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Term |
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Definition |
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A |
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Annual Coordinated Election Period
(ACEP) |
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Period each year (November 15 to
December 31) during which beneficiaries can join or
change their Part C and D plans. Also known as an
Annual Election Period (AEP). |
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Annual Election Period (AEP) |
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Same as the ACEP (see above) |
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Actuarially Equivalent (AE) Plan |
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A Part D plan that is structured
differently from the Part D Standard Benefit but that,
from a fiscal point of view, offers a benefit package at
least as valuable as the Standard Benefit. An
actuarially equivalent plan typically, has the same
deductible but different cost-sharing. |
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Additional Low Income Medicare
Beneficiary program (ALMB) |
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A Medicare Savings Program (MSP)
that pays the Medicare Part B monthly premium. There is
an income test (135% of FPL), but no asset test. It is
state administered but subject to funding by Congress
each year, therefore, it is operated on a
“first-come-first-served” basis. Also known as the “QI”
(Qualified Individual) program. Benefits paid are
subject to estate recovery. |
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Administrative Law Judge (ALJ) |
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An individual who presides over
Medicare appeal hearings, with the power to administer
oaths, take testimony, rule on questions of evidence,
and make determinations of fact. |
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Annual Notice of Change (ANOC) |
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Notices sent each year to
beneficiaries by their Part D plans informing them of
changes to their plan in the coming year. ANOCs must be
received before the November 15 start of the AEP. |
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Appeal |
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A legal proceeding undertaken to
reverse a decision by bringing it to a higher
authority. For instance, if a Medicare beneficiary
receives a notice indicating the physical therapy
services in a skilled nursing facility will be
discontinued, the beneficiary can appeal to the Quality
Improvement Organization. (QIO) |
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Assignment |
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In traditional Medicare, this means
the doctor or supplier agrees to accept the
Medicare-approved amount as full payment. |
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Authorization |
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Verbal or written approval from a
Medicare Advantage plan indicating that care will be
covered. |
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Auto-Enrollment |
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The process by which CMS
automatically enrolls LIS-eligible individuals into Part
D benchmark plans to ensure that they are not without
coverage |
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B |
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Basic Alternative (BA)Plan |
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An actuarially equivalent Part D
plan that is structured differently from the Part D
Standard Benefit but that, on a fiscal basis, offers a
benefit package at least as valuable as the Standard
Benefit. Typically, has a smaller deductible, with or
without different cost sharing. |
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Beneficiary |
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General term used for one who
receives a benefit. Used to describe those people
receiving Medicare benefits, or, when accompanied by "Dual(ly)
Eligible", those receiving both Medicare and Medicaid
benefits. |
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Benchmark Plans |
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Part D plans that offer a basic
(not enhanced) benefit and have premiums at or below the
regional threshold amount set by CMS. |
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Benefit Period |
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Begins the day the beneficiary goes
to a hospital or skilled nursing facility. The benefit
period ends when a beneficiary has had no hospital or
skilled nursing facility level of care for 60
consecutive days. For each new benefit period,
beneficiaries must pay the inpatient hospital
deductible. There is no limit to the number of benefit
periods. Also know in Medicare as the “Spell of
Illness”. |
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C |
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Carrier |
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A private company that has a
contract with Medicare to administer claims Part B care
and services. |
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Catastrophic Coverage |
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Under the standard Part D benefit,
once beneficiaries' total Part D drug costs reach a
maximum amount, beneficiaries pay only a small
co-insurance or co-payment for covered drug costs until
the end of the calendar year. |
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Centers for Medicare & Medicaid
Services (CMS) |
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CMS is the Federal Agency that
administers Medicare, Medicaid, and the State Children's
Health Insurance Program. It is part of the U.S.
