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Health Insurance Terms

Health coverage is important, but can be confusing. Here's a handy list of definitions to terms and phrases you may see about health care and health insurance. Knowledge is power!

Words to help you understand your health plan

Access

The ability to get medical care

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Advance Directive

This is a document that details a person’s wishes about critical care when he or she is unable to decide for him or herself

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Agent and Broker

These are trained insurance professionals who can help you enroll in a health insurance plan. An agent may work for a single health insurance company, while a broker may represent several companies.  Agents and brokers must be licensed in their states and have signed agreements to sell health plans and are required to act in a consumer’s best interest. Agents and brokers often get payments or commissions from insurance companies for selling plans.

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Allowed Amount

The highest amount insurance will cover or pay for a service

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Ambulatory Surgical Center

This is an outpatient surgical facility that provides services to patients who do not require hospitalization and whose expected stay in the center does not exceed 24 hours.

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Annual Election Period or Annual Enrollment Period (AEP)

Also known as “Fall Open Enrollment” season and the “Open Enrollment Period for Medicare Advantage AND Medicare prescription drug coverage,” this is the period when people eligible for Medicare Advantage plans can enroll or make a change to their health insurance, usually October 15 to December 7.  The changes you make during that time are effective January 1.

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Appeal (Reconsideration)

A request for your health insurance company to review a decision that denies a benefit or payment.  If your health requires it, a “fast appeal” or “expedited reconsideration” may be requested. There are several levels to the appeals process.  If your initial appeal is denied, an Independent Review Organization (or Independent Review Entity/IRE), hired by Medicare, reviews our decision and determines whether the decision we made should be changed.  If the IRE agrees with our decision, that means they “uphold the decision or turning down your appeal.”

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Attest/Attestation

When you apply for health coverage, you're required to agree to or "attest" to providing truthful information and by signing the application.

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Authorized Representative (Legal Decision Maker)

Someone who you choose to act on your behalf, like a family member or other trusted person, who might even have legal authority to act on your behalf.

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BadgerCare Plus

A health care coverage program for low-income Wisconsin residents including children, pregnant women, and adults (may include adults ages 18 through 25 who were in foster care when they turned 18).  Learn about iCare's BadgerCare Plus plan!

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Benefits

Benefits are any health care services or items covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. Many insurance companies, including iCare, offer "added" benefits above and  beyond covered benefits, that are included at no additional charge.

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Benefit Period

 This is the timeframe that services are covered under your plan. It also defines the time when benefit maximums, deductibles and coinsurance limits build up. It has a start and end date. It is often one calendar year for health insurance plans.

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Brand Name Drugs

Drugs sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription and some may be available over the counter.

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Care Coordination

Securing the wellness of individuals by offering personalized, sustained and integrated care.  Independent Care Health Plan (iCare) is grounded in the premise that quality health care can be provided effectively and efficiently through care management. We strive to empower our members to participate actively in self-care management, which ultimately leads to a greatly improved quality of life. By partnering closely with providers and community resources we achieve strong, solid medical, behavioral, and social outcomes, ensuring positive results are achieved for individuals with special needs now and into the future.

"One of iCare's greatest strengths is their ability to creatively develop care plans and interventions suited to each member's individual needs."

- Wisconsin DHFS and MetaStar, Inc., Medicaid Special Managed Care Preliminary 2005 Annual Quality Site Review Report on Independent Care Health Plan

 

"iCare helps me keep the patients healthy and allows them to live more independent and meaningful lives. In addition, such coordination of care saves our system huge amounts of money in preventing unnecessary ER visits and redundant medical care."

- Edith Lepgold, MD, Medical Director-Center for Women’s Well-Being, St. Joseph Outpatient Center

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Care Coordinator

Considered one of the most important roles at the heart of a member’s care, the care coordinator brings together different specialists, and monitors and evaluates the care that a member receives.  The care coordinator is expert in understanding the member’s medical condition, medications and other instructions necessary during care.

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Care Giver

A care giver is typically a professional (home health aide, personal care aide, nursing assistant, in home companion, etc.), a family member or friend who provides vital physical, practical, and emotional support to a person who is elderly, disabled or senior.

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Care Manager

A Social Worker, Registered Nurse or individual with advanced medical knowledge and education in aging and disabilities who provide for their patients by matching their needs with appropriate support services.  Through personalized and integrated care coordination, iCare’s Care Managers help members to maintain their independence and make decisions regarding their healthcare.  This model of care is member-centric, with the member at the heart of everything.

