Glossary

Advance Directive

A written, legally binding document which authorizes the member to retain control over whether or not his or her life will be prolonged by the use of artificial means. This election, entirely optional, will allow the member to authorize the withholding or withdrawal of all treatment and procedures, including intravenous food and water (called nutrition and hydration).

Annual Enrollment Period

From November 15 through December 31 of each year. During this time, anyone with Medicare can switch from one way of getting Medicare to another, including when they can enroll in Medicare prescription drug coverage.

Appeal

An appeal is a special kind of complaint you may make if you disagree with a decision to deny a request for healthcare services and/or prescription drugs, or payment for services and/or prescription drugs you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving.

Authorization

An approval from the plan indicating that health services will be paid for or provided for by the plan. In determining if services will be authorized, Peoples Health reviews for the following criteria:

• Whether or not the person receiving the services is a member of a Peoples Health plan at the time of service
• Whether or not the service is a covered service as defined by the Evidence of Coverage for that Peoples Health plan
• Whether or not the service is medically necessary

Benefit Period

A benefit period is used to determine coverage for inpatient stays in hospitals and skilled nursing facilities. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or a skilled nursing facility (SNF). The benefit period ends when you have not been an inpatient at any hospital or SNF for 60 days in a row. If you go to the hospital (or SNF) after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have.

The type of care that is covered depends on whether you are considered an inpatient for hospital and SNF stays. You must be admitted to the hospital as an inpatient, not just under observation. You are an inpatient in a SNF only if your care in the SNF meets certain standards for skilled level of care. Specifically, in order to be an inpatient in a SNF, you must need daily skilled nursing or skilled-rehabilitation care, or both.

Brand Name Drug

A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand-name drugs often have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand-name drug has expired.

Calendar Year

The period that begins on January 1 and ends 12 consecutive months later on December 31.

Care Management Team

The Care Management team coordinates health management programs that provide Peoples Health plan members with resources to help manage chronic health conditions, such as diabetes, heart failure and chronic obstructive pulmonary disease (COPD). Case managers in the program may schedule appointments, call with reminders about taking medications and even accompany members to their appointments.

Catastrophic Coverage

Catastrophic coverage is the third phase in the Medicare Part D coverage “cycle.” The catastrophic coverage phase begins after you have paid a total of $4,350 (for the year 2009) in out-of-pocket costs for your prescription drugs (known as the “coverage gap” phase). During the catastrophic coverage phase, you pay reduced copays/coinsurance for your prescription drugs. Catastrophic coverage does not apply to members of Peoples Health’s special needs plan (SNP), Secure Health, or its employer group waiver plan (EGWP), Peoples Health Group Medicare.

Centers for Medicare & Medicaid Services (CMS)

The Federal Agency that runs the Medicare program.  CMS can be contacted by calling toll-free 1-800-MEDICARE (1-800-633-4227).  The TTY/TDD number is 1-877-486-2048 or by visiting www.medicare.gov <http://www.medicare.gov>.

Choice 1

This benefit option is available to plan members in all Peoples Health plans except its preferred provider organization (PPO) plan, HealthcCare Select. With this benefit option, plan members work closely with, and access care from, providers within their physician team. Exceptions are for emergency services and urgently needed care out of the plan’s service area (or, under unusual and extraordinary circumstances, provided when a member is in the service area but a participating provider is temporarily unavailable or inaccessible) and renal dialysis services while temporarily outside of the service area. Covered services must meet the Medicare medical necessity guidelines.

Choice 2

This benefit option is available to plan members in Peoples Health’s Choices 65, Choices Plus and Secure Health Medicare Advantage plans and in the Peoples Health Group Medicare plan. With this benefit option, plan members may access care from any provider outside of their physician team but within the provider network for their health plan. In most circumstances, a member accessing services through Choice 2 will have higher out-of-pocket expenses than for services accessed through Choice 1. Covered services must meet the Medicare medical necesity guidelines.

Choice 3

This benefit option is available to plan members in Peoples Health’s Choices Plus Medicare Advantage plan and Peoples Health Group Medicare plan. With this benefit option, members may access care from providers outside of their health plan’s provider network. In most cases, a member accessing services through Choice 3 will have higher out-of-pocket expenses than through Choices 1 or 2. Covered services must meet the Medicare medically necessary guidelines.