Department of Health and Human Services. |
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Certificate of Creditable Coverage |
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A written statement issued by an
insurance company that states the period of time the
beneficiary had health insurance through that company
that is/was at least as good as Medicare. |
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CHOICES |
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“Connecticut’s Programs for Health
Insurance Assistance, Outreach, Information and
Referral, Counseling and Eligibility Screening” (CHOICES
is Connecticut’s state health insurance and assistance
program (SHIP). The telephone number for CHOICES is 1
(800) 994-9422. |
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Code of Federal Regulations (CFR) |
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The annual collection of
executive-agency regulations published in the daily
Federal Register, combined with previously issued
regulations that are still in effect. |
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Coinsurance |
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The amount beneficiaries pay for
services after deductibles are met. For instance, in
Medicare Part B, this is often a percentage (20%) of the
Medicare approved amount. |
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Connecticut Department of Social
Services (DSS) |
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DSS provides a broad range of
services to the elderly, persons with disabilities, and
families. By statute it is the state agency responsible
for administering a number of programs under federal
legislation, including the Rehabilitation Act, the Food
Stamp Act, the Older Americans Act, and the Social
Security Act. DSS is also designated as a public housing
agency for the purpose of administering the Section 8
program under the federal Housing Act. For general
information, call 1 (800) 842-1508. |
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Connecticut Pharmaceutical
Assistance Contract to the Elderly and Disabled
(ConnPACE) |
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State funded prescription drug
assistance for qualified, lower-income older people (65
+) and people with disabilities. (See also “SPAP.”)
The telephone number for ConnPACE
is 1 (800)423-5026. |
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Coordination of Benefits (COB) |
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Process for determining the
respective responsibilities of two or more health
plans. The telephone number for the COB contractor is
1(800)999-1118. |
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Copayment |
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An amount that beneficiaries pay
for each medical service, like a doctor's visit or
prescription. It is a set amount rather than a
percentage of costs (coinsurance). For instance, it
might be $20.00 for each doctor's visit. There are
sometimes copayments in Medicare Advantage and Part D
plans and for some hospital outpatient services in
traditional Medicare. |
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Cost Sharing |
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The amount beneficiaries pay
out-of-pocket for health care, services, and
prescriptions. Cost-sharing includes copayments,
coinsurance, and deductibles. |
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Covered Employee |
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An individual who is (or was)
provided coverage under a group health plan. |
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Creditable Coverage |
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Past
health coverage that gives beneficiaries certain rights
when applying for new coverage. 1.
Creditable coverage for purposes of Medigap plans is
previous health insurance coverage that can be used to
shorten a pre-existing condition waiting period.
2. Creditable coverage for
purposes of Medicare Prescription Drug Coverage is
prescription drug coverage that is at least actuarially
equivalent to or better than the Medicare Part D
Standard Benefit. |
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D |
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Deductible |
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The amount beneficiaries pay for
health care, services, or prescriptions before Medicare
pays. For example, in traditional Medicare,
beneficiaries pay an annual Part B deductible. |
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Demonstration/Pilot (“Demo”) Plans |
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Medicare approved plans designed to
test improvements in Medicare coverage, payments and
quality of care. Usually offered to targeted
populations in a specified area. In 2009, Fresenius
Inc. operates a demo plan for individuals with ESRD
residing in certain counties of CT. |
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Donut Hole |
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The Medicare Part D coverage gap
during which beneficiaries have to pay 100% for most
medications. |
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DSS |
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See “Connecticut Department of
Social Services” |
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Dual Eligible |
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A beneficiary eligible for both
Medicare and Medicaid. |
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Durable Medical Equipment (DME) |
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Medical equipment that is ordered
by a doctor for use in the home. Examples are walkers,
wheelchairs, and hospital beds. |
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Durable Medical Equipment Regional
Carrier (DMERC) |
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A private company that contracts
with Medicare to pay for durable medical equipment. |
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E |
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Employer Group Health Plan (EGHP)
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Health insurance available through
an employer or union. |
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End Stage Renal Disease (ESRD) |
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Kidney failure that requires a
regular course of dialysis or a kidney transplant.
People with ESRD are eligible to receive Medicare
benefits prior to age 65. |
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Erectile Dysfunction (ED) Drugs |
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Drugs that correct male erectile
dysfunction. Their coverage is excluded by law under
Part D and Medicaid. |
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Evidence of Coverage (EOC) |
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Information sent by insurance
companies to new and renewing members describing plan
benefits and patient rights and responsibilities. |
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Expedited Appeal |
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1. In traditional Medicare,
available to beneficiaries who disagree with a facility
or agency’s discharge of the beneficiary from Medicare
covered SNF, Rehab hospital, home health care, or
hospice care. The beneficiary must request an expedited
determination by no later than noon of the day following
receipt of the initial written notice (“generic
notice”). The expedited determination will be done by a
QIO and should be done within 48 hours.
