Accepts Medicare Assignment

A term that means physicians, physical therapists, occupational therapists and Durable Medical Equipment suppliers who participate in Medicare will accept Medicare Allowable Charges.  That payment will be considered paid in full for services provided to Medicare beneficiaries.

Account

A bank account used with a Medicare Medical Savings Account (MSA) Plan. The plan deposits money from Medicare in the account.  The member uses the account money toward payment of his or her medical bills.

Acute Care

Health care received for an immediate and severe illness or disease.  Acute Care also refers to the treatment of injuries from an accident or during recovery from surgery.  Acute Care is usually received in a hospital from highly trained personnel using complex and advanced technical equipment and materials. 

Advantra®

The registered name of Coventry Health Care's Medicare products.

Advantra® Freedom

Advantra Freedom is a Medicare Advantage Private Fee-for-Service Plan (PFFS) offered through Coventry Health Care, Inc. subsidiaries who contract with the Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare.

Advantra®Rx

A Medicare Prescription Drug Plan offered through Coventry Health Care, Inc. subsidiaries who contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency that administers Medicare.  

Advantra® Savings

A Medicare Advantage Medical Savings Account Plan offered through First Health Life & Health Insurance Company, a subsidiary of Coventry Health Care who contracts with the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare.

Appeal

The type of complaint a member may make to request a reconsideration of a decision (known as a determination) that was made regarding a service or what the plan will pay for a service. Examples of when a member may file an Appeal include:

• If the plan refuses to cover or pay for services the member thinks the plan should cover
• If the plan or a provider refuses to give the member a service he or she thinks should be covered
• If the plan or a provider reduces or cuts back on services the member has been receiving
• If the member thinks that the plan is stopping his or her coverage too soon

Assignment

A payment agreement between Medicare and a doctor or supplier. Doctors and suppliers who accept assignment from Medicare agree to accept a Medicare-allowed amount.  They cannot try to collect more than the Medicare deductible and coinsurance amounts from the person with Medicare, the person's other insurance (if any), or from anyone else. Doctors and suppliers who do not agree to accept assignment may bill at a slightly higher rate, but are still limited in what they can bill by non-assigned Medicare-allowed amounts.

Balance Billing

Physicians, occupational therapists or durable medical equipment suppliers who do not accept Medicare Assignment can choose to bill the Medicare beneficiary for the balance of private fees that exceed the Medicare allowed charges.  This bill can not  exceed 115% of Medicare’s allowable charges.

Benefit Period

A way of measuring your use of services under Medicare Part A. A Benefit Period begins with the first day the member goes to a Medicare-covered inpatient hospital or a Skilled Nursing Facility.  The Benefit Period ends when the member has not received any hospital or Skilled Nursing Facility care for sixty (60) days in a row. If the member goes to the hospital (or Skilled Nursing Facility) after one Benefit Period has ended, a new Benefit Period begins. There is no limit to the number of Benefit Periods a member can have. Original Medicare hospital Benefit Periods do not apply for inpatient hospital stays through an Advantra Savings plan.

Brand Name Drug

A drug that is sold under a trademarked brand name. AdvantraRx and First Health Part D cover thousands of brand name medications across a wide range of therapeutic classes.

Calendar Year

A twelve (12) month period that begins on January 1 and ends twelve (12) consecutive months later on December 31.

Catastrophic Coverage

Coverage that begins when a member reaches their maximum true out-of-pocket (TrOOP) drug costs. The Member pays a percentage of his or her drug costs (or a small copayment) for the rest of the calendar year.

Centers for Medicare & Medicaid Services (CMS)

The federal agency responsible for administering Medicare.

Claim

Notification in a form acceptable to the plans that a covered service has been received or furnished to an enrollee. This notification must explain in full the details of such covered service as required by the plans.

Coinsurance

A percentage of the cost of a covered service an enrollee is required to pay either at the time of service, toward the cost of a prescription, or when billed by the provider. An enrollee's coinsurance amount is based on Medicare Allowable Charges.

