Carilion Clinic Medicare Health Plan: What's special about the Carilion Medicare Health Plan? All the benefits of original medicare with a lower premium cost

Glossary

Defines terms you may encounter when dealing with Medicare or with health care-related issues. Click on a letter below to view the list of words that start with that letter, or scroll down to browse all the words in the glossary.

A
Annual Disenrollment Period (ADP)
The ADP is a 45 day disenrollment period, with one opportunity to disenroll from a Medicare Advantage plan and go back to original Medicare. This period runs from January 1 to February 14.
Annual Election Period (Medicare Advantage Managed Care and Medicare Part D)
The AEP begins on October 15 and ends on December 7 with coverage effective on January 1. During this period, you may change prescription drug plans, change Medicare Advantage plans, return to original Medicare, or enroll in a Medicare Advantage plan for the first time.
Appeal
An appeal is a complaint you may file if you disagree with any decision about your health care services. For example, if Medicare doesn't pay for a service you received, you may appeal. An appeal is sent in writing to your Medicare health plan or the Original Medicare plan. There is a formal process you must follow when filing an appeal. More info: Medicare appeals.
Authorized Representative
Someone who has the legal right to make health care decisions on your behalf (for example, through a power of attorney) or someone you designate to make decisions about enrolling or disenrolling from a Medicare prescription drug plan.

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C
Centers for Medicare and Medicaid Services (CMS)
The agency of the federal government that administers the Medicare, Medicaid, and state Children's Health Insurance programs. Formerly known as the Health Care Financing Administration (HCFA).
Copayment
A copayment is a set dollar amount that you pay for services. For example, $10.
Co-Insurance
A co-insurance is the percentage of the total cost for services that you pay. For example, 20%
Coverage Determination (Medicare Prescription Drug Coverage)
You can request this from your Medicare Drug Plan if your pharmacist tells you that your drug plan will not cover a drug you think should be covered or wants to charge you a higher price than you think you should pay. More info: Coverage Determinations.
Coverage Gap (or Donut Hole)
The gap phase of Part D prescription drug coverage during which you are responsible for paying 100% of your drug costs. Drugs included on your plan's formulary that you purchase through your plan's pharmacy or network count toward your donut-hole costs.

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D
Deductible
An amount that you must pay for health care or prescription drugs before Medicare, a Medicare Advantage plan, or prescription drug plan begins to pay.
Drug Categories
Drugs in the same class that are used to treat a specific condition or illness such as high blood pressure, high cholesterol, heartburn or depression.

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E
Election Periods
The time when you may choose to join or leave Original Medicare or a Medicare managed care plan. There are four periods during which you may join or leave Medicare managed care plans: Annual Election Period, Initial Coverage Election Period, and Special Election Period.
Exception (Medicare Prescription Drug Coverage)
A request for a coverage determination that requires you to submit a supporting statement from your doctor explaining why you need the drug you are requesting. More info: Drug Coverage Appeals.
Expedited Appeal
An appeal of a health care decision (where a medical service is at issue) for Medicare Advantage, Original Medicare, or Medicare Prescription Drug Coverage enrollees that is expedited, or decided quickly. This type of appeal can be a verbal or written request. More info: Medicare appeals.

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F
Fast-Track Appeal
An appeal process available to members if their coverage for care in a hospital, skilled nursing facility, home health care agency or a comprehensive rehabilitation facility is about to end.
Formulary
A list of the drugs covered by a Medicare prescription drug plan (PDP) or Medicare Advantage Prescription Drug plan (MA-PD).

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G
Grievance
A complaint about the way your Medicare Advantage plan or Medicare prescription drug plan is providing care. A grievance is not the same as an appeal. An appeal is the way to file a complaint about a treatment decision or a service that is not covered. A beneficiary may file a grievance at the same time an appeal is filed. More info: Medicare appeals.

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H
Health Maintenance Organization (HMO)
A group of doctors, hospitals, and other health care providers that provide health care. In an HMO (also known as a Medicare Advantage plan, formerly known as a Medicare managed care plan or Medicare+Choice plan), you typically get all your care from the providers who are part of the plan.

