Ambulatory Surgical Center – An Ambulatory
Surgical Center
is an entity that operates exclusively for the purpose of furnishing outpatient surgical
services to
patients not requiring hospitalization and whose expected stay in the center
doesn’t exceed 24 hours.
Appeal – An appeal is something you do if
you disagree with
our decision to deny a request for coverage of health care services or prescription
drugs or payment
for services or drugs you already got. You may also make an appeal if you disagree with
our decision
to stop services that you’re getting.
Balance Billing – When a provider (such as
a doctor or
hospital) bills a patient more than our plan’s allowed cost-sharing amount. As a
member of Community y
Más, you only have to pay our plan’s cost-sharing amounts when you get
services covered by our plan.
We don’t allow providers to balance bill or otherwise charge you
more than the amount
of cost sharing our plan says you must pay.
Benefit Period – The way that both our
plan and Original
Medicare measures your use of hospital and skilled nursing facility (SNF) services. A
benefit period
begins the day you go into a hospital or skilled nursing facility. The benefit period
ends when you
haven’t gotten any inpatient hospital care (or skilled care in a SNF) for 60 days
in a row. If you go
into a hospital or a skilled nursing facility after one benefit period has ended, a new
benefit period
begins. There is no limit to the number of benefit periods.
Biological Product – A prescription drug
that is 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. (go to “Original Biological Product” and
“Biosimilar”).
Biosimilar – A biological product
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 prescription drug that
is manufactured
and sold by the pharmaceutical company that originally researched and developed the
drug. Brand name
drugs have the same active-ingredient formula as the generic version of the drug.
However, generic
drugs are manufactured and sold by other drug manufacturers and are generally not
available until
after the patent on the brand name drug has expired.
Catastrophic Coverage Stage – The stage in
the Part D Drug
Benefit that begins when you (or other qualified parties on your behalf) have spent
$2,100 for Part D
covered drugs during the covered year. During this payment stage, our plan pays the full
cost for your
covered Part D drugs.
Centers for Medicare & Medicaid Services
(CMS) – The
federal agency that administers Medicare.
Chronic-Care Special Needs Plan (C-SNP) –
C-SNPs are SNPs
that restrict enrollment to MA eligible people who have specific severe and chronic
diseases.
Coinsurance – An amount you may be
required to pay,
expressed as a percentage (for example 20%) as your share of the cost for services or
prescription
drugsComplaint - The formal name for making a complaint is
filing a
grievance. The complaint process is used only for certain types of
problems. This
includes problems about quality of care, waiting times, and the customer service you
get. It also
includes complaints if our plan doesn’t follow the time periods in the appeal
process.
Comprehensive Outpatient Rehabilitation Facility (CORF)
– A
facility that mainly provides rehabilitation services after an illness or injury,
including physical
therapy, social or psychological services, respiratory therapy, occupational therapy and
speech-language pathology services, and home environment evaluation services.
Copayment (or copay) – An amount you may be
required to pay as your
share of the cost for a medical service or supply, like a doctor’s visit, hospital
outpatient visit,
or a prescription drug. A copayment is a set amount (for example $10), rather than a
percentage.
Cost Sharing – Cost sharing refers to
amounts that a member
has to pay when services or drugs are gotten. Cost sharing includes any combination of
the following 3
types of payments: 1) any deductible amount a plan may impose before services or drugs
are covered; 2)
any fixed copayment amount that a plan requires when a specific service or drug is
gotten; or 3) any
coinsurance amount, a percentage of the total amount paid for a service or drug, that a
plan requires
when a specific service or drug is gotten.
Cost-Sharing Tier – Every drug on the list
of covered drugs
is in one of 6 cost-sharing tiers. In general, the higher the cost-sharing tier, the
higher your cost
for the drug.
Coverage Determination – A decision about whether
a drug prescribed
for you is covered by our plan and the amount, if any, you’re required to pay for
the prescription. In
general, if you bring your prescription to a pharmacy and the pharmacy tells you the
prescription
isn’t covered under our plan, that isn’t a coverage determination. You need
to call or write to our
plan to ask for a formal decision about the coverage. Coverage determinations are called
coverage decisions in this document.
Covered Drugs – The term we use to mean
all the prescription
drugs covered by our plan.
Covered Services – The term we use to mean
all the health
care services and supplies that are covered by our plan.
Creditable Prescription Drug Coverage –
Prescription drug
coverage (for example, from an employer or union) that is expected to pay, on average,
at least as
much as Medicare’s standard prescription drug coverage. People who have this kind
of coverage when
they become eligible for Medicare can generally keep that coverage without paying a
penalty if they
decide to enroll in Medicare prescription drug coverage later.