Choices 65

A health maintenance organization (HMO) plan offered by Peoples Health that has two levels of coverage. Members of this plan can access their care through their physician team or through a participating healthcare provider within the Choices 65 provider network. It is offered to residents living in the following Louisiana parishes: Jefferson, Orleans, Plaquemines and St. Tammany.

Choices Plus

A point of service (POS) plan offered by Peoples Health that has three levels of coverage. Members of this plan may access care through their physician team, through a participating healthcare provider within the Choices Plus provider network or through a non-participating provider. It is offered to residents living in the following Louisiana parishes: Ascension, East Baton Rouge, Livingston, St. Bernard, St. James, St. John, Tangipahoa, Washington and West Baton Rouge.

Coinsurance

A member's share of the cost for covered services, paid to providers at the time care is received. This share is a percentage of the total cost of the services.

Copay (copayment)

A set dollar amount that members must pay at the time of service to a provider for certain covered services.

Cost-Sharing

Cost-sharing refers to the cost that a member has to pay when drugs/services are received. It includes any combination of the following two types of payments: (1) any fixed copay amounts that a member must pay when specific drugs/services are received or (2) any “coinsurance” amount that must be paid as a percentage of the total amount paid for a drug/service.

Coverage Determination

A decision from your Peoples Health plan about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to your plan’s Appeals and Grievances department to ask for a formal decision about the coverage if you disagree.

Covered Services

The general term we use in this booklet to mean all of the health care services and supplies that are covered by Choices Plus. Covered services are listed in the Benefits Chart in your Evidence of Coverage.

Covered Drugs

General term to describe all of the prescription drugs covered by a Peoples Health plan.

Coverage Gap

The coverage gap is the second phase in the Medicare Part D coverage “cycle.” The coverage gap begins after your total prescription drugs costs for the year reach $2,700 (for the year 2009). During the coverage gap, you pay 100 percent of the costs for non-preferred brand-name drugs and specialty drugs until your total out-of-pocket drug costs reach $4,350 during the covered year (2009). Plan members who receive low-income subsidy (LIS, or “extra help”) are generally not responsible for costs in the coverage gap. The coverage gap does not apply to members of Peoples Health’s employer group waiver plan (EGWP), Peoples Health Group Medicare.

Covered Services

General term to describe all of the healthcare services and supplies that are covered by a Peoples Health plan.

Creditable Prescription Drug Coverage

Coverage (for example, from an employer or union) that is at least as good as Medicare’s prescription drug coverage.

Custodial Care

Care for personal needs rather than medically necessary needs. Custodial care is care that can be provided by people who don’t have professional skills or training. This care includes help with walking, dressing, bathing, eating, preparation of special diets and taking medication. Medicare does not cover custodial care unless it is provided as other care you are getting in addition to daily skilled nursing care and/or skilled rehabilitation services.

Disenroll or Disenrollment

The process of ending your membership in a Peoples Health plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice). Generally, plan members are only allowed to voluntarily disenroll from a Peoples Health plan during either the annual enrollment period (AEP) or the open enrollment period (OEP), unless special circumstances apply.

Durable Medical Equipment

DME includes equipment needed for medical reasons, which is sturdy enough to be used multiple times without wearing out, such as walkers and hospital beds. DME also includes diabetic supplies and equipment or medication that help a member breathe.

Emergency Care

Covered services that are 1) provided by a healthcare provider qualified to provide emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.

Emergency Medical Condition

A medical condition brought on by severe symptoms (including severe pain) such that the average person, with an average knowledge of health and medicine, could reasonably expect that the health of the individual could be in danger, or all or part of the individual bodily organs or functions could become impaired or dysfunctional, if the individual does not receive immediate medical attention.

Employer Group Waiver Plan (EGWP)

A customized Medicare Advantage Prescription Drug Plan that offers healthcare benefits to retirees through their employers. Peoples Health Group Medicare is an Employer Group Waiver Plan.

Evidence of Coverage (EOC) and Disclosure Information

The EOC along with your enrollment form, explains your covered services, defines our obligations,and explains your rights and responsibilities as a member of a Peoples Health plan.

