Appeal
Any of the procedures that deal with the review of adverse organization or coverage determinations on the health care services or prescription drug benefits a member is entitled to receive or any amounts the member must pay for a covered service. These procedures include reconsiderations by IntegraNet, the Part D Quality Improvement Council, hearings before an administrative law judge, reviews by the Medical Appeals Council and federal judicial reviews. This process is separate from the provider administrative appeals/dispute process.

Balance + Rx Plan
The Balance + Rx Plan provides coverage of major medical services after satisfaction of an annual deductible. Outpatient services, such as primary care and specialist visits, are covered with reasonable copays for professional services outside of the deductible. This includes Medicare Part D prescription coverage. This plan has no out-of-network benefits.

Basic benefits
Services covered for all Medicare beneficiaries under Medicare Part A and Part B. All Medicare Advantage members receive all basic benefits, including all health care services covered under Medicare Part A and B programs, except for hospice services. IntegraNet also provides supplemental benefits not covered by fee-for-service Medicare

CMS
Centers for Medicare & Medicaid Services; the federal agency responsible for administering the Medicare program.

Classic + Rx Plan
The Classic + Rx Plan has copays for most services, and includes Medicare Part D prescription coverage.

Contracting hospital
A hospital that has a contract to provide services and/or supplies to Medicare members.

Contracting medical group
A group of physicians organized as a legal entity for the purpose of providing medical care with a contract to provide medical services to Medicare members.

Contracting pharmacy
A pharmacy that has a contract to provide Medicare members with medications prescribed by their providers in accordance with the IntegraNet contract.

Coverage determination
The first decision made by a plan regarding the prescription drug benefits an enrollee is entitled to receive under the plan, including a decision not to provide or pay for a Part D drug, a decision concerning an exception request and a decision on the amount of cost sharing for a drug.

• Provided or furnished by providers or authorized by IntegraNet or its providers
• Emergency services and urgently needed services that may be provided by non-par providers
• Renal dialysis services provided while members are temporarily outside the service area
• Basic and supplemental benefits

Dual-eligible
A Medicare enrollee who is eligible for Medical Assistance from the state and for whom the state has a responsibility for payment of Medicare cost-sharing obligations under the state plan. Dual-eligibles are limited to the following categories of recipients: Qualified Medicare Beneficiary (QMB) Only, QMB Plus, Specified Low-income Medicare Beneficiary (SLMB) Plus and other Full Benefit Dual Eligible (FBDE) recipients.

Emergency medical condition
a medical condition manifesting itself 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 the absence of immediate medical attention to result in:

• 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
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part

Emergency services
Covered inpatient or outpatient services furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition in accordance with the prudent layperson standard.

Experimental procedures and items
Procedures and items determined by IntegraNet and Medicare not to be generally accepted by the medical community. When making a determination as to whether a service or item is experimental, IntegraNet will follow CMS guidance (via the Medicare Carriers Manual and Coverage Issues Manual) if applicable or CMS guidance already made by Medicare. Section 1862(a)(1)(E) of the Social Security Act, prohibits payment for procedures that are deemed experimental and/or investigational in nature.

Exceptions
An exception request is a type of coverage determination request. Through the exception process, the member can request an off-formulary drug, an exception to the IntegraNet tiered costsharing structure or an exception to the application of a cost utilization management tool (e.g., step therapy requirement, dose restriction or precertification requirement).

Fee-for-service Medicare
A payment system by which doctors, hospitals and other providers are paid for each service performed (also known as traditional and/or original Medicare).

Full Benefit Dual-Eligible (FBDE)
An individual who is eligible for both Medicare Part A and/or Part B and for state benefits (services), including those who are categorically eligible and those who qualify as medically needy under the state plan.

Grievance
A complaint or dispute other than one involving an organization determination. Examples of issues involving a complaint that is resolved through the grievance rather than the appeal process are waiting times in physician offices and rudeness or unresponsiveness of customer service staff.

Home health agency
A Medicare-certified home health agency is one that provides intermittent skilled nursing care and other therapeutic services in a member’s home when medically necessary, when members are confined to their home and when authorized by their primary care physician.

