Activities of daily living (ADL): The things
people do on a
normal day, such as eating, using the toilet, getting dressed, bathing, or brushing
teeth.
Administrative law judge: An Administrative Law
Judge (ALJ) is
a judge who hears and decides cases involving government agencies. A judge that reviews
a level 3
appeal.
AIDS drug assistance program (ADAP): A program
that helps
eligible individuals living with HIV/AIDS have access to life-saving HIV medications.
Ambulatory surgical center: A facility that
provides
outpatient surgery to patients who don’t need hospital care and who aren’t
expected to need more than 24
hours of care.
Appeal: A way for you to challenge our action if
you think we
made a mistake. You can ask us to change a coverage decision by filing an appeal.
Chapter
9 of this Member Handbook explains appeals, including how to make
an appeal.
Behavioral Health: Refers to our emotional,
psychological, and
social well-being. In simpler terms: It’s about how we think, feel, and interact
with others. It’s an
all-inclusive term referring to mental health and substance use disorder services.
Biological Product: A drug that’s made
from natural and living
sources like animal cells, plant cells, bacteria, or yeast. Biological products are more
complex than
other drugs and can’t be copied exactly, so alternative forms are called
biosimilars. (See also
“Original Biological Product” and “Biosimilar”).
Biosimilar: A biological drug that’s very
similar, but not
identical, to the original biological product. Biosimilars are as safe and effective as
the original
biological product. Some biosimilars may be substituted for the original biological
product at the
pharmacy without needing a new prescription. (Go to “Interchangeable
Biosimilar”).
Brand name drug: A drug that’s made and
sold by the company
that originally made the drug. Brand name drugs have the same ingredients as the generic
versions of the
drugs. Generic drugs are usually made and sold by other drug companies and are generally
not available
until the patent on the brand name drug has ended.
Case manager: One main person who works with
you, with the
health plan, and with your care providers to make sure you get the care you need.
Care plan: Refer to “Individualized Care
Plan.”
Care team: Refer to “Interdisciplinary
Care Team.”
Catastrophic coverage stage: The stage in the
Medicare Part D
drug benefit where our plan pays all costs of your Part D drugs until the end of the
year. You begin
this stage when you (or other qualified parties on your behalf) have spent $2,100 for
Part D covered
drugs during the year. You pay nothing. You may have cost sharing for excluded drugs
that are covered
under our enhanced benefit.
Centers for Medicare & Medicaid Services
(CMS): The
federal agency in charge of Medicare. Chapter 2 of this Member
Handbook
explains how to contact CMS.
Community-Based Adult Services (CBAS):
Outpatient,
facility-based service program that delivers skilled nursing care, social services,
occupational and
speech therapies, personal care, family/caregiver training and support, nutrition
services,
transportation, and other services to eligible members who meet applicable eligibility
criteria.
Complaint: A written or spoken statement saying
that you have
a problem or concern about your covered services or care. This includes any concerns
about the quality
of service, quality of your care, our network providers, or our network pharmacies. The
formal name for
“making a complaint” is “filing a grievance”.
Comprehensive outpatient rehabilitation facility
(CORF): A
facility that mainly provides rehabilitation services after an illness, accident, or
major operation. It
provides a variety of services, including physical therapy, social or psychological
services,
respiratory therapy, occupational therapy, speech therapy, and home environment
evaluation services.
Copay: A fixed amount you pay as your share of
the cost each
time you get certain drugs. For example, you might pay $2 or $5 for a drug.
Cost-sharing: Amounts you have to pay when you
get certain
drugs. Cost-sharing includes copays.
Cost-sharing tier: A group of drugs with the
same copay. Every
drug on the List of Covered Drugs (also known as the Drug List) is in
one of 6
cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost
for the drug.
Coverage decision: A decision about what
benefits we cover.
This includes decisions about covered drugs and services or the amount we pay for your
health services.
Chapter 9 of this Member Handbook explains how to ask us for a
coverage
decision.
Covered drugs: The term we use to mean all of
the prescription
and over-the-counter (OTC) drugs covered by our plan.
Covered services: The general term we use to
mean all the
health care, long-term services and supports, supplies, prescription and
over-the-counter drugs,
equipment, and other services our plan covers.