Exception

A type of coverage determination that, if approved, allows you to get a drug that is not on the plan’s formulary (a formulary exception), or get a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if your plan requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Exclusion

Items or services that a Peoples Health plan does not cover. You are responsible for paying for excluded items or services.

Experimental Procedures and Items

Items and procedures determined by Medicare not to be generally accepted by the medical community. When deciding if a service or item is experimental, Peoples Health will follow the Centers for Medicare & Medicaid Services manuals or will follow decisions already made by Medicare. With the exception of procedures and items under approved clinical trials, experimental procedures and items are not covered under a Peoples Health plan.

Formulary

A list of covered drugs provided by the Peoples Health plans.

Generic Drug

A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Generic Incentive Program

If you receive a prescription for a brand-name drug that has a generic equivalent, Peoples Health gives you two options. You can choose the generic drug and pay the generic drug copay. If you choose the brand-name drug, you will pay the generic copay plus the difference in cost between the brand-name drug and the generic drug. The second option will result in higher out-of-pocket costs for you.

Grievance

A type of complaint you may make about us, or one of our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

Health Maintenance Organization (HMO)

An HMO is a type of managed care organization (MCO) that provides a form of healthcare coverage that is provided by a network of contracted hospitals, doctors and other healthcare providers. Choices 65 is an HMO plan.

HealthCare Select

A preferred provider organization (PPO) plan offered by Peoples Health that has two levels of coverage. There is a premium for the HealthCare Select plan. Members of this plan can access care from participating providers within the HealthCare Select provider network or through a non-participating provider. It is offered to residents living in the following parishes: Jefferson, Orleans, Plaquemines, St. Bernard, St. Charles, St. John and St. Tammany parishes.

Home Health Agency

A Medicare-certified agency that provides skilled nursing care and other therapeutic services in your home when medically necessary.

Home Health Aide

A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

Home Health Care

Skilled nursing care and certain other healthcare services that you get in your home for the treatment of an illness or injury. Covered services are listed in the Evidence of Coverage for each Peoples Health plan. If you need home health care services, your Peoples Health plan will cover these services for you, provided the Medicare coverage requirements are met. Home health care can include services from a home health aide if the services are part of the home health plan of care for your illness or injury. They aren’t covered unless you are also getting a covered skilled service. Home health services don’t include the services of housekeepers, food service arrangements or full-time nursing care at home.

Hospice Care

A special way of caring for people who are terminally ill and providing counseling for their families. Hospice care is physical care and counseling that is given by a team of people who are part of a Medicare-certified public agency or private company. Depending on the situation, this care may be given in the home, a hospice facility, a hospital or a nursing home. Care from a hospice is meant to help patients in the last months of life by giving comfort and relief from pain. The focus is on care, not cure. For more information on hospice care visit www.medicare.gov and under “Search Tools” choose “Find a Medicare Publication” to view or download the publication “Medicare Hospice Benefits.” Or, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

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 primarily provides custodial care, including training in routines of daily living.

Hospitalist

A physician who specializes in treating patients when they are in the hospital and who may coordinate a patient's care when he or she is admitted to a hospital.

In-Network

Any professional person, organization, health facility, hospital or other person or institution licensed by the State and certified by Medicare to deliver or provide healthcare services and who is contracted directly with Peoples Health to provide benefits to our plan members.

Independent Physician Association (IPA)

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 to practice medicine.

Initial Coverage Limit

The maximum limit of coverage under the initial coverage period of the Medicare Part D prescription drug program.

Initial Coverage Period

Initial coverage period is the first phase in the Medicare Part D coverage “cycle.” During the initial coverage period, you pay your plan’s standard drug copays/coinsurance until your total drug costs have reached $2,700 (for the year 2009), including amounts you’ve paid and what your Peoples Health plans had paid on your behalf. The initial coverage period does not apply to members of Peoples Health’s special needs plan (SNP), Secure Health, or its employer group waiver plan (EGWP), Peoples Health Group Medicare.

Inpatient Care

Healthcare that you get when you are admitted to a hospital.

Late Enrollment Penalty (LEP)

An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that expects to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions.

Lock-in Period

People with a Medicare Advantage and prescription drug plan are “locked-in,” meaning they can only switch Medicare plans during certain times of the year unless they qualify for special circumstances. The lock-in period runs from April 1 to November 14.

