AARP AARP (formerly known as the American Association of Retired Persons) - membership organization leading positive social change and delivering value to people age 50 and over through information, advocacy and service. Actuarially Equivalent Drug coverage equal to or greater than the standard Part D benefit. Actuarially equivalent has a different meaning when discussing group retiree. Advertising Advertising materials are intended to attract or appeal to a plan sponsor consumer. Advertising materials contain less detail than other marketing materials. Examples include: television, radio ads, print ads, billboards and direct mail. Annual Election Period – November 15th through December 31st annually. The period when consumers and members can make new AEP – (MAPD & Part D) plan choices. Consumers may elect to join a Medicare Advantage (MA) or Prescription Drug (Part D) Plan for the first time. Members can change or add Part D, change MA Plans or return to Original Medicare. Elections made during this period will become effective January 1st of the following year. Annual Notice of Change – Notification to active members of premium, benefits and cost-sharing changes for the next calendar year. ANOC – (MAPD & Part D) Also, the name used to describe the process of generating the plan information for the next calendar year notifications. Appeal – (Part D, including Also known as a re-determination. Any of the procedures that deal with the review of adverse coverage Part D benefits offered as determinations made by the Part D Plan sponsor on the benefits under a Part D Plan the member believes part of an MAPD Plan) he or she is entitled to receive. Appeals must be addressed within seven calendar days (72 hours for medically urgent issues). Appeals may be segmented into one of two categories: • Clinical Appeals: The appeal for coverage is associated with the provision of member health information and accompanying clinical justification for coverage (e.g. Medical Necessity). • Administrative Appeals: The appeal for coverage is not associated with the provision of accompanying clinical justification for coverage (e.g. Vacation Overrides). ASI AARP Services, Inc. Assets – (Part D, including Property the government may review when Medicare consumers apply for assistance. For help with Part D Part D benefits offered as Plan’s costs, the government counts cash or any property that can be turned into cash within 20 days. This part of an MAPD Plan) includes checking and savings accounts, certificates of deposit, IRAs and 401K’s, stocks, bonds and similar items. It does not include consumers’ primary home or certain property related to burial expenses, depending on the state. Auto-Enrolled – (MAPD & Consumers who are dually eligible for both Medicare and Medicaid and have been automatically enrolled in Part D) a Medicare Part D Plan without actively selecting a plan. Also called Auto-assigned. Beneficiary One who receives Medicare. Referred to as "consumers" throughout this document. One who is entitled to Medicare Part A and enrolled in Part B. Catastrophic Coverage – Once members reach the plan’s out-of-pocket limit during the coverage gap, they automatically get (MAPD & Part D) “catastrophic coverage.” Catastrophic coverage assures that once they have spent up to the plan’s out-of- pocket limit for covered drugs, they only pay a small coinsurance amount or a copayment for the rest of the year. Note: If a member gets “extra help” paying their drug costs, they won’t have a coverage gap and will pay a small or no copayment once they reach catastrophic coverage. Centers for Medicare & CMS is the Federal government agency that oversees the Medicare and Medicaid Programs by establishing Medicaid Services – CMS regulations and guidance for health care providers, assessing quality of care in facilities and services, and ensuring that both programs are run properly by contractors and state agencies. Clinical Parameters – (MAPD Clinical boundaries for choosing medications within established therapeutic categories for the formulary; & Part D) often indicates how many therapy options are needed within the therapy category to ensure the formulary is clinically sound. Clinical parameters are often represented by one of three classifications: Essential (Must Have on the Formulary as Offers Unique Clinical Advantages); Non-Essential (Optional addition to the Formulary similar to Other Formulary Alternatives); or Inappropriate (Potentially less safe or obsolete compared to Other Formulary Alternatives). Closed Benefit – (MAPD & Benefit excludes medications not housed within the benefit; if a closed benefit applies to a tier structure, only Part D) those medications assigned to one of the tiers are covered. Closed benefits can have exceptions processes into place to support appeals to the benefit