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Centers for Medicare & Medicaid Services (CMS)

The federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated programs.

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Chronic Disease Management

An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve your quality of life while reducing your health care costs if you have a chronic disease by preventing or minimizing the effects of a disease.

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Claim

A request for payment that you or your health care provider submits to your health insurer when you get items or services you believe are covered.

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Complaint or Grievance

Any expression of dissatisfaction by a member or member's authorized representative about:

  • Independent Care Health Plan's services or procedures
  • a contracted provider’s services or procedures
  • services arranged by iCare or a contracted provider

iCare will treat every complaint as a grievance. This means that iCare will keep track of member complaints, take your concerns seriously and make sincere efforts to resolve them.

Dissatisfaction with a determination of coverage is not considered a grievance, but may be treated as an appeal. It is iCare’s responsibility to determine whether your complaint is a grievance or an appeal, or has pieces of both.

iCare would like to know if you have a complaint about your care. Please contact iCare at:

Member Advocate

Independent Health Care Plan

1555 N. RiverCenter Dr., Suite 206

Milwaukee, WI 53212

Tel: 1-800-777-4376

TTY: 1-800-947-3539

Fax: 1-414-231-1092

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Comprehensive Outpatient Rehabilitation Facility (CORF)

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.

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Condition

An injury, ailment, disease, illness or disorder.

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Contract

The agreement between an insurance company and the policyholder.

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Copayment (Copay)

The amount you pay to a healthcare provider at the time you receive services. You may have to pay a copay for each covered visit to your doctor, depending on your plan. Not all plans have a copay.

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Covered Charges

Charges for covered services that your health plan paid for. There may be a limit on covered charges if you receive services from providers outside your plan's network of providers. “Coverage and Covered Services” refer to the medical care, long term care, home and community based services and the prescription drugs available to you as a member.

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Creditable Coverage

 Healthcare overage of a person under Medicare, Medicaid, a health plan for active military personnel, Indian Health Service or other tribal organization program, and/or any other plan which gives complete hospital, medical and surgical services.

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Custodial Care

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.

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Customer Service

A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals. iCare’s customer service can be reached at 1-800-777-4376.

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Department of Health and Human Services (HHS)

The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

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Dependant

Someone who relies on you to take care of them.  This could include a child or spouse.

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Drug Formulary/Drug List

The list of prescription drugs that are covered by an insurance plan. For your health plan with iCare, your drug list/formulary can be found here:

Click

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Disability

A limit in a range of major life activities like seeing, hearing, walking and tasks like thinking and working.

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Disenroll or Disenrollment

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

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Dispensing Fee

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.

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Dual Eligible Individual

A person who qualifies for Medicare and Medicaid coverage.

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Durable Medical Equipment (DME)

Equipment and supplies ordered by a health care provider for everyday or extended use like oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

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Eligible Immigration Status

An immigration status that's considered eligible for getting health coverage. The rules for eligible immigration status may be different in each insurance affordability program.

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Emergency

A life-threatening medical condition resulting from an injury, sickness or mental illness that happens suddenly and needs treatment right away.

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Emergency Medical Condition

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.  This may include any factor that:

  • Puts a person's health at serious risk
  • Puts an unborn child's health at serious risk
  • Results in serious damage to the person's body and how his or her body works
  • Results in serious damage of a person's organ or any part of the person
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Emergency Medical Transportation

Ambulance services for an emergency medical condition.

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Enhanced or Added Benefits

All Medicare Advantage plans must include, at a minimum, all the benefits included in Original Medicare, except for hospice care, which is still covered under Medicare Part A. You do not lose any benefits if you enroll in or switch to a Medicare Advantage plan. However, you may be able to enroll in a plan that also includes additional Medicare Advantage benefits. Often referred to as "Enhanced Benefits" or "Added Benefits, examples of these additional benefits include:

  • Part D coverage for prescription drugs
  • Vision care
  • Dental care
  • Wellness programs such as Weight Watchers or SilverSneakers
  • An Over-the-Counter (OTC) medication allowance

The iCare Medicare Plan, the iCare Family Care Partnership Plan, Aurora CompleteCare,  and iCare Medicare Advantage Plan are examples of plans that feature added/enhanced benefits.

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Evidence of Coverage (EOC) and Disclosure Information

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

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Exception

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).

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Excluded Services

Health care services that are not covered by your insurance plan.

