PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II Chapter 12: Defi nitions of important words Dispensing Fee – A fee charged each time a covered drug is dispensed to pay for the cost of fi lling a prescription. Th e dispensing fee covers costs such as the pharmacist’s time to prepare and package the prescription. Durable Medical Equipment – Certain medical equipment that is ordered by your doctor for use at home. Examples are walkers, wheelchairs, or hospital beds. Emergency – 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. Th e medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. Emergency Care – Covered services that are: 1) rendered by a provider qualifi ed to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition. Evidence of Coverage (EOC) and Disclosure Information – Th is document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan. Exception – A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if your plan 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 Help – A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance. Generic Drug – A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a “generic” drug works the same as a brand name drug and usually costs less. Grievance - A type of complaint you make about us or one of our network providers or pharmacies, including a complaint concerning the quality of your care. Th is type of complaint does not involve coverage or payment disputes. Home Health Aide – A 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. Hospital Inpatient Stay – A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Initial Coverage Limit – Th e maximum limit of coverage under the Initial Coverage Stage. Initial Coverage Stage – Th is is the stage before your total drug expenses have reached $2,970, including amounts you’ve paid and what our plan has paid on your behalf. Initial Enrollment Period – When you are fi rst eligible for Medicare, the period of time when you can sign up for Medicare Part B. For example, if you’re eligible for Part B 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. 211
212 2013 Evidence of Coverage for PPO II Chapter 12: Defi nitions of important word In-Network Maximum Out-of-Pocket Amount – Th e most you will pay for covered Part A and Part B services received from network (preferred) providers. After you have reached this limit, you will not have to pay anything when you get covered services from network providers for the rest of the contract year. However, until you reach your combined out-of-pocket amount, you must continue to pay your share of the costs when you seek care from an out-of-network (non-preferred) provider. See Chapter 4, Section 1.4 for information about your in-network maximum out-of-pocket amount. Late Enrollment Penalty – An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected 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. Th ere are some exceptions. For example, if you receive Extra Help from Medicare to pay your prescription drug plan costs, the late enrollment penalty rules do not apply to you. If you receive Extra Help, you do not pay a penalty, even if you go without “creditable” prescription drug coverage. List of Covered Drugs (Formulary or “Drug List”) – A list of prescription drugs covered by the plan. Th e drugs on this list are selected by the plan with the help of doctors and pharmacists. Th e list includes both brand name and generic drugs. Low Income Subsidy (LIS) – See “Extra Help.” Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state. Medically Accepted Indication – A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5, Section 4 for more information about a medically accepted indication. Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. Medicare – Th e Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare, a Medicare Cost Plan, a PACE plan or a Medicare Advantage Plan. Medicare Advantage Disenrollment Period – A set time each year when members in a Medicare Advantage plan can cancel their plan enrollment and switch to Original Medicare. Th e Medicare Advantage Disenrollment Period is from January 1 until February 14, 2013. Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan off ered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefi ts. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also off er Medicare Part D (prescription drug coverage). Th ese plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and
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PPO II - EmblemHealth

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