| Appeal |
what you file when you ask your plan to look
at why you were denied a service. |
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| Benefits package |
the services Medicare Advantage
or your plan covers. |
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| Chronic condition |
a sickness or disease that can't be cured
but can be treated (like diabetes). |
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| CMS |
stands for the "Centers for Medicare
and Medicaid Services." CMS is the government agency
that is in charge of Medicare and Medicaid. |
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| Co-insurance |
the amount that has to be paid after the deductible
for Medicare Part A and/or Part B is paid. The coinsurance
payment is a percentage of the approved amount for the service
(like 20%). Passport Health Plan usually pays this for you
because you are enrolled in Medicaid. |
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| Copay/copayment |
the $1.00 you pay for prescription drugs or
other services. It is called a copay because you pay some
and Passport Health Plan pays the rest. |
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| Covered benefit |
the services Medicare Advantage or your plan
will pay for. |
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| Deductible |
the amount of money paid for medical services
before Medicare begins paying its portion of the bill. Passport
Health Plan usually pays this for you because you are enrolled
in Medicaid. |
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| Dual eligible |
means you are enrolled in Medicaid and entitled
to Medicare Part A and/or B benefits. |
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| Emergency care |
care you get when your health problem is life
threatening. |
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| Evidence of Coverage (EOC) |
the contract between you and your Medicare
plan. This is a large, thick book that explains your coverage. |
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| Formulary |
a list of drugs (medicines) that your Medicare
Advantage plan covers with or without a prior authorization
(PA). Your doctor will know about this. |
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| Generic drugs |
drugs that cost less than "brand name"
drugs but are just as effective. |
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| Medicaid |
a program for families and individuals who
are age 65 or older, blind, disabled, or who have limited
income and/or resources. It is also for people who have
children under 18, dependent children, foster children,
or for pregnant women. (To find more information about Medicaid,
you must call the Department for Community Based Services
(DCBS) office in your area. You can call 1-800-372-2973
and ask for the name and number of your local DCBS office). |
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| Medical Home |
your PCP office. This is the place that keeps
all your medical records and tracks your health needs (see
"PCP"). |
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| Medically necessary services |
are services that keep you healthy, treat
a disease or injury, or keep a sickness from getting worse. |
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| Medicare |
a health insurance program provided by the
U.S. Government for people age 65 and older and for people
with disabilities. |
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| Medicare Advantage plan |
any private health plan that offers Medicare
coverage for people like you. These plans can give you more
choices and, sometimes, extra benefits. |
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| Medicare Modernization Act (MMA) |
the MMA is a new law that changes Medicare
as well as lets you choose who provides your Medicare prescription
drug benefits (beginning January 1, 2006). |
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| Medicare Part A |
the part of Medicare that either pays all
or some of your hospital care, skilled nursing facility
care, home health care services, and hospice services. |
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| Medicare Part B |
the part of Medicare that pays some of your
doctor costs; physical, occupational and speech therapy
sessions; ambulance services; prostheses; medical equipment;
and home health services. |
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| Medicare Part D |
the part of Medicare that covers some of
your prescription drugs. |
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| Member ID cards |
the cards you carry that tell your providers
which plan you have. Right now, you have a Passport Health
Plan card, and Medicaid card, and a Medicare card. |
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| Network |
all the practitioners and other providers
(like hospitals) who are contracted to work with your insurance
plan. |
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| Over the Counter (OTC) Drugs |
medications you can buy directly from a store.
You may or may not get a prescription for these. |
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| Practitioner |
a doctor or nurse that treats you. |
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| Pre-existing condition |
a sickness or disability you had before you
joined an insurance plan. |
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| Premium |
an amount of money some insurance plans charge. |
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| Primary Care Provider (PCP) |
a doctor or nurse practitioner that takes
care of your health care needs and serves as your "medical
home." A PCP can manage all of your health care needs
and arrange for care from other doctors, when needed. |
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| Provider |
a doctor, nurse, group, hospital, or facility
that treats you. |
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| Referral |
a request for a service that you cannot get
from your PCP or "medical home" cannot provide. |
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| Service area |
the area you must live in to join your Medicare
Advantage plan. Passport Health Plan's service area is the
16 counties in and around Jefferson County, Kentucky. |
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| Special Needs Plan |
a new kind of health plan created by the
Medicare Modernization Act (MMA) that can serve people on
both Medicaid and Medicare. |
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| Specialist |
a doctor who only practices a special type
of medicine or surgery, like a cardiologist (heart doctor). |
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| Summary of Benefits |
a shortened list of what your Medicare plan
provides you (like the EOC, but shorter). |
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| Urgent care |
care you get when your health problem is not
life threatening, but needs care right away. |
