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Allowable Expenses
The amount a physician or provider has agreed to accept as payment in
full for services provided. Allowable charge usually refers to an amount
that a health insurance carrier determines is reasonable, and may be
less than the actual charge.
Approved Amount
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.
At-Home Recovery Benefits
Care that is provided while you are confined to your home under your
doctor's care. Medicare pays the full cost of medically necessary home
health visits by a Medicare-approved home health agency for nursing
care, physical therapy, speech therapy or other therapeutic services.
There are limitations to this service.
Benefit Period
This time period begins the day the insured person is hospitalized and
ends after the insured person has been out of the hospital, skilled
nursing facility or rehabilitation facility for 60 days in a row. If you
go back to the hospital after 60 days, a new benefit period begins.
Calendar Year Blood
Deductible
You have a three-pint annual deductible, which means if you are given
whole blood or units of packed cells by a hospital or skilled nursing
facility, you are responsible for paying for the first three pints. Any
additional blood needed and approved will then be covered until the end
of the calendar-year. A calendar year runs from January to December,
after which a new calendar year deductible must be met.
Coinsurance
The dollar amount that you are responsible for paying, usually a
percentage of the Medicare-approved amount.
Copayment
Means a flat, fixed dollar amount for a medical service or medical
supply.
Deductible
The dollar amount that you must pay for covered services before Medicare
or your health insurance carrier begins payment.
Effective Date
The date your coverage begins. Your effective date will be the first of
the month following the date we receive your application, unless you
request a later date.
Emergency Care
Services and supplies for emergency treatment of traumatic bodily
injuries resulting from an accident or a sudden onset of a
life-threatening medical condition. Examples of life-threatening
conditions include: appendicitis, ruptured artery, severe burns, cardiac
arrest, skull fracture, respiratory failure, spinal cord injury and heat
stroke.
Guaranteed Issue
This is guaranteed coverage for a Medicare Supplement policy regardless
of any health problems you may have.
Home Health Care
Medicare pays the full cost of medically necessary home health visits by
a Medicare-approved home health agency. A home health agency is a public
or private agency that provides skilled nursing care, physical therapy,
speech therapy and other therapeutic services. Services are provided on
an intermittent or part-time basis, not full-time, by a visiting nurse
and/or home health aide.
To qualify for coverage, you must:
- Need intermittent skilled nursing care, physical therapy, or
speech therapy.
- Be confined to your home.
- Be under a doctor's care.
A stay in the hospital is not needed to qualify for
the home health benefit, and you do not have to pay a deductible or
coinsurance for services. You do have to pay 20 percent of the approved
amount for durable medical equipment such as wheelchairs and hospital
beds provided under a plan-of-care set up and reviewed periodically by a
doctor.
Lifetime Reserve
For hospital care, Medicare gives you 60 reserve days for you to use in
your lifetime. After you have been in the hospital for 90 days in one
benefit period, you can use your reserve days and Medicare will pay all
covered costs except for the $438 per day Medicare Part A expense.
Medicare Assignment
Doctors who accept Medicare assignment agree to accept Medicare’s
approved amount as the total charge for a service or supply. Always ask
your doctors and medical suppliers whether they accept assignment of
Medicare claims. If they do, this acceptance could mean savings for you.
Pre-Existing Condition
A pre-existing condition is any medical condition* you had in the six
months before the date you are officially covered by your new plan (your
"effective date"). If you received medical advice or care for
a condition during that time, it is a pre-existing condition. If medical
treatment was recommended for a condition you had during that time, it
is a pre-existing condition. Anthem Medicare Supplement and Medicare
Select plans have a six-month waiting period before pre-existing
conditions are covered.
You may have your waiting period for pre-existing
conditions waived if . . .
- Your policy’s effective date is within six months after your
65th birthday;
- You were insured by any other Blue Cross and/or Blue Shield policy
immediately before your new policy’s effective date;
- You were insured by any type of Medicare Supplement policy
immediately before your new policy’s effective date;
- You are 65 or older and within six months of your Medicare Part B
coverage effective date; or
- You meet certain eligibility guidelines coming from a
Medicare+Choice, Medicare Select, Medicare Supplement or employer
group health plan.
If you have any questions, please call your Member
Services representative for more details.
Skilled Nursing Facility
A special facility that primarily furnishes skilled nursing and
rehabilitation services. It may be a separate facility or a distinct
part of another facility, such as a hospital or nursing home.
*If you have previously been determined to be free
from breast cancer based on negative follow-up care for a period of five
years or more, the pre-existing condition limitation shall not apply to
routine follow-up care for breast care rendered during the six months
immediately preceeding or following your effective date.
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