A set time each fall when members can change their health or drug plans or switch to Original Medicare. The Annual Enrollment Period is from October 15 until December 7.
An action you can take if you disagree with the decision made by Medicare or another type of health plan. An appeal is allowed if your plan denies a claim for a service, item, or medication that you believe that you need or have already received.
The way that the Community (HMO D-SNP) measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you’re admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.
A drug sold by a drug company under a specific name or trademark that is protected by a patent. Brand name drugs may be available by prescription or over the counter and have the same active-ingredient formula as the generic version of the drug.
A request for payment submitted to Medicare or Community Health Choice after when you get items and services.
An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.
A general term for the health care services and supplies that are covered by Community Health Choice (HMO D-SNP).
A special type of Medicare Advantage Plan that provides more focused health care for those who have both Medicare and Medicaid.
The sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical care that you receive within 72 hours after the onset.
Covered services rendered by a provider qualified to furnish emergency care necessary to treat, evaluate, or stabilize an emergency medical condition.
A document provided by Community Health Choice that explains your coverage, our responsibilities, your rights, and what you have to do as a member of our plan.
Medicare exception requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. An enrollee’s prescriber must submit a supporting statement to the plan sponsor supporting the request.
A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits.
A prescription drug that has the same active ingredient(s) as the brand name drug. Generally, a generic drug works the same as a brand name drug in terms of dosage, safety, strength, how it is taken, quality, performance, and intended use.
A person or organization licensed to give healthcare. Doctors, nurses, and hospitals are examples of health care providers.
Health care services and supplies a doctor decides you may get in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.
A hospital stay during which you have been formally admitted to the hospital that accepts Medicare as an inpatient after an official doctor’s order, which says you need inpatient hospital care to treat your illness or injury.
The physicians, facilities, pharmacies, and other health care providers that participate in the Medicare program. The Community (HMO D-SNP) plans only cover in-network services and providers.
The time period when you can sign up for Medicare Part A and Part B when you first become eligible (generally when you turn 65). Your Initial Enrollment Period lasts for 7 months, starting 3 months before you turn 65, and ending 3 months after the month you turn 65.
Services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living, like dressing or bathing. These services can be provided at home, in the community, in assisted living, or in nursing homes. Medicare and most health insurance plans don’t pay for long-term care.
A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.
Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
From January 1 – March 31 each year, Medicare Advantage Plan members can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan) once during this time.
A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all your Part A and Part B benefits, with a few exclusions. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for by Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage (Medicare Part D).
A Community department responsible for answering your questions about your membership, benefits, grievances, and appeals. If you have any questions, call Member Services toll-free at 833.276.8306 (TTY 711).
A pharmacy that is contracted with Community where Members can get their prescription drug benefits.
Primary care physicians, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State of Texas to provide health care services.
A pharmacy that doesn’t have a contract with our plan to coordinate or provide covered drugs to Members. Covered drugs are available at out-of-network pharmacies in emergencies or unusual circumstances and for non-routine access to covered Part D drugs.
Certain doctors and other health care providers who don’t want to work with the Medicare program may “opt out” of Medicare. Medicare doesn’t pay for any covered items or services you get from an opt out doctor or other provider, except in the case of an emergency or urgent need. If you still want to see an opt out provider, you and your provider can set up payment terms that you both agree to through a private contract.
Health or prescription drug costs that you must pay on your own because they aren’t covered by Medicare or other insurance.
A Prescription Drug Benefit Manager (PBM) is a third-party administer of the prescription drug (Part D) benefit.
Healthcare to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms).
The doctor you see first for most health problems. They make sure you get the care you need to keep you healthy. They also may talk with other doctors and healthcare providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other healthcare provider.
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.
Healthcare services that help you keep, get back, or improve skills and functioning for daily living that you’ve lost or have been 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.
A geographic area where a health plan accepts members if it limits membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you permanently move out of the plan’s service area.
You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. Rules about when you can make changes and the type of changes you can make are different for each Special Enrollment Periods (SEP).
For more definitions of Medicare terminology, please see the Medicare glossary.
October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week, and April 1 through September 30, 8:00 am to 8:00 pm, Monday through Friday. On certain holidays your call will be handled by our automated phone system.
Footnotes
