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Actual Charge
The amount a physician or supplier actually
bills for a particular medical service or supply.
Approved
Amount
The amount Medicare determines to be reasonable for a service that is
covered under Part B of Medicare. It may be less than the actual charge.
For many services, including physician services, the approved amount is
taken from a fee schedule that assigns a dollar value to all
Medicare-covered services that are paid under that fee schedule.
Assignment
An arrangement whereby a physician or medical supplier agrees to accept
the Medicare-approved amount as full payment for services and supplies
covered under Part B. Medicare usually pays 80% of the approved amount
directly to the physician or supplier after the beneficiary meets the
annual Part B deductible of $100. The beneficiary pays the other 20
percent.
Authorization
Is the approval by your Medical Group of a referral made by your Primary
Care Physician. It is also the approval of your Primary Care Physician or
Medicare Group in an emergency.
Benefit
Period
A benefit period is a way of measuring a beneficiary's use of hospital and
skilled nursing facility services covered by Medicare. A benefit period
begins the day the beneficiary is hospitalized. It ends after the
beneficiary has been out of the hospital or other facility that primarily
provides skilled nursing or rehabilitation services for 60 days in a row.
If the beneficiary is hospitalized after 60 days, a new benefit period
begins, most Medicare Part A benefits are renewed, and the beneficiary
must pay a new inpatient hospital deductible. There is no limit to the
number of benefit periods a beneficiary can have.
Benefit
Period (Part A)
As defined by Medicare, this begins when you first enter a hospital or
skilled nursing facility. It ends when you have been discharged, and not
readmitted to a hospital or other facility for at least 60 consecutive
days.
CMS
The Centers for Medicare and Medicaid Services is the federal government
agency responsible for administering Medicare and federal participation in
Medicaid. (Formerly known as the Health Care Financing Administration)
Coinsurance
The portion or percentage of the Medicare-approved amount that a
beneficiary is responsible for paying.
Contracting
Hospital
A hospital which has a Blue Cross Senior Secure plan Agreement in effect
at the time services are rendered and which is also Medicare certified.
Copayment
The amount of payment indicated in the Summary Of Benefits section of your
contract book. It is due and payable (at the time of service) by the
Member to the Medical Group, hospital or other provider of care.
Covered
Services
Medically necessary services or supplies which are listed in the Summary
Of Benefits section of this Agreement, and for which the member is
entitled to receive benefits.
Custodial
Care
Care provided primarily to meet the personal needs of the member. This
includes help in walking, bathing or dressing. It also includes preparing
food or special diets, feeding, administered, or any other care which does
not require the continuing services of medical personnel.
Deductible
The amount of expense a beneficiary must first incur before Medicare
begins payment for covered services.
Drugs,
Formulary
Drugs which the medical literature indicates are clinically effective,
safe and of reasonable cost. The goal of Blue Cross' formulary list of
prescription drugs, as established for the WellPoint Pharmacy Plan, is to
identify and promote prescription drugs which are therapeutically
appropriate and cost effective.
Drugs,
non-formulary
Prescription drugs not on Blue Cross' formulary list.
Durable
Medical Equipment
Equipment which can withstand repeated use, is primarily and usually used
to serve a medical purpose, is generally not useful to a person in the
absence of illness or injury, and is appropriate for use in the home. To
be covered, durable medical equipment must be medically necessary and
prescribed by a contracting physician for use in the home. Examples are
oxygen equipment, wheelchairs and hospital beds. These items are covered
in accordance with Medicare laws, regulations and guidelines.
Emergency
A sudden, serious or unexpected acute illness, injury or condition which
could permanently endanger your health if medical treatment is not
received immediately.
Excess
Charge
The difference between the Medicare-approved amount for a service or
supply and the actual charge, if the actual charge is more than the
approved amount.
Experimental Procedures
Procedures that are mainly limited to laboratory and/or animal research,
but which are not generally accepted as proven and effective procedures
within the organized medical community. When making a determination as to
whether a service is experimental, Blue Cross Senior Secure will use
Medicare guidelines or rely upon determinations already made by Medicare.
Experimental procedures and items are not covered under Blue Cross Senior
Secure.
HMO (Health
Maintenance Organization)
An organization that provides a wide range of comprehensive health care
services through a designated group, or network of doctors, hospitals,
labs and other providers. To receive benefits, the member must see the
doctor he selects as his primary care physician first for care or a
referral, except in the case of an emergency. The choice of doctors is
restricted to those in the network.
Home Health
Agencies and Visiting Nurse Associations
These are home health care providers, licensed according to state and
local laws, to provide skilled nursing and other services on a visiting
basis in the Member's home. They must be approved as home health care
providers under Medicare and the Joint Commission on Accreditation of
Hospitals.
Hospice
An organization or agency, certified by Medicare, that is primarily
engaged in providing pain relief, symptom management, and supportive
services to terminally ill people and their families.