Low-Income Subsidy (LIS) or "Extra Help"

Extra help from Medicare that provides financial assistance for Medicare beneficiaries who have limited assets, income and resources. LIS offers help paying for things such as premiums, deductibles, coinsurance and copays.

 

Maintenance Medications

Drugs that are commonly taken on a regular basis. Maintenance medications can be qualified to be filled as a 90-day supply.

Medicaid

Medicaid is a federal program for low-income, financially needy people, set up by the federal government and administered differently in each state. Medicare, also a federal program, is not tied to individual need. Rather, it is an entitlement program; you are entitled to it because you or your spouse paid for it through employment or self-employment taxes.

Medicare

The federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant).

Medicare Advantage Organization

A public or private organization licensed by the State as a risk-bearing entity that is under contract with the Centers for Medicare & Medicaid Services (CMS) to provide covered services. Medicare Advantage Organizations can offer one or more Medicare Advantage plans. Peoples Health is a Medicare Advantage Organization.

Medicare Advantage (MA) Plan

Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A (hospital) and Part B (medical) benefits. An MA plan offers a specific set of health benefits at the same premium and level of cost-sharing to all people with Medicare who live in the service area covered by the plan. Medicare Advantage Organizations can offer one or more Medicare Advantage plans in the same service area. A Medicare Advantage plan can be a Health Maintenance Organization (HMO), preferred provider organization (PPO), a Private Fee-for-Service (PFFS) plan or a Medicare Medical Savings Account (MSA) plan. In most cases, Medicare Advantage plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

The plans that Peoples Health offers are Medicare Advantage plans with prescription drug coverage.

Medicare Prescription Drug Coverage (Medicare Part D)

Insurance to help pay for outpatient prescription drugs, vaccines, biologicals and some supplies not covered by Medicare Part A or Part B.

Medigap (Medicare Supplement Insurance) Policy

Medicare supplement insurance sold by private insurance companies to fill “gaps” in the Original Medicare Plan coverage. Medigap policies only work with the Original Medicare Plan. (A Medicare Advantage plan is not a Medigap policy.)

Medigap (Medicare Supplement Insurance) Policy

Medicare supplement insurance sold by private insurance companies to fill “gaps” in the Original Medicare Plan coverage. Medigap policies only work with the Original Medicare Plan. (A Medicare Advantage plan is not a Medigap policy.)

Member (member of a Peoples Health plan, or “plan member”)

A person with Medicare who is eligible to get covered services, who has enrolled in a Peoples Health plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Member Services

A department within Peoples Health responsible for answering your questions about member benefits, grievances and appeals. Hours of operation are Monday through Friday, 8 a.m. to 5 p.m. in person and 8 a.m. to 8 p.m. by phone.

(504) 849-4500, ext. 2
(800) 631-8443, ext. 2 Toll-free
(888) 631-9979 TTY/TDD Telephone Device for the Hearing Impaired

Network

A group of healthcare providers under contract with Peoples Health that are licensed by the State and/or certified by Medicare with the purpose of delivering or furnishing healthcare services.

Network Pharmacy

A network pharmacy is a pharmacy where members of a Peoples Health plan can get their prescription drug benefits. We call them “network pharmacies” because they contract with Peoples Health. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

Network Provider ("Participating Provider" or "Plan Provider")

“Provider” is the general term we use for doctors, other healthcare professionals, hospitals and other healthcare facilities that are licensed or certified by Medicare and by the State to provide healthcare services. We call them “network providers” when they have an agreement with Peoples Health to accept our payment as payment in full, and in some cases to coordinate as well as to provide covered services to members of one of our plans. Peoples Health pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as “plan providers.”

Non-Participating Provider or Facility (Out-of-Network Provider or Out-of-Network Facility)

A provider or facility with which Peoples Health has not arranged to coordinate or provide covered services to members of our Plan. Out-of-network providers are providers that are not employed, owned or operated by Peoples Health or are not under contract to deliver covered services to you.

Non-Preferred Network Pharmacy

A network pharmacy that offers 90-day supplies of covered drugs to members of Peoples Health plans at a higher out-of-pocket cost than would apply at a preferred network pharmacy.