2. In Part D, a decision made as
speedily as the beneficiary’s life or health requires.
For a Coverage Determination, the decision must be
rendered within 24 hours or faster, as required. For a
Part D Redetermination or Reconsideration, the decision
is required within 72 hours. In all cases, timing
begins upon receipt of the physician’s information. |
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Expedited Organization
Determination |
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A fast decision from a Medicare
Advantage Plan about whether it will provide a health
service. A beneficiary may receive an expedited
decision within 72 hours when life, health, or ability
to regain function may be jeopardized. |
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Expedited Review |
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Available to beneficiaries in
traditional Medicare who disagree with a discharge from
the hospital. To exercise this right, beneficiaries
must contact the QIO by noon of the date of discharge.
The QIO will collect relevant medical information,
evaluate it, and issue a decision by close of business
of the first working day after it receives all requested
information
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Extra Help |
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See Low Income Subsidy (LIS). |
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F |
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Facilitated Enrollment |
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In Part D, immediate enrollment of
a full dual eligible into a Part D benchmark plan when
the beneficiary is without coverage. It takes place at
the pharmacy and is also known as “point-of-service”
(POS) enrollment. |
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Federal
Poverty Level (FPL) |
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The national income levels
used to define poverty. New figures are issued each
year in the Federal Register by the Department of
Health and Human Services (HHS). The FPL is used to
determine eligibility for many public programs.
Information available online
at
http://aspe.hhs.gov/poverty/. |
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Food and
Drug Administration (FDA) |
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The federal
agency responsible for protecting the public health by
assuring the safety, efficacy, and security of human and
veterinary drugs, biological products, medical devices,
the nation's food supply, cosmetics, and products that
emit radiation. |
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Formulary |
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A list of
medications covered by a Part D plan. Formularies vary
from plan to plan and also change annually. |
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G |
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Generic
Substitution |
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Part D plans
are allowed to substitute generic drugs for brand name
drugs at the pharmacy, without advance notice to
members. |
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Grievance |
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A complaint
about a Medicare Advantage or Part D plan. For example,
a grievance might be filed if a beneficiary is unhappy
about the way a staff person at the plan treated her on
the telephone. |
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Guaranteed Issue |
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The duty of a company to offer an
insurance plan to all. Some Medicare beneficiaries are
protected in this way from discrimination by insurance
companies that offer Medigap policies. |
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Guaranteed Renewable |
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A law that requires insurance
companies to automatically renew or continue Medigap
policies, unless the beneficiary makes untrue statements
to the company, commits fraud, or does not pay
premiums. |
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H |
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Health Maintenance Organization
(HMO) |
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A type of insurance and Medicare
Advantage Plan. Members generally must obtain a
referral from their primary care physician in order to
see a specialist. IN Medicare HMOs must cover all
Medicare Part A and Part B health care. Some HMO's
offer additional benefits, such as waiving the three-day
qualifying hospital stay for skilled nursing facility
coverage. In most HMOs, except in emergency or urgent
situations, beneficiaries must receive care from the
healthcare providers within the Plan's network. |
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Home Health Care |
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Medical and supportive care
provided at home. Medicare covers part-time or
intermittent skilled nursing care and home health aide
services, physical therapy, speech therapy, occupational
therapy, medical social services, durable medical
equipment, medical supplies, and other services provided
in the home. Beneficiaries must be homebound to obtain
Medicare coverage. |
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Hospice Care |
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Team-oriented approach to care that
addresses the medical, physical, social, emotional and
spiritual needs of dying patients and their caregivers.
