AFI Benefits
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Accepts Medicare Assignment —Physicians, physical therapists, occupational therapists and Durable Medical Equipment suppliers that participate in Medicare and accept Medicare Allowable Charges as payment in full for services provided to Medicare beneficiaries.

Acute Care —A pattern of health care in which an Enrollee is treated for an acute (immediate and severe) episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Acute Care is usually received in a Hospital from specialized personnel using complex and sophisticated technical equipment and materials. This pattern of care is often necessary for a short time, unlike chronic care, where no significant improvement can be expected.

Advance Coverage Decision —A decision made by a Medicare Advantage Private Fee-For- Service Organization as to whether a requested health care service is a Medically Necessary Covered Service.

Appeal —A special kind of complaint you make if you disagree with certain kinds of decisions made by Medicare or your health or prescription drug plan. You can appeal if you request a health care service, supply or prescription that you think you should be able to get, or you request payment for health care you already received, and Medicare or a plan denies the request. You can also appeal if you are already receiving coverage and the plan stops paying. There is a specific process your plan must use when you ask for an appeal. Balance


Billing —Physicians, occupational therapists or durable medical equipment suppliers that do not Accept Medicare Assignment and choose to bill the Medicare beneficiary for the balance of their private fees that exceed the Medicare Allowed Charges, not to exceed the Medicare Limiting Charge of 115% of Medicare Allowable Charges.

Benefit Period —The way that the Original Medicare Plan measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven’t received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods.


Centers for Medicare & Medicaid Services (CMS) —The Federal Agency responsible for administering Medicare.

Coinsurance —The amount you may be required to pay for services after you pay any plan deductibles. In the Original Medicare Plan, this is a percentage (like 20%) of the Medicare-approved amount. You have to pay this amount after you pay the deductible for Part A and/or Part B. In a Medicare Prescription Drug Plan, the coinsurance will vary depending on how much you have spent.

Copayment —In some Medicare health and prescription drug plans, the amount you pay for each medical service, like a doctor’s visit, or prescription. A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor’s visit or prescription. Copayments are also used for some hospital outpatient services in the Original Medicare Plan.

Coverage Determination (Part D)— The first decision made by a Medicare Prescription Drug Plan (not the pharmacy) about the drug benefits you may be entitled to get, including a decision about whether or not to provide or pay for a Part D drug a formulary exception request you may have made what you must pay out-of-pocket for a drug whether you have satisfied a prior authorization requirement for a requested drug If you disagree with the decision, the next step is an appeal.

Covered Services —Medically Necessary services or supplies provided under the terms of the Combined Evidence of Coverage and Disclosure Information and the Schedule of Benefits.

Creditable Prescription Drug Coverage —Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

Critical Access Hospital —A small facility that gives limited outpatient and inpatient services to people in rural areas.

Custodial Care —Not a Covered Service. Custodial Care includes services that assist an individual in the activities of daily living. Examples include: assistance in walking, getting in or out of bed, bathing, dressing, feeding and using the toilet, preparation of special diets, and supervision of the administration of medication that usually can be self-administered. Custodial Care includes all homemaker services, respite care, convalescent care or extended care not requiring skilled nursing. Custodial Care does not require the continuing attention of trained medical or paramedical personnel.


Deductible —The amount you must pay for health care or prescriptions, before the Original Medicare Plan, your prescription drug plan, or other insurance begins to pay. For example, in the Original Medicare Plan, you pay a new deductible for each benefit period for Part A and each year for Part B. These amounts can change every year.

Deemed Provider (Deemed Physician) —Providers (Physicians, physical therapists, occupational therapists and Durable Medical Equipment suppliers that participate in Medicare) are deemed to have a contract with a Medicare Advantage Private Fee-For-Service Organization if (a) they are Medicare Eligible and (b) they know, before furnishing services, that a Medicare beneficiary is enrolled in a Medicare Advantage Private-Fee-For-Service Plan and either know the Terms and Conditions of plan payment or has reasonable access to the Terms and Conditions.

Disenroll or Disenrollment —The process of ending your enrollment in Advantra Freedom. Disenrollment can be voluntary or involuntary.

Durable Medical Equipment (DME) —Equipment that can withstand repeated use; is primarily and usually used to serve a medical purpose; is generally not useful to a person in the absence of illness or injury; and is appropriate for use in the home. To be covered, Durable Medical Equipment must be Medically Necessary and prescribed by a Provider for use in your home, such as oxygen equipment, wheelchairs, hospital beds and other items that are determined Medically Necessary, in accordance with Medicare law, regulations and guidelines.