Hospice
A Medicare-certified organization or agency primarily engaged in providing pain relief, symptom management and support services to terminally ill people and their families.

Hospital
A Medicare-certified institution licensed by the state that provides inpatient, outpatient, emergency, diagnostic and therapeutic services. The term hospital does not include a convalescent nursing home, rest facility or facility for the aged that furnishes primarily custodial care, including training in routines of daily living.

Hospitalist
A member of a growing medical specialty who has chosen a field of medicine that specifically focuses on the care of the hospitalized patient. Before selecting this new medical specialty, hospitalists complete education and training in internal medicine. As a key member of the health care team and an experienced medical professional, the hospitalist takes primary responsibility for inpatient care by working closely with the patient’s primary care physician during the member’s inpatient stay.

Independent practice association
A group of physicians that function as a contracting medical provider/group but in which the individual member physicians operate their respective independent medical offices.

Medicaid
The federal health insurance program established by Title XIX of the Social Security Act and administered by states for low-income individuals.

Medically necessary
Medical services or hospital services determined by IntegraNet to be:

• Rendered for the diagnosis or treatment of an injury or illness.
• Appropriate for the symptoms, consistent with diagnosis and otherwise in accordance with sufficient scientific evidence and professionally recognized standards.
• Not furnished primarily for the convenience of the member, the attending provider or other provider of service.

We make determinations of medical necessity based on peer-reviewed medical literature, publications, reports and evaluations; regulations and other types of policies issued by federal government agencies, Medicare local carriers and intermediaries; and such other authoritative medical sources as deemed necessary by IntegraNet. Section 1862(a)(1)(A) of the Social Security Act, states that Medicare payment can only be made for services/items that are medically necessary and reasonable.

Medicare
The federal health insurance program established by Title XVIII of the Social Security Act and administered by the federal government for elderly and disabled individuals.

Medicare Part A
Medicare Part A covers hospital insurance benefits, including inpatient hospital care, skilled nursing facility care, home health agency care and hospice care offered through Medicare.

Medicare Part A premium
Medicare Part A is financed by part of the Social Security payroll withholding tax paid by workers and their employers and by part of the self-employment tax paid by self-employed persons. If members are entitled to benefits under either the Social Security or Railroad Retirement systems or worked long enough in federal, island or local government employment to be insured, they do not have to pay a monthly premium. If members do not qualify for premium-free Part A benefits, members may buy the coverage from Social Security if they are at least 65 years old and meet certain other requirements.

Medicare Part B
Optional, supplemental medical insurance requiring a monthly premium. Medicare Part B covers physician (in both hospital and nonhospital settings) and certain nonphysician services. Other Part B services include lab testing, durable medical equipment, diagnostic tests, ambulance services, prescription drugs that cannot be self-administered, certain self-administered anti-cancer drugs, some other therapy services, certain other health services and blood products not covered under Part A.

Medicare Part B premium
A monthly premium paid to Medicare (usually deducted from a member’s Social Security check) to cover Part B services. Members must continue to pay this premium to Medicare to receive covered services, whether members are covered by a Medicare Advantage plan or by original Medicare.

Medicare Part C
Optional coverage that can be elected by the Medicare beneficiary. Coverage under Part C is provided by health maintenance organizations. The health maintenance organization must provide all Part A and B services in its plan and may offer additional benefits to the beneficiary.

Medicare Part D
The prescription drug coverage provided by a Medicare Advantage (MA) plan or by a stand-alone Prescription Drug Plan (PDP) contracted with CMS. The MA plan or PDP may charge the beneficiary premiums and cost sharing for this coverage. IntegraNet offers MA-PD plans in specific markets.

Medicare Advantage (MA) agreement
The agreement between IntegraNet and CMS to provide Medicare Part C and other health plan services to IntegraNet members.

Medicare Advantage (MA) plan
A policy or benefit package offered by a Medicare Advantage Organization (MAO) in which a specific set of health benefits are offered at a uniform premium level of cost sharing to all Medicare beneficiaries residing in the corresponding service area. An MAO may offer more than one benefit plan in the same service area. The Amerivantage plan is a kind of MA plan.