for coverage of excluded medications. Also known as a Closed Formulary. Co-Branding The relationship between two or more separate legal entities, one of which is an organization that sponsors a medical plan. Coinsurance A kind of cost-sharing where consumers pay the cost of a benefit on a percentage basis. Consumer A term when used refers to the customer, beneficiary, lead, member or prospect for all products. Coordinated Care – (MAPD) In Part C, health care plans that coordinate a consumer's care by the physicians and hospitals visited. These plans may have some restrictions on the physicians and hospitals used for care. These plans are also referred to as “managed care” plans. PFFS and MSA Plans are not coordinated care plans. Copayment An amount the member may be required to pay as their share of the cost for a medical service or supply, like a physician’s visit or a prescription. A copayment is usually a set amount, rather than a percentage. Cost–sharing – (MAPD & The amounts that a member has to pay when drugs or services are received. The most common types of Part D) cost-sharing are coinsurance and copayments. Coverage Determination – Decision to cover (or not cover) therapies within the plan’s benefit design that are associated with utilization (Part D, including Part D management programs. Part D coverage decisions must be addressed and communicated within 72 hours benefits offered as part of an for Standard Coverage Determination and 24 hours for Expedited Coverage Determination of the request MAPD Plan) being received. Coverage Gap – (MAPD & Most Medicare drug plans have a coverage gap. This means that after the member and plan have spent a Part D) certain amount of money for covered drugs, the member has to pay all costs out-of-pocket for their drugs up to a limit. The member’s yearly deductible, coinsurance or copayments, and what they pay in the coverage gap all count toward this out-of-pocket limit. The limit does not include the drug plan’s premium. There are plans that offer some coverage in the gap. However, plans with coverage in the gap may charge a higher monthly premium. Check with the plan first, to see if the consumer’s drugs would be covered in the gap. Creditable Coverage – Prescription medication coverage, for a plan other than a Part D Plan, which meets certain Medicare (MAPD & Part D) standards. For consumers currently enrolled in a drug plan that gives prescription medication coverage, their plan will tell them if it meets the Medicare standards for creditable coverage. See late-enrollment penalty. Creditable Coverage – Certain kinds of previous health insurance coverage that can be used to shorten a pre-existing condition (Medigap/Medicare waiting period under a Medigap Plan. Supplement Plans) Note: This is not the same as creditable prescription medication coverage. Critical Access Hospital – A small facility that gives limited outpatient and inpatient services to consumers in rural areas. (PFFS) Deductible The amount a consumer or member must pay for health care or prescriptions, before Original Medicare, their prescription drug plan, or other insurance begins to pay. Deemed Provider – (PFFS) A Medicare-eligible provider who agrees to accept the Plan’s terms and conditions of payment for a specific member visit by virtue of the fact that the provider is aware, in advance, that the patient is a PFFS member and the provider has reasonable access to the Plan’s terms and conditions of payment. Members must inform providers of PFFS Plan membership and present their ID card prior to receiving covered services. If the provider does not agree to be deemed, the PFFS member must find another provider. Providers agree to bill the plan and will not balance bill the member. A provider must agree to be deemed each time a member seeks covered medical services. The provider can decide whether or not to accept the Plan’s terms and conditions of payment each time they see a PFFS member. A decision to treat one plan member does not obligate the provider to treat other PFFS members, nor does it obligate providers to accept the same member for treatment at a subsequent visit. Doughnut Hole (CMS Name for the step in a Part D Plan in which members pay all expenses for eligible medications, until they preferred term is coverage have spent $4,550. See coverage gap. gap) – (MAPD & Part D) Drug Utilization Management Drug claims processing coverage rules utilized to advocate clinically appropriate, cost-effective medication – UM – (MAPD & Part D) use in an effort to minimize unnecessary cost to the benefit. Dual Eligible Consumers and/or members receiving benefits from both Medicare and Medicaid. Educational Event Is defined by the way in which an event is marketed to a consumer. The purpose is to provide information about the Original Medicare program and/or health