Drugs (Part D)
This is the fee added to Part D premium.
What is Late Enrollment Penalty (LEP)?
An individual or facility authorized to provide health care services.
What is a Provider?
A request for review and change for a coverage decision made by an insurance plan.
What is an Appeal?
Medical treatment that does not require an overnight stay in a hospital or facility.
What is Outpatient?
Form giving an individual the ability to speak on grievances, determinations, and appeals on a member's behalf.
What is Appointment of Representative (AOR)?
Assistance for low income individuals with the premium, deductible, and co-payments of a prescription drug program.
What is Low Income Subsidy (LIS), also known as "Extra Help".
A physician that focuses on a specific area of medicine.
What is a Specialist?
Approval from a plan to cover a service, drug, or treatment that is deemed medically necessary.
What is a Prior Authorization (PA)?
The most a member will pay out-of-pocket for in-network covered services (Part C).
What is Maximum Out of Pocket (MOOP)?
Document giving a plan's summary of costs and coverage.
What is Summary of Benefits (SB)?
Evidence of what LIS level an individual should have.
What is Best Available Evidence (BAE)?
An individual who qualifies for Medicare and Medicaid.
What is Dual Eligible?
Any complaint or dispute (other than a determination) expressing dissatisfaction with a Medicare Health Plan.
What is a Grievance?
Medical treatment received in a hospital or other health care facility that requires an individual to stay overnight after being formally admitted.
What is Inpatient?
Document giving a plan's complete list of services, limitations, and exclusions.
What is Evidence of Coverage (EOC)?
Amount of money that determines when a member reaches their out-of-pocket threshold (Part D).
What is True Out of Pocket (TROOP)?
A service, drug or treatment that is covered by a health insurance plan.
What is Benefit?
A fixed amount paid by an individual before a plan will pay any expenses.
What is a Deductible?
Plan for individuals that are eligible for Medicare and have a severe or disabling chronic condition.
What is Chronic Special Needs Plan (C-SNP)?
Document explaining a plan's changes from year to year.
What is Annual Notice of Change (ANOC)?
Program that helps members manage Part D medications. (Certain restrictions apply.)
What is Medication Therapy Management Program (MTMP)?
Group of health care providers that have an agreement to provide services for an insurance plan at a discounted cost.
What is Network?
An approval to see a specialist given by a primary care physician.
What is a Referral?
A US law that provides privacy standards to protect patient's medical records.
What is Health Insurance Portability and Accountability Act (HIPAA)?
An organization that helps individuals find affordable health insurance.
What is Marketplace?