Medicare Terms Flashcards
BAE
Best Available Evidence is when the member is questioning why their copayment isn’t lower. Member questions “extra help” letter they had received – related to Medicare coverage.
LEP
A Late Enrollment Penalty that is added to a person’s Medicare Part D premium. This amount changes each year. Member’s have this penalty on their account when:
They didn’t join a Medicare drug plan when first eligible for Part A/Part B AND they didn’t have other creditable Rx coverage that met Medicare’s minimum standards.
Member had a break in Medicare’s Rx coverage or other creditable coverage of at least 63 days in a row.
LIS
Considered “Extra Help”, people with limited incomes may qualify for Low Income Subsidy to pay for their Medicare prescription drug costs. If qualified Medicare could pay up to 75% or more in drug costs including monthly prescription drug premiums, annual deductibles and co-insurance. Additionally, those who qualify won’t have a coverage gap or late enrollment penalty.
MTM
Navitus is required to offer the Medication Therapy Management program to Medicare members by CMS. Members must meet certain criteria established by CMS. These criteria are used to identify people who have more than one chronic illness disease and are at risk for problems related to medications.
The State of Minnesota also has their own, separate program for commercial members that offers $0 copays and overall health consults re: all products they take.
CD
Coverage Determination form. Medicare member’s use this form over Commercial, Exchange and TX Medicaid’s ETC form.
CMS
Centers for Medicare and Medicaid Services, known as the “government”.
EGWP
Employer Group Waiver Plan. Navitus, along with the Medicare Part D Plan Sponsor (Dean), offers an EGWP PDP + Wrap product to employer or union groups with Medicare-eligible retirees.
EGWP coordinates a Medicare D standard benefit with a Commercial (Wrap) benefit.
1PS
One Pharmacy Submission (Relating to EGWP Medicare claim submissions); meaning pharmacy uses one ID number, and processes one claim, and it is automatically submitted to 1st: Medicare 2nd: Wrap coverage.
EOB
Explanation of Benefits. Is a document explaining how the benefit was administered for services or products rendered. (I.e. A “This is not a bill” statement is an example of an EOB many people receive.)
