Glossary

Here are the definitions for some commonly used terms regarding your Medicare Plan options and health care benefits:

Appeal
A special type of complaint you make if you disagree with certain decisions made by Medicare or your health plan. You can appeal if you want reconsideration when: 1) The Plan refuses to cover or render a service, supply or medication you think should be covered; 2) The Plan refuses to pay for care you already received; or 3) The Plan reduces or stops your coverage.

Balance Bill
Certain providers who accept the terms and conditions of HealthMarkets Care Assured^SM and who do not accept Medicare assignment are permitted to balance bill you 9% of our fee schedule. This amount is in addition to your copayment. The only providers who are permitted to balance bill you are physicians who do not accept Medicare assignment and providers who furnish certain therapy services who do not accept Medicare assignment. This applies only to certain services (such as physician services) and does not apply to hospital services, some supplies and durable medical equipment. HealthMarkets Care Assured can assist you in finding out whether a particular physician accepts Medicare assignment.

Beneficiary
An eligible person who obtains health care benefits though the Medicare or Medicaid program.

Benefit Period
How Medicare measures your use of hospital and Skilled Nursing Facility services. A benefit period begins the day you are hospitalized and ends when you have not received hospital care for 60 consecutive days.

Brand Name Drug
A drug that is sold and marketed under a trade name.

Centers for Medicare and Medicaid Services (CMS)
The federal agency that runs the Medicare program.

Coinsurance
A percentage of the Medicare allowable charge that you pay directly to the provider for a covered service or medication.

Copayment
A fixed dollar amount that you pay directly to a provider for a covered service or medication.

Coverage Gap
Also called the “donut hole.” In a Medicare Prescription Drug Plan, after the initial coverage limit has been reached ($2,510 in 2008) and until your out-of-pocket expenses for covered medications reaches a certain amount ($4,050 in 2008), you will generally be responsible for the cost of your medications.

Creditable Coverage
Other prescription drug coverage you may have through an employer or union plan that is at least as good as Medicare Part D coverage. It is important for you to get this information from your current plan if you are considering enrolling in the Plan’s prescription drug coverage.

Deemed Provider
A Medicare eligible provider is considered a deemed provider if: 1) The provider is aware in advance of furnishing services that you are enrolled in a Care Assured Plan; 2) The provider has information about or reasonable access to the Care Assured Plan’s terms and conditions of payment; and 3) The provider subsequently renders covered services to you and bills the Care Assured Plan.

Donut Hole
See “Coverage Gap.”

Deductible
The amount you pay out-of-pocket for health care before the Plan begins to pay for services.

Formulary
A list of prescription drugs covered by a Medicare Part D Plan, like the Care Assured prescription drug plan, and it is subject to cost-sharing and certain limitations to coverage.

Generic Drug
A drug that has the same active ingredient formula as a brand name drug and has been approved by the Food and Drug Administration (FDA). Generic drugs usually cost less than brand name drugs and your doctor may determine that a generic drug will work just as well for you.

Maintenance Drug
A drug that you are required to take every day. You can typically get a prescription for a 3-month or longer supply for maintenance drugs.

Medicare Advantage (MA) Plan
A type of Medicare Plan offered by private insurers that covers all of the benefits of Original Medicare and may provide more generous coverage for preventive care, vision, and hearing services.

Medicare Allowable Charge
The payment amount for a covered service that is paid under Original Medicare.

Medicare Prescription Drug Plan
Coverage offered by private insurers for prescription drugs. Available as a standalone plan or in conjunction with a Medicare Advantage Plan. Also called Medicare Part D.

Medicare Supplement (Medigap Plan)
A health plan offered by private insurers to cover the cost sharing under Original Medicare.

Medigap Plan
See Medicare Supplement.

Non-Contracted Provider
A provider who furnishes services to a PFFS enrollee but the deeming requirements are not met.

Original Medicare
A fee-for-service plan managed by the Federal Government. Original Medicare has two parts: Part A and Part B.

Prior Authorization
An approval required before certain services or prescription drugs are covered by some Medicare plans. Prior authorizations are not [generally] required for the Care Assured Plans.

Private Fee-For-Service(PFFS) Plan
A Medicare Advantage PFFS plan works differently than a Medicare supplement plan. Your doctor or hospital is not required to agree to accept the plan’s terms and conditions, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide health care services to you, except in emergencies. Providers can download the plan’s Terms and Conditions.

Quantity Limit
For certain drugs, limits as to the amount of the drug a plan will cover.

Step Therapy
A course of treatment where you are required to try certain drugs first, before a plan covers another drug for that condition.

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Glossary