Glossary—ABC

Ambulatory Care—All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are hospitalized.

Appeal—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. Please visit: How to File an Appeal for more information on appeals, including the process involved in making an appeal.

Beneficiary—An individual participating in the federal Medicare program.

Benefits—Covered services as defined by the contract or policy.

Benefits Advisor—A telephone representative who assists members with enrolling in an Elderplan plan.

Capitation—A per-member, per-month (PMPM) payment to a health care provider or health plan for each member enrolled, regardless of the amount of care a member requires.

Care Management—The process by which all health-related matters of a case are managed by a physician, nurse or designated health professional.

Care Manager—A nurse, doctor or social worker who works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care.

Centers for Medicare and Medicaid Services (CMS)—The federal agency that oversees all aspects of financing and regulation for the Medicare program, including Medicare Advantage and Part D plans.

Coordination of Benefits (COB)—A term used when a member has medical coverage from two different sources and both parties share the cost. The COB department handles all insurance matters.

Co-insurance—The portion of the bill or contracted charge for which you (the member) are responsible. For example, a 25% co-insurance for specialty tier 4 drugs means you pay 25% of the costs for that prescription and Elderplan pays 75% of the cost.

Co-payment—The fee you pay at the time of medical services in accordance with Elderplan. For example, a $0 co-payment (or co-pay) to see your regular doctor means you pay nothing.¹

Coverage—The services or benefits provided.

Customer Service Representative (CSR)—An individual whose primary responsibility is to help members, physicians and interested Medicare beneficiaries with Elderplan questions or issues.