improvement and wellness. These events may not include any sales activities such as the distribution of marketing materials or the distribution or collection of plan enrollment applications. End-Stage Renal Disease – Permanent kidney failure requiring dialysis or a kidney transplant. ESRD Exception – (MAPD & Part D) A type of coverage determination that, if approved, allows a Part D Plan member to obtain a medication that is not on the Plan sponsor’s formulary or to obtain a non-preferred medication at the preferred cost-sharing level (a tiering exception). Excluded Medications – Medications that are not housed within the benefit. These medications may be excluded due to a Plan (MAPD & Part D) sponsor’s business or clinical decision to not cover the medication or they could be excluded because the Medicare Modernization Act (MMA) excludes the medications. Federal Poverty Level – FPL Is used to determine financial eligibility for certain programs. Guidelines vary by family size. In addition, there is one set of FPL figures for the 48 contiguous states and D.C.; one set for Alaska; and one set for Hawaii. Formulary A list of medications covered within the benefit plan; often represents the level of cost-sharing associated with various groupings of medications (Generics, Preferred Brand, Non-Preferred Brands). The formulary is often published to the web or in a written document. However the document may only reference the preferred medications. (Often referred to as Preferred Drug List or PDL). Full Dual Eligible Consumers and/or members eligible for both Medicare and full Medicaid benefits. Generic Drugs A prescription drug that has the same active ingredients as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. Also known as Generic Medications. Grandfathering – (MAPD & Allows for continued coverage of specific therapies that may have been covered previously, but are no Part D) longer being covered after a formulary or benefit change. Group Retiree A Group Retiree is an individual who has retired from his/her previous employer and is looking to continue health care and/or prescription coverage with their previous employer. Health plans have existing relationships with employer groups which allow them the opportunity to offer products and administer benefits for Group Retirees through contractual agreements and arrangements. With Endorsed plans, the employer does not pay any portion of the premium, but with the Subsidized plans they do. Guaranteed Issue When insurance companies are required by law to sell or offer consumers a Medigap policy. In these situations, an insurance company can’t deny consumers a Medigap policy, or place conditions on a Medigap policy, such as exclusions for pre-existing conditions, and can’t charge consumers more for a Medigap policy because of past or present health problems. Health Insurance Claim Consumer’s Medicare identification number. Number – HICN HMO Health Maintenance Organization. Initial Coverage Limit – ICL – The maximum limit of coverage under the initial coverage period. (MAPD & Part D) Initial Coverage Period – ICP The period after a PDP Plan member has met their deductible and before their total medication expenses – (MAPD & Part D) have reached $2,830 (the 2010 ICL) including amounts the member has paid and what the Plan has paid on their behalf. Late-Enrollment Penalty – An amount added to a consumer’s monthly premium for Medicare Part A and/or Part B, or for a Medicare LEP – (MAPD & Part D) drug plan (Part D), if they do not elect to join when they are first eligible. Consumers pay this higher amount as long as they have Medicare. There are some exceptions. Long-Term Care Pharmacy – A pharmacy owned by or under contract with a long-term care facility to provide prescription medications to LTC – (MAPD & Part D) the facility’s residents. Low Income Copayment – Reduced prescription copayment level for the member. LIC – (MAPD & Part D) Low Income Subsidy – LIS – A program from Medicare to help consumers, with limited income and resources, pay prescription medication (MAPD & Part D) costs. Marketing/Sales Steering or attempting to steer a consumer toward a plan or limited number of plans. Maximum Allowable Cost – The highest dollar amounts that the Federal government will pay for medication that is dispensed to a MAC – (MAPD & Part D) Medicare or Medicaid consumer. 