Cultural competence training: Training that
provides
additional instruction for our health care providers that helps them better understand
your background,
values, and beliefs to adapt services to meet your social, cultural, and language needs.
Daily cost- sharing rate: A rate that may apply
when your
doctor prescribes less than a full month’s supply of certain drugs for you and
you’re required to pay a
copay. A daily cost-sharing rate is the copay divided by the number of days in a
month’s supply.
Here is an example: Let’s say the copay for your drug for a full month’s
supply (a 30-day supply) is
$1.35. This means that the amount you pay for your drug is less than $0.05 per day. If
you get a 7-day
supply of the drug, your payment is less than $0.05 per day multiplied by 7 days, for a
total payment
less than $0.35.
Department of Health Care Services (DHCS): The
state
department in California that administers the Medicaid Program (known as Medi-Cal).
Department of Managed Health Care (DMHC): The
state department
in California responsible for regulating most health plans. DMHC helps people with
appeals and
complaints about Medi-Cal services. DMHC also conducts Independent Medical Reviews
(IMR).
Disenrollment: The process of ending your
membership in our
plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own
choice).
Drug management program (DMP): A program that
helps make sure
members safely use prescription opioids and other frequently abused medications.
Drug tiers: Groups of drugs on our Drug
List.
Generic, brand name, or over-the-counter (OTC) drugs are examples of drug tiers. Every
drug on the
Drug List is in one of 6 tiers.
Dual eligible special needs plan (D-SNP): Health
plan that
serves individuals who are eligible for both Medicare and Medicaid. Our plan is a D-SNP.
Durable medical equipment (DME): Certain items
your doctor
orders for use in your own home. Examples of these items are wheelchairs, crutches,
powered mattress
systems, diabetic supplies, hospital beds ordered by a provider for use in the home, IV
infusion pumps,
speech generating devices, oxygen equipment and supplies, nebulizers, and walkers.
Emergency: A medical emergency when you, or any
other person
with an average knowledge of health and medicine, believe that you have medical symptoms
that need
immediate medical attention to prevent death, loss of a body part, or loss of or serious
impairment to a
bodily function (and if you’re a pregnant woman, loss of an unborn child). The
medical symptoms may be
an illness, injury, severe pain, or a medical condition that’s quickly getting
worse.
Emergency care: Covered services given by a
provider trained
to give emergency services and needed to treat a medical or behavioral health emergency.
Exception: Permission to get coverage for a drug
not normally
covered or to use the drug without certain rules and limitations.
Excluded Services: Services that aren’t
covered by this health
plan.
Extra Help: Medicare program that helps people
with limited
incomes and resources reduce Medicare Part D drug costs, such as premiums, deductibles,
and copays.
Extra Help is also called the “Low-Income Subsidy”, or “LIS”.
Generic drug: A drug approved by the FDA to use
in place of a
brand name drug. A generic drug has the same ingredients as a brand name drug.
It’s usually cheaper and
works just as well as the brand name drug.
Grievance: A complaint you make about us or one
of our network
providers or pharmacies. This includes a complaint about the quality of your care or the
quality of
service provided by your health plan.
Health Insurance Counseling and Advocacy Program
(HICAP): A
program that provides free and objective information and counseling about Medicare.
Chapter
2 of this Member Handbook explains how to contact HICAP.
Health plan: An organization made up of doctors,
hospitals,
pharmacies, providers of long-term services, and other providers. It also has care
coordinators to help
you manage all your providers and services. All of them work together to provide the
care you need.
Health risk assessment (HRA): A review of your
medical history
and current condition. It’s used to learn about your health and how it might
change in the future.
Home health aide: A person who provides services
that don’t
need the skills of a licensed nurse or therapist, such as help with personal care (like
bathing, using
the toilet, dressing, or carrying out the prescribed exercises). Home health aides
don’t have a nursing
license or provide therapy.
Hospice: A program of care and support to help
people who have
a terminal prognosis live comfortably. A terminal prognosis means that a person has been
medically
certified as terminally ill, meaning having a life expectancy of 6 months or less.
An enrollee who has a terminal prognosis has the right to elect hospice.
A specially trained team of professionals and caregivers provide care for the
whole person,
including physical, emotional, social, and spiritual needs.
We’re required to give you a list of hospice providers in your geographic
area.