Medicare has a comprehensive hospice benefit. |
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I |
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Initial Coverage Election Period (ICEP) |
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See “Initial Enrollment Period” |
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Initial Coverage Period |
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During
this period, members of standard Part D Plans pay 25% of
their drug costs until the annual threshold amount is
reached (The plan’s 75% share of costs also goes toward
the threshold amount.) Members of actuarially
equivalent and enhanced plans may have a system of
tiered co-pays and co-insurance, instead of 25%
cost-sharing, during this period. Once the threshold
amount is reached, the member goes into the Donut
Hole. |
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Initial Enrollment Period (IEP) |
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The seven-month period in which
individuals are initially eligible to enroll in
traditional Medicare, Part B and Part D. For purposes
of Part C, this same period is called the Initial
Coverage Election Period (ICEP). The seven-month
period consists of the three months before, the month
of, and the three months after the individual’s 65th
birthday or 24th month of disability. |
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Insurance Department |
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Each state has an insurance
department which provides assistance and information,
regulates the insurance industry, and enforces insurance
laws. In Connecticut, the insurance department can be
reached at 1(800)203-3447. |
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Inpatient Care |
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Healthcare received in a hospital
of a skilled nursing facility. It does not include
outpatient services at a hospital. |
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L |
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Late Enrollment Penalty (LEP) |
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An amount added to monthly premiums
for Medicare Part B or Part D (and Part A for voluntary
enrollees) if a Medicare beneficiary fails to enroll
during the initial enrollment period and does not
qualify for a Special Enrollment Period or for a “good
cause” exemption. |
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Lifetime Reserve Days |
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In traditional Medicare, a total of
60 extra days that Medicare will pay for when
beneficiaries are hospitalized for more than 90 days
during a benefit period. Once these 60 days are used,
they are exhausted. In other words, they cannot be used
again. |
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Limiting Charge |
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In traditional Medicare, the amount
of money beneficiaries can be charged by doctors who do
not accept assignment. The limiting charge is 15% over
Medicare's approved amount. The limiting charge does
not apply to supplies or equipment. |
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Lock In |
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Prohibition against changing
Medicare Advantage and Part D plans except during
specific periods during each year or during special
enrollment periods. |
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Low Income Subsidy (LIS) |
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Also known as "Extra Help." LIS is
administered by the Social Security Administration and
helps pay for Part D premiums and drug costs, for
eligible individuals. |
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M |
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Medicaid |
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State administered medical
assistance for low income families, disabled and elderly
individuals. In Connecticut. Medicaid is also known as
Title 19, as it is Title XIX of the Social Security Act.
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Medical Savings Account (MSA) |
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A type of Medicare Advantage plan
consisting of a high deductible health plan and a bank
account. Medicare gives the plan a certain amount of
money each year for a beneficiary's health care, and the
plan deposits a portion of the money into an account.
The amount deposited is usually less than the deductible
amount, so a beneficiary will have to pay out-of-pocket
for medical costs before coverage begins. MSAs do not
offer prescription drug coverage; therefore, members can
purchase drug insurance through a PDP. |
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Medicare Advantage Plan (MA or
MA-PD) |
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A private plan, often an HMO, that
provides the benefits of Medicare Part A and Part B (MA
plan) or Part A, Part B, and Part D (MA-PD
plan). Medicare Advantage Plans include PPOs, HMOs, PFFS
plans, MSA plans and SNPs. |
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Medicare Coordinated Care Plan |
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A collective term used for the
various private Medicare Advantage plan options: HMOs,
PSOs, PPOs and other "network" plans (except MSA and
PFFS plans). |
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Medicare Cost Plans |
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Medicare Advantage plans that are a
type of HMO. The plans only pay for services outside
their networks when they are emergencies or urgently
needed services. However, those who enroll in a
Medicare Cost Plan can get routine services outside of
the plan's network without a referral. These services
will be billed to traditional Medicare and the
beneficiary will be responsible for traditional
Medicare's deductibles and coinsurance. There are no
Medicare Cost Plans in CT in 2009. |
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Medicare Health Plans |
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A collective term used by Medicare
to refer to Medicare Advantage plans, Medicare Cost
Plans, Demonstration Plans and PACE programs. |
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Medicare Part A |
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The component of Medicare that
covers inpatient hospital care, skilled nursing (not
custodial or long term care), hospice services, and home
health care. |
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Medicare Part B |
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The component of Medicare that
covers medically necessary doctor’s services, outpatient
care (laboratory, x-ray, etc), durable medical
equipment, ambulance, and many other services, including
some preventive services. |
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Medicare Part C |
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The component of the Medicare Act
that establishes private “Medicare Advantage” plans to
finance services enumerated in Medicare Part A and Part
B, and sometimes additional benefits. |
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Medicare Part D |
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The component of Medicare that
covers outpatient prescription drugs via private plans. |
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Medicare Savings Programs (MSP) |
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Programs that assist lower income
people pay for Medicare Part A, B and D premiums,
deductibles, and copayments. There are three MSP
programs: QMB, SLMB, and ALMB (the latter is also
called the QI program). Beneficiaries who are enrolled
in MSP programs automatically qualify for the Medicare
Part D low-income (LIS) subsidy. |
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Medicare Summary Notice (MSN) |
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Notices Medicare beneficiaries
receive that list all medical claims billed to Medicare
Parts A and B. They list what the provider billed,
Medicare's approved amount, how much Medicare paid,
beneficiary liability, and appeal rights. |
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Medicare Approved Amount |
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In traditional Medicare, Medicare's
system for paying providers is based on a fee schedule.
