Healthcare Words


To find the definition of a term, click on the corresponding first letter of the word above.


Advance Primary Care (APC)
Advance Primary Care is a new kind of coordinated healthcare centered on the patient. Blue Cross has partnered with Rhode Island’s leading physicians to offer this new type of team-based care, which offers patients services like free visits with a nurse care manager or pharmacist in a doctor’s office, extended hours, free classes, screening and test reminders, and much more.
Annual Enrollment Period (AEP)
The time of year when anyone with Medicare may switch from one way of getting Medicare to another for the following year. The AEP is from October 15 through December 7, and plan changes take effect on January 1. During the AEP, you are not limited in the type of change you may make to your coverage. The plan cannot accept enrollment forms before November 15.
An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services and/or prescription drugs or payment for services and/or prescription drugs you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our Plan doesn’t pay for a drug/item/service you think you should be able to receive.


Benefit Period
For both our Plan and the Original Medicare Plan, 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 haven’t 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 that is covered depends on whether you are considered an inpatient for hospital and SNF stays. You must be admitted to the hospital as an inpatient, not just under observation. You are an inpatient in a SNF only if your care in the SNF meets certain standards for skilled level of care. Specifically, in order to be an inpatient in a SNF, you must need daily skilled-nursing or skilled-rehabilitation care, or both.
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 generally not available until after the patent on the brand name drug has expired.


Catastrophic Coverage
The phase in the Part D prescription drug benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,850 in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high-quality healthcare.
Cost-sharing refers to amounts that a member has to pay in addition to the plan’s premium when services or drugs are received. It 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.
Cost-sharing Tier
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.
Coverage Determination
A decision from your Medicare drug plan 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 if you disagree.
Coverage Gap
The Medicare Part D coverage gap (informally known as the Medicare donut hole) is a period of consumer payment for prescription medication costs between the initial coverage limit and the catastrophic-coverage threshold, when the consumer is a member of a Medicare Part D prescription-drug program administered by the United States federal government.
Covered Drugs
The term we use to mean all of the prescription drugs covered by our Plan.
Covered Services
The general term we use to mean all of the healthcare services and supplies that are covered by our plan.


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).
Durable Medical Equipment (DME)
Certain medical equipment that is ordered by your doctor for use in the home. A BlueCHiP for Medicare contracted participating DME provider must be used. Examples are walkers, wheelchairs, or hospital beds.


Emergency Care
Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.
Evidence of Coverage (EOC)
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 the preferred 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).


Generic Drug
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, generic drugs cost less than brand-name drugs.
A type of complaint you make about us or one of our network providers/pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.


Initial Coverage Limit
The maximum limit of coverage under the initial coverage period.
Initial Coverage Period
This is the stage before your total drug expenses have reached $3,310, including amounts you’ve paid and what our Plan has paid on your behalf.
Inpatient Hospitalization
Healthcare that you get when you are admitted to a hospital.


Late Enrollment Penalty
An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that expects 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.
List of Covered Drugs (Formulary or “Drug List”)
A list of covered drugs provided 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.
Low Income Subsidy/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.


Medicaid (or Medical Assistance)
A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
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 your convenience or that of your doctor.
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 Medicare ora Medicare Advantage plan.
Medicare Advantage (MA) 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 (Hospital) and Part B (Medical) 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. 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).
Medicare Advantage Disenrollment Period
From January 1 through February 14, anyone with Medicare can switch to Original Medicare. If you choose to switch to Original Medicare during this period, you can also enroll in a separate Medicare prescription drug plan at the same time.
Medicare Concierge Team
A department within our Plan responsible for answering your questions about your Medicare membership, benefits, grievances, and appeals.
Medicare Coverage Gap Discount Program
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.
Medicare Part A
Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare.
Medicare Part B
Medicare medical insurance that helps pay for doctors' services,outpatient hospital care, durable medical equipment, and some medical services that aren't covered by Part A.
Medicare Part C
See “Medicare Advantage (MA) Plan.”
Medicare Part D
The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)
Medicare Prescription Drug Coverage (Medicare Part D)
Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.
Medigap (Medicare Supplement Insurance) policy
Medicare supplement insurance sold by private insurance companies to fill “gaps” in the Original Medicare Plan coverage. Medigap policies only work with the Original Medicare Plan. (A Medicare Advantage plan is not a Medigap policy.)
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).