Copayment

The portion of the covered service that is the responsibility of the enrollee and is shown on the Summary of Benefits. The copayment can also be a pre-set, fixed amount the enrollee pays toward the cost of prescription medications.

Coventry Health Care, Inc.

Coventry Health Care, Inc. and its family of subsidiary companies, offer Medicare Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Point of Service (POS), Prescription Drug Plan (PDP), Private Fee-for-Service (PFFS) and Medical Savings Account (MSA) plans.

Coverage Gap

The gap in the member's prescription drug coverage between paying all of the eligible medication expenses up to the maximum. AdvantraRx offers a plan that provides coverage in the gap.

Covered Services

Medically necessary services or supplies provided under the terms of the combined Evidence of Coverage and disclosure information and the Summary of Benefits.

Custodial Care

Not a covered service. Custodial care includes services that assist an individual in the activities of daily living. Examples include: assistance in walking, getting in or out of bed, bathing, dressing, feeding and using the toilet, preparation of special diets, and supervision of the administration of medication that usually can be self-administered. Custodial care includes all homemaker services, respite care, convalescent care or extended care not requiring skilled nursing. Custodial care does not require the continuing attention of trained medical or paramedical personnel.

Customer Service

A department dedicated to answering the member's questions concerning (but not limited to) enrollment, covered services, grievances and appeals rights.

Deductible

The amount the member must pay out-of-pocket before the plan begins to pay. Certain plans have no deductible, which means that the member has first dollar coverage as soon as her or she is eligible.

Deemed Provider (Deemed Physician)

Providers (physicians, physical therapists, occupational therapists and durable medical equipment suppliers) who participate in Medicare are deemed to have a contract with a Medicare Advantage Private Fee-for-Service organization if (a) they are Medicare eligible and (b) they know, before furnishing services, that a Medicare beneficiary is enrolled in a Medicare Advantage Private-Fee-For-Service Plan and agrees to accept the plan's terms and conditions of payment.

Disenroll or Disenrollment

The process of ending a member's enrollment in any Plan. Disenrollment can be voluntary or involuntary.

Durable Medical Equipment (DME)

Equipment that can withstand repeated use; is primarily and usually used to serve a medical purpose; is generally not useful to a person in the absence of illness or injury; and is appropriate for use in the home. To be covered, durable medical equipment must be medically necessary and prescribed by a provider for use in your home, such as oxygen equipment, wheelchairs, hospital beds and other items that are determined medically necessary, in accordance with Medicare law, regulations and guidelines.

Effective Date

This is the date benefits start. The effective date will always begin on the first of the month. The first month of coverage will vary depending on when the application was received and period in which the member is enrolled. For example, an application received between November 15 and December 31 (Medicare’s Annual Enrollment Period) will have an effective date of coverage of January 1.

Emergency Medical Condition

A medical condition with symptoms so bad that without immediate medical attention could result in: 1) placing the enrollee's health in serious danger; 2) serious harm to basic body functions; 3) serious failure of any bodily organ or part.

Emergency Services

Covered services that are 1) furnished by an emergency room provider qualified to provide emergency services, and 2) needed to evaluate or stabilize an emergency medical condition. Please see definition of emergency medical condition.

Enrollee (Member)

A person with Medicare who is eligible to receive covered services, who has enrolled in a Plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Evidence of Coverage and Disclosure Information

A document that explains covered services and defines the member's rights and responsibilities as an enrollee and those of the plans.

Excess Charges — (“Medicare Part B Excess Charges”)

The amount of charges that physicians, physical therapists, occupational therapists and durable medical equipment suppliers may bill Medicare beneficiaries for services provided if these providers choose to not accept Medicare Assignment as payment in full. Medicare established a Medicare Limiting Charge of 115% of Medicare Allowable Charges or the maximum permitted under State law, which defines the maximum amount that these Providers may bill a Medicare beneficiary.

Exclusion or Excluded

Items or services which are not covered for payment.. Exclusions are disclosed in the Evidence of Coverage. The member is responsible for paying for excluded items or services.