Improper/inappropriate billing: A situation when
a provider
(such as a doctor or hospital) bills you for services. Call Member Services if you get
any bills you
don’t understand.
Because we pay the entire cost for your services, except for drugs, you
don’t owe any
cost-sharing. Providers, other than pharmacies, shouldn’t bill you anything for
these services.
In Home Supportive Services (IHSS): The IHSS
Program will help
pay enrolled care providers for services provided to you so that you can remain safely
in your own home.
IHSS is an alternative to out-of-home care, such as nursing homes or board and care
facilities. To
receive services, an assessment is conducted to determine which types of services may be
authorized for
each participant based on their needs. The types of services which can be authorized
through IHSS are
housecleaning, meal preparation, laundry, grocery shopping, personal care services (such
as bowel and
bladder care, bathing, grooming and paramedical services), accompaniment to medical
appointments, and
protective supervision for the mentally impaired. County social service agencies
administer IHSS.
Independent Medical Review (IMR): If we deny
your request for
medical services or treatment, you can make an appeal. If you disagree with our decision
and your
problem is about a Medi-Cal service, including DME supplies and drugs, you can ask the
California
Department of Managed Health Care for an IMR. An IMR is a review of your case by experts
who aren’t part
of our plan. If the IMR decision is in your favor, we must give you the service or
treatment you asked
for. You pay no costs for an IMR.
Independent review organization (IRO): An
independent
organization hired by Medicare that reviews a level 2 appeal. It isn’t connected
with us and isn’t a
government agency. This organization decides whether the decision we made is correct or
if it should be
changed. Medicare oversees its work. The formal name is the Independent Review
Entity.
Individualized Care Plan (ICP or Care Plan): A
plan for what
services you’ll get and how you’ll get them. Your plan may include medical
services, behavioral health
services, and long-term services and supports.
Initial coverage stage: The stage before your
total Medicare
Part D drug expenses reach $2,100. This includes amounts you paid, what our plan paid on
your behalf,
and the low-income subsidy. You begin in this stage when you fill your first
prescription of the year.
During this stage, we pay part of the costs of your drugs, and you pay your share.
Inpatient: A term used when you’re
formally admitted to the
hospital for skilled medical services. If you’re not formally admitted, you may
still be considered an
outpatient instead of an inpatient even if you stay overnight.
Interdisciplinary Care Team (ICT or Care team):
A care team
may include doctors, nurses, counselors, or other health professionals who are there to
help you get the
care you need. Your care team also helps you make a care plan.
Integrated D-SNP : A dual-eligible special needs
plan that
covers Medicare and most or all Medicaid services under a single health plan for certain
groups of
individuals eligible for both Medicare and Medicaid. These individuals are known as
full-benefit dually
eligible individuals.
Interchangeable Biosimilar : A biosimilar that
may be
substituted at the pharmacy without needing a new prescription because it meets
additional requirements
about the potential for automatic substitution. Automatic substitution at the pharmacy
is subject to
state law.
List of Covered Drugs (Drug List): A list of
prescription and
over-the-counter (OTC) drugs we cover. We choose the drugs on this list with the help of
doctors and
pharmacists. The Drug List tells you if there are any rules you need to follow
to get your
drugs. The Drug List is sometimes called a “formulary”.
Long-term services and supports (LTSS):
Long-term services and
supports help improve a long-term medical condition. Most of these services help you
stay in your home
so you don’t have to go to a nursing facility or hospital. LTSS covered by our
plan include
Community-Based Adult Services (CBAS), also known as adult day health care, Nursing
Facilities (NF), and
Community Supports. IHSS and 1915(c) waiver programs are Medi-Cal LTSS provided outside
our plan.
Low-income subsidy (LIS): Refer to “Extra
Help”
Mail Order Program: Some plans may offer a
mail-order program
that allows you to get up to a 3-month supply of your covered prescription drugs sent
directly to your
home. This may be a cost-effective and convenient way to fill prescriptions you take
regularly.
Medi-Cal: This is the name of California Medicaid program. Medi-Cal is
managed by the
state and is paid for by the state and the federal government.
It helps people with limited incomes and resources pay for long-term services and
supports and
medical costs.
It covers extra services and some drugs not covered by Medicare.