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Exemption

Most people must have qualifying health insurance or pay a fee. But people who qualify for a health coverage exemption don’t have to pay the fee. Exemptions are granted based on certain hardships and life events, health coverage or financial status, membership in some groups, and other circumstances.

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Explanation of Benefits (EOB)

This document shows that your claim was paid.  This is informational only and not a bill.

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External Review

A review of a plan's decision to deny coverage for or payment of a service by an independent third-party. If the plan denies an appeal, an external review can be requested. In urgent situations, an external review may be requested even if the internal appeals process isn't yet completed. External review is available when the plan denies treatment based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, when the plan determines that the care is experimental and/or investigational, or for rescissions of coverage. An external review either upholds the plan's decision or overturns all or some of the plan’s decision. The plan must accept this decision.

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Extra Help

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

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The Family Care Partnership Program

An integrated health and long-term care program for frail elderly and people with disabilities. The Partnership Program consists of several managed care organizations located in different geographical regions of Wisconsin. The goals of the Partnership Program are to: improve quality of health care and service delivery while containing costs; reduce fragmentation and inefficiency in the existing health care delivery system; and increase the ability of people to live in the community and participate in decisions regarding their own health care.

Learn about iCare's Family Care Partnership Plan by clicking Learn More!

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Federally Recognized Tribe

Any Indian or Alaska Native tribe, Alaska Native Claims Settlement Act (ANCSA) Corporation (regional or village), band, nation, pueblo, village, rancheria, or community that the Department of the Interior acknowledges to exist as an Indian tribe.

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Federal Poverty Level (FPL)

A measure of income set each year by the Department of Health and Human Services (HHS) that a family needs for food, clothing, shelter, transportation and other necessities, which varies depending on family size.

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Federally Qualified Health Center (FQHC)

A federally funded nonprofit health center or clinic that serves medically underserved areas and populations. A federally qualified health center provides primary care services regardless of your ability to pay. Services are provided on a sliding scale fee based on your ability to pay.

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Fee

A payment you will be charged if you don’t have health insurance that counts as qualifying health coverage. 

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Fee for Service

A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.

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Formulary

A list of prescription drugs covered by a health plan.  Also called a “drug list.”

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Generic Drugs

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

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Habilitative/Habilitation Services

Health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

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HMO (Health Maintenance Organization)

Offers healthcare services only with specific HMO providers. Under an HMO plan, you might have to choose a primary care doctor. This doctor will be your main healthcare provider. The doctor will refer you to other HMO specialists when needed. Services from providers outside the HMO plan are hardly ever covered except for emergencies.

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Health Assessment

A health survey that measures your current health, health risks and quality of life.

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Health Insurance

A contract that requires your health insurance to pay some or all of your health care costs in exchange for a premium.

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Health Status

Refers to your medical conditions (both physical and mental health), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.

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HIPAA

HIPAA is the Health Insurance Portability and Accountability Act. Enacted in 1996 this act governs health data privacy and storage guidelines. The primary goal is to improve continuity of health insurance coverage, simplify administration of health insurance, improve access to long-term coverage and services, combat waste, fraud, and abuse in the delivery of health insurance and healthcare.

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Home and Community-Based Services (HCBS)

Services and support provided by most state Medicaid programs in your home or community that gives help with such daily tasks as bathing or dressing. This care is covered when provided by care workers or, if your state permits it, by your family.

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Home Health Aide

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.

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Home Health Care

Health care services a person receives at home.

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Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.

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Hospital Outpatient Care

Care in a hospital that usually doesn’t require an overnight stay.

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Hospital Readmissions

A situation where you were discharged from the hospital and wind up going back in for the same or related care within 30, 60 or 90 days. The number of hospital readmissions is often used in part to measure the quality of hospital care, since it can mean that your follow-up care wasn't properly organized, or that you weren't fully treated before discharge.

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Hospice Services

Services to provide comfort and support for people in the last stages of a terminal illness.

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Internist (Internal Medicine Doctor)

This is a doctor who specializes in the diagnosis and medical treatment of diseases in adults.

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Initial Coverage Election Period (ICEP)

When you are first eligible for Medicare, the timeframe 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.

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In-Network

Providers (hospitals, physicians, pharmacies) that have contracts with your health insurance are considered in-network and will have a lower coinsurance or copayment. By selecting care that is “in-network” it will normally cost you less out of pocket.

