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ADVANCE DIRECTIVES
A set of instructions that you can write so your family and doctors will know what kind of treatment you want and don't want if you're too sick to make a decision about your own care. A living will is an example of an advance directive. Advance directives are legal documents and must be signed and witnessed.
APPEAL
A formal request for review of a claim after it has been processed, if you disagree with the payment or if the claim was denied. Medica has a responsibility to respond to all formal appeals.
BEHAVIORAL HEALTH CARE
Services provided for mental health, or for addiction or substance abuse.
CARE SYSTEM
A group of health care providers and clinics that work together to form a coordinated provider group, including primary and specialty care doctors.
CERTIFICATE OF COVERAGE (POLICY)
The most complete description of what's covered and not covered under your health plan. Your Certificate of Coverage carefully explains your level of benefits, your share of costs, the member bill of rights and other important enrollment information.
COINSURANCE
A percentage of the covered amount that you pay for certain health care services.
COMPLAINT OR GRIEVANCE
A member's formal statement that expresses dissatisfaction with any part of a Medica plan or service. Medica and all health plans have an obligation to respond to complaints and grievances.
CONTINUITY OF CARE
A provision that may allow a Medica member to continue receiving care from a doctor who's not in the Medica network or care system for a defined period of time. The decision to allow out-of-network coverage in this situation is made on a case-by-case basis. Members work with Customer Service to determine if continuity of care applies to their situations.
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COORDINATION OF BENEFITS (COB) NOTIFICATION
The information you give us about any other health plan you may have, so that Medica can process your claims accurately. Coordination of benefits assures that all of the health plans you have pay the appropriate amount for your care.
COPAY
Short for "copayment." A fixed amount you pay each plan year before the plan begins to pay for covered services. Charges that aren't covered by your plan don't count toward satisfying the deductible.
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DEDUCTIBLE
The fixed-dollar amount you pay each plan year before the plan begins to pay for covered services. Charges that aren't covered by your plan don't count toward satisfying the deductible.
FORMULARY
A list of covered prescription drugs. The Medica Formulary is the expansive list of drugs approved by Medica's independent review team of physicians and pharmacists for treatment of a wide variety of conditions.
GENERIC-EQUIVALENT DRUGS
drugs that are equivalent in quality and effectiveness to brand-name drugs, but usually lower in cost. Generic equivalents are approved by the Food and Drug Administration (FDA).
LIFETIME MAXIMUM
The dollar amount your plan will pay for eligible health care expenses in a member's lifetime. Each member has a separate lifetime maximum.
MEDICA CALLLINK
Your 24-hour telephone nurse line. Registered nurses provide advice about safe and appropriate care and treatment for Medica members. See the "Getting started" and "Looking and feeling your best" sections of this handbook for the Medica CallLink toll-free number.
MEMBER
Any person covered by a Medica plan.
NETWORK PROVIDER
A term used to describe a provider who has entered into a written agreement with Medica or has made other arrangements with Medica to provider benefits to you. The network of providers will change from time to time.
OPEN-ACCESS PLAN
A health care plan that allows the member to choose any provider—even specialists—from the network for care without a referral. Medica Choice is an open access plan.
OUT-OF-NETWORK CARE
Services you receive from a health care provider who is not in the Medica network or system. Costs for these services may be significantly higher for members. Always contact Customer Service before you receive care from a provider who is not in your plan's network.
OUT-OF-NETWORK PROVIDER
A term used to describe a provider who does not have a written agreement with Medica.
OUT-OF-POCKET MAXIMUM
The total amount of charges for covered services that you may have to pay each plan year in deductibles, copays and coinsurance. Once the maximum is met, your plan pays 100 percent of the covered charges that are received from network providers, up to the lifetime maximum.
OUT-OF-POCKET
A general term describing your share of the cost of health care services. Copays, coinsurance and deductibles are all examples of out-of-pocket expenses because they are paid with your money, out of your "pocket"
PLAN HIGHLIGHTS
A summary of your plan's covered services, your share of expenses, and any limits. The Plan Highlights is only a summary of what's covered and what's not covered; the Certificate of Coverage contains more detailed information. If the Plan Highlights and the Certificate of Coverage conflict, the Certificate of Coverage is always considered to be correct.
PLAN YEAR
The 12-month period from a plan's effective date to the following year's effective date. For example, some plans are effective for a calendar year; some plans may be effective from April 1 through March 31 of the following year.
PREVENTIVE CARE SERVICES
Health care designed to keep you well, like checkups, immunizations and cancer screenings.
PRIMARY CARE DOCTOR
The doctor you choose to coordinate your total care. Primary care doctors know your health history and provider referrals, if your plan requires them, when you need care from a specialist.
PRIOR APPROVAL
Medica's decision to allow a member to receive the highest level of coverage when the member's primary care doctor has written a referral for care from a provider who is not in the plan's network. Call Customer Service for prior approval, if required.
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PROVIDER NETWORK
A list of doctors, hospital and other health care providers whose credentials have been verified and who have agreed to accept a contract payment from Medica for the care they provide to our members.
PROVIDER
A doctor, hospital, clinic, home health agency, skilled-nursing facility or pharmacy that provides health care or prescriptions.
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SPECIALIST
A health care provider who specializes in the care of a specific system of the body. Some examples of specialists are cardiologists (heart health), dermatologists (care of the skin), and allergists (treatment and control of allergies and asthma).
SUBSCRIBER
The person to whom the policy is issued.
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