Medicaid programs vary from state to state, but most health care costs are
covered if you qualify
for both Medicare and Medi-Cal.
Medi-Cal plans: Plans that cover only Medi-Cal
benefits, such
as long-term services and supports, medical equipment, and transportation. Medicare
benefits are
separate.
Medicaid (or Medical Assistance): A program run
by the federal
government and the state that helps people with limited incomes and resources pay for
long-term services
and supports and medical costs. Medi-Cal is the Medicaid program for the State of
California.
Medically necessary: This describes services,
supplies, or
drugs you need to prevent, diagnose, or treat a medical condition or to maintain your
current health
status. This includes care that keeps you from going into a hospital or nursing
facility. It also means
the services, supplies, or drugs meet accepted standards of medical practice.
Medicare: The federal health insurance program
for people 65
years of age or older, some people under age 65 with certain disabilities, and people
with end-stage
renal disease (generally those with permanent kidney failure who need dialysis or a
kidney transplant).
People with Medicare can get their Medicare health coverage through Original Medicare or
a managed care
plan (refer to “Health plan”).
Medicare Advantage: A Medicare program, also
known as
“Medicare Part C” or “MA”, that offers MA plans through private
companies. Medicare pays these companies
to cover your Medicare benefits.
Medicare Appeals Council (Council): A council
that reviews a
level 4 appeal. The Council is part of the Federal government.
Medicare-covered services: Services covered by
Medicare Part A
and Medicare Part B. All Medicare health plans, including our plan, must cover all the
services covered
by Medicare Part A and Medicare Part B.
Medicare diabetes prevention program (MDPP): A
structured
health behavior change program that provides training in long-term dietary change,
increased physical
activity, and strategies for overcoming challenges to sustaining weight loss and a
healthy lifestyle.
Medicare-Medi-Cal enrollee: A person who
qualifies for
Medicare and Medicaid coverage. A Medicare- Medicaid enrollee is also called a
“dually eligible
individual”.
Medicare Part A: The Medicare program that
covers most
medically necessary hospital, skilled nursing facility, home health, and hospice care.
Medicare Part B: The Medicare program that
covers services
(such as lab tests, surgeries, and doctor visits) and supplies (such as wheelchairs and
walkers) that
are medically necessary to treat a disease or condition. Medicare Part B also covers
many preventive and
screening services.
Medicare Part C: The Medicare program, also
known as “Medicare
Advantage” or “MA”, that lets private health insurance companies
provide Medicare benefits through an MA
Plan.
Medicare Part D: The Medicare drug benefit
program. We call
this program “Part D” for short. Medicare Part D covers outpatient drugs,
vaccines, and some supplies
not covered by Medicare Part A or Medicare Part B or Medicaid. Our plan includes
Medicare Part D.
Medicare Part D drugs: Drugs covered under
Medicare Part D.
Congress specifically excludes certain categories of drugs from coverage under Medicare
Part D. Medicaid
may cover some of these drugs.
Medication Therapy Management (MTM): A Medicare
Part D program
for complex health needs provided to people who meet certain requirements or are in a
Drug Management
Program. MTM services usually include a discussion with a pharmacist or health care
provider to review
medications. Refer to Chapter 5 of this Member Handbook for
more information.
Medi-Medi Plan: A Medi-Medi Plan is a type of
Medicare
Advantage plan. It’s for people who have both Medicare and Medi-Cal, and combines
Medicare and Medi-Cal
benefits into one plan. Medi-Medi Plans coordinate all benefits and services across both
programs,
including all Medicare and Medi-Cal covered services.
Member (member of our plan, or plan member): A
person with
Medicare and Medi-Cal who qualifies to get covered services, who has enrolled in our
plan, and whose
enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS)
and the state.
Member Handbook and Disclosure Information: This
document,
along with your enrollment form and any other attachments, or riders, which explain your
coverage, what
we must do, your rights, and what you must do as a member of our plan.
Member Services: A department in our plan
responsible for
answering your questions about membership, benefits, grievances, and appeals. Refer to
Chapter
2 of this Member Handbook for more information about Member
Services.
Network pharmacy: A pharmacy (drug store) that
agreed to fill
prescriptions for our plan members. We call them “network pharmacies”
because they agreed to work with
our plan. In most cases, we cover your prescriptions only when filled at one of our
network pharmacies.
