Understanding health care terms

ADLs are the basic tasks of everyday life, such as eating, bathing, dressing, toileting and transferring (e.g., moving from the bed to a chair).

An Ambulatory Surgical Center is an entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the center does not exceed 24 hours.

A set time each fall when members can change their health or drug plan, or switch to Original Medicare. View enrollment periods.

A written or oral request, by or on behalf of a member, to re-evaluate a specific determination made by Sharp Health Plan or any of its delegated entities (for example, plan providers).

When a provider (such as a doctor or hospital) bills a patient more than the plan's allowed cost-sharing amount. As a member of Sharp Advantage, you only have to pay our plan's cost-sharing amounts when you get services covered by our plan. We do not allow providers to "balance bill" or otherwise charge you more than the amount of cost-sharing your plan says you must pay.

A person who benefits from health insurance coverage under either Medicare or Medicaid programs.

The way that both our plan and Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods.

All health care products or services covered under a specific health insurance plan are considered benefits. You can see which benefits are covered under your individual health insurance plan, as well as which services are excluded from coverage, in your plan's coverage documents.

A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.

Best Available Evidence (BAE) is a process in place that allows Medicare members to provide proof that they should be receiving a Low-income Subsidy (LIS). 

Acceptable Proof of BAE

• A copy of the beneficiary's Medicaid card
• A letter from SSA showing that the individual receives SSI

The stage in the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $5,000 in covered drugs during the covered year.

The Federal agency that administers Medicare.

A Chronic Condition is a medical condition due to a disease, illness or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration.

A claim is a request for payment for services and benefits you received. Claims are also called bills for all Part A and Part B services billed through Fiscal Intermediaries. “Claim” is the word used for Part B physician/supplier services billed through the Carrier. (See Carrier; Fiscal Intermediaries; Medicare Part A; Medicare Part B.)

A percentage of the cost of a covered benefit (for example, 20%) that an enrollee pays after the enrollee has paid the deductible, if a deductible applies to the covered benefit, such as the prescription drug benefit.

The formal name for “making a complaint” is “filing a grievance.” The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. See also “Grievance,” in this list of definitions.

A facility that mainly provides rehabilitation services after an illness or injury, and provides a variety of services including physical therapy, social or psychological services, respiratory therapy, occupational therapy and speech-language pathology services, and home environment evaluation services.

A fixed dollar amount (for example, $20) that an enrollee pays for a covered benefit after the enrollee has paid the deductible, if a deductible applies to the covered benefit, such as the prescription drug benefit.

Cost-sharing refers to amounts that a member has to pay when services  or drugs are received. Cost-sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed “copayment” amount that a plan requires when a specific service or drug is received; or (3) any “coinsurance” amount, a percentage of the total amount paid for a service or drug, that a plan requires when a specific service or drug is received. A “daily cost-sharing rate” may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment.

Every drug on the list of covered drugs is in one of five cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug.

A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are also called “coverage decisions”.

Also called a "donut hole," this is a span of time during which you may pay a higher premium for prescription drugs until you spend the minimum required to qualify for catastrophic coverage.

The term we use to mean all of the prescription drugs covered by our plan.

The general term we use to mean all of the health care services and supplies that are covered by our plan.

This is health insurance coverage that you may have had previously that can be applied to waiting periods for pre-existing conditions. Under a Medigap policy, your waiting period may be reduced.

Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

Custodial care is personal care provided in a nursing home, hospice, or other facility setting when you do not need skilled medical care or skilled nursing care. Custodial care is personal care that can be provided by people who don’t have professional skills or training, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. Medicare doesn’t pay for custodial care.

A department within our plan responsible for answering your questions about your membership, benefits, grievances and appeals.

A “daily cost-sharing rate” may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply. Here is an example: If your copayment for a one-month supply of a drug is $30, and a one-month’s supply in your plan is 30 days, then your “daily cost-sharing rate” is $1 per day. This means you pay $1 for each day’s supply when you fill your prescription.