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 assistance to people who meet certain eligibility criteria. Medigap cannot be sold to individuals who receive assistance from Medicaid unless assistance is limited to help with Part B premiums, or Medicaid buys the Medigap Plan for the individual. Medicare A Federal government health insurance program for: • People age 65 and older • People of all ages with certain disabilities • People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or kidney transplant) Medicare Advantage A Medicare Advantage Plan with only medical coverage. It does not have an integrated Part D prescription "Medical Only" Plan – MA medication benefit. Only – (MAPD) Medicare Advantage Plans Health plans offered by private insurance companies that contract with the Federal government to provide Medicare coverage. Medicare Advantage Plans may be available both with and without Part D Plans. Medicare Advantage Plans may also be referred to as Medicare Health Plans. Medicare Advantage A Medicare Advantage Plan that integrates Part D prescription drug benefits with the medical coverage. Prescription Drug – MAPD – (MAPD) Medicare Part A The part of Medicare that provides help with the cost of hospital stays, skilled nursing services following a hospital stay, and some other kinds of skilled care. Medicare Part B The part of Medicare that provides help with the cost of physician visits and other medical services. Medicare Part B Premium The premium amount deducted from a Medicare consumer's Social Security check. Most people will pay the standard premium amount of $96.40 in 2009. The monthly premium will be higher if the yearly income is greater than $85,000 for individuals and $170,000 for married couples. The Part B Premium varies from year to year. Medicare Part C – (MAPD) Medicare Part C Plans are referred to as Medicare Advantage Plans. • Include both Part A (Hospital Insurance) and Part B (Medical Insurance) • Private insurance companies approved by Medicare provide this coverage • In most plans, members need to use plan physicians, hospitals and other providers or they pay more • Members usually pay a monthly premium (in addition to their Part B premium) and a copayment for covered services • Costs, extra coverage and rules vary by plan Medicare Part D – (MAPD & Known as Medicare Prescription Drug Plans. The part of Medicare that provides coverage for outpatient Part D) prescription medications. These plans are offered by insurance companies and other private companies approved by Medicare. Consumers can get Part D coverage as part of a Medicare Advantage Plan (if offered where a consumer lives), or as a Stand-alone Prescription Drug Plan. Medicare Private Fee-for- Medicare Advantage Plans offered by private insurance companies that allow members to go to any Service Plan – PFFS Medicare eligible provider who agrees to accept the PFFS Plan's terms and conditions of payment rates. The PFFS Plan pays instead of Original Medicare. PFFS Plans may or may not offer Part D coverage. Medicare Savings Plan – A type of Medicare Advantage Plan. MSA Plans combine a high deductible Medicare Advantage Plan and a MSA – (MAPD) bank account. The plan deposits money from Medicare in the account. Consumers can use it to pay their medical expenses until their deductible is met. Medicare Savings Programs Many older adults have low incomes, but not low enough to qualify for Medicaid. There are several Medicare – MSP Savings Programs available under Medicaid to help lower income seniors and disabled individuals pay for some of their out-of-pocket medical expenses. They are: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualified Individual 1 (QI-1), Qualified Disabled and Working Individual (QDWI). Medication Therapy A type of Drug Use Review and associated interventions which look to address members’ safety and cost Management – (MAPD & concerns through prescriber consultation and member pharmacist counseling. The service is required by the Part D) Medicare Modernization Act and targets members with complex medication regimens and costly medication expenditures. Medigap Policy Medicare Supplement insurance sold by private insurance companies to fill "gaps" (deductibles, coinsurance, copayments) in Original Medicare. A Medigap Policy can not be sold to a Medicare Advantage member unless the member is switching to Original Medicare. A Medigap Policy can and is sold to members in Part D (not MAPD) Plans. Member A term when used refers to the customer, beneficiary, lead, consumer or prospect for all products. MIPPA Medicare Improvements for Patients and Providers Act of 2008. Monthly Plan Premium The fee a member pays if they belongs to a Medicare Advantage Plan (like HMO or PPO), in addition to the Medicare Part B premium for covered services, if applicable. Monthly Premium (Part D) Most drug plans charge a monthly fee that varies by plan. Members pay this in addition to the Medicare Part B premium. If a member belongs to a Medicare Advantage Plan (like HMO or PPO) or a Medicare Cost Plan that includes Medicare prescription drug coverage, the monthly premium may include an amount for prescription drug coverage. Multi-Source Brand A brand name medication that has a generic equivalent. National Drug Code – NDC – An