The amount a physician or supplier actually bills for a particular
medical service or supply.
The amount Medicare determines to be reasonable
for a service that is covered under Part B
of Medicare. It may be less than the actual
charge. For many services, including physician
services, the approved amount is taken from
a fee schedule that assigns a dollar value
to all Medicare-covered services that are
paid under that fee schedule.
An arrangement whereby a physician or medical supplier agrees to accept
the Medicare-approved amount as full payment for services and supplies
covered under Part B. Medicare usually pays 80% of the approved amount
directly to the physician or supplier after the beneficiary meets the
annual Part B deductible of $100. The beneficiary pays the other 20
Is the approval by your Medical Group of a referral made by your Primary
Care Physician. It is also the approval of your Primary Care Physician
or Medicare Group in an emergency.
A benefit period is a way of measuring a beneficiary's use of hospital
and skilled nursing facility services covered by Medicare. A benefit
period begins the day the beneficiary is hospitalized. It ends after the
beneficiary has been out of the hospital or other facility that
primarily provides skilled nursing or rehabilitation services for 60
days in a row. If the beneficiary is hospitalized after 60 days, a new
benefit period begins, most Medicare Part A benefits are renewed, and
the beneficiary must pay a new inpatient hospital deductible. There is
no limit to the number of benefit periods a beneficiary can have.
Benefit Period (Part A)
As defined by Medicare, this begins when you first enter a hospital or
skilled nursing facility. It ends when you have been discharged, and not
readmitted to a hospital or other facility for at least 60 consecutive
The Centers for Medicare and Medicaid Services is the federal government
agency responsible for administering Medicare and federal participation
in Medicaid. (Formerly known as the Health Care Financing
The portion or percentage of the Medicare-approved amount that a
beneficiary is responsible for paying.
A hospital which has a Blue Cross Senior Secure plan Agreement in effect
at the time services are rendered and which is also Medicare certified.
The amount of payment indicated in the Summary Of Benefits section of
your contract book. It is due and payable (at the time of service) by
the Member to the Medical Group, hospital or other provider of care.
Medically necessary services or supplies which are listed in the Summary
Of Benefits section of this Agreement, and for which the member is
entitled to receive benefits.
Care provided primarily to meet the personal needs of the member. This
includes help in walking, bathing or dressing. It also includes
preparing food or special diets, feeding, administered, or any other
care which does not require the continuing services of medical
The amount of expense a beneficiary must first incur before Medicare
begins payment for covered services.
Drugs which the medical literature indicates are clinically effective,
safe and of reasonable cost. The goal of Blue Cross' formulary list of
prescription drugs, as established for the WellPoint Pharmacy Plan, is
to identify and promote prescription drugs which are therapeutically
appropriate and cost effective.
Prescription drugs not on Blue Cross' formulary list.
Durable Medical Equipment
Equipment which can withstand repeated use, is primarily and usually
used to serve a medical purpose, is generally not useful to a person in
the absence of illness or injury, and is appropriate for use in the
home. To be covered, durable medical equipment must be medically
necessary and prescribed by a contracting physician for use in the home.
Examples are oxygen equipment, wheelchairs and hospital beds. These
items are covered in accordance with Medicare laws, regulations and
A sudden, serious or unexpected acute illness, injury or condition which
could permanently endanger your health if medical treatment is not
The difference between the Medicare-approved amount for a service or
supply and the actual charge, if the actual charge is more than the
Procedures that are mainly limited to laboratory and/or animal research,
but which are not generally accepted as proven and effective procedures
within the organized medical community. When making a determination as
to whether a service is experimental, Blue Cross Senior Secure will use
Medicare guidelines or rely upon determinations already made by
Medicare. Experimental procedures and items are not covered under Blue
Cross Senior Secure.
HMO (Health Maintenance Organization)
An organization that provides a wide range of comprehensive health care
services through a designated group, or network of doctors, hospitals,
labs and other providers. To receive benefits, the member must see the
doctor he selects as his primary care physician first for care or a
referral, except in the case of an emergency. The choice of doctors is
restricted to those in the network.
Home Health Agencies and Visiting Nurse Associations
These are home health care providers, licensed according to state and
local laws, to provide skilled nursing and other services on a visiting
basis in the Member's home. They must be approved as home health care
providers under Medicare and the Joint Commission on Accreditation of
An organization or agency, certified by Medicare, that is primarily
engaged in providing pain relief, symptom management, and supportive
services to terminally ill people and their families.
Hospitals that are not part of the Blue Cross Prudent Buyer network and
that have not signed a standard contract with Blue Cross.
Blue Cross does not pay benefits for services provided by
non-contracting hospitals except in the case of a medical emergency.
