The 12-month period that begins on January 1 and ends on December 31 is the calendar year. When you enroll in Medicare, coverage begins on the effective date of your policy and ends on the following December 31.
Method of payment for health services in which a dentist or specialist is paid a fixed amount for each person served regardless of the number or nature of services provided to each person, usually associated with a prepaid/HMO.
See Nonduplication of Benefits.
This is the maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given fiscal year (October 1 to September 30). Point-Of-Service (POS) cost-shares and the POS deductible are not applied to the catastrophic cap.
Offered with Medicare Part D, catastrophic coverage is designed to prevent you from having to pay very high out-of-pocket expenses. Once you have spent a pre-determined amount on your healthcare within a year, you will pay no more than 5% for each prescription drug. You will still need to pay your monthly premiums for the plan.
A catastrophic illness is a very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services for this type of condition could cause you financial hardship if you are not properly insured.
This refers to geographic areas determined by the Assistant Secretary of Defense (Health Affairs) that are defined by a set of five-digit ZIP codes, usually within an approximate 40-mile radius of a military inpatient treatment facility.
The Centers for Disease Control and Prevention is an agency of the federal Department of Health and Human Services.
Centers for Medicare & Medicaid Services (CMS)
The primary governing entity for the Medicare Advantage Program, CMS was formerly known as the Healthcare Financing Administration (HCFA). All materials, forms, letters, attachments, etc., that are distributed to retirees by the Medicare Advantage plan must be submitted to CMS.
To be eligible for a Medicare Supplement plan, you must have Medicare Part A and Part B. You have the right to buy a Medicare Supplement policy if you are in your Medicare Supplement Open Enrollment Period or covered under a protection. Your Medicare Supplement Open Enrollment Period, for Medicare Supplement plans, lasts six months. It starts on the first day of the month in which you are BOTH age 65 or older AND enrolled in Medicare Part B. Once your Medicare Supplement Open Enrollment Period starts it cannot be changed. Federal law doesn’t require insurance companies to sell Medicare Supplement policies to those under age 65. However, some states may require insurance companies to sell you a Medicare Supplement policy, even if you are under age 65. To find out more, check with your state insurance department.
Certificate of coverage
A description of the benefits included in a benefit insurer's plan, the certificate of coverage is required by state law and explains the coverage provided under the contract.
Certificate of insurance
This certificate serves as proof of insurance and outlines benefits and provisions.
CHAMPUS Maximum Allowable Charge (CMAC)
CMAC is a nationally determined allowable charge level that is adjusted by locality indices and is equal to or greater than the Medicare Fee Scheduled amount. CMAC is the TRICARE-allowable charge for covered services when appropriately applied to services priced under CMAC.
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
CHAMPVA is the federal health benefits program for eligible family members of 100% totally and permanently disabled Veterans. CHAMPVA is administered by the Department of Veterans Affairs and is a separate federal program from the Department of Defense TRICARE program. For questions regarding CHAMPVA, call 1-800-733-8387 or email firstname.lastname@example.org.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
The health care program established to provide purchased health care coverage for ADFMs and retired service members and their family members outside the military’s direct care system. TRICARE Management Activity was organized as a separate office under the Assistant Secretary of Defense and replaced CHAMPUS in 1994. The purchased care benefits authorized under the CHAMPUS law and regulations are now covered under TRICARE Standard.
A claim is information submitted by a provider or covered person for reimbursement for services or materials.
A claim is a request for payment (also called a bill) for services and benefits you have received. Medicare Part A and Part B services are billed through private insurance companies. Bills from private insurance companies for Part B physician/supplier services are sometimes also referred to as claims. See definitions for Medicare Part A and Medicare Part B.
The number that uniquely identifies the claim Customer Care can use this number to track your claim if you have questions.
A number assigned by Humana to identify a claim internally.
The amount of Coordination of Benefits (COB) savings from prior claims applied to pay allowable expenses on subsequent claims. This amount is not otherwise paid by the primary other insurance and regular plan benefits.
On the spending account Claim Form, this is the type of expense incurred, such as a healthcare expense for you, a spouse, or a dependent.
Review of a claim is done before reimbursement is submitted to the provider or subscriber.
Physicians, therapists, mid-level practitioners, nurses, and other medical professionals who provide care to patients in the clinic setting are known as clinicians.
With a closed panel, you can only receive benefits if services are performed by providers who have signed an agreement with Humana to provide treatment to eligible patients.
This law requires employers to offer continued benefits coverage to employees who have had their benefits terminated.