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.
Network 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 “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.”


Organization Determination
The Medicare Advantage organization has made an organization determination when it, or one of its providers, makes a decision about whether services are covered or how much you have to pay for covered services.
Original Medicare Plan
(“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.
Out-of-network Pharmacy
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 the Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our Plan unless certain conditions apply.
Out-of-network Provider or Out-of-network Facility
A provider or facility with which we have not arranged to coordinate or provide covered services to members of our Plan. Out-of-network providers are providers that are not employed, owned, or operated by our Plan or are not under contract to deliver covered services to you.


Part D Drugs
Drugs that Congress permitted our Plan to offer as part of a standard Medicare prescription drug benefit. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs, such as benzodiazepines, barbiturates, and over-the-counter drugs were specifically excluded by Congress from the standard prescription drug package. These drugs are not considered Part D drugs but may be offered in some plans
Primary Care Physician (PCP)
A healthcare professional you select to coordinate your health care. Your PCP is responsible for providing or authorizing covered services while you are a plan member.
Prior Authorization
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.


Quality Improvement Organization (QIO)
Groups of practicing doctors and other healthcare experts that 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 Medicare Providers. Livanta is the QIO for the State of Rhode Island.
Quantity Limits
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.


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


Service Area
“Service area” is the geographic area approved by the Centers for Medicare & Medicaid Services (CMS) within which an eligible individual may enroll in a certain plan, and in the case of network plans, where a network must be available to provide services.
Skilled Nursing Facility (SNF) Care
A level of care in a SNF ordered by a doctor that must be given or supervised by licensed healthcare professionals. It may be skilled nursing care, or skilled rehabilitation services, or both. Skilled nursing care includes services that require the skills of a licensed nurse to perform or supervise. Skilled rehabilitation services are physical therapy, speech therapy, and occupational therapy. Physical therapy includes exercise to improve the movement and strength of an area of the body, and training on how to use special equipment, such as how to use a walker or get in and out of a wheelchair. Speech therapy includes exercise to regain and strengthen speech and/or swallowing skills. Occupational therapy helps you  learn how to perform usual daily activities, such as eating and dressing by yourself.
Special Election Period
A set time that a beneficiary can change health plans or return to Original Medicare, such as: you move outside the service area, your Medicare Advantage plan violates its contract with you, the organization does not renew its contract with CMS, or other exceptional conditions determined by CMS. The Special Election Period is different from the Special Enrollment Period (SEP).
State Health Insurance Assistance Program (SHIP)
A state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. The SHIP for Rhode Island is the Rhode Island Department of Elderly Affairs.
State Pharmaceutical Assistance Program (SPAP)
A state organization that provides limited-income and medically needy senior citizens and individuals with disabilities financial help for prescription drugs. The SPAP for Rhode Island is Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE).
Step Therapy
When a health plan requires you to first try certain drugs to treat your medical condition before the plan will cover another drug for that condition. For example, the plan may say you need to try a lower cost drug that is approved for your condition. If that drug is not effective, then the plan will pay for a higher cost drug.
Supplemental Security Income (SSI)
A monthly benefit paid by the Social Security Administration to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits.


Urgently Needed Care
Urgently needed care is a non-emergency situation when you need medical care right away because of an illness, injury, or condition that you did not expect or anticipate, but your health is not in serious danger. For more definitions, please see the glossary on the Centers for Medicare & Medicaid Services website.

Last updated: 01/01/2018

H4152_2018web5 Approved

Blue Cross & Blue Shield of Rhode Island is an HMO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal.