Those instances when a provider agrees to accept the TRICARE allowable charge(s).
Your ability to obtain care in your network–i.e., covered medical and dental services, etc.
The length of time an individual has to accumulate covered expenses to satisfy a required deductible and/or calendar year or plan-year maximum. This varies based on your plan type and the start date of your plan year.
The amount of money a doctor or supplier charges for a specific medical service or supply. This is often higher than the approved amount that your health plan and Medicare pay because insurance companies and Medicare negotiate lower rates for members.
Your entry into a medical facility as a registered inpatient according to the rules and regulations of that facility. Your admission ends when you are discharged or released from the facility.
The doctor responsible for admitting you into a hospital or other inpatient health facility.
Advance coverage decision
A determination on whether a specific service is covered under your private fee-for-service (PFFS) plan prior to receiving service.
Radiology tests that use complex, highly developed, non-invasive technology to view the interior of the body. Examples include CT scans, ultrasound, MRA and MRI tests.
Affordable Care Act (ACA)
The comprehensive healthcare reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
The maximum amount a benefits plan will pay for a procedure.
The maximum charge accepted by a health plan for a specific covered medical service or supply.
Any health service that does not require an overnight hospital stay.
Ambulatory surgical center
A non-hospital location where outpatient surgery is performed.
Americans with Disabilities Act (ADA)
A 1990 federal law that defines "disability" and prohibits discrimination against people who are disabled.
Amount you pay
The amount you must pay your provider(s).
Services received in support of your medical care, such as laboratory work, X-rays and anesthesia.
A way to control pain before or during a procedure using medicine called anesthetics. The types of anesthesia include general anesthesia, intravenous sedation/analgesia, local anesthesia, non-intravenous conscious sedation or regional anesthesia.
The amount of covered expenses you must pay in a plan year before your insurance plan pays any benefits.
Annual Election (Spending Accounts)
The total amount of flexible spending account (FSA) or personal care account (PCA) funds the employee selects for the plan year.
Annual Election Period
The Annual Election Period (AEP) runs from October 15 through December 7 of each year and applies to Medicare Advantage and prescription drug plans. During this time Medicare beneficiaries can join a Medicare Advantage health plan, prescription drug plan or change their existing coverage. You can enroll in Medicare Supplement plans, however, at any time if you meet the eligibility requirements.
Annual maximum benefit (Dental)
The total amount you'll spend between your plan effective date and the end of your plan year.
Annual Notice of Change (ANOC)
A Centers for Medicare & Medicaid Services-mandated notification of yearly plan benefit changes sent to enrolled members.
Annual plan premium
The amount you pay to have a Humana Medicare plan during the calendar year.
You can request the reversal of a decision if you were denied a request for coverage of healthcare services or items, payment for healthcare services or items or a change in the amount you paid for a healthcare service, supply or item received. You can also appeal if you disagree with a decision to stop coverage for services or items you are receiving. Medicare Advantage and Medicare prescription drug plan carriers as well as Medicare Parts A and B must follow a specific appeals process.
You must submit a signed document to an insurance company to be considered for a policy.
The fee Medicare sets as reasonable for a covered medical service or item. This is the amount Medicare pays for a service or item. The amount may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the approved charge.
Assignment means a doctor agrees to accept Medicare's approved amount as full payment. You may be able to save money by going to a doctor who accepts assignment, but you may still have some costs, such as coinsurance. See also the definitions for actual charge, approved amount and coinsurance.
Assignment of benefits
An arrangement by which you request that your health benefit payments be made directly to a designated person or facility, such as a doctor or hospital.
A living arrangement in which you are assisted with everyday life activities and receive personal care services such as meals, housekeeping and transportation. This assistance is offered, as needed, to people who still live on their own in a residential facility. In most cases, assisted living residents pay regular monthly rent plus fees for additional services they receive.
The licensed doctor who has primary responsibility for your medical care and treatment.
You must have a verbal or written authorization from your insurance plan for some services before you receive care.
Authorization for care (TRICARE)
The determination that the requested treatment is medically necessary, delivered in the appropriate setting, a TRICARE benefit, and that the treatment will be cost-shared by the Department of Defense.