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: 1) placing the Enrollee’s health in serious jeopardy; 2) serious impairment to bodily functions; 3) serious dysfunction of any bodily organ or part. In the case of a pregnant woman, an Emergency Medical Condition exists if the Enrollee is in active labor, meaning labor at a time at which either of the following would occur: a) there is inadequate time to effect safe transfer to another hospital prior to delivery; or b) a transfer may pose a threat to the health and safety of the Enrollee or the unborn child.

Emergency Services —Covered Services that are 1) furnished by an emergency room Provider qualified to furnish Emergency Services, and 2) needed to evaluate or stabilize an Emergency Medical Condition. Please see definition of Emergency Medical Condition.

Excess Charges —(“Medicare Part B Excess Charges”) —The amount of charges that Physicians, physical therapists, occupational therapists and Durable Medical Equipment suppliers may bill Medicare beneficiaries for services provided if these Providers choose to not Accept Medicare Assignment as payment in full. Medicare established a Medicare Limiting Charge of 115% of Medicare Allowable Charges, which defines the maximum amount that these Providers may bill a Medicare Beneficiary.

Exclusion or Excluded —Items or services which are not covered under this Evidence of Coverage and Disclosure Information, which includes the Summary of Benefits. Exclusions are disclosed in the Summary of Benefits. You are responsible for paying for excluded items or services.


Formulary —A list of drugs covered by a plan.


Health Maintenance Organization(HMO) Plan —A type of health plan available in some areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Your costs may be lower than in the Original Medicare Plan.

Home Health Agency —A Medicare-certified agency, which provides intermittent Skilled Nursing Care and other Medically Necessary therapeutic services in your home when you are confined to your home.

Hospice —An organization or agency, certified by Medicare, that is primarily engaged in providing pain relief, symptom management and supportive services to terminally ill people and their families.

Hospital —A Medicare-certified institution licensed by the State, which 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 which furnishes primarily Custodial Care, including training in routines of daily living.


Institution —A facility that meets Medicare’s definition of a long-term care facility, such as a nursing facility or skilled nursing facility, not including assisted or adult living facilities, or residential homes.


Lifetime Reserve Days —In the Original Medicare Plan, 60 days that Medicare will pay for when you are in a hospital more than 90 days during a benefit period. These 60 days can be used only once during your lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.

Limitations —Items, benefits or services that are limited under the Enrollee Handbook, Evidence of Coverage and Summary of Benefits. Long-term Care—A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn’t pay for this type of care if this is the only kind of care you need.


Medicaid —A joint Federal and State program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medically Necessary —Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of you or your doctor.

Medicare (Original Medicare) —The federal government health insurance program established by Title XVIII of the Social Security Act for people 65 years of age or older, certain younger people with disabilities, and people with end-stage renal disease (ESRD).

Medicare Part A —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 —A monthly premium 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. Generally, people age 65 and older can obtain premium-free Medicare Part A benefits based on their own or their spouse’s employment. If you are under 65, you can obtain premium-free Medicare Part A benefits if you have been a disabled beneficiary under Social Security Administration or the Railroad Retirement Board for more than 24 months. If you do not qualify for premium-free Part A benefits, you may buy the coverage if you are at least 65 years old and meet certain requirements. Also, you may be able to buy Medicare Part A if you are disabled and lost your premium-free Part A because you are working.

Medicare Part B —Supplementary medical insurance that is optional and requires a monthly premium. Part B covers physician services (in both Hospital and non-hospital settings) and services furnished by certain non-physician practitioners. 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 not covered under Part A.

Medicare Part B Premium —A monthly premium paid to Medicare (usually deducted from your Social Security check) to cover Part B services. You must continue to pay this premium to Medicare to receive Covered Services whether you are covered by a Medicare Advantage Plan or Medicare.

Medicare Advantage Plan (Part C)— A type of Medicare plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Also called Part C, Medicare Advantage Plans are HMOs, PPOs, Private Fee-for-Service Plans, or Medicare Medical Savings Account Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under the Original Medicare Plan.

Medicare-approved Amount —In the Original Medicare Plan, this is the amount a doctor or supplier can be paid, including what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges.

Medicare Medical Savings Account (MSA) Plan —MSA Plans combine a high-deductible Medicare Advantage Plan (like an HMO or PPO) with a Medical Savings Account for medical expenses.

Medicare Participating Providers —Medicare Eligible Physicians, physical therapists, occupational therapists and Durable Medical Equipment suppliers that accept Medicare Allowed Charges as payment in full for services provided to Medicare beneficiaries.