Custodial Care – Custodial care is
personal care provided in
a nursing home, hospice, or other facility setting when you don’t need skilled
medical care or skilled
nursing care. Custodial care, provided by people who don’t have professional
skills or training,
includes help with activities of daily living like bathing, dressing, eating, getting in
or out of a
bed or chair, moving around, and using the bathroom. It may also include the kind of
health-related
care that most people do themselves, like using eye drops. Medicare doesn’t pay
for custodial care.
Daily cost-sharing rate – A daily
cost-sharing rate 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 copayment. A daily cost-sharing rate is the copayment divided by the
number of days
in a month’s supply. Here is an example: If your copayment for a one-month supply
of a drug is $30,
and a one-month’s supply in our plan is 30 days, then your daily cost-sharing rate
is $1 per day.
Deductible – The amount you must pay for
health care or
prescriptions before our plan pays.
Disenroll or Disenrollment – The process of
ending your membership
in our plan.
Dispensing Fee – A fee charged each time a covered drug is
dispensed to pay for the
cost of filling a prescription, such as the pharmacist’s time to prepare and
package the prescription.
Dual Eligible Special Needs Plans (D-SNP) – D-SNPs enroll people
who are entitled to
both Medicare (Title XVIII of the Social Security Act) and medical assistance from a
state plan under
Medicaid (Title XIX). States cover some Medicare costs, depending on the state and the
person’s
eligibility.
Dually Eligible Individual – A person who
is eligible for
Medicare and Medicaid coverage.
Durable Medical Equipment (DME) – Certain
medical equipment
that is ordered by your doctor for medical reasons. Examples include walkers,
wheelchairs, crutches,
powered mattress systems, diabetic supplies, IV infusion pumps, speech generating
devices, oxygen
equipment, nebulizers, or hospital beds ordered by a provider for use in the home.
Emergency – A medical emergency is when
you, or any other
prudent layperson with an average knowledge of health and medicine, believe that you
have medical
symptoms that require immediate medical attention to prevent loss of life (and, if
you’re a pregnant
woman, loss of an unborn child), loss of a limb, or loss of function of a limb, or loss
of or serious
impairment to a bodily function. The medical symptoms may be an illness, injury, severe
pain, or a
medical condition that is quickly getting worse.
Emergency Care – Covered services that
are: 1) provided by a
provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or
stabilize an
emergency medical condition.
Evidence of Coverage (EOC) and Disclosure
Information – This
document, along with your enrollment form and any other attachments, riders, or other
optional
coverage selected, which explains your coverage, what we must do, your rights, and what
you have to do
as a member of our plan.
Exception – A type of coverage decision
that, if approved,
allows you to get a drug that isn’t on our formulary (a formulary exception), or
get a non-preferred
drug at a lower cost-sharing level (a tiering exception). You may also ask for an
exception if our
plan requires you to try another drug before getting the drug you’re asking for,
if our plan requires
a prior authorization for a drug and you want us to waive the criteria restriction, or
if our plan
limits the quantity or dosage of the drug you’re asking for (a formulary
exception).
Extra Help – A Medicare program to help
people with limited
income and resources pay Medicare prescription drug program costs, such as premiums,
deductibles, and
coinsurance.
Generic Drug – A prescription drug
that’s approved by the
FDA as having the same active ingredient(s) as the brand name drug. Generally, a generic
drug works
the same as a brand name drug and usually costs less.
Grievance – A type of complaint you make
about our plan,
providers, or pharmacies, including a complaint concerning the quality of your care.
This doesn’t
involve coverage or payment disputes.
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 (e.g.,
bathing,
using the toilet, dressing, or carrying out the prescribed exercises).
Hospice – A benefit that provides special
treatment for a
member who has been medically certified as terminally ill, meaning having a life
expectancy of 6
months or less. Our plan must provide you with a list of hospices in your geographic
area. If you
elect hospice and continue to pay premiums, you’re still a member of our plan. You
can still get all
medically necessary services as well as the supplemental benefits we offer.
Hospital Inpatient Stay – A hospital stay when you have been
formally admitted to
the hospital for skilled medical services. Even if you stay in the hospital overnight,
you might still
be considered an outpatient.
Income Related Monthly Adjustment Amount (IRMAA)
– If your
modified adjusted gross income as reported on your IRS tax return from 2 years ago is
above a certain
amount, you’ll pay the standard premium amount and an Income Related Monthly
Adjustment Amount, also
known as IRMAA. IRMAA is an extra charge added to your premium. Less than 5% of people
with Medicare
are affected, so most people won’t not pay a higher premium.
