The following terms are frequently utilized within this website and other materials developed by DaVita VillageHealth.
Appeal - An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services or payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving.
Benefit Period - For both DaVita VillageHealth and the Original Medicare Plan, 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. The benefit period ends when you haven't 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.
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 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.
Catastrophic Coverage - The phase in the Part D Drug Benefit where you pay a low co-payment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $5,600 in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS) - The Federal agency that runs the Medicare program.
Cost-Sharing - Cost-sharing refers to amounts that a member has to pay when services are received. It includes any combination of the following three types of payments: (1) any deductible amount DaVita VillageHealth may impose before services are covered; (2) any fixed "copayment" amounts that a plan may require be paid when specific services are received; or (3) any "coinsurance" amount that must be paid as a percentage of the total amount paid for a service.
Coverage Determination - A decision from your Medicare drug plan about whether a drug prescribed for you is covered by DaVita VillageHealth 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 DaVita VillageHealth Plan, that isn't a coverage determination. You need to call or write to DaVita VillageHealth to ask for a formal decision about the coverage if you disagree.
Covered Drugs - The general term we use to mean all of the prescription drugs covered by DaVita VillageHealth.
Covered Services - The general term we use to mean all of the health care services and supplies that are covered by DaVita VillageHealth.
Customer Services - A department within DaVita VillageHealth responsible for answering your questions about your membership, benefits, grievances, and appeals.
Deductible - The amount of money you must first pay for your Covered Services before DaVita VillageHealth will begin providing coverage.
Emergency Care - Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.
Evidence of Coverage and Disclosure Information - A document, along with your enrollment form and any other attachments, which explains your coverage, what we must do, your rights, and what you have to do as a member of DaVita VillageHealth. This document is automatically mailed to you upon enrollment and once a year thereafter.
Exception - A type of coverage determination that, if approved, allows you to get a drug that is not on the DaVita VillageHealth sponsor'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 DaVita VillageHealth requires you to try another drug before receiving the drug you are requesting, or DaVita VillageHealth limits the quantity or dosage of the drug you are requesting (a formulary exception).
Formulary - A list of covered drugs provided by DaVita VillageHealth.
Generic Drug - A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.
Grievance - A type of complaint you make about us or one of DaVita VillageHealth providers, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
Initial Coverage Limit - The maximum limit of coverage under the initial coverage period.
Initial Coverage Period - This is the period after you have met your deductible (if you have one) and before your total drug expenses, have reached $2,510 including amounts you've paid and what DaVita VillageHealth has paid on your behalf.
Managed Care - A concept of health care intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases.
Medically Necessary - Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition; are used for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for your convenience or that of your doctor.
Medicare - The federal health insurance program providing benefits for people 65 years of age or older, some people under age 65 with certain disabilities, and people with permanent kidney failure (who need dialysis or a kidney transplant).
Medicare Advantage Plan with Prescription Drug Coverage - A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. In most cases, Medicare Advantage Plans also offer Medicare prescription drug coverage. A Medicare Advantage Plan can be an HMO, PPO, or a Private Fee-for-Service Plan.
Medicare Health Plan - A Medicare Advantage Plan (such as an HMO, PPO, or Private Fee-for-Service Plan) or other plan such as a Medicare Cost Plan. Everyone who has Medicare Part A and Part B is eligible to join any Medicare Health Plans that are offered in their area, except people with End-Stage Renal Disease. Persons with ESRD may only join Special Needs Plans contracted with CMS to enroll person with ESRD or enroll in Original Medicare.
Medicare Prescription Drug Coverage - Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part B.
Member - A person with Medicare who is eligible to get covered services, who has enrolled in DaVita VillageHealth and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).
Network Pharmacy - A network pharmacy is a pharmacy where members of DaVita VillageHealth can get their prescription drug benefits. We call them "network pharmacies" because they contract with DaVita VillageHealth. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.
Non-plan Provider or Out-of-Network Provider - A provider or facility with which we have not arranged to coordinate or provide covered services to members of DaVita VillageHealth. Non-plan providers are not under contract to deliver covered services to you.
Organization Determination - The Medicare Advantage Organization (MAO) organization has made an organization determination when it, or one of its providers, makes a decision about MAO services or payment that you believe you should receive.
Original Medicare - Some people call it "traditional Medicare" or "fee-for-service" Medicare. The Original Medicare Plan is the way many people get their health care coverage. It is the national pay-per-visit program that lets you go to any doctor, hospital, or other health care 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 Pharmacy - A pharmacy that doesn't have a contract with DaVita VillageHealth to coordinate or provide covered drugs to members of DaVita VillageHealth. As explained in this Evidence of Coverage, most services you get from non-network pharmacies are not covered by DaVita VillageHealth unless certain conditions apply.
Part D - The voluntary Prescription Drug Benefit Program. (For ease of reference, we will refer to the new prescription drug benefit program as Part D.)