Experimental Procedures and Items

Items and procedures determined by the health plans and Medicare not to be generally accepted by the medical community. When making a determination as to whether a service or item is experimental, the health plans will follow the Centers for Medicare & Medicaid Services (CMS) guidance (via the Medicare Carriers Manual and Coverage Issues Manual) if applicable, or rely upon determinations already made by Medicare. Experimental procedures and items are not covered.

Formulary

A list of prescription medications covered by the Prescription Drug Plans. The Plan’s formulary covers thousands of medications, including most of the Medicare Top 200 Drugs.

Generic Drug

A drug that has been rated by the FDA as being identical in strength, safety and quality as its brand name counterpart. Generic medications usually are available at lower copayments than brand name medications.

Generic Substitution

When there is a generic version of a brand name drug available, our network pharmacies will automatically give the member the generic version, unless his or her doctor has told us that he or she must take the brand name drug.

Grievance

The type of complaint a member may make about an issue or a problem that does not involve payment or services by the Plans. For example, a member would file a Grievance if he or she has a problem with matters such as the quality of care received, general dissatisfaction with the way the Plan’s benefits are designed, waiting times, the way doctors or pharmacists or others behave, being able to reach someone by phone or obtain the information needed, or the cleanliness or condition of a doctor's office.

 Health Maintenance Organization (HMO)

An HMO is a managed care plan that provides health care services to its members through networks of doctors, hospitals and other health care providers.

Home Health Agency

A Medicare-certified agency, which provides intermittent Skilled Nursing Care and other Medically Necessary therapeutic services in-home when a member is confined to home.

Hospice

An organization or agency, certified by Medicare, that is primarily engaged in providing pain relief, symptom management and supportive services to terminally ill people and their families.

Hospital

A licensed Medicare-certified institution that provides inpatient, outpatient, emergency, diagnostic and therapeutic services. The term "hospital" does not include a convalescent nursing home, rest facility or facility for the aged which provides mainly custodial care, including training in routines of daily living.

Hospitalist

When a member is admitted for a medically necessary procedure or treatment at a hospital, his or her health care may be coordinated by a physician who specializes in treating hospitalized patients.

Independent Review Entity

An entity under contract with the Centers for Medicare & Medicaid Services (CMS), such as the Maximus Center for Health Dispute Resolution, that reviews appeals by enrollees of Medicare-managed care plans.

Individual Election Form (IEF)

The enrollment form a Medicare beneficiary or legal representative must complete (with signature and date) in order to be enrolled as an enrollee. This form is submitted to the Centers for Medicare & Medicaid Services (CMS) for approval.

Initial Coverage Limit

The amount of drug coverage before a member reaches the coverage gap. The gap is sometimes referred to as the “donut hole.”

Late Enrollment Penalty

An additional monthly fee a member must pay if he or she did not join a Prescription Drug Plan when first eligible. The premium cost may go up a certain percentage per month for every month that the member did not join – for as long as he or she has Medicare prescription drug coverage.

Limitations

Items, benefits or services that are limited and listed within the enrollee handbook, Evidence of Coverage and Summary of Benefits section.

Maintenance Drug

A daily medication that is taken for an extended period of time. AdvantraRx plans offer a mail order option for delivery of certain maintenance medications, allowing you to pay only two copayments for a three month supply.

Medicaid

A joint federal/state medical assistance program established by the Social Security Act. Some Medicare beneficiaries are also eligible for Medicaid. Medicaid, unlike Medicare, can cover long-term care, such as Custodial Care. Medicaid can cover all or part of Medicare premiums and/or Deductibles and Coinsurance, if income and resources are low enough. Persons may inquire about Medicaid and related programs at their local Department of Social Services.

Medical Director

A licensed physician who is an employee or contractor of Coventry Health Care and is responsible for monitoring and overseeing the quality of care to our members.