IPA (Independent Practice Association)
A partnership, association, or corporation that delivers or arranges for
the delivery of health services and which has entered into a contract
with health professionals, a majority of whom are licensed to practice
medicine or osteopathy.
Health care coverage for individuals or single family units.
Limited Fee Schedule
A list of maximum amounts Blue Cross will pay for certain services
provided by non-network providers. The member is responsible for paying
the co-insurance and any amount over the limited fee schedule.
The maximum amount a physician may charge a Medicare beneficiary for a
covered physician service if the physician does not accept assignment of
the Medicare claim. The limit is 15 percent above the fee schedule
amount for non-participating physicians. Limiting charge information
appears on Medicare's Explanation of Medicare Benefits (EOMB) form.
Under Blue Cross Senior Secure, means the member is
"locked-in" to the use of Blue Cross Senior Secure providers.
The member must receive all medical care from Contracting Blue Cross
Senior Secure Providers, except: emergency services, urgently needed
services outside of the Blue Cross Senior Secure service area, such as
referral to a specialist or to a non-contracting provider; out of area
renal dialysis; or the Choices Plus Self-Referral Benefit. The use of
non-contracting providers, except as stated above, will result in the
obligation to pay for routine care. Neither Blue Cross Senior Secure nor
Medicare will pay for these services.
An insurance organization under contract to the federal government to
process Medicare Part B claims from physicians and other suppliers. The
names and addresses of the carriers and areas they serve are listed in
the back of The Medicare Handbook, available from any Social Security
Medicare Hospital Insurance
This is Part A of Medicare. It helps pay for medically necessary
inpatient care in a hospital, skilled nursing facility or psychiatric
hospital, and for hospice and home health care.
A group of physicians, organized as a legal entity, which has an
Agreement in effect with Blue Cross Senior Secure to furnish medical
care to Members. INDEPENDENT PRACTICE ASSOCIATION (IPA) is a
Participating Medical Group but with the following differences: The
Primary Care Physicians are located at various addresses throughout a
geographically close area; the Physician's relationship with the IPA
administrator is that of an independent contractor. The Member is
required, at the time of enrollment, to select a Medical Group to
provide services covered under this Agreement. However, in the event the
Member does not indicate his or her selection on the enrollment form,
Blue Cross Senior Secure will assign the Member to a Medical Group
nearest to the Member's residence.
Services or supplies are those Blue Cross Senior Secure determines to
- Appropriate and necessary for the symptoms, diagnosis or treatment
of the medical condition, and provided for the diagnosis or direct
care and treatment of medical condition;
- Within standards of good medical practice within the organized
- Not primarily for the convenience of the Member, the Member's
physician, or another provider;
- The most appropriate supply or level of service which can safely
be provided. For Hospital stays, this means that acute care as a bed
patient is needed due to the kind of services the Member is
receiving or the severity of the Member's condition, and that safe
and adequate care cannot be received as an outpatient or in a less
intense medical setting.
Medicare Medical Insurance
This is Part B of Medicare. This part helps pay for medically necessary
physician services and many other medical services and supplies not
covered by Part A.
Mental or Nervous Disorders
Conditions that affect thinking and the ability to figure things out,
perception, mood and behavior. A mental or nervous disorder is
recognized primarily by symptoms or signs that appear as distortions of
normal thinking, distortions of the way things are perceived (for
example seeing or hearing things that are not there), moodiness, sudden
and/or unusual behavior such as depressed behavior. Some mental or
nervous disorders are: schizophrenia, manic depressive and other
conditions usually classified in the medical community as psychosis:
drug, alcohol or other substance addiction or abuse: depressive phobic,
manic and anxiety conditions ( including panic disorder); bipolar
affective disorders including mania and depression; obsessive compulsive
disorder; hypochondria; personality disorders ( including paranoid,
schizoid, dependent, anti-social and borderline); dementia and delirious
states; post traumatic stress disorder, hyperkinetic syndromes
(including attention deficit disorders); adjustment reactions; reactions
to stress; anorexia nervosa and bulimia. Any condition meeting this
definition is a mental or nervous disorder no matter what the cause.
However, medical conditions that are caused by behavior of the Member
that may be associated with these mental conditions (for example
self-inflicted injuries) are not subject to these limitations.
The discounted rates that Blue Cross Prudent Buyer network doctors and
hospitals agree to charge for covered expenses.
The term used for services received from doctors, hospitals and other
providers contracting with Blue Cross to provide care at the negotiated
fee and to handle the paperwork.
