Glossary

A

Annual Election Period (AEP)

See Annual Enrollment Period (AEP)

Annual Enrollment Period (AEP)

Also called the Annual Election Period, this begins October 15 and ends December 7 in 2011. Generally, this is the only time you can enroll in Original Medicare, a Medicare Advantage plan, a standalone Part D plan or switch plans.

The annual enrollment period does not apply to Medicare Supplement plans. 

Visit When You Can Enroll to learn more.

Annual out-of-pocket maximum

The limit of how much you pay per year for medical care. What you pay for medical care is called your out-of-pocket costs.

Once the total you’ve paid reaches this amount, your plan pays the entire cost for all covered medical services for the rest of the year. (This means you no longer pay fees like copayments and coinsurance. You just pay your monthly premium.)

Appeal

A specific kind of complaint you make to your health plan about your plan’s benefits, coverage or payments. This includes problems like whether or not a specific medical service or prescription drug is covered, how they’re covered or how they’re paid.

You can learn more about appeals and how to make an appeal in the Evidence of Coverage or visit Making a Complaint.

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B

Brand-name drug

A prescription drug that’s manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand-name drugs have the same active ingredients as their generic drug counterparts, but brand-name drugs usually cost more.

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C

Catastrophic coverage

Also called the post-coverage gap period, this period comes after the coverage gap and starts when your yearly out-of-pocket drug costs reach a certain amount. For 2012, this amount is $4,700. This means in 2012 when your yearly out-of-pocket drug costs reach $4,700, you leave the coverage gap and enter the catastrophic coverage period.

The catastrophic coverage period lasts the rest of the year. During this time, your plan pays most of your drug costs.

Visit What’s the Coverage Gap? to learn more. 

Centers for Medicare & Medicaid Services (CMS)

The federal agency that runs the Medicare program. CMS also works with states to run Medicaid.

Coinsurance

A percentage of the cost you pay each time you use a medical service covered by your plan. For example, if your coinsurance for doctor visits is 10 percent, you’ll pay 10 percent of the cost each time you visit your doctor. Your plan pays the rest.

Copayment

A set fee you pay each time you use a medical service covered by your plan. For example, if your copayment for doctor visits is $20, you’ll pay $20 each time you visit your doctor. Your plan pays the rest.

Coverage gap

If you have prescription drug coverage (Medicare Part D), you enter the coverage gap period when your total yearly drug costs (this is both what you and your plan pay) reach a certain amount. For 2012, this amount is $2,930. This means in 2012 when your total yearly drug costs (both what you and your plan have paid) reach $2,930, you enter the coverage gap.

During the coverage gap in 2012, you’re responsible for 86 percent of your generic prescription drug costs and 100 percent of the discounted cost of your brand-name prescription drug costs until you reach the catastrophic coverage period (also called the post-coverage gap).

Visit What’s the Coverage Gap? to learn more. 

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D

Deductible

A set amount you must pay before your plan starts helping pay for your medical care or pharmacy benefits. For example, having a $250 deductible means you must pay for $250 of your medical services or prescription drug costs before your plan starts chipping in. With no deductible, your plan starts paying for your medical services right away.

Durable medical equipment

Medical equipment that’s prescribed by your doctor for use in your home. Wheelchairs, crutches, hospital beds, oxygen equipment and walkers are considered durable medical equipment.

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E

Emergency care

Medical care provided in an emergency medical situation where you believe your health is in serious danger. Examples of emergency situations include chest pain, a broken bone, poisoning, shortness of breath, fainting, seizures and unconsciousness.

Evidence of Coverage

Your Health Alliance Medicare Evidence of Coverage book explains the details about your specific plan and how to get the health care you need. It includes a complete list of your benefits, the services we cover and what you pay for each service.

You receive an Evidence of Coverage when you become a member of a Medicare Advantage plan. You will receive an updated version every fall.

View Health Alliance Medicare Evidence of Coverage

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F

Formulary

See Medicare Part D Formulary.

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G

Generic drug

Generic drugs are just as good brand-name drugs, and they usually cost less because generic manufacturers don’t have to spend money for research, development and marketing. (Brand-name manufacturers pay for these costs.) 