eleven-digit number assigned to all prescription medication products by the manufacturer or distributor of (MAPD & Part D) the product under FDA regulations. An NDC number is composed of three distinct parts: the first five digits identify the drug manufacturer, the next four identify the drug composition, strength and dosage form, and the last two identify the package size. Network – (MAPD & Part D) Group of physcians, hospitals and pharmacies who have contracts with a health insurance plan to provide care/services to the plan’s members. The Part D prescription drug plan’s network of pharmacies may help members save money on medications. Network Pharmacy A licensed pharmacy that is under contract with a Part D sponsor to provide covered Part D drugs at negotiated prices to its Part D Plan members. Nominal Value Items or services worth $15 or less based on the retail purchase price. Open Enrollment Period – A one-time only, six-month period when federal law allows consumers to buy any Medigap Policy they want (Medicare Supplement Plans) that is sold in their state. It starts in the first month that a consumer is covered under Medicare Part B and is age 65 or older. Some states may have additional open enrollment rights under state law. During this period, consumers can not be denied a Medigap Policy or charged more due to past or present health problems. Open Enrollment Period – January 1st to March 31st annually. The enrollment period when a Medicare consumer may make changes OEP – (MAPD) to their previously chosen Medicare coverage. A consumer may not add or drop prescription medication coverage during the OEP. Elections made during this period will become effective on the 1 st of the following month. Original Medicare One of the consumer’s health coverage choices as part of Medicare. • Part A (Hospital Insurance) and Part B (Medical Insurance) • Medicare provides this coverage. • Consumers have a choice of physicians, hospitals and other providers. • Generally, consumers pay deductibles and coinsurance Consumers usually pay a monthly premium for Part B Out-of-Network Pharmacy – A licensed pharmacy that is not under contract with a Part D sponsor to provide negotiated prices to Part D OON – (MAPD & Part D) Plan members. Out-of-Network Provider A licensed physician or hospital that is not contracted with UnitedHealthcare to provide medical services to its members. With Medicare Advantage PPO and POS plans, members can access out-of-network providers for covered services, generally at a higher cost than with in-network providers. Out-of-Pocket Maximum – An annual limit that some plans set on the amount of money a member will have to spend out of their own OOP Max - (MAPD & Part ) pocket for benefits. Pharmaceutical & The committee of physicians, pharmacists, and other health care professionals who establish and approve Therapeutic Committee – the clinical parameters for a formulary. The P&T includes specialized practitioners such as geriatricians and P&T – (MAPD & Part D) pharmacists specializing in geriatrics. The committee includes independent consultants and functions under policies that ensure fair/unbiased assessments of therapies and remove conflicts of interest. Pharmacy Benefit Manager – The subcontractor of the plan sponsor responsible for processing the pharmacy claims and/or administering PBM coverage determinations. May also be referred to as the Prescription Benefit Administrator (PBA). Plan Benefit Package – PBP Each plan or PBP has specific benefits and cost-sharing associated with it. Each PBP is tied to a single Bid – (MAPD & Part D) Pricing Tool (BPT), both of which are submitted to CMS in June of each year for a 1/1 effective date for the following year. Point-of-Service – POS – An HMO option that lets members use physicians and hospitals outside the plan's contracted provider (MAPD) network subjected to increased cost sharing, POS benefits are available for selected benefits. Preferred Provider A type of Medicare Advantage Plan in which the member can use either preferred physicians or hospitals, or Organization – PPO – go to non-preferred physicians and hospitals. If the member uses non-preferred providers, they will usually (MAPD) pay a larger share of the cost of their care. Premium The periodic payment to Medicare, an insurance company, or a health plan for health or prescription drug coverage. Prescription Drug Plan – PDP A stand-alone plan that offers Part D prescription medication coverage only. – (MAPD & Part D) Primary Care Physician – A physician seen first for most health problems. The PCP may also coordinate a member’s care with other PCP – (MAPD) physicians and health care providers. In some Medicare Advantage Plans, members must see their PCP before seeing any other health care provider. Prior Authorization – PA A type of utilization management