Deductible—A specified amount of money a member must pay before insurance benefits begin. Usually expressed in terms of an “annual” amount. In many for-profit Medicare plans that means you will pay out-of-pocket expenses before your coverage begins.
Dual-Eligible—to individuals who qualify for both Medicare and Medicaid.
Effective Date of Enrollment—The date that is shown on the Elderplan identification card is the date the membership in Elderplan begins. The effective date is always the first day of the month.
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.
Emergency Services—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.
Exclusion—A health care service or medication not reimbursable through an insurance plan or HMO (e.g., elective cosmetic surgery, etc.).
Fee-for-Service (FFS)—A payment system by which doctors, hospitals and other providers are paid a specific amount for each service performed as it is rendered and identified by a claim for payment.
Formulary—A list of covered drugs provided by the plan.