Medical Savings Account (MSA)

Medicare introduced this new type of Medicare Advantage plan in 2007.  An MSA Plan combines a high deductible Medicare Advantage Plan (like a PFFS) with a Medical Savings Account for medical expenses. 

Medically Necessary

Services or supplies that are needed for the diagnosis or treatment of a medical condition and that meets accepted standards of medical practice. 

Medicare (Original Medicare)

Also called traditional Medicare. The federal government health insurance program established by the Social Security Act for persons 65 years of age and older, certain younger people with disabilities, and people with end-stage renal disease (ESRD).

Medicare Advantage Plan (Part C)

A type of Medicare plan offered by a private company such as Coventry Health Care that contracts with Medicare to provide Medicare Part A and Part B benefits. Medicare Advantage plans are also called Part C plans and include HMOs, PPOs, Private-Fee-for-Service Plans, Special Needs Plans or Medicare Medical Savings Account Plans. If enrolled in a Medicare Advantage plan, Medicare services are covered through that plan and are not paid under the Original Medicare plan. Some Medicare Advantage plans include prescription drug coverage.

Medicare Advantage Organization (MAO)

A public or private organization licensed and under contract with the Centers for Medicare & Medicaid Services (CMS) to provide health care coverage to Medicare Eligible enrollees.

Medicare-Approved Amount

The amount a doctor or supplier who accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that the member pays. It may be less than the actual amount a doctor or supplier charges.

Medicare Allowable Charges

The amount Medicare has determined is the allowable charges for services provided to Medicare beneficiaries.

Medicare Eligible Physician

A Physician who is state licensed, has a Medicare billing number or is eligible to obtain one, and eligible to furnish services to a plan’s members.

Medicare Part A

Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. 

Medicare Part A Premium

A monthly fee that is funded by part of the Social Security payroll withholding tax paid by workers and their employers and by part of the Self-Employment Tax paid by self employed persons.  Generally, people age 65 and older can obtain premium-free Medicare Part A benefits based on their own or their spouse's employment.  Individuals under 65 may obtain premium-free Medicare Part A benefits if they have been a disabled beneficiary under Social Security Administration or the Railroad Retirement Board for more than 24 months.  Individuals who do not qualify for premium-free Part A benefits, may buy the coverage if they are at least 65 years old and meet certain requirements.  Also, individuals may be able to buy Medicare Part A if they are disabled and lost their premium-free Part A because they aren't working. 

Medicare Part B

Medicare medical insurance that is optional and requires payment of a monthly premium.  Part B helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Part A.

Medicare Part B Premium

A monthly fee paid to Medicare (usually deducted from the Medicare eligible person's Social Security check) to cover Part B services. The Medicare eligible person must continue to pay this premium to Medicare to receive Covered Services whether covered by a Medicare Advantage plan or Medicare.

Medicare Part C (Medicare Advantage)

Refers to a Medicare Advantage plan offered by a private company that contracts with Medicare to provide all Medicare Part A and Part B benefits.  Includes Private-Fee-for-Service (PFFS), Medical Savings Account (MSA), Health Maintenance Organization (HMO), Preferred Provider Organization (PPO) and Point of Servicer (POS) plan choices.  If enrolled in Part C (a Medicare Advantage plan), Medicare services are covered through that plan.  Some Medicare Advantage plans include prescription drug coverage. 

Medicare Part D Prescription Drug Plan (PDP)

A stand-alone prescription drug plan that began in January 2006 and is provided by insurers and private companies, like Coventry Health Care, to people who get benefits through Original Medicare.  Part D is offered to Medicare eligible persons through a Medicare Advantage HMO or PPO Plan, a Private-Fee-for-Service Plan, a Medicare Cost Plan, or a Medicare Medical Savings Account Plan.  A person must be entitled to Medicare Part A and/or enrolled in Medicare Part B to be eligible for Medicare Part D.  Beneficiaries who enroll in Part D may pay a monthly premium (depending on the plan) in addition to their Part B premium. 

