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Priority Health Medicare Advantage plans for 2012 are available in Allegan, Antrim, Barry, Bay, Benzie, Branch, Cass*, Charlevoix, Clare, Crawford, Emmet, Gladwin, Grand Traverse, Gratiot, Hillsdale, Ingham, Ionia, Isabella, Jackson, Kalamazoo, Kalkaska, Kent, Lake, Leelanau, Lenawee, Livingston, Macomb, Manistee, Mason, Mecosta, Midland, Missaukee, Monroe, Montcalm, Muskegon, Newaygo, Oakland, Oceana, Osceola, Otsego, Ottawa, Roscommon, St. Clair*, St. Joseph, Saginaw, Sanilac, Shiawassee, Tuscola, Wayne, Washtenaw, and Wexford counties. *PriorityMedicare SelectSM (PPO) is the only Medicare Advantage plan we offer in these two counties.
When authorization rules apply, it means you or your doctor must ask Priority Health in advance to approve the service or drug for you before Priority Health will pay for it.
A person who has health care insurance through the Medicare or Medicaid program.
Under Original Medicare and Medigap plans, a "benefit period" begins the day you go to a hospital or skilled nursing facility (SNF) and ends when you haven't received any hospital or skilled nursing care 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 is no limit to the number of benefit periods. Under Medicare Advantage plans, benefit periods only apply for skilled nursing care, not for hospital care.
The national Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Managed Care survey asks Medicare plan members about their satisfaction with their Medicare plans. It is published each year by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality. Our 2008, 2009 and 2010 Medicare Advantage plans earned five stars, or Excellent, which is the highest rating category.
Under plans that include the Medicare Part D drug coverage, this is the stage where you pay a low copay or coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,550 in covered drugs during the covered year.
The percentage of the bill you pay when you visit a doctor or receive a service or prescription covered by your plan. Your plan then pays the rest of the cost.
A set amount you pay when you visit a doctor or receive a service or prescription covered by your plan. Your plan then pays the rest of the cost.
The amount you pay for health care and/or prescriptions. This can include copayments, coinsurance, and/or deductibles.
A time period during which Medicare does not cover your prescription drugs. It comes after you reach $2,830 in 2010 and $2,840 in 2011 in total drug costs and before you reach $4,550 in yearly out-of-pocket drug costs.
When a service or a drug is "covered," it means it is a benefit of the plan. For example, Priority Health Medicare Advantage plans do not cover cosmetic surgery, but they do offer coverage for physical exams, Pap smears and mammograms.
The amount you pay each year for covered services or drugs before the plan you enroll in starts to pay for them. You may have no deductibles or more than one deductible. An example would be a plan with a $0 deductible for services in our network, and a $300 deductible for services outside our network.
The discount that Priority Health negotiates for drugs or services from health care providers in its network. Priority Health's discount on prescription drugs averages 16% on most brand name drugs and 58% or more on generic drugs.
Equipment that can be used for long periods of time, such as crutches, walkers, hospital beds and wheelchairs.
If you are in Original Medicare, this is the difference between a doctor's or other health care provider's actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.
A list of drugs covered by a plan.
You can request that we cover a drug for you that is not on the Approved Drug List (the formulary) for your plan, when there is no drug on the list that works for you. This is called "requesting a formulary exception." You will need to follow our procedure for requesting an exception.
A prescription drug approved by the Federal Food and Drug Administration (FDA) that is produced and sold without patent protection. A generic equivalent drug contains the same active ingredient as a brand-name version.
In certain situations, such as losing your employer-sponsored retiree health insurance, a health insurance company cannot deny you from enrolling in its Medigap policies or increase your Medigap premium because of your health conditions. This period is called your "guaranteed issue" period. During this period, you have a "guaranteed issue right" to enroll.
This plan is an HMO that gives you the option to go out of the plan's network to see doctors, hospitals or other health care providers, an option called "point-of-service" (POS). In a HMO-POS plan you choose a primary care doctor or other primary health care provider (a "PCP") in the plan's network to coordinate your care, but you don't need a referral from your PCP to go out of network or to see specialists.
In-network services are those you receive from doctors, hospitals, and other health care providers who contract with Priority Health to provide services to our Medicare plan members within our Michigan service area. Priority Health has contracts with more than 12,000 primary care and specialist doctors, plus 44 Michigan hospitals, and more than 67,000 pharmacies nationwide.
Health care that you get when you are admitted to a hospital or skilled nursing facility.
In Original Medicare, a total of 60 extra days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. Once these 60 reserve days are used, you don't get any more extra days during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of you or your doctor.