Generic drugs are reviewed and approved by the Food and Drug Administration and have the same active ingredients as their brand-name counterparts.

Grievance

A complaint you make about the quality of care your health plan is providing. A grievance may be a complaint about the customer service you received, like how an employee acted toward you. It may also be a complaint about waiting times or the quality of medical care you received.  

Grievances are not complaints about benefits, coverage or payments such as a complaint that a service isn’t covered. See appeal for these types of complaints.

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H

HMO (Health Maintenance Organization) plan

A type of Medicare Advantage plan. With an HMO plan, you must go to certain doctors and hospitals, unless it’s an emergency. You’ll need to choose a personal doctor, called a Primary Care Physician (PCP), to manage your overall health care. If you need care from a specialist, you must get a referral from your PCP. The doctors and hospitals you can go to are listed in the plan’s provider directory.  

Find Health Alliance Medicare HMO plans

Find HMO doctors

Home health care

Medical care, treatment or skilled care you get in your home.

Hospice care

A special way to care for people who terminally ill. Hospice care includes medical and physical care and helps with social, emotional and spiritual needs. Support for family and caregivers is also provided.

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I

Initial Enrollment Period (IEP)

A seven-month period around when you turn age 65 that you can enroll in Medicare. This period begins three months before your 65th birthday, includes the month of your 65th birthday and continues for three months after your 65th birthday.    

During this time, you can enroll in Original Medicare, a Medicare Advantage plan or a standalone Part D plan. You can also enroll in a Medicare Supplement plan.    

Learn More about When You Can Enroll

In-network

Refers to doctors, hospitals, pharmacies and other health care professionals who have made an agreement with a health plan to provide services to plan members.

In-network pharmacy

A pharmacy that has made an agreement with a health plan to provide prescription drugs to plan members. In most cases, you must go to an in-network pharmacy for your prescriptions to be covered. In-network pharmacies are listed in the pharmacy directory.

In-network provider

A doctor, hospital or other health care professional who has made an agreement with a health plan to provide health care services to plan members. In-network providers are listed in the provider directory.    

Health Alliance Medicare PPO plan members pay less when they use in-network providers, though they can use any provider (see out-of-network provider). Health Alliance Medicare HMO plan members must use plan providers.

Inpatient care

Health care services you get when you’re admitted to a hospital.

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J

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K

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L

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M

Medicaid

A shared federal and state program that helps people with low incomes pay for medical costs. Medicaid programs vary from state to state because each state sets its own guidelines for eligibility and services. However, most health care costs are covered if you qualify for Medicare and Medicaid.

Medically necessary

A term used to describe drugs, medical services or supplies that are appropriate and needed for the diagnosis or treatment of a certain illness or injury. The drug, service or item must be consistently used for the illness or injury, and it must be considered the most appropriate care that can be safely provided to you. The service can’t be used only for convenience.

Medicare

A health insurance program available to people age 65 and older and some others younger than 65 with disabilities. The Centers for Medicare & Medicaid Services (CMS) runs the Medicare program.   

Learn More about What is Medicare?

Medicare Advantage plan

A type of health plan offered as an alternative to Original Medicare. Medicare Advantage plans are Part C plans—they include coverage for both Part A and Part B. With some Health Alliance Medicare Advantage plans, Part D coverage is also included to help pay for your drug costs.   

Medicare Advantage plans are offered by private companies like Health Alliance that have a contract with Medicare. We offer HMO and PPO types of Medicare Advantage plans and all come with free programs and no-cost extras that can help you save money and be healthy.   

Find Health Alliance Medicare HMO plans

Find Health Alliance Medicare PPO 10 plans or PPO 30 plans     

Learn More about Medicare Advantage

Medicare Part A (hospital insurance)

Helps cover hospital costs like room and board and other inpatient care provided in a hospital or skilled nursing facility. Part A also helps cover the cost of hospice care and some home health care. Most people don’t have to pay a monthly premium for Part A because they or their spouse already paid for it through payroll taxes while working. Part A is included with Original Medicare.

