People
Beneficiary enrolled in a WellCare Plan or health plan.
Who is a "Member?"
An expression of dissatisfaction with any aspect of the operations, activities or behavior of a plan or its delegated entity in the provision of health care items, services, or prescription drugs, regardless of whether remedial action is requested or can be taken.
What is "a Grievance?"
A federally funded health insurance program for people aged 65 and older and younger people with disabilities.
What is "Medicare"?
The rate that a plan subscriber pays for coverage of specific health services
What is "Premium"?
When a particular drug is available through the mail. A Member usually needs to fill out a form and send it to the health plan along with the prescription in order to have the drug (s) mailed to their address.
This is usually indicated on the formulary as MO
What is "Mail Order" Drug.
Doctor, hospital, other health care facility, and pharmacy or other health care professional licensed to provide medical services and care.
Who is a Provider?
This must be clicked in CareConnects in order to use the Language Line Solutions (LLS) and/or Voiance services.
What is "Translator?"
This is a letter that is sent to ALL existing Members comparing year-to-year benefit changes, and is required by the government requires this document to be in the Member's hands on/or before September 30th. .
What is an Annual Notice Of Changes (ANOC) Letter?
One option a member may choose to use where they pay Wellcare Directly is the Direct Self Payment option. They would mail a check or money order to Wellcare using a _____________ ________ .
What is a "Coupon book?"
A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Private Fee-for-Service plans, some Medicare Cost plans, and Medicare Medical Savings Account plans. These plans are offered by insurance companies and other private companies approved by Medicare. Also called Part D.
What is "Prescription Drug Plan (PDP)" ?
An insurance company or other organization responsible for the cost of care so that individual patients do not directly pay for services.
Who is a
Third-party payer?
Any of the procedures that deal with the review of adverse initial decisions (or rejection) on the health care services a member feels they are entitled to receive or any amounts that the member must pay for a covered service.
What is an "Appeal?"
A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
What is
Low Income Subsidy (LIS)/ Extra Help?
An amount added to your Medicare Part D monthly premium if
for any continuous period of 63 days or more after their initial Enrollment Period is over, go without one of these: (Part D); (Part C); or Creditable prescription drug coverage
What is Late Enrollment Penalty (LEP)
These are drugs covered on the plan's formulary.
The co-pays for these (generic or brand) generally have lower co-pays than {other}drugs.
What are
"Preferred Drugs" ?
An authorization to act on someone else’s behalf in a legal or business matter.
What is a
Power of Attorney
All Medicare Member Services agents MUST stop referring members to this, unless a Centralpoint article or Call Flow specifically advises you to do so. Supervisor approval is always required in such a case.
Important Note: Referring members here will result in disciplinary action.
Where is to "Medicare" or "1-800-Medicare?"
The federal agency responsible for administering the Medicare program.
What is the "Centers for Medicare and Medicaid Services (CMS)?"
These costs determine when a person’s catastrophic coverage will begin. It defines when a member exits the Coverage Gap and enters into the Catastrophic Coverage stage of a Medicare Part D prescription drug plan
What is
True Out-of-Pocket (TrOOP)?
Lists of the Prescriptions covered under Part D
A list of certain drugs and their proper dosages. In some Medicare health plans, doctors must order or use only drugs listed on the health plan's _____________.
What is
"Formulary" ?
A location, often a hospital, that provides medical, substance use, or behavioral health services.
What is a "facility?"
♥♥♥HAHAHA♥♥♥
Bonus
If a member's health is at risk and it is a life and death situation, you can provide the caller this in order to be able to access and makes changes in the member's account.
What is a "one-time courtesy"?
*Understanding PHI, Identity Verification, HIPAA and Third Party Callers
A type of managed care plan that generally covers only the care from doctors, hospitals, and other health care providers that are in that network.
These members must choose a primary care doctor (PCP) who coordinates their care and decides when they can go to a specialist
What is "Health Maintenance Organization (HMO)?"
Please advise the member to allow _______ ______ ________ days from the received by date (which will be based on when we receive the payment), for a payment to be posted to their account.
What is (7) to ten (10) business days
A utilization management tool that requires the member to first try certain drugs to treat their medical condition before the plan will cover another drug for that condition.
What is " Step Therapy?"
On the formulary you will see it indicated by "ST"