Medicare Participating Providers

Medicare Eligible Physicians, physical therapists, occupational therapists and durable medical equipment suppliers who accept Medicare Allowed Charges as payment in full for services provided to Medicare beneficiaries.

Medicare Non-Participating Providers

Medicare eligible physicians, physical therapists, occupational therapists and durable medical equipment suppliers who do not accept Medicare Allowable Charges as payment in full for services provided to Medicare beneficiaries. The amount of charges that these Providers may bill Medicare beneficiaries for services provided is established by Medicare. The Medicare Limiting Charge of 115% of Medicare Allowable Charges defines the maximum amount that these Providers may bill the beneficiary.

Medigap Policy

Medicare supplement insurance policy sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage.  

Network (or Participating) Pharmacy

The list of local, national and regional drug stores that offer discounted pricing to our Prescription Drug Plan (PDP) members. 

Non-Preferred Drug

A drug that is covered by our Prescription Drug Plans, but at a higher copayment than a preferred drug.

Office Visit

A visit for covered services to a primary care physician, specialist or other provider.

Out-of-Pocket Maximum (or Maximum Out-of-Pocket "MOOP")

This is the limited amount (during each calendar year, January 1 - December 31) the plan member must pay for covered services before the plan will pay for all Medicare-covered expenses.  This includes all copayments and coinsurance.  Expenses not covered by the plan do NOT count toward the annual Out-of-Pocket Maximum.

Outpatient Services

Medical services received while not admitted to an inpatient facility or Skilled Nursing Facility.

Physician

An officially licensed and or certified provider of health care services in the United States, such as a Medical Doctor (MD), Osteopath (DO), Psychologist or other practitioner (as defined by Medicare).  See also Primary Care Physician and Specialist. 

Plan Premium 

The monthly fee, when applicable, paid to Medicare, an insurance company, or a health care plan, such as a Medicare Advantage plan, for health and/or prescription drug coverage.

Point of Service (POS) Plan

A type of managed care health organization that combines characteristics of both an HMO and PPO plan.  Members of a POS plan do not have to make a choice about a health care provider until the point at which the service is required or to be delivered. 

Preferred Drug

A covered medication that helps maximize prescription savings.

Preferred Provider Organization (PPO)

A type of managed care organization consisting of medical doctors, hospitals, and other health care providers who are contracted to provide health care at reduced rates.

Preventive Services

Health care services to help stay healthy or to prevent illness. For example, PAP tests, prostate screenings, flu shots, and screening mammograms.

Primary Care Physician (PCP)

Physicians specializing in Internal Medicine, Family Practice, Pediatrics or General Practice who can assist with coordinating care. Certain plans do not require members to choose a PCP.

Prior Authorization

An approval that may be required from a Part D Prescription Drug Plan (PDP) before you fill a prescription. Without Prior Authorization, the PDP may not cover the cost of the drug.

Private Fee-for-Service (PFFS) Plan

A type of Medicare Advantage plan in which plan members may go to any Medicare-approved doctor or hospital that accepts Medicare and the plan’s payment terms and conditions. The plan, rather than Medicare, decides how much it will pay and what the member will pay for the services. Members may pay more or less for Medicare-covered benefits, but the plan provides extra benefits that Original Medicare does not cover.

Provider

Any professional person, organization, health facility, hospital, or other person or institution licensed and/or certified by both the state in which they operate and by Medicare to deliver or furnish health care services.

Qualified Medical Expense

Refers to the costs of Medicare-covered Part A and Part B services for diagnosis, treatment, prevention, or to alleviate physical disease, or mental defect or illness (e.g. doctors' visits, lab tests, hospital stays, and the premiums paid for insurance that cover the expenses of medical care).  These are types of services and products that otherwise could be deducted as medical expenses on yearly income tax returns.  They do not include expenses that are merely beneficial to general health, such as vitamins.  Qualified Medical Expenses count toward the Medicare plan deductible only if the expenses are for Medicare-covered Part A and Part B services.