Medicare Part B (medical insurance)

Helps cover medical costs like doctor visits and other outpatient care. Part B also covers some other medical services Part A doesn’t cover, like some physical therapy. With Original Medicare, you have the option to purchase Part B. Most people pay a monthly premium for Part B.

Medicare Part C (Medicare Advantage)

Another name for a Medicare Advantage plan that includes coverage for both Part A and Part B. Medicare Advantage plans replace Original Medicare and are offered by private companies like Health Alliance that have a contract with Medicare. Health Alliance Medicare HMO and PPO plans are examples of Medicare Advantage plans. Some Health Alliance Medicare Advantage plans also cover Part D.    

Find Health Alliance Medicare HMO plans

Find Health Alliance Medicare PPO 10 plans or PPO 30 plans

Learn More about Medicare Advantage

Medicare Part D (prescription drug coverage)

An optional program that helps cover your prescription drug costs. Medicare Part D is only offered through private companies like Health Alliance that are approved by Medicare.    

You can get Medicare Part D coverage by purchasing a standalone Part D plan from Health Alliance Medicare. Or, some Health Alliance Medicare Advantage plans, like our Rx and Rx Plus plans, include Part D coverage.  

Find Health Alliance Medicare Stand-Alone Part D Plans

Find Health Alliance Medicare Rx Plans   

Learn More about Prescription Coverage

Medicare Part D Formulary

A list of drugs covered by your plan. This list includes generic drugs and brand-name drugs.  

To meet the needs of our members, the Health Alliance Medicare Part D Formulary is an open formulary, which allows some drugs that are not specifically listed in the formulary to still be covered.    

How to Use the Formulary

View the Health Alliance Medicare Part D Abridged Formulary

View the Health Alliance Medicare Part D Comprehensive Formulary

Medicare Supplement plan

A type of Medicare plan that helps cover medical costs Original Medicare doesn’t pay. Medicare Supplement plans only work with Original Medicare. They are not Medicare Advantage plans. Medicare Supplement plans don’t cover prescription drug costs.    

These plans are offered by private companies like Health Alliance, and they’re often called “Medigap” plans because they fill in the “gaps” of Original Medicare coverage.    

With a Health Alliance Medicare Supplement plan, you can go to any doctor and hospital in Illinois. 

Find Health Alliance Medicare Supplement plans

Learn More about Medicare Supplement

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N

Network

See provider network or pharmacy network.

Notice of Privacy Practices

A document that describes how your health information may be used and disclosed by your health plan. It also explains your rights regarding this information.

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O

Original Medicare

A health plan managed by the federal government where you pay a portion of your health care costs. You pay a set amount (called a deductible) before you get help paying for your care. You also pay part of the cost each time you use medical services—for example, each time you visit the doctor. You can go to any doctor or hospital that accepts Medicare and is accepting new Medicare patients.    

Original Medicare has two parts. See Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) for definitions of each part. Part A is included with Original Medicare. You have the option to purchase Part B. Original Medicare doesn’t help pay for your prescription drug costs. 

Learn More about Original Medicare

Out-of-network

Refers to doctors, hospitals, pharmacies and other health care professionals who have not made an agreement with the health plan to provide services to plan members.

Out-of-network pharmacy

A pharmacy that has not made an agreement with the health plan to provide prescription drugs to plan members. Your prescriptions are generally not covered at an out-of-network pharmacy.   

(You must go to an in-network pharmacy to get coverage for your prescriptions.)

Out-of-network provider

A doctor, hospital or other health care professional who has not made an agreement with the health plan to provide health care services to plan members.  

Health Alliance Medicare PPO plan members can go to out-of-network providers, but they’ll pay less when they use in-network providers. Health Alliance Medicare HMO plan members must use plan providers except in emergency or urgent care situations.

Out-of-pocket costs

What you pay for medical care.  

When the yearly total you’ve paid for medical care reaches a certain amount (this is your annual out-of-pocket maximum), most fees like copayments and coinsurance amounts are waived.

Out-of-pocket drug costs

What you pay for prescription drugs.  