Non-Preferred Brand-Name Drug

A brand-name drug that is available at a higher copay than a preferred brand-name drug.
See “Brand-Name Drug.”

Office Visit

A visit for covered services to your doctor or other healthcare provider.

Organization Determination

The Medicare Advantage organization has made an organization determination when it, or one of its providers, makes a decision about Medicare Advantage services or payments that you believe you should receive.

Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare)

The Original Medicare Plan is the way many people get their healthcare coverage. It is the national pay-per-visit program that lets you go to any doctor, hospital or other healthcare provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: part A (hospital insurance) and part B (medical insurance) and is available everywhere in the United States.

Out-of-Network Provider or Out-of-Network Facility

A provider or facility with which Peoples Health has not arranged to coordinate or provide covered services to members of our Plan. Out-of-network providers are providers that are not employed, owned or operated by Peoples Health or are not under contract to deliver covered services to you.

Out-of-Network Pharmacy

A pharmacy that doesn’t have a contract with Peoples Health to coordinate or provide covered drugs to members of Peoples Health plans. Most drugs you get from out-of-network pharmacies are not covered by Peoples Health unless certain conditions apply.

Part A

The part of Medicare that typically pays for your inpatient hospital expenses.

Part B

The part of Medicare that typically covers your outpatient healthcare expenses including doctor fees.

Part C

See “Medicare Advantage (MA) Plan”

Part D

The voluntary Prescription Drug Benefit Program.

Part D Drugs

Drugs that Congress permitted Peoples Health to offer as part of a standard Medicare prescription drug benefit. We may or may not offer all Part D drugs. (See the Peoples Health formulary for a specific list of covered drugs.) Certain categories of drugs, such as benzodiazepines, barbiturates and over-the-counter drugs were specifically excluded by Congress from the standard prescription drug package, and these drugs are not considered Part D drugs.

Participating Provider (“Network Provider” or “ Plan Provider”)

“Provider” is the general term we use for doctors, other healthcare professionals, hospitals and other healthcare facilities that are licensed or certified by Medicare and by the State to provide healthcare services. We call them “network providers” when they have an agreement with Peoples Health to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of one of our plans. Peoples Health pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services. Network providers may also be referred to as “plan providers.”
PCP

See “Primary Care Physician”

Peoples Health Group Medicare

An employer group waiver plan (EGWP) offered by Peoples Health that has three levels of coverage. Members of this plan can access care through their physician team, through a participating healthcare provider within the Peoples Health Group Medicare provider network or through a non-participating provider. The plan is only available to retirees of employers that contract with Peoples Health to provide these healthcare benefits.

Pharmacy Benefit Manager

Company that contracts with Medicare Advantage Organizations (MAOs) to manage pharmacy services provided to members of the MAO’s plans. The Peoples Health Pharmacy Benefit Manager is RxAmerica.

Physician Team

A team of physicians (both primary care and specialty care) that has contracted with Peoples Health to provide benefits to plan members. Under Choice 1, physicians are required to use specific hospitals associated with their physician team. If a Peoples Health plan member decides to access care using Choice 1, all covered services, except for emergency and urgently needed services, must be obtained from his or her physician team with which his or her primary care physician (PCP) is affiliated.

Point of Service Plan

A combination of a health maintenance organization (HMO) plan and a preferred provider organization (PPO) plan. Like an HMO, a POS plan provides healthcare coverage that is fulfilled through hospitals, doctors and other providers with which the POS plan has a contract.; like a PPO, members of a POS plan also have the option to obtain services from outside of the provider network contracted with the POS plan.

Preferred Brand-Name Drug

A brand-name drug that is available at a lower copay than a non-preferred brand-name drug. See “Brand-Name Drug.”

Preferred Network Pharmacy

A network pharmacy that offers 90-day supplies of covered drugs to members of a Peoples Health plan at a lower out-of-pocket cost than apply at a non-preferred network pharmacy.

Primary Care Physician (PCP)

A healthcare professional you select to coordinate your healthcare. Your PCP is responsible for providing or authorizing covered services while you are a plan member.

Preferred Provider Organization Plan (PPO)

A Preferred Provider Organization (PPO) is similar to a Health Maintenance Organization (HMO) because it offers a network of physicians, hospitals and healthcare facilities to members. Members of PPOs also have the option to see providers that are out-of-network, although these services may be at an increased cost to the member.

