Drugs (Part D)
MA (Part C)
Member
Medical
Website
100

This is the fee added to Part D premium.

What is Late Enrollment Penalty (LEP)?

100

An individual or facility authorized to provide health care services.

What is a Provider?

100

A request for review and change for a coverage decision made by an insurance plan.

What is an Appeal?

100

Medical treatment that does not require an overnight stay in a hospital or facility.

What is Outpatient?

100

Form giving an individual the ability to speak on grievances, determinations, and appeals on a member's behalf.

What is Appointment of Representative (AOR)?

200

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".

200

A physician that focuses on a specific area of medicine.

What is a Specialist?

200

Approval from a plan to cover a service, drug, or treatment that is deemed medically necessary.

What is a Prior Authorization (PA)?

200

The most a member will pay out-of-pocket for in-network covered services (Part C).

What is Maximum Out of Pocket (MOOP)?

200

Document giving a plan's summary of costs and coverage.

What is Summary of Benefits (SB)?

300

Evidence of what LIS level an individual should have.

What is Best Available Evidence (BAE)?

300

An individual who qualifies for Medicare and Medicaid.

What is Dual Eligible?

300

Any complaint or dispute (other than a determination) expressing dissatisfaction with a Medicare Health Plan.

What is a Grievance?

300

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?

300

Document giving a plan's complete list of services, limitations, and exclusions.

What is Evidence of Coverage (EOC)?

400

Amount of money that determines when a member reaches their out-of-pocket threshold (Part D).

What is True Out of Pocket (TROOP)?

400

A service, drug or treatment that is covered by a health insurance plan.

What is Benefit?

400

A fixed amount paid by an individual before a plan will pay any expenses.

What is a Deductible?

400

Plan for individuals that are eligible for Medicare and have a severe or disabling chronic condition.

What is Chronic Special Needs Plan (C-SNP)?

400

Document explaining a plan's changes from year to year.

What is Annual Notice of Change (ANOC)?

500

Program that helps members manage Part D medications. (Certain restrictions apply.)

What is Medication Therapy Management Program (MTMP)?

500

Group of health care providers that have an agreement to provide services for an insurance plan at a discounted cost.

What is Network?

500

An approval to see a specialist given by a primary care physician.

What is a Referral?

500

A US law that provides privacy standards to protect patient's medical records.

What is Health Insurance Portability and Accountability Act (HIPAA)?

500

An organization that helps individuals find affordable health insurance.

What is Marketplace?