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I
Initial Coverage Election Period (ICEP)
The ICEP is the period where individuals newly eligible for Medicare can join a Medicare Advantage plan. This period begins 3 months before the person is eligible for Medicare and ends the last day of the month one’s Medicare benefits begin.
Initial Enrollment Period (IEP)
The IEP for individuals who are turning age 65 is a 7-month period, which begins on the first day of the third month before the month in which they turn 65, includes the month of their 65th birthday, and ends on the last day of the third month after their 65th birthday. During this 7-month period, Medicare beneficiaries can enroll in Medicare Part A, Part B, and a Medicare drug plan (Part D). See “Initial Coverage Election Period” for Medicare Advantage plans (Part C), above.

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L
Low-Income Subsidy (LIS)
This benefit helps low-income people with Medicare to pay for Medicare Prescription Drug Coverage. More info: Extra Help.

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O
Original Medicare
Medicare is the federal health insurance program. It covers most people age 65 or older, some people under age 65 who are disabled, and people with end-stage renal disease. Original Medicare is divided into two parts: Part A: Hospital Insurance, and Part B: Medical Insurance. (Note: Part C and Part D are both offered by private insurance companies. Original Medicare (Parts A and B) is provided by the government.
The term ‘Original Medicare’ also refers to having fee-for-service Medicare, meaning having just Medicare and possibly a supplement insurance such as a Medigap, and not being enrolled in a Medicare Advantage plan.
Out-of-Network Providers
Doctors and other health care providers who are not contracted to offer services with a specific Medicare HMO or PPO plan.

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P
Part A
The hospital insurance part of Original Medicare that covers inpatient hospital stays, hospice care, home health care, and care provided in skilled nursing facilities.
Part B
The medical insurance part of Original Medicare that covers doctors' services and outpatient care. Some of the other services covered include X-rays, medical equipment, and limited ambulance service.
Point-of-Service (POS) Option
HMO-POS plans allow members – at the point of service (where they receive care) – to decide whether they want to receive certain designated services within the provider network system or outside of the HMO’s provider network at increased cost.
Premium
A periodic or monthly payment made to Medicare, an insurance company, or health care plan for health care coverage.
Primary Care Physician (PCP) (for people in Medicare Advantage plans)
A General Practice, Internal Medicine, or Family Practice physician that helps coordinate your care with other physicians and specialists.
Provider
An individual or facility, such as a doctor or hospital, that is licensed and certified to provide health care services.

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Q
Quality Assurance
The process of looking at how well a medical service is provided. The process may include formally reviewing health care given to a person, or group of persons, locating the problem, correcting the problem, and then checking results to see if the treatment or therapy was successful.

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R
Railroad Retirement
A social insurance program administered by the Railroad Retirement Board (RRB) that provides retirement benefits to the country's railroad workers.
Reconsideration
The first step in the appeals process for denied Part C claims. More info: Medicare Appeals
Redetermination
The first step in the appeals process for denied Medicare Part A, B or D claims. If you don't agree with Medicare's initial determination for your Part A or B claim (stated on your Medicare Summary Notice, also known as an MSN), you must submit a written, signed request to appeal within 120 days of the determination. The MSN will direct you where and how to file the request. If you don't agree with your plan's coverage determination for your Part D claim, you must submit a written request to appeal within 60 days of the determination. More info: Medicare Appeals.

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S
Service Area
The geographic area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.
Special Election Period
A set time period triggered by certain events when a beneficiary can change health plans or return to Original Medicare. These events include when you move outside the service area, or your Medicare managed care plan violates its contract with you, or the plan does not renew its contract with the federal government, or other exceptional conditions. The Special Election Period is different from the Special Enrollment Period (SEP).
Special Enrollment Period (SEP)
This is a set time when you can sign up for Medicare Part B if you did not take Part B during the Initial Enrollment Period because you or your spouse was currently working and had group health plan coverage through an employer or union. You can sign up for Medicare Part B at any time while you are covered under the group plan. If the employment or group health coverage ends, you have eight months to sign up. The eight-month SEP starts the month after the employment ends or the group health coverage ends, whichever comes first. The Special Enrollment Period (SEP) is different from the Special Election Period.

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T
TRICARE
TRICARE is the health care program for members of the military, eligible dependents, and military retirees. TRICARE was formerly called the CHAMPUS program.
True Out of Pocket (TrOOP) Costs
Expenses that count toward your Part D out-out-pocket threshold and trigger catastrophic coverage.

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