Network provider: “Provider” is the
general term we use for
doctors, nurses, and other people who give you services and care. The term also includes
hospitals, home
health agencies, clinics, and other places that give you health care services, medical
equipment, and
long-term services and supports.
They’re licensed or certified by Medicare and by the state to provide
health care services.
We call them “network providers” when they agree to work with our
health plan, accept our payment,
and don’t charge members an extra amount.
While you’re a member of our plan, you must use network providers to get
covered services. Network
providers are also called “plan providers”.
Nursing home or facility: A facility that
provides care for
people who can’t get their care at home but don’t need to be in the
hospital.
Ombudsman: An office in your state that works as
an advocate
on your behalf. They can answer questions if you have a problem or complaint and can
help you understand
what to do. The ombudsman’s services are free. You can find more information in
Chapters
2 and 9 of this Member Handbook.
Organization determination: Our plan makes an
organization
determination when we, or one of our providers, decide about whether services are
covered or how much
you pay for covered services. Organization determinations are called “coverage
decisions”.
Chapter 9 of this Member Handbook explains coverage decisions.
Original Biological Product: A biological
product that has
been approved by the FDA and serves as the comparison for manufacturers making a
biosimilar version.
It’s also called a reference product.
Original Medicare (traditional Medicare or
fee-for-service
Medicare ): The government offers Original Medicare. Under Original
Medicare, services are
covered by paying doctors, hospitals, and other health care providers amounts that
Congress determines.
You can use any doctor, hospital, or other health care provider that accepts
Medicare. Original
Medicare has two parts: Medicare Part A (hospital insurance) and Medicare Part B
(medical
insurance).
Original Medicare is available everywhere in the United States.
If you don’t want to be in our plan, you can choose Original Medicare
Out-of-network pharmacy: A pharmacy that
hasn’t agreed to work
with our plan to coordinate or provide covered drugs to members of our plan. Our plan
doesn’t cover most
drugs you get from out‑of‑network pharmacies unless certain conditions apply.
Out-of-network provider or Out-of-network
facility: A provider
or facility that isn’t employed, owned, or operated by our plan and
isn’t under contract to provide
covered services to members of our plan. Chapter 3 of this Member
Handbook
explains out-of-network providers or facilities.
Out-of-pocket costs: The cost- sharing
requirement for members
to pay for part of the services or drugs they get is also called the
“out-of-pocket” cost requirement.
Refer to the definition for “cost-sharing” above.
Over-the-counter (OTC) drugs: Over-the-counter
drugs are drugs
or medicines that a person can buy without a prescription from a health care
professional.
Part A: Refer to “Medicare Part A.”
Part B: Refer to “Medicare Part B.”
Part C: Refer to “Medicare Part C.”
Part D: Refer to “Medicare Part D.”
Part D drugs: Refer to “Medicare Part D
drugs.”
Personal health information (also called Protected health
information)
(PHI): Information about you and your health, such as your name, address,
social security
number, physician visits, and medical history. Refer to our Notice of Privacy Practices
for more
information about how we protect, use, and disclose your PHI, as well as your rights
with respect to
your PHI.
Preventive services: Health care to prevent
illness or detect
illness at an early stage, when treatment is likely to work best (for example,
preventive services
include Pap tests, flu shots, and screening mammograms).
Primary care provider (PCP): The doctor or other
provider you
use first for most health problems. They make sure you get the care you need to stay
healthy.
They also may talk with other doctors and health care providers about your care
and refer you to
them.
In many Medicare health plans, you must use your primary care provider before you
use any other
health care provider.
Refer to Chapter 3 of this Member Handbook for
information about getting
care from primary care providers.
Prior authorization (PA): An approval you must
get from us
before you can get a specific service or drug or use an out-of-network provider. Our
plan may not cover
the service or drug if you don’t get approval first.
Our plan covers some network medical services only if your doctor or other network
provider gets PA
from us.
Our plan covers some drugs only if you get PA from us.
Program of All-Inclusive Care for the Elderly
(PACE): A
program that covers Medicare and Medicaid benefits together for people age 55 and over
who need a higher
level of care to live at home.