After you pay any plan deductibles, you may still be responsible for a percentage of the billed charges for services you received. This is called coinsurance. For instance, if your health plan pays 70% of billed charges, your coinsurance payment is the remaining 30%.
In the drug-screen context, collection is the gathering of a patient’s urine, blood, or hair for laboratory testing.
Refers to the stage of benefits processing when HumanaDental has received an estimate or claim and has released an explanation of benefits or explanation of remittance.
Comprehensive Outpatient Rehabilitation Facility (CORF)
A CORF facility provides a full range of rehabilitation services to outpatients with physical disabilities. A physician supervises these services, which may include physical therapy, occupational therapy, or speech pathology services.
Continuation refers to a state or federal (COBRA) option for a member who no longer qualifies as an active employee but can extend his or her insurance coverage for a specific amount of time. The member is responsible for any premium. This generally applies to medical coverage only, but can include dental depending on legislation and group size. Coverage and premium are the same as the group's.
Contract fee schedule plan
In this plan, participating providers agree to accept set fees for treatment.
This refers to a provider who agrees to abide by special terms, conditions, and reimbursement arrangements.
Types of contracts or plans include Traditional, PPO, or Prepaid/DHMO selected.
Contract types (dental)
Type of contract or plan such as Traditional, PPO, or Prepaid/DHMO selected.
This is the period of time from the effective date of the contract to the expiration date of the contract.
An employer benefit plan in which employees pay at least part of the premium.
This certificate privilege allows the insured to choose to convert from a group life policy to an individual policy before leaving the group to continue insurance coverage.
Coordination of Benefits
If you have multiple benefits plans, the COB determines which plan pays benefits first.
Coordination of benefits (Dental)
Provision in a contract that applies when a person is covered by more than one group dental program, the coordination of benefits requires that all programs coordinate payment of benefits to eliminate overinsurance or duplication of benefits.
Coordination of benefits (Medicare)
If you have more than one health plan or insurance policy that covers the same benefits the coordination of benefits process will be used to determine which plan should pay first. If one of the plans is a Medicare health plan, federal law may decide who pays first. This is also called cross-over.
Copays are cost-sharing arrangements in which you pay a specified charge at the time for service for example, $15 for an office visit.
The flat amount you pay to a healthcare provider or pharmacy at the time of service, copayments vary depending on your plan and the services you receive. Copayments do not reduce your annual deductible or out-of-pocket maximums.
Corporate services provider
A class of TRICARE-authorized providers consisting of institutional-based or freestanding corporations and foundations that render professional ambulatory or in-home care and technical diagnostic procedures.
Cost sharing is the amount you pay for medical care or prescription drugs yourself. This may include a copayment, coinsurance, or deductible.
Coverage refers to the benefits offered as part of your dental plan.
There is a coverage gap for Medicare Part D in which you will be responsible for 100% of drug costs as your expenses for prescriptions exceed ordinary coverage but don’t yet meet the out-of-pocket threshold. To protect yourself, you should have what is called Donut Hole Coverage.
A covered benefit is a health service or item your health plan pays for either partially or in full.
Under HIPAA, this is a health plan, a healthcare clearinghouse, or a healthcare provider who transmits any health information in electronic form in connection with a HIPAA transaction.
These are qualifying costs that you incur and which your plan may pay or reimburse you for in accordance with the terms of your policy.
This refers to an individual who meets a health plan's eligibility requirements and has paid the required premiums for coverage.
These are qualifying services performed by your provider and which your plan may pay for or reimburse you for in accordance with the terms of your policy.
Covered services (Medicare)
Services a health plan pays for in part or in full, a covered service is defined and limited by statute. For instance, covered services under Medicare Supplement plans include most doctor services, care in outpatient departments of hospitals, diagnostic tests, durable medical equipment, ambulance services, and other health services that are not covered by Medicare Part A.
This is the process of approving a provider to participate in a benefit plan.
The process by which providers are allowed to participate in the TRICARE network. This includes a review of the provider’s training, educational degrees, licensure, practice history, etc.
Creditable coverage (Medicare supplement plans)
This is any sort of health insurance plan that you are eligible to use which can shorten the pre-existing condition/ long waiting period that is part of your Medicare Supplement policy.
Creditable coverage (prescription drug plans)
This refers to prescription drug coverage (such as plans offered by an employer or union) that pays out, on average, as much as or more than Medicare’s standard prescription drug coverage.
On the spending account Expenses Requiring Verification Table, this is the amount remaining that needs to be validated or repaid.