When the yearly total you’ve paid for prescription drugs (called your yearly out-of-pocket drug costs) reaches a certain amount, you leave the coverage gap.    

Learn More about the Coverage Gap

Out-of-pocket maximum

See annual out-of-pocket maximum

Outpatient care

Medical care or treatment that doesn’t include staying overnight in a hospital.

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P

Part A

See Medicare Part A (hospital insurance)

Part B

See Medicare Part B (medical insurance)

Part C

See Medicare Part C (Medicare Advantage)

Part D

See Medicare Part D (prescription drug coverage)

Part D plan

A Medicare plan that only helps cover your prescription drug costs, sometimes referred to as a standalone prescription drug plan. These plans are only offered by private companies like Health Alliance that have a contract with Medicare. They can be purchased with Original Medicare or with Original Medicare and a Medicare Supplement plan.  

Find Health Alliance Medicare Stand-Alone Part D Plans

Pharmacy directory

A list of pharmacies you can use to fill your prescriptions. These pharmacies make up the pharmacy network and have agreed to provide you prescription drugs. You must use a pharmacy listed, called an in-network pharmacy, for your prescriptions to be covered. At Health Alliance Medicare we have two pharmacy directories.    

View HMO Pharmacy Directory

Lists the many pharmacies our Medicare HMO members can use.   

View PPO Pharmacy Directory

Lists the many pharmacies our Medicare PPO members can use.

Pharmacy network

A group of pharmacies (also referred to as in-network pharmacies) that have made an agreement with a health plan to provide prescription drugs to the plan’s members. These pharmacies make up the pharmacy network and are listed in the plan’s pharmacy directory.

Plan provider

A doctor, hospital or other health care professional who has made an agreement with a health plan to provide health care services to the plan’s members. Plan providers are listed in the provider directory.  

Health Alliance Medicare HMO plan members must use plan providers. For Health Alliance Medicare PPO plan members, plan providers are called in-network providers. PPO plan members pay less when they use the in-network providers listed.

PPO (Preferred Provider Organization) plan

A type of Medicare Advantage plan. With a PPO plan, you can go to any doctor and hospital, but you will pay less if you go to the in-network doctors and hospitals listed in the plan’s provider directory.  

Find Health Alliance Medicare PPO plans

Search PPO Provider Directory

Premium

The monthly amount you pay for your health care coverage.

Prescription drug coverage

See Medicare Part D (prescription drug coverage)

Preventive services

Services like tests, screenings and vaccines that help keep you healthy or aim to prevent illness. Examples include flu shots, mammograms and Pap tests.

Primary Care Physician (PCP)

A health care professional you choose to manage your overall health care. Your Primary Care Physician is your personal doctor, acting much like a family doctor would. They’re responsible for your overall health care and coordinate your care with specialists and other providers.

Prior authorization

Approval in advance from your health plan to get certain services or drugs. 

Health Alliance Medicare requires you or your doctor to get prior authorization for certain medical services to be covered. Services we cover that require prior authorization are listed in our Evidence of Coverage.  

View Health Alliance Medicare Evidence of Coverage  

You also need prior authorization for certain drugs to be covered. This approval helps guide appropriate use of certain medications. Drugs Health Alliance Medicare covers that require prior authorization are marked in our Medicare Part D Formulary. 

View Health Alliance Medicare Part D Formulary

Provider

The general term used to describe 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.

Provider directory

A list of doctors and hospitals that you can use. The doctors and hospitals on your plan’s list have agreed to provide you health care services. They make up the plan’s provider network and are considered in-network providers or plan providers. Health Alliance Medicare has two provider directories.   

Search HMO Provider Directory

Lists the many doctors and hospitals available to our Medicare HMO members.  

Search PPO Provider Directory

If our Medicare PPO members go to the doctors and hospitals on this broad list, they pay less than if they go to those not listed.

Provider network

A group of doctors and hospitals (also referred to as in-network providers or plan providers) who have made an agreement with a health plan to provide health care services to the plan’s members. These providers make up the provider network and are listed in the plan’s provider directory.