Medicare Non-Participating Providers —Medicare Eligible Physicians, physical therapists, occupational therapists and Durable Medical Equipment suppliers that do not accept Medicare Allowable Charges as payment in full for services provided to Medicare beneficiaries. The amount of charges that these Providers may bill Medicare beneficiaries for services provided is established by Medicare. The Medicare Limiting Charge of 115% of Medicare Allowable Charges defines the maximum amount that these Providers may bill the Beneficiary.

Medicare Prescription Drug Plan(Part D)— A stand-alone drug plan offered by insurers and other private companies to people who get benefits through the Original Medicare Plan, through a Medicare Private Fee-for-Service Plan that doesn’t offer prescription drug coverage, a Medicare Cost Plan, or Medicare Medical Savings Account Plan. Medicare Advantage Plans may also offer prescription drug coverage that must follow the same rules as Medicare Prescription Drug Plans.

Medigap Policy —Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage. Except in Massachusetts, Minnesota, and Wisconsin, there are up to 12 standardized Medigap policies labeled Medigap Plan A through Plan L. Medigap policies only work with the Original Medicare Plan.


Penalty —An amount added to your monthly premium for Medicare Part B, or for a Medicare drug plan (Part D), if you don’t join when you’re first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.

Physician —Any duly licensed Physician, Osteopath, Psychologist or other practitioner (as defined by Medicare) who provides health care services. Physicians are licensed Providers in the United States. See also Primary Care Physician and Specialist.

Point-of-Service —A Health Maintenance Organization (HMO) option that lets you use doctors and hospitals outside the plan for an additional cost.

Preferred Provider Organization(PPO) Plan —A type of Medicare Advantage Plan (Part C) available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost. Premium—The periodic payment to Medicare, an insurance company, or a health care plan for health care or prescription drug coverage.

Preventive Services —Health care to keep you healthy or to prevent illness (for example, Pap tests, pelvic exams, flu shots, and screening mammograms).

Primary Care Doctor —A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.

Private Fee-for-Service (PFFS) Plan —A type of Medicare Advantage Plan (Part C) in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits and may have extra benefits than in the Original Medicare Plan.

Provider —Any professional person, organization, health facility, Hospital, or other person or institution licensed and/or certified by the State and Medicare to deliver or furnish health care services.


Referral —A written order from your primary care doctor for you to see a specialist or get certain services. In many HMOs, you need to get a referral before you can get care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for your care.


Service Area —A geographic area approved by CMS within which a Medicare Advantage eligible individual must reside in order to enroll in. Medicare Advantage Plans.

Skilled Nursing Facility Care —This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (such as help with activities of daily living, like bathing and dressing) cannot qualify you for Medicare coverage in a skilled nursing facility if that’s the only care you need. However, if you qualify for coverage based on your need for skilled nursing care or rehabilitation, Medicare will cover all of your care needs in the facility, including help with activities of daily living.

Special Enrollment Period (SEP)— Under Part B, a period when you can enroll in Medicare Part B if you didn’t sign up when first eligible because you or your spouse (or a family member, if disabled) was still working and you were covered under a group health plan from an employer or union. You sign up for Part B at anytime while covered under the group health plan based on that employment, or during the 8-month period that begins the month the employment ends or the group health plan coverage ends, whichever comes first. Usually, if you join Part B in the SEP, you don’t pay a penalty. Under Part D, you may get a SEP to join a plan that provides Medicare prescription drug coverage, or switch to a different plan in certain situations, like if you move out of the service area of a Medicare drug plan, or lose creditable prescription drug coverage.

Special Needs Plan —A special type of Medicare Advantage Plan (Part C) that provides more focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions.

Specialist —Any Physician, Osteopath, Psychologist or other practitioner (as defined by Medicare) who provides health care services for a specific disease, condition or body part. Specialists are licensed Providers in the United States. Specialists may also be considered a Primary Care Physician, such as Cardiologists who practice their sub-specialty as well as their Primary Care specialty of Internal Medicine.

Summary of Benefits —The document which provides the details of your particular benefit plan, including any Copayments and Coinsurance that you should pay when receiving a Covered Service. Together with the Evidence of Coverage and Disclosure Information document, the Schedule of Benefits explains your health care coverage.

State Health Insurance Assistance Program —A state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.


Telemedicine —Medical or other health services given to a patient using a communications system (like a computer, telephone, or television) by a practitioner located away from the patient.

TTY —A teletypewriter (TTY) is a communication device used by people who are deaf, hard of hearing, or have a severe-speech impairment. People who don’t have a TTY can communicate with a TTY user through a message relay center (MRC). An MRC has TTY operators available to send and interpret TTY messages.