The fee schedule assigns a dollar value to each medical
service based on work, the cost of running a practice,
and the cost of malpractice insurance. As a general
rule, Medicare Part B pays providers 80% of the approved
amount. Beneficiaries are responsible for paying the
remainder (generally 20% for providers who take
assignment). |
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Medigap
(Also known as Medicare Supplement
Insurance) |
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Insurance sold by insurance
companies to fill in the "gaps" of traditional
Medicare. Except in Massachusetts, Minnesota, and
Wisconsin there are 12 standardized plans labeled Plan A
through Plan L. |
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“Medicare Prescription Drug,
Modernization and Improvement Act of 2003” (MMA) |
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Federal law that, among other
provisions, created the Medicare Part D prescription
drug program, the Medicare Advantage private plan
system, and added some preventive care coverage to the
Part B benefit. |
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Medicare Improvement for Patients
and Providers Act” (MIPPA) |
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2008 Federal legislation that makes
significant changes to the Part D, LIS and MSP
programs. Changes will be rolled out over several
years, beginning in 2009. |
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O |
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Open Enrollment Period (OEP) |
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Period that runs from January 1 to
March 31 of each year. Beneficiaries may enroll or
disenroll from Medicare Advantage Plans. However,
during this period, they may not drop or add
prescription drug coverage. There is a limit of one
change (or "election") during this enrollment period. |
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Outpatient Hospital Care |
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Medical or surgical care provided
at the hospital without the beneficiary being admitted
as an inpatient. This includes emergency room care and,
per Medicare policy, care provided on observation
status, even if the beneficiary remains in the hospital
overnight. |
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Over-the-Counter (OTC) Drugs |
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Drugs that may be purchased without
a medical prescription. |
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P |
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Programs of All-Inclusive Care for
the Elderly (PACE) |
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Medicare approved programs that
offer medical, social, long term care and prescription
drug coverage for the frail elderly and disabled. CT
does not have a PACE program at this time. |
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Point of Service Option (POS) |
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An insurance coverage option that
permits beneficiaries to use doctors and hospitals
outside of the plan’s network for an additional cost to
the beneficiary. |
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Point of Service Enrollment |
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See “Facilitated Enrollment.” |
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Pre-Existing Condition |
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A medical condition that exists
prior to enrolling in an insurance policy. |
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Preferred Provider Organization
(PPO) |
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A Medicare Advantage plan that
encourages members to use providers in its network by
requiring those who use providers outside of the network
to pay additional costs. |
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Premium |
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The periodic payment required to
keep insurance in effect. |
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Prescription Drug Plan (PDP) |
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A Part D plan that covers
outpatient prescription drug coverage only (no hospital
or medical coverage). PDPs are regulated and subsidized
by Medicare. They are sometimes referred to as "stand
alone" drug plans and are always private plans. |
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Preventive Services |
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Health care offered for purposes of
prevention or early diagnosis. Examples include flu
shots and mammograms. |
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Primary Care Physician (PCP) |
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A doctor who provides basic
(non-specialized) health care. In many Medicare
Advantage plans, beneficiaries must see their primary
care physician and obtain a referral before they can see
a specialist. |
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Prior Authorization (PA) |
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A utilization management tool used
by Medicare Advantage and Part D plans to control
costs. The beneficiary's physician must obtain approval
from the beneficiary's plan before the plan will cover
the given service, item or payment for a prescription
medication. |
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Private Fee-For-Service Plan (PFFS) |
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A type of Medicare Advantage
private plan in which enrollees may go to any
Medicare-approved provider that accepts the plan's
payment. The insurance company that runs the plan
(rather than CMS) decides how much it will pay and how
much cost-sharing enrollees must bear. |
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Q |
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Quality Improvement Organization |
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A contractor paid by the federal
government to monitor the care given to Medicare
patients. It reviews complaints about the quality of
care given by hospitals (inpatient and outpatient),
skilled nursing facilities, and home health agencies.
In Connecticut the QIO is Qualidigm. Qualidigm's
telephone number is 1(800)553-7590. |
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Qualified Individual (QI) Program |
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One of three Medicare Savings
Programs (see also “SLMB” and “QMB”). It pays for the
Part B monthly premium. There is an income test (135%
of FPL), but no asset test. It is state administered
but subject to funding by Congress each year, therefore,
it is operated on a “first-come-first-served” basis. It
is also known as the “ALMB” program. Benefits paid are
subject to estate recovery |
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Qualified Medicare Beneficiary
Program (QMB) |
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One of three Medicare Savings
Programs (see also “ALMB” and “SLMB”). For some lower
income people it pays Medicare Part A and B
coinsurance, deductibles, and premiums for
beneficiaries with incomes below 100% of the FPL and
with limited assets. In this way, it is like a Medigap
policy, however, payment to providers are capped at
Medicaid rates. Benefits are subject to estate
recovery. |
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Quantity Limits (QL) |
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One of three utilization management
tools used by Part D plans to control costs. The plan
places limits on the drug dosages or quantities it will
cover. |
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R |
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Referral |
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A written order from a primary care
physician to see a specialist. In many Medicare
Advantage plans, payment will not be made for specialist
care unless the beneficiary first obtains a referral.
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Regional Home Health Intermediary (RHHI)
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Private companies that contract
with Medicare to administer home health and hospice
claims in the traditional Medicare program. They also
monitor the quality of care rendered by home health
agencies. |
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Rehabilitation |
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Services to promote recovery from
illness or injury or to prevent or slow deterioration.
Generally provided by nurses and physical, occupational,
and speech therapists. |
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Regional Office (RO) of the Centers for Medicare &
Medicaid Services |
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CMS has 10 regional offices
responsible for the consistent application of Medicare
policy and guidance in their respective territories. CT
is covered by RO 1 in Boston, which also oversees Maine,
Massachusetts, New Hampshire, Rhode Island and Vermont. |
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Secondary Payer |
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An insurance policy, plan, or
program that pays second on a claim for medical care. |
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Service Area |
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The area where a Medicare Advantage
Plan or Part D Prescription Drug Plan accepts members
and, as a general rule, covers services |
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Skilled Care |
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Health care that must be
administered, managed, supervised, observed or assessed
by a licensed professional. |
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Skilled Nursing Facility (SNF) |
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A licensed facility that has the
staff and equipment necessary to provide skilled nursing
and rehabilitation. To be covered by Medicare the
facility must also be certified by Medicare. |
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Skilled Nursing Facility Level of
Care |
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Care that requires the involvement
of nurses or rehabilitation staff and that, as a
practical matter, can not be provided on an outpatient
basis. |
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Special Enrollment Period (SEP) |
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A period triggered by exceptional
conditions, as defined by law and CMS policy, during
which beneficiaries can enroll or disenroll from their
Part C or D plans, outside the normal Annual and Open
Election Periods. Changes may include leaving Medicare
Advantage and returning to traditional Medicare. |
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Special Enrollment Period (Part B) |
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A period during which beneficiaries
can sign up for Medicare Part B if they did not sign up
during the Initial Enrollment Period because either the
beneficiary or beneficiary's spouse continued to work
and thus the beneficiary continued to be insured by an
employee group health plan. The period lasts for eight
months, beginning the month after the employment or
employee group health coverage ends (whichever comes
first). |
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Special Needs Plan |
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A type of Medicare Advantage plan
that is supposed to provide focused health care for
specific groups of people, such as those who have both
Medicare and Medicaid, who live in nursing homes, or who
have chronic medical conditions. |
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Specialist |
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A physician who treats only certain
parts of the body, certain health problems, or certain
age groups. For instance, nephrologists diagnose and
manage kidney disease. |
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Specified Low-Income Medicare
Beneficiaries (SLMB) |
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One of three Medicare Savings
Programs (see also “ALMB” and “QMB”). It pays for the
Medicare Part B monthly premium for certain low income
individuals with income below 120% of FPL and with
limited assets. Unlike ALMB, which also pays the Part