Member
A Medicare beneficiary entitled to receive covered services who has voluntarily elected to enroll in a Medicare Advantage plan and whose enrollment has been confirmed by CMS.

Noncontracting medical provider or facility
Any professional person, organization, health facility, hospital or other person or institution that is licensed and/or certified by the state and/or Medicare to deliver or furnish health care services; and that is neither employed, owned, operated by nor under contract with IntegraNet to deliver covered services to Medicare members.

Provider
Any professional person, organization, health facility, hospital or other person or institution licensed and/or certified by the state and/or Medicare to deliver or furnish health care services. This individual or organization has a contract directly or indirectly with IntegraNet to provide services directly or indirectly to Medicare members pursuant to the terms of the participating provider agreement.

Provider liability appeal
A request for IntegraNet to review a decision by the IntegraNet Health Care Management department for services already rendered and denied without Medicare member liability.

Provider payment dispute
A request for IntegraNet to review the claim adjudication as the provider feels payment was not rendered as per the contractual agreement between IntegraNet and the provider.

Primary Care Provider (PCP)
A provider physician selected by a member to coordinate the member’s health care. The PCP is responsible for providing covered services for Medicare members and coordinating referrals to specialists. PCPs usually practice internal medicine, family practice or general practice medicine.

Specified Low-income Medicare Beneficiary (SLMB) without other Medicaid (SLMB only)
An individual who is entitled to Medicare Part A, has an income of greater than 100 percent of the Federal Poverty Level (FPL) but less than 120 percent of the FPL, and his or her resources do not exceed twice the limit for Supplement Security Income (SSI) eligibility and who is not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only.

Specified Low-income Medicare Beneficiary with full Medicaid (SLMB Plus)
An individual who is entitled to Medicare Part A, has an income of greater than 100 percent of the FPL but less than 120 percent of the FPL, and his or her resources do not exceed twice the limit for SSI eligibility and who is eligible for full Medicaid benefits. Medicaid pays their Medicare Part B premiums and provides full Medicaid benefits.

Qualified Medicare Beneficiary (QMB)
An individual who is entitled to Medicare Part A, has income that does not exceed 100 percent of the FPL and whose resources do not exceed twice the SSI limit. A QMB is eligible for Medicaid payment of Medicare premiums, deductibles, coinsurance and copays (except for Medicare Part D). Collectively these benefits (services) are called QMB Medicaid benefits (services). Categories of QMBs covered by this contract are as follows:

• QMB ONly - QMB who is not otherwise eligible for full Medicaid
• QMB Plus - QMB who also meets the criteria for full Medicaid coverage and is entitiled to all benefits (services) under the state plan for fully eligible Medicaid recipients

Service area
A geographic area approved by CMS within which an eligible individual may enroll in a Medicare Advantage plan. The geographic area for each Medicare Advantage plan is located in the Summary of Benefits document.

Special Needs Plan (SNP)
A type of Medicare Advantage plan that also incorporates services designed for a certain class of members. In the case of the IntegraNet SNP, the special class of members is comprised of persons who are both Medicare and Medicaid eligible. Plans offering SNPs receive special approval from CMS. A SNP also provides Medicare Part D drug coverage.

Dual Coordination, Dual Premier, and Dual Secure Plan
The IntegraNet dual-eligible special needs plan available to full benefit dual-eligible, Qualified Medicare Beneficiaries (QMB/QMB Plus), and Specified Low-Income Medicare Beneficiaries (SLMB Plus), depending on the state. Although this plan has cost sharing for certain services, cost sharing is paid by the state Medicaid agency or by IntegraNet through an arrangement with Medicaid. There are low copays for Medicare Part D prescription coverage. This plan has no out-of-network benefits.

Urgently needed services
Those covered services provided when the member is temporarily absent from the Medicare Advantage service area, or under unusual and extraordinary circumstances, services provided when the member is in the service area but the member’s PCP is temporarily unavailable or inaccessible, when such services are medically necessary and immediately required as a result of an unforeseen illness, injury or condition; and it is not reasonable given the circumstances to obtain the services through the PCP.