Prior Authorization

Approval in advance to get services and certain drugs that may or may not be on the Peoples Health formulary. In a Health Maintenance Organization (HMO) with a referral model, some in-network services are covered only if your doctor or other network provider gets “prior authorization” from Peoples Health. Some drugs are covered only if your doctor or other network provider gets “prior authorization” from us. Covered drugs that need prior authorization are marked in the formulary.

Provider

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A doctor, hospitalist, healthcare professional or healthcare facility licensed and/or certified by the State or Medicare to deliver or furnish healthcare services

Quality Improvement Organization (QIO)

Groups of practicing doctors and other healthcare experts that are paid by the federal government to check and improve the care given to Medicare patients. They must review your complaints about the quality of care given by Medicare providers.

Quantity Limits

A management tool that is designed to limit the use of selected drugs for quality, safety or utilization reasons. Limits may be on the amount of the drug that your plan covers per prescription or for a defined period of time.

Reconsideration

An appeal to a health plan about Part C medical care or services.

Redetermination

An appeal to the plan about a Part D drug.

Referral

A request from one provider to another for covered services to be provided on your behalf. Some referrals require authorizations.

Rehabilitation Services

These services include physical therapy, speech and language therapy, and occupational therapy.

Secure Health

A special needs plan (SNP) plan offered by Peoples Health that has two levels of coverage. Members of this plan can access care through their physician team, or through a participating healthcare provider within the Secure Health provider network. It is offered to residents living in the following parishes in Louisiana: Ascension, East Baton Rouge, Jefferson, Livingston, Orleans, Plaquemines, St. Bernard, St. Charles, St. James, St. John, St. Tammany, Tangipahoa, Washington and West Baton Rouge.

Service Area

A geographic area approved by the Centers for Medicare & Medicaid Services (CMS) within which a Medicare Advantage (MA) eligible individual may enroll in a particular plan offered by a Medicare Advantage Organization.

Silver&Fit™

Complimentary fitness program offered by Peoples Health. Through this program, plan members have the option of receiving complimentary membership at a fitness center contracted with Silver&Fit™ and Peoples Health or exercising at home with the Silver&Fit™@Home program.

Skilled Nursing Facility (SNF) Care

A level of care in a skilled nursing facility (SNF) ordered by a doctor that must be given or supervised by licensed healthcare professionals. It may be skilled nursing care, skilled rehabilitation services or both. Skilled nursing care includes services that require the skills of a licensed nurse to perform or supervise. Skilled rehabilitation services are physical therapy, speech therapy and occupational therapy. Physical therapy includes exercise to improve the movement and strength of an area of the body, and training on how to use special equipment, such as how to use a walker or get in and out of a wheelchair. Speech therapy includes exercise to regain and strengthen speech and/or swallowing skills. Occupational therapy helps you learn how to perform usual daily activities, such as eating and dressing by yourself.
Social Security

Social Security programs include retirement benefits, disability benefits, family benefits,
survivors’ benefits and benefits for the aged and blind.

Special Needs Plan (SNP)

A special needs plan (SNP) is a Medicare Advantage plan that addresses the
healthcare needs of individuals who are living in a long-term care facility or skilled nursing facility, have severe or disabling chronic conditions or are dually eligible for both Medicare and Medicaid.

Specialist

A doctor who treats only certain parts of the body, certain health problems or certain age groups. For example, some doctors treat only heart problems.

Step Therapy

A utilization tool that requires you to first try another drug to treat your medical condition before Peoples Health will cover the drug your physician may have initially prescribed.

Supplemental Security Income (SSI)

A monthly benefit paid by the Social Security Administration to people with limited income and resources who are disabled, blind or age 65 and older. SSI benefits are not the same as Social Security benefits.

Urgently Needed Care

Urgently needed care refers to a non-emergency situation when you are temporarily outside of your plan’s service area and obtain services from out-of-network provider because you are in need of an unforeseen illness, injury or condition and it isn’t reasonable, given the situation, for you to obtain medical care through your plan’s participating provider network. Under unusual or extraordinary circumstances, care may be considered urgently needed and paid for by your plan when you are in the service area, but the provider network of the your plan is temporarily unavailable or inaccessible.