The amount an enrollee pays for certain covered benefits before Sharp Health Plan begins payment for all or part of the cost of the covered benefit under the terms of the policy.

The HHS is the government organization that provides federal oversight for the Centers for Medicare and Medicaid Services (CMS).

The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).

A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription. The dispensing fee covers costs such as the pharmacist’s time to prepare and package the prescription.

Certain medical equipment that is ordered by your doctor for medical reasons. Examples are walkers, wheelchairs, or hospital beds.

A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical condition.

ESRD indicates that the kidneys are in failure mode and will not be able to reverse course. This condition requires a transplant or ongoing dialysis.

This document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan.

A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting
(a formulary exception).

A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.

A formulary, or "drug list," is a list of all prescription drugs that are covered by an insurance plan.

A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a “generic” drug works the same as a brand name drug and usually costs less.

A written or oral expression of dissatisfaction regarding Sharp Health Plan, a provider and/or a pharmacy, including quality of care concerns.

HIPAA is the standard of privacy for all interactions between medical facilities and their patients. Also called the "Privacy Rule," HIPAA is a law that maintains and protects the security and privacy of your health records, while also allowing for other medical providers to access your health information when necessary, promote high-quality health care and uphold public health standards.

A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

An enrollee who has 6 months or less to live has the right to elect hospice. We, your plan, must provide you with a list of hospices in your geographic area. If you elect hospice and continue to pay premiums you are still a member of our plan. You can still obtain all medically necessary services as well as the supplemental benefits we offer. The hospice will provide special treatment for your state.

A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an “outpatient.”

If your income is above a certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium. For example, individuals with income greater than $85,000 and married couples with income greater than $170,000 must pay a higher Medicare Part B (medical insurance) and Medicare prescription drug coverage premium amount. This additional amount is called the income-related monthly adjustment amount. Less than 5 percent of people with Medicare are affected, so most people will not pay a higher premium.

The maximum limit of coverage under the Initial Coverage Stage.

This is the stage before your total drug costs including amounts you have paid and what your plan has paid on your behalf for the year have reached $3,750.

When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you’re eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions. For example, if you receive “Extra Help” from Medicare to pay your prescription drug plan costs, you will not pay a late enrollment penalty.

A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.

See “Extra Help.”

The most that you pay out-of-pocket during the calendar year for in-network covered Part A and Part B services. Amounts you pay for your plan premiums, Medicare Part A and Part B premiums, and prescription drugs do not count toward the maximum out-of-pocket amount.

Medicaid is a program sponsored jointly by the state and federal government that helps to alleviate medical costs for individuals with limited income. The requirements and benefits of Medicaid vary across different states, although if you qualify for both Medicare and Medicaid, most of your health care costs will be covered at minimal to no cost to you.

A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medi-Cal programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medi-Cal.

A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books.

Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.

The Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original, a PACE plan, or a Medicare Advantage Plan.

Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

Offered by a private health insurance provider, this is a type of Medicare health plan that also contracts with the Medicare program. This plan allows you to receive all of your Part A and Part B benefits. This type of plan may include Health Maintenance Organizations, Private Fee-For-Service Plans, Medicare Medical Savings Account Plans and Special Needs Plans. Most Medicare services are covered under this type of plan, and most of these plans provide prescription drug coverage.

Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

A program that provides discounts on most covered Part D brand name drugs to Part D enrollees who have reached the Coverage Gap Stage and who are not already receiving “Extra Help.” Discounts are based on agreements between the Federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted.

A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).

This Medicare coverage is provided for inpatient hospital stays, Skilled Nursing Facility (SNF) stays, hospice care and some home health care.

This Medicare coverage is provided for outpatient care to include services from specific doctors, medical supplies and preventive care.

Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.

This Medicare coverage is optional and comes at an additional charge for Medicare patients. It provides benefits for prescription drugs available to Medicare patients, and is offered by Medicare-approved insurance and/or private companies.