program that requires that before the plan will cover certain services/prescriptions, a consumer and/or their physician must contact the plan. A member’s physician may need to show that the service/medication is medically necessary for it to be covered. Qualified Individuals – QI-1 A Qualified Individual Program is a limited expansion of SLMB and granted on a first-come first-serve basis. In the Qualified Individual Program, Medicaid assists with payment of the Medicare Part B premium only. Qualified Medicare Qualified Medicare Beneficiary Program in which Medicaid provides payment of: Beneficiary – QMB – (MAPD) • Medicare Part A monthly premiums (when applicable) • Medicare Part B monthly premiums and annual deductible • Payment of coinsurance and deductible amounts for services covered under both Medicare Parts A and B Quantity Limits – QL – A management tool that is designed to limit the use of selected medications for quality, safety, or utilization (MAPD & Part D) reasons. Limits may be on the amount of the medication that the plan covers per prescription or for a defined period of time. Referral – (MAPD) A formal recommendation by the member's contracting primary care physician (PCP) or his/her contracting medical group to receive health care from a specialist, contracting medical provider, or non-contracting medical provider. Region – (MAPD & Part D) Prescription drug plans (PDP Plans) and Regional PPO (MAPD Plans) are offered by regions. The Centers for Medicare & Medicaid Services created regions based on population size so that plans within a region are able to enroll and provide appropriate services to consumers. At times a state is a region and at other times a region will include several states or several counties within a state. The PDP regions and Regional PPO regions are not always the same service area. Regional Preferred Provider A type of Medicare Advantage Plan. The MMA introduced the Regional PPO option in an effort to expand the Organization – RPPO – reach of Medicare managed care to Medicare consumers, including those in rural areas. The RPPOs can (MAPD) only be offered in an MA Region which is defined by CMS. Service Area – (MAPD) Is the geographic area approved by CMS within which an eligible consumer may enroll in a certain plan. SNF Skilled Nursing Facility Special Election Period – A period when a Medicare consumer may sign up or make changes to their Medicare coverage outside of a SEP general enrollment period. These periods are available under specified circumstances defined by Medicare. Also referred to as Special Enrollment Period. Specified Low Income A Specified Low-Income Medicare Beneficiary Program in which Medicaid provides payment of the Medicare Medicare Beneficiary – SLMB Part B monthly premium only. State Pharmaceutical A State program that provides help paying for medication coverage based on financial need, age or medical Assistance Programs – condition. SPAP – (MAPD & Part D) Step Therapy – ST – (MAPD A utilization tool that requires a member to first try another medication to treat their medical condition before & Part D) the Part D Plan will cover the medication their physician may have initially prescribed. Therapeutic Alternatives Drug products containing different chemical entities, but which provide the same pharmacological action or chemical effect when administered to patients in therapeutically equivalent doses. Therapeutic Class Drugs grouped by their purpose, the symptom or disease they are used to treat. Therapeutic Substitution A decision by a physician to replace a prescribed medication with a similar medication that is more effective or equally effective. Tier – (MAPD & Part D) Covered medications have various levels of associated member cost-sharing. Example: Tier One (primarily Generics); Tier Two (primarily Preferred Branded Medications); Tier Three (primarily Non-Preferred Branded Medications); Tier Four (Specialized High Cost Medications). Tier Exceptions – (MAPD & A type of coverage determination to provide coverage (based on clinical justification) of a Tier Three (Non- Part D) Preferred Brand Drug) prescription at the Tier Two (Preferred Brand Drug) coverage level. Tier Exceptions are not applicable to Tier Four products (Specialty Tier) or Tier Two products (Preferred Brands). True Out-of-Pocket Expense An accumulation of payments – monies spent – by the member of a plan. This will included copayments and – TrOOP – (MAPD & Part D) deductibles, but does not include premium payments or any payments made by the plan. Yearly Deductible The amount a member must pay for health care before the plan begins to pay. Yearly Deductible (Part D) The amount the member pays for prescriptions before the plan begins to pay. Some drug plans charge no deductible.
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