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Inpatient Care

Health care that you get when you're admitted to a health care facility, like a hospital or skilled nursing facility.

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Institution

A hospital or other care facility.

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Legal Guardian

The person who takes care of a child and makes healthcare decision for the child. This person is the natural parent or was made caretaker by a court of law.

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Living will

A document where you state your wishes for medical treatment if you have a medical emergency and are not able to speak for yourself

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Long-Term Care

Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing. Long-term supports and services can be provided at home, in the community, in assisted living or in nursing homes. Individuals may need long-term supports and services at any age. Medicare and most health insurance plans don’t pay for long-term care.

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Long-term Insurance

A type of health insurance that covers certain services over a set amount of time (typically a 12-month period).

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Managed Care

A medical delivery system that manages the quality and cost of medical services that individuals receive by measuring performance of those services. The goal of managed care is to reduce the cost of providing for-profit health care while improving the quality of that care.

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Maximum Out-of-Pocket Expense

Excluding premiums, the maximum out-of-pocket amount is the largest amount of money in which you are financially responsible for paying for covered services over a calendar year after deductibles, copayments, and coinsurances are calculated.

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Medical Care

Medical services received from a healthcare provider or facility to treat a condition.

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Medically Necessary

Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. For example, Inpatient care is medically necessary if your condition can't be treated properly as an outpatient service.

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Medicaid (Title 19 or BadgerCare Plus)

A joint Federal and state insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities.

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Medicare Advantage Open Enrollment Period (MA OEP)

This is an additional period when Medicare Advantage Plan members can make a plan change from January 1 to March 31. Individuals may make only one election during the MA OEP.

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Medicare

Medicare is the federal health insurance program for:

  • People who are 65 or older
  • Certain younger people with disabilities
  • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

The different parts of Medicare (Medicare Part A, Part B, Part C, and Part D) help cover specific services:

  • Medicare Part A =  Hospital Insurance which covers inpatient hospital stays, care in skilled nursing facility, hospice care, and some home health care.
  • Medicare Part B = Medical Insurance which covers certain doctors' services, outpatient care, medical supplies and preventive services.
  • Medicare Part C = Medicare Advantage Plans which are offered by a private company that contracts with Medicare.  Medicare Advantage Plans provide all of your Part A and Part B benefits and include:
    • Health Maintenance Organizations (HMOs)
    • Preferred Provider Organizations (PPOs)
    • Private Fee-for-Service Plans
    • Special Needs Plans (SNP)

If you are enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan.  Medicare services are not paid for by Original Medicare.  Most Medicare Advantage Plans offer Prescription drug Coverage or Medicare Part D.

  • Medicare Part D = Prescription Drug Coverage, which adds prescription drug coverage to Original Medicare, some Medicare Cost Plans and some Medicare Private-Fee-for-Service Plans.
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Member (Member of our Plan, or Plan Member)

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 & Medicaid Services (CMS).

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Mental Health

The condition of being sound mentally and emotionally.

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Network

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

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Network Pharmacy

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.

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Network Provider

“Provider” is the general term for doctors, other health care professionals, hospitals, and other health care facilities that provide medical care. They are “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.

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Non-network Provider/Out-of-network Provider

A healthcare provider who is not part of a plan’s network. Costs associated with out-of-network providers may be higher or not covered by your plan.

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Notice

An official form of communication that informs individuals about the status of their applications, their eligibility for programs, or other important information.

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Obstetrician-gynecologist (OB/GYN)

A provider who specializes in childbirth, caring for and treating women in connection with childbirth and health maintenance and diseases of women

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Original Medicare

Also known as "Traditional Medicare" or "Fee-for-Service Medicare, 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.

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Outpatient Services

Services that do not need an overnight stay in a hospital.   These services are often provided in a doctor’s office, hospital or clinic. 

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Out-of-Pocket Costs

Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.

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OTC

Over-the-Counter medications and supplies such as first-aid supplies, diagnostic equipment, incontinence supplies, weight loss supplies, vitamins and minerals. iCare offers plans that include a monthly allowance that members can use towards their OTC needs. Items are shipped to members’ homes free of charge.

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PACE Plan

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) for as long as possible, while getting the high-quality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid benefits through the plan.

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Personal Emergency Response System (PERS)

Also known as a Medical Emergency Response System, it lets you call for help in an emergency by pushing a button. The button sends a signal to a console connected to your phone, which calls an emergency response center.

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Physician Services

Health care services a licensed medical physician provides or coordinates.