A licensed provider who has not signed an Agreement with Blue Cross
Senior Secure to furnish care for Blue Cross Senior Secure Members
The term used for services received from doctors, hospitals or to the
provider that are not part of the Blue Cross network. You pay
substantially more for out-of-network services.
The most you pay for covered expenses during the year before the plan
begins paying 100% of covered expenses count toward the maximum. For
example, any charges above the limited fee schedule for out-of-network
doctor's services do not count.
Participating Physician and Supplier
A physician or supplier who agrees to accept assignment on all Medicare
Participating Prudent Buyer Physician
A physician who has a Prudent Buyer Plan Participating Physician
Agreement in effect with Blue Cross of California at the time services
A permanent absence is an uninterrupted absence of more than 6 months
outside the Blue Cross Senior Secure service area. If you move or travel
and do not intend to return to the Blue Cross Senior Secure Service Area
within 6 months, it is considered a permanent move and you must notify
Blue Cross Senior Secure.
PMG (Participating Medical Group)
A group of doctors both primary care physicians and specialists, who are
in practice together and provide health care services.
PPO (Preferred Provider Organization)
Health care providers who are under contract to provide care at
discounted or fixed fees. Unlike HMOs, health plans with a PPO allow the
member to choose any doctor at any time. However, if the member selects
a non-PPO provider he will pay more out of pocket for services than he
would if he selected a PPO "network" provider.
Pre-existing Condition or Pre-existing Waiting Period
If the member receives medial advice, or treatment was recommended or
received for any accident, illness, or other medical condition during
six months before he enrolled in a Blue Cross plan, he won't be covered
for the care he receives as a result of that condition until he has been
enrolled in the Blue Cross plan for six months. If he satisfied the
six-month waiting period while enrolled in another medical plan, and
enrolled with Blue Cross within 30 days of completing that waiting
period, he won't need to complete another pre-existing waiting period.
He will receive partial credit if he was insured under another plan for
less than six months.
Primary Care Physician
A physician who is a member of a Medical Group that the Member has
selected to provide health care. A Primary Care Physician is responsible
for authorizing, coordinating and controlling the delivery of covered
services to the Member. Primary Care Physicians include general and
family practitioners, internists and such other specialists as Blue
Cross Senior Secure may approve to be designated a Primary Care
A system whereby a provider must receive approval from a staff member of
the health plan, such as the health plan Medical Director, before a
member can receive certain health care services.
Psychiatric Health Facility
An acute 24-hour facility as defined in California Health and Safety
Code 1230.2. It must be :
- Licensed by the Department of Health Services;
- Qualified to provide short-term inpatient treatment according to
the State law;
- Accredited by the Joint Commission on Accreditation of Health Care
- Staffed by an organized medical or professional staff which
includes a physician as a Medical Director.
Qualifying Prior Coverage
Any individual or group plan that provides medical, hospital, and
surgical coverage, including continuation or conversion coverage or
coverage under a publicly sponsored program such as Medicare or
Medicaid. It does not include accident only, credit, disability income,
Medicare supplement, long term care insurance, automobile insurance,
no-fault insurance, or any medical coverage designed to supplement other
private or governmental plans.
Any request for authorization by the Primary Care Physician to the
Medical Group for covered specialty services or hospitalization. This
may also require utilization review by the Medical Group.
A geographic area approved by the Centers for Medicare & Medicaid
Services (CMS) within which a Medicare+Choice eligible individual may
enroll in a particular Medicare+Choice Plan offered by a Medicare+Choice
Organization. This is the area within which you generally must get
non-emergency and urgently needed services other than dialysis.
Skilled Nursing Care
Refers to services that can only be performed by, or under the
supervision of, licensed nursing personnel.
Skilled Nursing Facility
Provides skilled nursing care, continuous 24-hour nursing service, and
maintains daily medical records for each patient. It must be licensed
under all applicable state and local laws. It must be approved for
payment of Medicare benefits or be qualified to receive that approval if
so requested. It does not include any home or facility used primarily
for rest, educational care, treatment of mental or nervous disorders or
a facility for the aged which furnishes primarily custodial care,
including training in routines of daily living.
A temporary absence from the Service Area is an absence of 6 months or
less outside the Blue Cross Senior Secure service area. If the member
moves or travels and does not intend to return to the Blue Cross Senior
Secure Service Area within 6 months, it is considered a permanent move
and the member must notify Blue Cross Senior Secure.
Urgently Needed Services
Services needed immediately as a result of an unforeseen illness,
injury, or condition; and it is not reasonable given the circumstances
to get the services through your Primary Care Physician or other plan
providers. Ordinarily, these services are provided when you are out of
the service area. In extraordinary cases, these are services provided
when you are in the service area but plan providers are not available.
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