Glossary

Advance Directive

A written, legally binding document which authorizes the member to retain control over whether or not his or her life will be prolonged by the use of artificial means. This election, entirely optional, will allow the member to authorize the withholding or withdrawal of all treatment and procedures, including intravenous food and water (called nutrition and hydration).

Appeal

A type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for a service. Sections 10 and 11 explain about appeals, including the process involved in making an appeal.

Benefit Period

For both Choices Plus and Original Medicare, a benefit period is used to determine coverage for inpatient stays in hospitals and skilled nursing facilities. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or a skilled nursing facility. The benefit period ends when you have not been an inpatient at any hospital or SNF for 60 days in a row. If you go to the hospital (or SNF) after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. The type of care you actually receive during the stay determines whether you are considered to be an inpatient for SNF stays, but not for hospital stays.

• You are an inpatient in a SNF only if your care in the SNF meets certain skilled level of care standards. Specifically, in order to have been an inpatient while in a SNF, you must need daily skilled nursing or skilled rehabilitation care, or both. (Section 7 tells what is meant by skilled care.)
• Generally, you are an inpatient of a hospital if you are receiving inpatient services in the hospital (the type of care you actually receive in the hospital does not determine whether you are considered to be an inpatient in the hospital).

Brand Name Drug

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 not available until after the patent on the brand name drug has expired.

Calendar Year

The period that begins on January 1 and ends 12 consecutive months later on December 31.

Centers for Medicare & Medicaid Services (CMS)

The Federal Agency that runs the Medicare program.  CMS can be contacted by calling toll-free 1-800-MEDICARE (1-800-633-4227).  The TTY/TDD number is 1-877-486-2048 or by visiting www.medicare.gov <http://www.medicare.gov>.

Coinsurance

A member's share of the cost for covered services, paid to providers at the time care is received.

Copayment

A set dollar amount that members must pay at the time of service to a provider for certain covered services.

Coverage Determination

The plan sponsor has made a coverage determination when it makes a decision about the prescription drug benefits you can receive under the plan, and the amount that you must pay for a drug.

Covered Services

The general term we use in this booklet to mean all of the health care services and supplies that are covered by Choices Plus. Covered services are listed in the Benefits Chart in your Evidence of Coverage.

Creditable Coverage

Coverage that is at least as good as the standard Medicare prescription drug coverage.

Custodial Care

Care furnished for the purpose of meeting non-medically necessary personal needs which could be provided by persons without professional skills or training, such as assistance in walking, dressing, bathing, eating, preparation of special diets and taking medication. Custodial care is not covered by Choices Plus or Original Medicare unless provided with skilled nursing care and/or skilled rehabilitation services.

Disenroll or Disenrollment

The process of ending your membership in Choices Plus.
Disenrollment can be voluntary (your own choice) or involuntary (not your own choice). The Evidence of Coverage explains more about disenrollment.

Durable Medical Equipment

Equipment needed for medical reasons, which is sturdy enough to be used many times without wearing out. A person normally needs this kind of equipment only when ill or injured. It can be used in the home. Examples of durable medical equipment include wheelchairs, hospital beds, or equipment that supplies a person with oxygen.

Emergency Care

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

The Evidence of Coverage provides more detail about emergency services.

Emergency Medical Condition

A medical condition brought on by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect that not getting immediate medical attention could result in 1) Serious jeopardy to the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child); 2) Serious impairment to bodily functions; or 3) Serious dysfunction of any bodily organ or part.

Evidence of Coverage and Disclosure Information

This document along with your enrollment form, which explains your covered services, defines our obligations, and explains your rights and responsibilities as a member of Choices Plus.

Exception

A type of coverage determination that, if approved, allows you to obtain a drug that is not on our formulary (a formulary exception), or receive a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if we require 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).

Exclusion

Items or services that Choices Plus does not cover. You are responsible for paying for excluded items or services.

Formulary

A list of covered drugs provided by the plan.

Generic Drug

A prescription drug that has the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

Grievance

A type of complaint you make about us or one of our plan providers, including a complaint concerning the quality of your care. This type of complaint does not involve payment or coverage disputes. See the Evidence of Coverage for more information about grievances.

Home Health Agency

A Medicare-certified agency that provides skilled nursing care and other therapeutic services in your home when medically necessary.

Hospice

A Medicare-certified organization or agency that is primarily engaged in providing pain relief, symptom management and supportive services to terminally ill people and their families.

Hospital

A Medicare-certified institution licensed by the State, that provides inpatient, outpatient, emergency, diagnostic and therapeutic services. The term hospital does not include a convalescent nursing home, rest facility or facility for the aged that primarily provides custodial care, including training in routines of daily living.

Hospitalist

A physician who specializes in treating patients when they are in the hospital and who may coordinate a patient's care when he or she is admitted to a Choices Plus hospital.

In-Network

Any professional person, organization, health facility, hospital or other person or institution licensed and/or certified by the State or Medicare to deliver or furnish healthcare services and who is contracted directly with Choices Plus or engaged by an IPA to provide benefits to members.

Independent Physician Association (IPA)

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 to practice medicine or osteopathy. Under Choice 1, physicians are required to use a specific hospital associated with their IPA. If you decide to access your care using Choice 1, all covered services, except for emergency and urgently needed services, must be obtained from the IPA with which your PCP is affiliated.

Inpatient Care

Healthcare that you get when you are admitted to a hospital.

Maintenance Medications

Drugs that are commonly taken on a regular basis in order to be qualified for a 90-day supply.  Drugs must be classified as “maintenance” by First DataBank.

Medically Necessary

Services or supplies that are proper and needed for the diagnosis or treatment of your medical condition; are used for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for the convenience of you or your doctor.