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Plan

A health insurance benefit that pays for your health care services.

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Plan Year

A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year.

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Power of Attorney

A legal document giving one person (the agent) the power to act for you. The agent will make medical decisions for you when you are not able to speak for yourself.

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Pre-Admissions Certificate

This requires a patient to gain approval from the insurance company to be admitted to a hospital before services provided will be covered. A case manager may also assist in obtaining approval.

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Pre-Existing Condition

A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies can't refuse to cover treatment for your pre-existing condition or charge you more.

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Preferred Provider

A provider who has a contract with your health insurer or plan to provide services to you at a discount.

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Premium

The amount you pay for your health insurance every month, in addition to your premium, including a deductible, copayments, and coinsurance.

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Prescription Drugs

Drugs and medications that, by law, require a doctor’s written authorization.

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Prevention

Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings.

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Primary Care

Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health-related issues. They may also coordinate your care with specialists.

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Primary Care Physician (PCP)

The PCP is responsible for providing basic care for a patient and will coordinate specialty service if they determine that should be the next step in your care plan.

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Preauthorization / Prior Authorization

Approval from a health plan that may be required before you are provided a service or fill a prescription that is to be covered by your plan. Sometimes called prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost though.

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PPO (Preferred Provider Organization)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

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 Prosthetics and Orthotics

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.

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Qualified Health Plan

An insurance plan that provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. All qualified health plans must meet the Affordable Care Act requirement for having health coverage, known as “minimum essential coverage.”

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Quality Improvement Organization (QIO)

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.

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Quantity Limits

A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be set on the amount of the drug that is covered as per the prescription or for a certain timeframe.

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Quality Ratings (or 'star' ratings)

Ratings for the quality of a health plan ranging from 1 to 5, with 5 stars being the highest rating possible.  Each health plan has an “overall” quality rating, which is based on scores for 3 elements: member experience, medical care, and plan administration.

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Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

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Rehabilitative/Rehabilitation Services

Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

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Retirement Benefit (Pension)

A payment or series of payments made to you after you retire from work.

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Self-Advocacy

Self-advocacy means taking control and making your own decisions. It means having a say in who your providers are, the types of services you receive, and when, where and how those services are delivered.

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Service Area

 A geographic area where a health insurance 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. Your coverage may end if you move out of the plan's service area.

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Skilled Nursing Care

Services provided by licensed nurses, technicians or therapists that occur in your own home or in a nursing home.

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Social Security

A system that distributes financial benefits to retired or disabled people, their spouses, and their dependent children based on their reported earnings. While you work, you may pay taxes into the Social Security system. When you retire or become disabled, you, your spouse, and your dependent children may get monthly benefits that are based on your reported earnings. Your survivors may be able to collect Social Security benefits if you die.

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Special Health Care Need

A special type of Medicare Advantage Plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.

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Specialist

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

Examples of specialists include:  Oncologists, who care for patients with cancer; Cardiologists who care for patients with heart conditions; Orthopedists, who care for patients with certain bone, joint, or muscle conditions.

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State Health Insurance Assistance Program (SHIP)

A state program that gets funding from the federal government to provide free local health coverage counseling to people with Medicare.

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Supplemental Security Income (SSI)

A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or 65 or older. SSI benefits aren't the same as Social Security retirement or disability benefits. The iCare Medicaid SSI Plan is available for indivuals who qualify for SSI and meet other eligiblity requirements.

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Step Therapy

A utilization tool that requires you to first try another drug to treat your medical condition before the drug that your physician prescribed.

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Summary of Benefits and Coverage

An easy-to-read summary that provides comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you. You'll get the "Summary of Benefits and Coverage" (SBC) when you renew or change your coverage or request an SBC from your health insurance company.

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Usual, Customary, and Reasonable

This refers to amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service.

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Urgent Care

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care.

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Vision Coverage

A health benefit that at least partially covers vision care, like eye exams and glasses.

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Well-baby and Well-child visits

Routine doctor visits for comprehensive preventive health services that occur when a baby is young and annual visits until a child reaches age 21. Services may include physical exam and measurements, vision and hearing screening, and health risk assessments.

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Wellness Programs

 A program intended to improve and promote health and fitness that's usually offered through the work place, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.

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Sources: HealthCare.gov, iCare Evidence of Coverage documentation, iCare Formulary, medmutual.com, wisconsinhealthmarketadvisor.com, bls.gov, ftc.gov, cms.gov

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