B premium, SLMB is not subject to refunding each year,
therefore, it is operated as an entitlement. Also known
as the “QI” (Qualified Individual) program. Benefits
paid are subject to estate recovery. |
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Spend-down |
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Process by which individuals who
would be eligible for Medicaid except for their monthly
income subtract their incurred medical bills from their
income to get it down to, or below, the medically needy
income limits for Medicaid. Eligibility is recalculated
every six months. |
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State Health Insurance Assistance
Program (SHIP) |
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A state program that is funded in
part by the federal government to give free local health
insurance counseling to people with Medicare. CHOICES
is Connecticut's SHIP. See
www.shiptalk.org. |
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State Pharmacy Assistance Program (SPAP)
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State funded prescription drug
assistance for certain lower income older people (65 +)
and people with disabilities. Approximately 34 states
have SPAPs. ConnPACE is Connecticut's SPAP. |
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Step Therapy (ST) |
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A utilization management tool used
by Part D plans to control costs. Requires a trial of a
less expensive medication and failure on that medication
before the plan will pay for a more expensive prescribed
medication. (Also known as “Fail First”.) |
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Social Security Administration (SSA)
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The federal agency that administers
the Social Security Program, including the retirement
benefit. Medicare is administered by another agency, the
Centers for Medicare & Medicaid Services (CMS), but the
SSA district offices determine eligibility for Medicare
and process premium payments. |
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Social Security Disability
Insurance (SSDI) |
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Social Security benefits paid to
individuals and certain members of their families after
the individual has been found to be disabled. To
qualify, beneficiaries must have earned enough credits
by working enough work quarters. This program is
administered through SSA. |
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Supplemental Security Income (SSI)
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Program administered through SSA.
It provides limited financial assistance to elderly and
disabled individuals who have insufficient work quarters
to collect Social Security retirement or disability
benefits. |
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Tiers |
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To control costs, many Part D plans
place medications on different "tiers". This means they
have different cost sharing requirements, with brand
name drugs, for example, having higher co-pays than
generics,. |
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Traditional Medicare |
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The Medicare system as originally
designed: a national public program, including coverage
under Parts A and B. (Sometimes referred to as the
“fee-for-service” program and as “original” Medicare. |
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TriCare |
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A public health insurance program
for active duty service members, National Guard and
Reserve members, retirees, their families, survivors,
and certain former spouses. |
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TriCare for Life (TFL) |
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Additional, “wrap around” insurance
for individuals eligible for Tricare who are also
Medicare beneficiaries. For most medical care, TFL pays
second, after Medicare pays. |
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True Out-of-Pocket costs (TrOOP) |
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The cost of formulary drugs paid by
the plan member (or family, a charity, the LIS or an
SPAP) and applied toward the Donut Hole threshold
amount. Once TrOOP costs reach the annual threshold
amount, the member goes into the final stage of the Part
D annual drug benefit, Catastrophic Coverage. |
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United States Code (USC) |
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A multivolume, published
codification of federal statutory law. |
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Urgently Needed Care |
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Care for a sudden illness or injury
that needs medical care right away, but is not life
threatening. If a member of a Medicare Advantage plan
is out of the plan's service area and requires urgently
needed care, the plan must pay for the care. |
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Utilization Management Tools |
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In Part D, this refers to the three
ways plans use certain approaches to control costs:
prior authorization, quantity limits, and step therapy. |
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W |
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Workers Compensation |
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Insurance that employers are
required to have to cover medical costs for employees
who get sick or injured on the job. |
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Wrap-around |
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Coverage provided by the State of
Connecticut to dual eligible and ConnPACE beneficiaries
that fills in Part D gaps in coverage. Includes
coverage during the deductible and Donut Hole periods,
coverage of some non-formulary drugs and coverage of
all co-pays for dual eligibles. Caps co-pays at $16.25
for ConnPACE members. Also, Tri-Care For Life is said
to “wrap-around” Medicare for certain veterans and
family members, |