Medicare

The federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant).

Medicare Advantage Organization

A public or private organization licensed by the State as a risk-bearing entity that is under contract with theCenters for Medicare & Medicaid Services (CMS) to provide covered services. Medicare Advantage Organizations can offer one or more Medicare Advantage Plans. Tenet Choices, Inc. is a Medicare Advantage Organization.

Medicare Advantage Plan

A benefit package offered by a Medicare Advantage Organization that offers a specific set of health benefits at a uniform premium and uniform level of cost-sharing to all people with Medicare who live in the service area covered by the Plan. A Medicare Advantage Organization may offer more than one plan in the same service area. Choices Plus is a Medicare Advantage Plan.

Medicare Managed Care Plan

Means a Medicare Advantage HMO, Medicare Cost Plan, or Medicare Advantage PPO.

Medicare Prescription Drug Coverage

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

“Medigap” (Medicare supplement insurance) policy

Many people who get their Medicare through Original Medicare buy “Medigap” or Medicare supplement insurance policies to fill “gaps” in Original Medicare coverage.

Member (member of Choices Plus, or “plan member”)

A person with Medicare who is eligible to get covered services, who has enrolled in Choices Plus, and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Member Services

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

Network

A group of healthcare providers under contract with Choices Plus that is licensed and/or certified by Medicare with the purpose of delivering or furnishing healthcare services.

Network Pharmacy

A network pharmacy is a pharmacy where members of our Plan can receive covered 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.

Non-Participating Provider or Facility

A provider or facility that Choices Plus has not arranged with to coordinate or provide covered services to members of Choices Plus. Non-participating providers are providers that are not employed, owned or operated by Choices Plus and are not under contract to deliver covered services to you.

Non-Preferred Network Pharmacy

A network pharmacy that offers covered drugs to members of our Plan at higher cost-sharing levels than apply at a preferred network pharmacy.

Non-plan provider or non-plan facility

A provider or facility that we have not arranged with to coordinate or provide covered services to members of Choices Plus. Non-plan providers are providers that are not employed, owned, or operated by Choices Plus and are not under contract to deliver covered services to you. As explained in this booklet, you may pay more if you see non-plan providers unless it is for an emergency.

Office Visit

A visit for covered services to your PCP, specialist or other participating provider.

Organization Determination

The MA organization has made an organization determination when it, or one of its providers, makes a decision about MA services or payment that you believe you should receive.

Original Medicare

Some people call it “traditional Medicare” or “fee-for-service” Medicare. Original Medicare is the way most people get their Medicare Part A and Part B health care. It is the national pay-per-visit program that lets you go to any doctor, hospital, or other health care provider who 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.

Part D

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

Part D Drugs

Any drug that can be covered under a Medicare Prescription Drug Plan. Generally, any drug not specifically excluded under Medicare drug coverage is considered a Part D Drug.

Participating Provider

“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 “participating providers” when they have an agreement with Choices Plus to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of Choices Plus. Choices Plus pays plan providers based on the agreements it has with the providers.

Peoples Health Member Services Department

Monday through Friday, 8:00 a.m. to 5:00 p.m.
(504) 849-4500, ext. 2    Local
(800) 631-8443, ext. 2    Toll-free
(888) 631-9979    TTY/TDD Telephone Device for the Hearing Impaired

Pharmacy Benefit Manager

Companies that contract with Medicare Advantage Organizations to manage pharmacy services. The Choices Plus Pharmacy Benefit Manager is Walgreens Health Initiative (WHI).

Preferred Network Pharmacy

A network pharmacy that offers covered drugs to members of our Plan at lower cost-sharing levels than apply at another network pharmacy.

Primary Care Physician (PCP)

A healthcare professional who is trained to give you basic care. Your PCP is responsible for providing or authorizing covered services while you are a member. You may utilize the Choice 1 option under Choices Plus to see your PCP for referral to a specialist within your IPA. Each Choices Plus PCP is associated with an IPA.

Preferred Provider Organization Plan

A Preferred Provider Organization plan is an
MA plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they are received from network or non-network providers. Member cost sharing may be higher when plan benefits are received from non-network providers.

Prior Authorization

Approval in advance to get services. Some in-network services are covered only if your doctor or other plan provider gets “prior authorization” from a participating medical group, IPA or Choices Plus.  Covered services that need prior authorization are marked in the Benefits Chart. Prior authorization is not required for out-of-network services. You do not need prior authorization to obtain out-of-network services. However, you may want to check with your plan before obtaining services out-of-network to confirm that the service is covered by your plan and what your cost share responsibility is.

Quality Improvement Organization (QIO)

Groups of practicing doctors and other health care experts who are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by doctors in inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private fee-for-service plans and ambulatory surgical centers. The Evidence of Coverage provides details about how to contact the QIO in your state and information about making complaints to the QIO.

Referral

A request from one provider to another for covered services to be provided on your behalf. See the definition for "notification" and "authorization" for details on the Referral process (some referrals require authorizations.)

Rehabilitative Services

Services including physical, cardiac, speech and occupational therapies that are rendered under the direction of a participating provider.

Service Area

A geographic area approved by the Centers for Medicare & Medicaid Services (CMS) within which a Medicare Advantage (MA) eligible individual may enroll in a particular MA plan offered by a Medicare Advantage Organization. This is the area within which you generally must get non-emergency and urgently needed services other than dialysis.  The Choices Plus service area includes Jefferson, Orleans, Plaquemines and St. Tammany parishes in Louisiana.

Specialist

A doctor who treats only certain parts of the body, certain health problems or certain age groups. For example, some doctors treat only heart problems.

Urgently Needed Care

The Evidence of Coverage explains about urgently needed services. These are different from emergency services.