For a complete list of the services and products that count at Qualified Medical Expenses and for other tax information, call the Internal Revenue Service at 1-800-TAX-FORM (1-800-829-3676).  Ask for a free copy of the IRS publication #502, "Medical and Dental Expenses" and IRS publication #969 "Health Savings Accounts and Other Tax-Favored Health plans."  Or, visit www.irs.gov on the web and select "Form and Publications" to view or print a copy of the publication.

Quality Improvement Organization (QIO)

A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care to people with Medicare. 

Quantity Limits

Limits on the amount of certain medications that a Prescription Drug Plan (PDP) will cover for a prescription or for a defined period of time.

Referral

A written order from a primary care doctor for a patient to see a specialist or get certain medical services.  In many HMO plans, the patient needs to get a referral before getting medical care from anyone except their primary care doctor.  Without first getting a referral, the plan may not pay for the services. 

Service Area

A geographic area where a health insurance plan accepts and provides services to members based on where they live.  For plans that limit which doctors and hospitals plan members may use, it's also generally the area where they can get routine (non-emergency) services.  The plan may disenroll a member if they move out of the plan's service area. 

Skilled Nursing Care

Medically necessary services that can only be performed by, or under the supervision of, licensed nursing personnel.

Skilled Nursing Facility (SNF) Care

A nursing facility with staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services, such as intravenous injections or physical therapy. 

Specialist

Any Physician, Osteopath, Psychologist or other practitioner (as defined by Medicare) who provides health care services for a specific disease, condition or body part. Specialists are licensed Providers in the United States. Specialists may also be considered a Primary Care Physician, such as Cardiologists who practice their sub-specialty as well as their Primary Care specialty of Internal Medicine.

Step Therapy

A form of prior authorization that requires the patient to first try one drug to treat a medical condition before the plan will cover another drug for that condition. For example, if Drug A and Drug B both treat a medical condition, the plan may require the doctor to prescribe Drug A first. If Drug A does not work for the patient, then the plan will cover Drug B.

Summary of Benefits

The official document that provides the details of particular plan benefits, including any copayments and coinsurance that a member must pay for receiving a covered service.  Together with the Evidence of Coverage, the Summary of Benefits explains the health care coverage. 

Technology Assessment

A review of new procedures, devices and drugs conducted by Coventry Health Care and based on specific guidelines to determine whether or not they are safe and effective for our members. New procedures and technology that are safe and effective are eligible to become Covered Services. If a procedure or new technology becomes a Covered Service it will be subject to all other terms and conditions of the plan, including Medical Necessity and any applicable member copayments or other payment contributions. When medical necessity requires a rapid determination of the safety and efficacy of a new technology or new application of an existing technology for an individual who is a member of a Coventry Health Care plan, the Medical Director will determine Medical Necessity. 

Terms and Conditions

Payment and plan participation conditions that Medicare providers must agree to in order to provide covered services to members of Medicare Advantage Private Fee-for-Service (PFFS) plans, except in the case of emergencies.

Therapeutic Class

This is a term used to classify similar medications used to treat a specific condition or disease.

Time-Sensitive

A situation in which waiting for a standard decision on an authorization, request for services or an appeal could seriously jeopardize life, health, or ability to recover from an illness, injury or condition.

True Out-Of-Pocket (TrOOP)

TrOOP costs are the expenses that count toward the annual Medicare Prescription Drug (Part D) limit for the year. These Part D plans will keep track of your TrOOP costs. For every month that members purchase prescriptions covered by the plan, the member will be mailed an Explanation of Benefits (EOB) that shows the member's TrOOP costs to date.

TTY/TDD

A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have severe speech impairment.  A person who does not have a TTY can communicate with a TTY user through a message relay center (MRC) which has operators available to send and interpret TTY messages. 

Urgently Needed Services

Covered Services that are medically necessary and immediately required as a result of an unforeseen illness, injury or condition. Urgently needed services may be provided in an urgent care facility when the primary care physician is temporarily unavailable or inaccessible. Covered services provided by an emergency room provider are considered Emergency Services, not Urgently Needed Services.