Hospitals,
non-Contracting
Hospitals that are not part of the Blue Cross Prudent Buyer network and
that have not signed a standard contract with Blue Cross. Blue Cross
does not pay benefits for services provided by non-contracting
hospitals except in the case of a medical emergency.
IPA
(Independent Practice Association)
A partnership, association, or corporation that delivers or arranges for
the delivery of health services and which has entered into a contract with
health professionals, a majority of whom are licensed to practice medicine
or osteopathy.
Individual
Insurance
Health care coverage for individuals or single family units.
Limited Fee
Schedule
A list of maximum amounts Blue Cross will pay for certain services
provided by non-network providers. The member is responsible for paying
the co-insurance and any amount over the limited fee schedule.
Limiting
Charge
The maximum amount a physician may charge a Medicare beneficiary for a
covered physician service if the physician does not accept assignment of
the Medicare claim. The limit is 15 percent above the fee schedule amount
for non-participating physicians. Limiting charge information appears on
Medicare's Explanation of Medicare Benefits (EOMB) form.
Lock-in
Under Blue Cross Senior Secure, means the member is "locked-in" to the use
of Blue Cross Senior Secure providers. The member must receive all medical
care from Contracting Blue Cross Senior Secure Providers, except:
emergency services, urgently needed services outside of the Blue Cross
Senior Secure service area, such as referral to a specialist or to a
non-contracting provider; out of area renal dialysis; or the Choices Plus
Self-Referral Benefit. The use of non-contracting providers, except as
stated above, will result in the obligation to pay for routine care.
Neither Blue Cross Senior Secure nor Medicare will pay for these services.
Medicare
Carrier
An insurance organization under contract to the federal government to
process Medicare Part B claims from physicians and other suppliers. The
names and addresses of the carriers and areas they serve are listed in the
back of The Medicare Handbook, available from any Social Security
Administration office.
Medicare
Hospital Insurance
This is Part A of Medicare. It helps pay for medically necessary inpatient
care in a hospital, skilled nursing facility or psychiatric hospital, and
for hospice and home health care.
Medical
Group
A group of physicians, organized as a legal entity, which has an Agreement
in effect with Blue Cross Senior Secure to furnish medical care to
Members. INDEPENDENT PRACTICE ASSOCIATION (IPA) is a Participating Medical
Group but with the following differences: The Primary Care Physicians are
located at various addresses throughout a geographically close area; the
Physician's relationship with the IPA administrator is that of an
independent contractor. The Member is required, at the time of enrollment,
to select a Medical Group to provide services covered under this
Agreement. However, in the event the Member does not indicate his or her
selection on the enrollment form, Blue Cross Senior Secure will assign the
Member to a Medical Group nearest to the Member's residence.
Medically
Necessary
Services or supplies are those Blue Cross Senior Secure determines to be:
- Appropriate and necessary for the
symptoms, diagnosis or treatment of the medical condition, and provided
for the diagnosis or direct care and treatment of medical condition;
- Within standards of good medical
practice within the organized medical community;
- Not primarily for the convenience of
the Member, the Member's physician, or another provider;
- The most appropriate supply or level
of service which can safely be provided. For Hospital stays, this means
that acute care as a bed patient is needed due to the kind of services
the Member is receiving or the severity of the Member's condition, and
that safe and adequate care cannot be received as an outpatient or in a
less intense medical setting.
Medicare
Medical Insurance
This is Part B of Medicare. This part helps pay for medically necessary
physician services and many other medical services and supplies not
covered by Part A.
Mental or
Nervous Disorders
Conditions that affect thinking and the ability to figure things out,
perception, mood and behavior. A mental or nervous disorder is recognized
primarily by symptoms or signs that appear as distortions of normal
thinking, distortions of the way things are perceived (for example seeing
or hearing things that are not there), moodiness, sudden and/or unusual
behavior such as depressed behavior. Some mental or nervous disorders are:
schizophrenia, manic depressive and other conditions usually classified in
the medical community as psychosis: drug, alcohol or other substance
addiction or abuse: depressive phobic, manic and anxiety conditions (
including panic disorder); bipolar affective disorders including mania and
depression; obsessive compulsive disorder; hypochondria; personality
disorders ( including paranoid, schizoid, dependent, anti-social and
borderline); dementia and delirious states; post traumatic stress
disorder, hyperkinetic syndromes (including attention deficit disorders);
adjustment reactions; reactions to stress; anorexia nervosa and bulimia.
Any condition meeting this definition is a mental or nervous disorder no
matter what the cause. However, medical conditions that are caused by
behavior of the Member that may be associated with these mental conditions
(for example self-inflicted injuries) are not subject to these
limitations.
Negotiated
Fee
The discounted rates that Blue Cross Prudent Buyer network doctors and
hospitals agree to charge for covered expenses.
Network/In-network
The term used for services received from doctors, hospitals and other
providers contracting with Blue Cross to provide care at the negotiated
fee and to handle the paperwork.