Abbreviation for any Medicare Advantage (MA) plan that includes a Medicare Prescription Drug Plan (PDP).
A plan offered by a private insurance company under contract with Medicare. Medicare Advantage plans replace Original Medicare Parts A (hospitalization) and B (doctor visits and medical coverage), but you must still pay your monthly Part B premium in addition to the Medicare Advantage plan premium.
Nickname for Medicare Supplement insurance, so called because Medigap plans help pay some of the health care costs, and may also cover certain things, that Original Medicare doesn't cover.
Refers to all doctors, hospitals and other health care providers who contract with Priority Health to provide services to the company's Medicare plan members. Priority Health has contracts with more than 12,000 primary care and specialist doctors, plus 44 Michigan hospitals, and more than 67,000 pharmacies nationwide.
These brand-name drugs are usually the newest and/or the highest-cost drugs. They are not included in the preferred brand tier because there are other drugs that work as well or better and cost less.
Medigap plans have two premium levels, preferred and non-standard. The non-standard premium applies to you if you are no longer in your open enrollment period and you are not eligible for a guaranteed issue right. It may also apply based on your health and whether or not you use tobacco.
Under Medigap, your open enrollment period is the six-month time period after you enroll in Medicare Part B. It begins on the first day of the month in which you are BOTH 1) age 65 or older and 2) enrolled in Medicare Part B.
A doctor, hospital, pharmacy, or other health care provider that does not have a contract with Priority Health to provide services to Priority Health Medicare plan members.
Your out-of-pocket costs are what you pay, the cash that comes from you. For prescription drugs, it includes your copays and/or the percentage of the cost that you pay.
The maximum amount you would pay for medical services, including your copays and any deductible. There is no out-of-pocket maximum for prescription drug coverage.
A primary care physician or other primary health care provider, such as a nurse practitioner, who coordinates your medical care. If your plan requires you to choose a PCP, you can choose a family practice physician, internist, or GP. Some OB/GYNs and other specialists can also be your primary care physician.
An HMO option that lets you use doctors and hospitals outside the plan's network for an additional cost.
PPO stands for Preferred Provider Organization. These plans are similar to HMOPOS plans because you can go out of the plan's network to see doctors, hospitals or other health care providers, at an additional cost. They are different from HMO and POS plans in that you don't need to choose a primary care doctor or other primary health care provider.
Medicare Part A insurance covers inpatient care in hospitals, including skilled nursing facilities, hospice, and home health care.
Medicare Part B medical insurance helps cover the costs doctor's services and outpatient care, including some preventive services to help maintain your health and to keep certain illnesses from getting worse.
Medicare Part C is coverage for Parts A and B offered by private insurance companies approved by Medicare. These plans are called Medicare Advantage plans. Priority Health's Medicare Advantage plans also include Medicare Part D prescription drug coverage.
Medicare Part D is prescription drug coverage. It may help lower your prescription drug costs and help protect you against higher costs in the future.
Preferred brand drugs have usually been on the market for a while or are commonly prescribed. They have been selected to be on the Approved Drug List (formulary) based on their effectiveness and safety.
Medigap plans have two premium levels, preferred and non-standard. The preferred premium applies to you if you are in your open enrollment period, or if you have a guaranteed issue right. It may also apply if you are healthy.
A referral is generally a written document that must be received by a doctor before he or she can give you care. Though Priority Health Medicare plans do not require you to get a referral to see a specialist, some specialists will ask for a referral before they will agree to see you.
The Priority Health service area for our Medicare prescription drug plan (PriorityMedicare Rx) is the entire state of Michigan. Our service area for our Medicare Advantage plans is 31 counties in 2010 and 38 counties in 2011, in lower Michigan.
A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).
Drugs or drug classes whose cost per month or per dose is higher than the limit established by the Federal government's Centers for Medicare and Medicaid Services (CMS). You can get a maximum of a 31-day supply per prescription or refill of a specialty drug.
This is the part of your monthly drug plan premium that Medicare pays if you qualify for extra help. A 100% subsidy means you will not have to pay for your drug plan or the drug plan portion of your Medicare Advantage plan. A 50% subsidy means you will only have to pay half of the regular drug plan premium. No matter how large a subsidy you get, you will still have to pay your Medicare Part B monthly premium.
Every drug covered by a Priority Health Medicare Advantage or prescription drug plan is listed in one of four cost-sharing levels, or "tiers." The higher the tier, the higher the cost of the drug and the higher your copay for the drug.
The total of what you have paid plus what your plan has paid for your prescription drugs during the year.
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