Initial Coverage Stage – This is the stage
before your
out-of-pocket costs for the year have reached the out-of-pocket threshold amount.
Initial Enrollment Period – When you’re first eligible for
Medicare, the period of
time when you can sign up for Medicare Part A and Part B. If you’re eligible for
Medicare when you
turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months
before the month
you turn 65, includes the month you turn 65, and ends 3 months after the month you turn
65.
Institutional Special Needs Plan (I-SNP) –
I-SNPs restrict
enrollment to MA eligible people who live in the community but need the level of care a
facility
offers, or who live (or are expected to live) for at least 90 days straight in certain
long-term
facilities. I-SNPs include the following types of plans: Institutional-equivalent SNPs
(IE-SNPs)
Hybrid Institutional SNPs (HI-SNPs), and Facility-based Institutional SNPs (FI-SNPs).
Institutional-Equivalent Special Needs Plan
(IE-SNP) – An
IE-SNP restricts enrollment to MA eligible people who live in the community but need the
level of care
a facility offers.
Interchangeable Biosimilar – A biosimilar
that may be used
as a substitute for an original biosimilar product 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 (formulary or Drug List)
– A list of
prescription drugs covered by our plan.
Low Income Subsidy (LIS) – Go to Extra
Help.
Manufacturer Discount Program – A program
under which drug
manufacturers pay a portion of our plan’s full cost for covered Part D brand name
drugs and biologics.
Discounts are based on agreements between the federal government and drug manufacturers.
Maximum Fair Price – The price Medicare negotiated for a selected
drug.
Maximum Out-of-Pocket Amount – The most
that you pay out of
pocket during the calendar year for in-network covered Part A and Part B
services. Amounts
you pay for Medicare Part A and Part B premiums, and prescription drugs don’t
count toward the maximum
out-of-pocket amount.
Medicaid (or Medical Assistance) – A joint
federal and state
program that helps with medical costs for some people with low incomes and limited
resources. State
Medicaid programs vary, but most health care costs are covered if you qualify for both
Medicare and
Medicaid.
Medically Accepted Indication – A use of a
drug that is
either approved by the FDA or supported by certain references, such as the American
Hospital Formulary
Service Drug Information and the Micromedex DRUGDEX Information system.
Medically Necessary – Services, supplies,
or drugs that are
needed for the prevention, diagnosis, or treatment of your medical condition and 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).
Medicare Advantage Open Enrollment Period
– The time period
from January 1 to March 31 when members in a Medicare Advantage plan can cancel their
plan enrollment
and switch to another Medicare Advantage plan or get coverage through Original Medicare.
If you choose
to switch to Original Medicare during this period, you can also join a separate Medicare
prescription
drug plan at that time. The Medicare Advantage Open Enrollment Period is also available
for a 3-month
period after a person is first eligible for Medicare.
Medicare Advantage (MA) Plan – Sometimes
called Medicare
Part C. A plan offered by a private company that contracts with Medicare to provide you
with all your
Medicare Part A and Part B benefits. A Medicare Advantage Plan can be i) an HMO, ii) a
PPO, iii) a
Private Fee-for-Service (PFFS) plan, or iv) a Medicare Medical Savings Account (MSA)
plan. Besides
choosing from these types of plans, a Medicare Advantage HMO or PPO plan can also be a
Special Needs
Plan (SNP). In most cases, Medicare Advantage Plans also offer Medicare Part D
(prescription drug
coverage). These plans are called Medicare Advantage Plans with Prescription
Drug
Coverage.
Medicare Cost Plan – A Medicare Cost Plan
is a plan operated
by a Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP) in
accordance with a
cost-reimbursed contract under section 1876(h) of the Act.
Medicare-Covered Services – Services
covered by Medicare
Part A and Part B. All Medicare health plans must cover all the services that are
covered by Medicare
Part A and B. The term Medicare-Covered Services doesn’t include the extra
benefits, such as vision,
dental, or hearing, that a Medicare Advantage plan may offer.
Medicare Health Plan – A Medicare health
plan is offered by
a private company that contracts with Medicare to provide Part A and Part B benefits to
people with
Medicare who enroll in our plan. This term includes all Medicare Advantage Plans,
Medicare Cost Plans,
Special Needs Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care
for the Elderly
(PACE).
Medicare Prescription Drug Coverage (Medicare Part
D) –
Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some
supplies not
covered by Medicare Part A or Part B.
Medication Therapy Management (MTM) program – 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.