Prosthetics and Orthotics: Medical devices
ordered by your
doctor or other health care provider that include, but aren’t limited to, arm,
back, and neck braces;
artificial limbs; artificial eyes; and devices needed to replace an internal body part
or function,
including ostomy supplies and enteral and parenteral nutrition therapy.
Quality improvement organization (QIO): A group
of doctors and
other health care experts who help improve the quality of care for people with Medicare.
The federal
government pays the QIO to check and improve the care given to patients. Refer to
Chapter
2 of this Member Handbook for information about the QIO.
Quantity limits: A limit on the amount of a drug
you can have.
We may limit the amount of the drug that we cover per prescription.
Real Time Benefit Tool: A portal or computer
application in
which enrollees can look up complete, accurate, timely, clinically appropriate,
enrollee-specific
covered drugs and benefit information. This includes cost sharing amounts, alternative
drugs that may be
used for the same health condition as a given drug, and coverage restrictions (prior
authorization, step
therapy, quantity limits) that apply to alternative drugs.
Referral: A referral is your primary care
provider’s (PCP’s)
or our approval to use a provider other than your PCP. If you don’t get approval
first, we may not cover
the services. You don’t need a referral to use certain specialists, such as
women’s health specialists.
You can find more information about referrals in Chapters 3 and 4 of
this Member
Handbook.
Rehabilitation services: Treatment you get to
help you recover
from an illness, accident, or major operation. Refer to Chapter 4 of
this Member
Handbook to learn more about rehabilitation services.
Sensitive services: Services related to mental
or behavioral
health, sexual and reproductive health, family planning, sexually transmitted infections
(STIs),
HIV/AIDS, sexual assault and abortions, substance use disorder, gender affirming care,
and intimate
partner violence.
Service area: A geographic area where a health
plan accepts
members if it limits membership based on where people live. For plans that limit which
doctors and
hospitals you may use, it’s generally the area where you can get routine
(non-emergency) services. Only
people who live in our service area can enroll in our plan.
Share of cost: The portion of your health care
costs that you
may have to pay each month before your benefits become effective. The amount of your
share of cost
varies depending on your income and resources.
Skilled nursing facility (SNF): A nursing
facility with the
staff and equipment to give skilled nursing care and, in most cases, skilled
rehabilitative services and
other related health services.
Skilled nursing facility (SNF) care: Skilled
nursing care and
rehabilitation services provided on a continuous, daily basis, in a skilled nursing
facility. Examples
of skilled nursing facility care include physical therapy or intravenous (IV) injections
that a
registered nurse or a doctor can give.
Specialist: A doctor who treats certain types of
health care
problems. For example, an orthopedic surgeon treats broken bones; an allergist treats
allergies; and a
cardiologist treats heart problems. In most cases, a member will need a referral from
their PCP to go to
a specialist.
Specialized pharmacy: Refer to Chapter
5 of
this Member Handbook to learn more about specialized pharmacies.
State Hearing: If your doctor or other provider
asks for a
Medi-Cal service that we won’t approve, or we won’t continue to pay for a
Medi-Cal service you already
have, you can ask for a State Hearing. If the State Hearing is decided in your favor, we
must give you
the service you asked for.
Step therapy: A coverage rule that requires you
to try another
drug before we cover the drug you ask for.
Supplemental Security Income (SSI): A monthly
benefit Social
Security pays to people with limited incomes and resources who are disabled, blind, or
age 65 and over.
SSI benefits aren’t the same as Social Security benefits.
Urgently needed care: Care you get for an
unforeseen illness,
injury, or condition that isn’t an emergency but needs care right away. You can
get urgently needed care
from out-of-network providers when you can’t get to them because given your time,
place, or
circumstances, it isn’t possible, or it’s unreasonable to get services from
network providers (for
example when you’re outside our plan’s service area and you require
medically needed immediate services
for an unseen condition but it isn’t a medical emergency).
CommuniCare Advantage Member Services
TTY | 1-855-266-4584 This number requires special telephone equipment and is
only for people who
have difficulties with hearing or speaking. Calls to this number are free. We are available 24 hours a day, 7 days a
week. |
FAX | 1-619-426-9437 |
WRITE | Community Health Group
Member Services Department
2420 Fenton Street,
Suite 100
Chula Vista,
CA 91914 |
WEBSITE | www.chgsd.com
|
shows the preventive
services in the Benefits Chart.