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Q

Quantity limits

A limit to the amount of a drug your plan will cover per prescription or for a specific period of time. Your plan might limit how many refills of a certain drug you can get or how much of a certain drug you can get each time you fill a prescription. 

For example, if it’s normally considered safe to take only one pill per day of a certain drug, Health Alliance Medicare may only cover your prescription for no more than one pill per day. Drugs that have quantity limits are marked in our Medicare Part D Formulary.  

View Health Alliance Medicare Part D Formulary

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R

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S

Service area

The geographic area within which you must live to be able to enroll in a certain plan. Service areas are approved by the Centers for Medicare & Medicaid Services (CMS).

Skilled care

Medical care ordered by a doctor that must be given or supervised by a licensed health care professional.

Skilled nursing care

Medical care given in a skilled nursing facility that’s ordered by a doctor and must be given or supervised by a licensed health care professional. Skilled care services include:

• Doctor services and regular nursing services
• X-rays and other radiology services
• Laboratory tests
• Physical, occupational and speech therapy
• Blood (storage and administration)
• Use of appliances like wheelchairs
• A semiprivate room (or private room if medically necessary)
• Meals, including special diets
• Medications prescribed to you as part of your plan for care

Skilled nursing facility

A nursing home, hospital or part of a facility that provides residents with medical care ordered by a doctor (skilled nursing care), rehabilitation services or both.

Special Election Period (SEP)

Represents the only other circumstances, outside of the Annual Enrollment Period (AEP) and the Initial Enrollment Period (IEP), under which you can enroll in Medicare or make any changes to your plan. These exceptions include:

• When you change your permanent address (for example, when you move out of your plan’s service area)
• When the contract between the Centers for Medicare & Medicaid Services (CMS) and a Medicare Advantage plan ends
• When a Medicare Advantage plan lets a member know it will discontinue a plan  

Contact Health Alliance Medicare Services for additional circumstances that would qualify for a Special Election Period.

Learn more about When You Can Enroll

Specialist

A doctor who provides health care services for a specific disease or part of the body. For example, dermatologists (focus on skin care), podiatrists (focus on care for feet and ankles) and oncologists (focus on care for those with cancer).

Specialty drug

A high-cost drug including infused or injectable drugs that usually require special storage and close monitoring. Specialty drugs are generally prescribed to people with an ongoing or complex medical condition. In the Medicare Part D Formulary, specialty drugs are listed as Tier 5 drugs.

Standalone prescription drug plan

See Part D plan

Step therapy

A process that requires you first to try one drug before we will cover another drug.  

For example, if Drug A and Drug B treat the same medical condition, Health Alliance Medicare may require you to try Drug A first. If Drug A doesn’t work for you, we will then cover Drug B. This requirement encourages you to try safer or more effective drugs before we will cover another drug. Drugs that require step therapy are marked in our Medicare Part D Formulary.  

View Health Alliance Medicare Part D Formulary

Summary of Benefits

This book provides a summary of services that a plan covers and what you pay for each service. It also compares what you pay for services with Original Medicare to what you pay for services with a Medicare Advantage plan.    

The Summary of Benefits only provides a partial list of services that are covered. The Evidence of Coverage provides a complete list.  

View Health Alliance Medicare Summary of Benefits

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T

Tier

A cost group a drug belongs to. Every drug listed in the Medicare Part D Formulary is put into one of five cost groups: Tier 1, Tier 2, Tier 3, Tier 4 or Tier 5 (specialty drug). Generally, the higher the tier, the more you’ll pay for the drug.

Tier 1 drugs require the lowest copayment because they’re the most cost-effective. Most generic drugs are Tier 1. Specialty drugs are listed on the Medicare Part D Formulary as Tier 5.

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U

Urgently needed care

A non-emergency situation where your health is not in serious danger, but because of an illness or injury you need medical care to prevent the illness or injury from getting worse.  

Typically, you need urgent care because you’re temporarily out of the service area or a plan provider is not available. Examples of urgently needed care situations include constant fever, bronchitis, sprains and unresponsive migraine headaches.

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V

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WXYZ

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