. The Medicare Part D plans insured through UnitedHealthcare have one preferred network pharmacy for mail service only.
preferred provider organization (PPO)	In Part C, a type of Medicare Advantage plan in which your client can use either preferred doctors or hospitals, or go to non–preferred doctors and hospitals. If your client uses non–preferred providers they will usually pay a larger share of the cost of their care.
premium	A fixed amount your client has to pay monthly to participate in a plan or program; in private insurance, the price your client pays monthly for a policy.
prescription drug plan (PDP)	In Part D, a stand-alone insurance policy that provides prescription drug coverage.
preventive care	Care that is meant to keep your client healthy, or to find illness early, when treatment is most effective. Examples of preventive care are flu shots, screening mammograms and diabetes screenings.
Private Fee–For–Service plan (PFFS)	In Part C, a type of Medicare Advantage Plan in which there is usually no network of providers and your client may visit any Medicare-eligible provider who is willing to accept the plan“s, payments, terms and conditions.

QL	Quantity Level Review or Quantity Limit. Quantity limits manage the amount of a drug that the plan will cover for a single copay or within a defined period of time. For example, if a blood pressure medication is typically taken once a day, the plan may limit coverage to 31 pills per 31 days (i.e. one pill per day for a month). If your client requires a quantity over this limit, your client or their doctor may request an exception from the plan. Exceptions will be considered when special circumstances apply. See exception.

radiology services	Only those procedures designated as “Radiology” in the Physicians” Current Procedural Terminology (CPT).
Rx	A symbol that means “prescription drugs.”

sales event	A sales event is used to market to potential members and steer them toward specific plans.
scope of appointment	The scope of the appointment must be agreed upon and documented either in writing with the prospect’s signature or by recorded phone conversation. The scope of an in-home appointment can include the following product lines: MA, Part D and Medicare Supplement. Agreeing to an MA product scope allows the agent to present any MA product, including HMO, PPO, PFFS and Special Needs Plans.
SEP	Special Enrollment Period. If your client qualifies, they are allowed to enroll in the plan outside the annual enrollment period in November and December. The qualifications are conditions set by the federal government. Qualification for an SEP generally means your client is facing unusual or emergency circumstances.
service area	The area where a health plan accepts members. For plans that require enrollees to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll an enrollee if they move out of the service area.
skilled nursing care	Nursing care which should be provided only by a licensed nurse.
skilled nursing facility	An institution (or unit of a Hospital) which: (1) is operated or licensed pursuant to state law or is approved for payment of Medicare benefits or is qualified to receive such approval if requested; (2) is primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under a licensed Physician‘s supervision; (3) provides on-duty, 24 hour nursing service under the supervision of registered or graduate nurses; and (4) maintains a daily record for each patient. The unit of the institution in which a member is confined must meet fully all four of these requirements. Note: Institutions or units thereof (by whatever name called), that otherwise meet these requirements, will NOT be considered a Skilled Nursing Facility when functioning primarily: (1) as a clinic, rest home, or convalescent home; (2) as a domiciliary, residential, or custodial care unit; (3) as an assisted living center; (4) as a home for the aged; (5) as an educational care unit; (6) for the treatment of substance abuse; or (7) for the convenience of the insured.
SPAP	State Pharmaceutical Assistance Program. Many state governments offer substantial subsidies to low and moderate-income seniors, with about half of those including younger adults with disabilities. SPAPs have existed for years to provide direct pharmaceutical assistance to eligible residents. A majority of these programs are recognized within the MMA, which formally defined the term in federal law.
special needs plan (SNP)	A type of Medicare Advantage Plan that serves people with special health care needs.
SSI	Supplemental Security Income. The SSI program provides monthly income to people who are age 65 or older, or are blind or disabled, and have limited income and financial resources. Your client can be eligible for SSI even if they have never worked in employment covered under Social Security. Generally, to be eligible for SSI, an individual also must be a resident of the United States and must be a citizen or a noncitizen lawfully admitted for permanent residence.
ST	Step Therapy. Step Therapy encourages your client to try safe, effective, lower-cost drugs before the plan covers a more costly drug. For example, if Drug A and Drug B treat the same medical condition, the plan may not cover Drug B unless your client tries Drug A first. If Drug A does not work for your client, the plan will then cover Drug B. Step Therapy can decrease your client“s out-of-pocket costs and could help them delay or avoid the coverage gap because the total drug cost is lower.
state health insurance assistance program	A state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.
state insurance department	A state agency that regulates insurance and can provide information about Medigap policies and other private insurance.
summary of benefits (SB)	This document informs prospective as well as existing members about the benefits offered by the plan. The SB covers important aspects about enrolling in the plan and describes the plan“s benefit package. The SB is a summary document so it does not include the same level of benefit detail as in the Evidence of Coverage. See Evidence of Coverage.
surgery	Only those procedures designated as “Cardiac Catheterization,” “Cardiovascular Therapeutic Services” which require introducing, positioning, or repositioning of catheters, and “Surgery,” as stated in the Physicians’ Current Procedural Terminology (CPT).

therapist	A licensed physical therapist, occupational therapist, or speech therapist who is acting within the scope of his or her license where the services are performed.
tier or copay level	Drugs in the plan’s Formulary (drug list) are organized into different categories, called tiers. Each tier has a different copayment or coinsurance. See copayment, coinsurance, coverage gap.
TrOOP	True out-of-pocket costs. Those costs an enrollee pays for covered Medicare Part D drugs for which they are not reimbursed. See out-of-pocket costs.
TTY	Teletypewriter. A communication device used by people who are deaf, hard of hearing, or have a severe speech impairment. A TTY consists of a keyboard, display screen, and modem. Messages travel over regular telephone lines. People who don“t have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.

UHC	United Healthcare Insurance Company. An insurance company whose affiliates and subsidiaries administer multiple Medicare Part D plans.
UHG	UnitedHealth Group. The holding, or parent company, for United HealthCare Insurance Company and all its state affiliate companies.

VA	Veterans Administration. The government body that oversees all programs and benefits available to military veterans.