Non-Contracting Provider
A licensed provider who has not signed an Agreement with Blue Cross Senior
Secure to furnish care for Blue Cross Senior Secure Members
Out-of-network/Non-network
The term used for services received from doctors, hospitals or to the
provider that are not part of the Blue Cross network. You pay
substantially more for out-of-network services.
Out-of-pocket/Maximum
The most you pay for covered expenses during the year before the plan
begins paying 100% of covered expenses count toward the maximum. For
example, any charges above the limited fee schedule for out-of-network
doctor's services do not count.
Participating Physician and Supplier
A physician or supplier who agrees to accept assignment on all Medicare
claims.
Participating Prudent Buyer Physician
A physician who has a Prudent Buyer Plan Participating Physician Agreement
in effect with Blue Cross of California at the time services are rendered.
Permanent
Absence
A permanent absence is an uninterrupted absence of more than 6 months
outside the Blue Cross Senior Secure service area. If you move or travel
and do not intend to return to the Blue Cross Senior Secure Service Area
within 6 months, it is considered a permanent move and you must notify
Blue Cross Senior Secure.
PMG
(Participating Medical Group)
A group of doctors both primary care physicians and specialists, who are
in practice together and provide health care services.
PPO
(Preferred Provider Organization)
Health care providers who are under contract to provide care at discounted
or fixed fees. Unlike HMOs, health plans with a PPO allow the member to
choose any doctor at any time. However, if the member selects a non-PPO
provider he will pay more out of pocket for services than he would if he
selected a PPO "network" provider.
Pre-existing Condition or Pre-existing Waiting Period
If the member receives medial advice, or treatment was recommended or
received for any accident, illness, or other medical condition during six
months before he enrolled in a Blue Cross plan, he won't be covered for
the care he receives as a result of that condition until he has been
enrolled in the Blue Cross plan for six months. If he satisfied the
six-month waiting period while enrolled in another medical plan, and
enrolled with Blue Cross within 30 days of completing that waiting period,
he won't need to complete another pre-existing waiting period. He will
receive partial credit if he was insured under another plan for less than
six months.
Primary
Care Physician
A physician who is a member of a Medical Group that the Member has
selected to provide health care. A Primary Care Physician is responsible
for authorizing, coordinating and controlling the delivery of covered
services to the Member. Primary Care Physicians include general and family
practitioners, internists and such other specialists as Blue Cross Senior
Secure may approve to be designated a Primary Care Physician.
Prior
Authorization
A system whereby a provider must receive approval from a staff member of
the health plan, such as the health plan Medical Director, before a member
can receive certain health care services.
Psychiatric
Health Facility
An acute 24-hour facility as defined in California Health and Safety Code
1230.2. It must be :
- Licensed by the Department of Health
Services;
- Qualified to provide short-term
inpatient treatment according to the State law;
- Accredited by the Joint Commission on
Accreditation of Health Care Organizations;
- Staffed by an organized medical or
professional staff which includes a physician as a Medical Director.
Qualifying
Prior Coverage
Any individual or group plan that provides medical, hospital, and surgical
coverage, including continuation or conversion coverage or coverage under
a publicly sponsored program such as Medicare or Medicaid. It does not
include accident only, credit, disability income, Medicare supplement,
long term care insurance, automobile insurance, no-fault insurance, or any
medical coverage designed to supplement other private or governmental
plans.
Referral
Any request for authorization by the Primary Care Physician to the Medical
Group for covered specialty services or hospitalization. This may also
require utilization review by the Medical Group.
Service
Area
A geographic area approved by the Centers for Medicare & Medicaid Services
(CMS) within which a Medicare+Choice eligible individual may enroll in a
particular Medicare+Choice Plan offered by a Medicare+Choice Organization.
This is the area within which you generally must get non-emergency and
urgently needed services other than dialysis.
Skilled
Nursing Care
Refers to services that can only be performed by, or under the supervision
of, licensed nursing personnel.
Skilled
Nursing Facility
Provides skilled nursing care, continuous 24-hour nursing service, and
maintains daily medical records for each patient. It must be licensed
under all applicable state and local laws. It must be approved for payment
of Medicare benefits or be qualified to receive that approval if so
requested. It does not include any home or facility used primarily for
rest, educational care, treatment of mental or nervous disorders or a
facility for the aged which furnishes primarily custodial care, including
training in routines of daily living.
Temporary
Absence
A temporary absence from the Service Area is an absence of 6 months or
less outside the Blue Cross Senior Secure service area. If the member
moves or travels and does not intend to return to the Blue Cross Senior
Secure Service Area within 6 months, it is considered a permanent move and
the member must notify Blue Cross Senior Secure.
Urgently
Needed Services
Services needed immediately as a result of an unforeseen illness, injury,
or condition; and it is not reasonable given the circumstances to get the
services through your Primary Care Physician or other plan providers.
Ordinarily, these services are provided when you are out of the service
area. In extraordinary cases, these are services provided when you are in
the service area but plan providers are not available.
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