Medigap (Medicare Supplement Insurance) Policy
– Medicare
supplement insurance sold by private insurance companies to fill gaps in
Original Medicare.
Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a
Medigap
policy.)
Member (Member of our Plan, or Plan Member)
– A person with
Medicare who is eligible to get covered services, who has enrolled in our plan, and
whose enrollment
has been confirmed by the Centers for Medicare & Medicaid Services (CMS).
Member Services – A department within our
plan responsible
for answering your questions about your membership, benefits, grievances, and appeals.
Network Pharmacy – A pharmacy that
contracts with our plan
where members of our plan can get their prescription drug benefits. In most cases, your
prescriptions
are covered only if they are filled at one of our network pharmacies.
Network Provider –
Provider is the general
term for doctors, other health care professionals, hospitals, and other health care
facilities that
are licensed or certified by Medicare and by the state to provide health care services.
Network providers have an agreement with our plan to accept our payment
as payment in
full, and in some cases to coordinate as well as provide covered services to members of
our plan.
Network providers are also called plan providers.
Open Enrollment Period – The time period of October 15 until
December 7 of each year
when members can change their health or drug plans or switch to Original Medicare.
Organization Determination – A decision
our plan makes about
whether items or services are covered or how much you have to pay for covered items or
services.
Organization determinations are called coverage decisions in this document.
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 is also called a reference product.
Original Medicare (Traditional Medicare or
Fee-for-Service
Medicare) – Original Medicare is offered by the government, and
not a private health
plan like Medicare Advantage plans and prescription drug plans. Under Original Medicare,
Medicare
services are covered by paying doctors, hospitals, and other health care providers
payment amounts
established by Congress. You can see any doctor, hospital, or other health care provider
that accepts
Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved
amount, and
you pay your share. Original Medicare has 2 parts: Part A (Hospital Insurance) and Part
B (Medical
Insurance) and is available everywhere in the United States.
Out-of-Network Pharmacy – A pharmacy that doesn’t have a
contract with our plan to
coordinate or provide covered drugs to members of our plan. Most drugs you get from
out-of-network
pharmacies aren’t covered by our plan unless certain conditions apply.
Out-of-Network Provider or Out-of-Network
Facility – A
provider or facility that doesn’t have a contract with our plan to coordinate or
provide covered
services to members of our plan. Out-of-network providers are providers that
aren’t employed, owned,
or operated by our plan.
Out-of-Pocket Costs – Go to the definition
for cost sharing
above. A member’s cost-sharing requirement to pay for a portion of services or
drugs gotten is also
referred to as the member’s out-of-pocket cost requirement.
Out-of-Pocket Threshold – The maximum
amount you pay out of
pocket for Part D drugs.
PACE plan – A PACE (Program of
All-Inclusive Care for the
Elderly) plan combines medical, social, and long-term services and supports (LTSS) for
frail people to
help people stay independent and living in their community (instead of moving to a
nursing home) as
long as possible. People enrolled in PACE plans get both their Medicare and Medicaid
benefits through
our plan.
Part C – Go to Medicare Advantage (MA) Plan.
Part D – The voluntary Medicare
Prescription Drug Benefit
Program.
Part D Drugs – Drugs that can be covered
under Part D. We
may or may not offer all Part D drugs. Certain categories of drugs have been excluded as
covered Part
D drugs by Congress. Certain categories of Part D drugs must be covered by every plan.
Part D Late Enrollment Penalty – An amount
added to your
monthly plan premium for Medicare drug coverage if you go without creditable coverage
(coverage that’s
expected to pay, on average, at least as much as standard Medicare prescription drug
coverage) for a
continuous period of 63 days or more after you’re first eligible to join a Part D
plan.
Preferred Cost Sharing – Preferred cost
sharing means lower
cost sharing for certain covered Part D drugs at certain network pharmacies.
Preferred Provider Organization (PPO) Plan
– A Preferred
Provider Organization plan is a Medicare Advantage Plan that has a network of contracted
providers
that have agreed to treat plan members for a specified payment amount. A PPO plan must
cover all plan
benefits whether they’re received from network or out-of-network providers. Member
cost sharing will
generally be higher when plan benefits are gotten from out-of-network providers. PPO
plans have an
annual limit on your out-of-pocket costs for services gotten from network (preferred)
providers and a
higher limit on your total combined out-of-pocket costs for services from both
in-network (preferred)
and out-of-network (non-preferred) providers.
Premium – The periodic payment to
Medicare, an insurance
company, or a health care plan for health or prescription drug coverage.
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 see
first for most health problems. In many Medicare health plans, you must see your primary
care provider
before you see any other health care provider.