This Medicare coverage is an add-on to other plans, supplementing those plans with prescription drug coverage. The types of plans that may accept this supplement include Original Medicare, Medicare Medical Savings Account Plans, some Medicare Private-Fee-for-Service Plans and some Medicare Cost Plans. This coverage is offered by Medicare-approved insurance and/or private companies.

This type of provider has been approved by Medicare to offer their services, such as home health care, hospital care, nursing home care or dialysis, to Medicare patients. To become certified by Medicare, providers must pass a state government inspection for approval. Patients enrolled in Medicare are only able to receive coverage for services from certified providers.

Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.

Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)

A person with Medicare who is eligible to get covered services, who has enrolled in our plan, and whose enrollment has been confirmed by the Centers for Medicare & Medi-Cal Services (CMS).

A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them “network pharmacies” because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

“Provider” is the general term we use for 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. We call them “network providers” when they have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Our plan pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as “plan providers.”

The Medicare Advantage plan has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. The Medicare Advantage plan’s network provider or facility has also made an organization determination when it provides you with an item or service, or refers you to an out-of-network provider for an item or service. Organization determinations are also called "coverage decisions."

Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare- approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States.

Services received while a member is outside the service area. Out-of-Area coverage includes urgent or emergent services for the sudden onset of symptoms of sufficient severity to require immediate medical attention to prevent serious deterioration of a member’s health resulting from unforeseen illness or injury or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the member returns to the service area. Out-of-Area medical services will be covered to meet your immediate medical needs. Applicable follow-up for the urgent or emergent service must be authorized by Sharp Advantage and will be covered until it is prudent to transfer your care into the plan’s service area.

A pharmacy that doesn’t have a contract with our plan to coordinate or provide covered drugs to members of our plan. As explained in this Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.

See the definition for “cost-sharing” above. A member’s cost-sharing requirement to pay for a portion of services or drugs received is also referred to as the member’s “out-of-pocket” cost requirement.

A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term care (LTC) services for frail people to help people stay independent and living in their community (instead of moving to a nursing home) as long as possible, while getting the high-quality care they need. People enrolled in PACE plans receive both their Medicare and Medi-Cal benefits through the plan.

See “Medicare Advantage (MA) Plan.”

The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)

Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.

A Pharmacy Benefit Manager (PBM) is an administrator to manage SHP prescription drug benefits.

Sharp Advantage

A group of physicians, organized as or contracted through a legal entity, that has met the plan’s criteria for participation and has entered into an agreement with the plan to provide and make available professional services and to provide or coordinate the provision of other covered benefits to members on an independent contractor basis and that is included in the member’s plan network.

The network of providers selected by the employer or the member, as indicated on the member identification card.

The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Your primary care provider is the doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare health plans, you must see your primary care provider before you see any other health care provider.

Approval in advance to get services or certain drugs that may or may not be on our formulary. Some in-network medical services are covered only if your doctor or other network provider gets “prior authorization” from our plan. Some drugs are covered only if your doctor or other network provider gets “prior authorization” from us. Covered drugs that need prior authorization are marked in the formulary.

These are medical devices ordered by your doctor or other health care provider. Covered items include, but are not limited to, arm, back and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function, including ostomy supplies and enteral and parenteral nutrition therapy.

A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients.

A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.

These services include physical therapy, speech and language therapy, and occupational therapy.

A geographic area where a health plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you permanently move out of the plan’s service area.

Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor.

A set time when members can change their health or drugs plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting “Extra Help” with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you.

A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.

Used by people who are deaf, hard-of-hearing or have impaired speech, a TTY is a teletypewriter, or a way to communicate with other typical people. If a TTY user is communicating with a person who does not have a TTY, their communication is picked up and transcribed through a Message Relay Center (MRC). An MRC will have TTY operators who are able to interpret and send TTY messages back and forth.

Urgently needed services are care provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.