Glossary

A health plan's decision on whether to pay all or part of a bill, or to give medical services, after you file an appeal. If the decision is not in your favor, the plan must give you a written notice. This notice must give a reason for the denial and a description of steps in the appeals process. (See Appeals Process.)

A pay-per-visit health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Other Managed Care Arrangement is used if the plan is not considered either a PCCM, PHP, Comprehensive MCO, Medicaid-only MCO, or HIO.

Other service facilities not previously identified.

Services provided to enrollees by providers that have no contractual or other relationship withM+C Organizations.

Generally, an out-of-network benefit provides a beneficiary with the option to access planservices outside of the plan’s contracted network of providers. In some cases, a beneficiary’sout-of-pocket costs may be higher for an out-of-network benefit.

What you pay out-of-pocket according to your health plan coverage when you get care from a provider or service that doesn't contract with your health plan for lower in-network service rates. An out-of-network copayment is a fixed amount (for example, $30) you pay for covered health care services from providers who don't contract with your health plan. Out-of-network copayments usually are more than in-network copayments. An out-of-network coinsurance is your share (for example, 40%) of the allowed amount for covered health care services to providers who don't contract with your health plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

A provider who doesn't have a contract with your plan to provide services. If your plan covers out-of-network services, you'll usually pay more to see an out-of-network provider than an in-network provider (or preferred provider). Out-of-network providers may also be called "non-preferred" or "non-participating." If your plan doesn't cover an out-of-network service, you may be responsible for arranging payment with the provider directly for the full cost of the care.

Health care costs that you must pay on your own because they are not covered by Medicare or other insurance.

The result of performance (or nonperformance) of a function or process.