Prior Authorization – Approval in advance
to get services
and/or certain drugs based on specific criteria. Covered services that need prior
authorization are
marked in the Medical Benefits Chart in Chapter 4. Covered drugs that need prior
authorization are
marked in the formulary and our criteria are posted on our website.
Prosthetics and Orthotics – Medical
devices including, but
not 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
practicing doctors and other health care experts paid by the federal government to check
and improve
the care given to Medicare patients.
Quantity Limits – A management tool that
is designed to
limit the use of a drug for quality, safety, or utilization reasons. Limits may be on
the amount of
the drug that we cover per prescription or for a defined period of time.
“Real-Time Benefit Tool” – A
portal or computer application
in which enrollees can look up complete, accurate, timely, clinically appropriate,
enrollee-specific
formulary and benefit information. This includes cost-sharing amounts, alternative
formulary
medications 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
medications.
Referral – A written order from your
primary care doctor for
you to visit a specialist or get certain medical services. Without a referral, our plan
may not pay
for services from a specialist.
Rehabilitation Services – These services
include inpatient
rehabilitation care, physical therapy (outpatient), speech and language therapy, and
occupational
therapy.
Selected Drug – A drug covered under Part D for which Medicare
negotiated a Maximum
Fair Price.
Service Area – A geographic area where you
must live to join
a particular health plan. For plans that limit which doctors and hospitals you may use,
it’s also
generally the area where you can get routine (non-emergency) services. Our plan must
disenroll you if
you permanently move out of our plan’s service area.
Skilled Nursing Facility (SNF) Care – Skilled nursing care and
rehabilitation
services provided on a continuous, daily basis, in a skilled nursing facility. Examples
of care
include physical therapy or intravenous injections that can only be given by a
registered nurse or
doctor.
Special Enrollment Period – A set time when members can change
their health or drug
plan or return to Original Medicare. Situations in which you may be eligible for a
Special Enrollment
Period include: if you move outside the service area, if you’re getting Extra Help
with your
prescription drug costs, if you move into a nursing home, or if we violate our contract
with you.
Special Needs Plan – A special type of Medicare Advantage Plan
that provides more
focused health care for specific groups of people, such as those who have both Medicare
and Medicaid,
who live in a nursing home, or who have certain chronic medical conditions.
Standard Cost Sharing– Standard cost sharing is cost
sharing other than
preferred cost sharing offered at a network pharmacy.
Step Therapy – A utilization tool that
requires you to first
try another drug to treat your medical condition before we’ll cover the drug your
physician may have
initially prescribed.
Supplemental Security Income (SSI) – A monthly
benefit paid by
Social Security to people with limited income and resources who are disabled, blind, or
age 65 and
older. SSI benefits aren’t the same as Social Security benefits.
Urgently Needed Services – A plan-covered
service requiring
immediate medical attention that’s not an emergency is an urgently needed service
if either you’re
temporarily outside our plan’s service area, or it’s unreasonable given your
time, place, and
circumstances to get this service from network providers. Examples of urgently needed
services are
unforeseen medical illnesses and injuries, or unexpected flare-ups of existing
conditions. Medically
necessary routine provider visits (like annual checkups) aren’t considered
urgently needed even if
you’re outside our plan’s service area or our plan network is temporarily
unavailable.
Community y Más Member Services
| Call | 1-800-232-3133 Calls to this number are free. We are available 24 hours a
day, 7 days a week.
Member Services 1-800-232-3133 (TTY users
call 1-855-266-4584) also has free language
interpreter services
available for non-English speakers. |
| 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 | 619-426-9437 |
| Write | Community Health Group Member Services Department 2420 Fenton Street,
Suite 100 Chula Vista,
CA 91914 |
| Website | www.chgsd.com
|
California Health Insurance Counseling and Advocacy Program (HICAP)
California Health Insurance Counseling and Advocacy Program (HICAP) is a state program
that gets
money from the federal government to give free local health insurance counseling to
people with
Medicare.
| Call | 1-800-434-0222 or 1-858-565-8772 Monday to Friday from
8:00
am to 5 pm |
| Write | HICAP San Diego 5151 Murphy Canyon Road, Suite 100 San Diego, CA 92123
|
| Website | www.chgsd.com
|
PRA Disclosure Statement According to the Paperwork Reduction Act of
1995, no
persons are required to respond to a collection of information unless it displays a
valid OMB
control number. The valid OMB control number for this information collection is
0938-1051. If you
have comments or suggestions for improving this form, write to: CMS, 7500 Security
Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.
This apple
shows preventive services in the Medical Benefits Chart.