Part D Drugs - Drugs that Congress permitted DaVita VillageHealth to offer as part of a standard Medicare prescription drug benefit. We may or may not offer all Part D drugs. See your formulary for a specific list of covered drugs. Certain categories of drugs, such as benzodiazepines and barbiturates, and over-the-counter drugs were specifically excluded by Congress from the standard prescription drug package. These drugs are not considered Part D drugs.
Plan Provider - "Provider" is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. We call them "plan providers" when they have a contract with DaVita VillageHealth to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of DaVita VillageHealth. DaVita VillageHealth pays plan providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services.
Primary Care Provider (PCP) - A health care professional you select to coordinate your health care. Your PCP is responsible for providing or authorizing covered services while you are a plan member.
Prior Authorization - Approval in advance to get certain drugs that may or may not be on our formulary. Some drugs are covered only if your doctor or other plan provider gets "prior authorization" from us. Covered drugs that need prior authorization are marked in the formulary.
Service Area - "Service area" is the geographic area approved by the Centers for Medicare & Medicaid Services (CMS) within which an eligible individual may enroll in DaVita VillageHealth.
Urgently Needed Care - Urgently needed care refers to a non-emergency situation where you are inside the United States, you are temporarily outside of DaVita VillageHealth's authorized service area, you need medical attention right away for an unforeseen illness, injury, or condition, and it isn't reasonable given the situation for you to obtain medical care through DaVita VillageHealth's participating provider network.
Appeal - An appeal is a special kind of complaint you make if you disagree with a decision to deny a request for health care services or payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving.
Benefit Period - For both DaVita VillageHealth and the Original Medicare Plan, 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. The benefit period ends when you haven't 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.
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 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.
Catastrophic Coverage - The phase in the Part D Drug Benefit where you pay a low co-payment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $5,600 in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS) - The Federal agency that runs the Medicare program.
Cost-Sharing - Cost-sharing refers to amounts that a member has to pay when services are received. It includes any combination of the following three types of payments: (1) any deductible amount DaVita VillageHealth may impose before services are covered; (2) any fixed "copayment" amounts that a plan may require be paid when specific services are received; or (3) any "coinsurance" amount that must be paid as a percentage of the total amount paid for a service.
Coverage Determination - A decision from your Medicare drug plan about whether a drug prescribed for you is covered by DaVita VillageHealth 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 DaVita VillageHealth Plan, that isn't a coverage determination. You need to call or write to DaVita VillageHealth to ask for a formal decision about the coverage if you disagree.
Covered Drugs - The general term we use to mean all of the prescription drugs covered by DaVita VillageHealth.
Covered Services - The general term we use to mean all of the health care services and supplies that are covered by DaVita VillageHealth.
Customer Services - A department within DaVita VillageHealth responsible for answering your questions about your membership, benefits, grievances, and appeals.
Deductible - The amount of money you must first pay for your Covered Services before DaVita VillageHealth will begin providing coverage.
Emergency Care - Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.
Evidence of Coverage and Disclosure Information - A document, along with your enrollment form and any other attachments, which explains your coverage, what we must do, your rights, and what you have to do as a member of DaVita VillageHealth. This document is automatically mailed to you upon enrollment and once a year thereafter.
Exception - A type of coverage determination that, if approved, allows you to get a drug that is not on the DaVita VillageHealth sponsor'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 DaVita VillageHealth requires you to try another drug before receiving the drug you are requesting, or DaVita VillageHealth limits the quantity or dosage of the drug you are requesting (a formulary exception).
Formulary - A list of covered drugs provided by DaVita VillageHealth.
Generic Drug - A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.
Grievance - A type of complaint you make about us or one of DaVita VillageHealth providers, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.
Initial Coverage Limit - The maximum limit of coverage under the initial coverage period.
Initial Coverage Period - This is the period after you have met your deductible (if you have one) and before your total drug expenses, have reached $2,510 including amounts you've paid and what DaVita VillageHealth has paid on your behalf.
Managed Care - A concept of health care intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases.
Medically Necessary - Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition; are used for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for your convenience or that of your doctor.
Medicare - The federal health insurance program providing benefits for people 65 years of age or older, some people under age 65 with certain disabilities, and people with permanent kidney failure (who need dialysis or a kidney transplant).
Medicare Advantage Plan with Prescription Drug Coverage - A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. In most cases, Medicare Advantage Plans also offer Medicare prescription drug coverage. A Medicare Advantage Plan can be an HMO, PPO, or a Private Fee-for-Service Plan.
Medicare Health Plan - A Medicare Advantage Plan (such as an HMO, PPO, or Private Fee-for-Service Plan) or other plan such as a Medicare Cost Plan. Everyone who has Medicare Part A and Part B is eligible to join any Medicare Health Plans that are offered in their area, except people with End-Stage Renal Disease. Persons with ESRD may only join Special Needs Plans contracted with CMS to enroll person with ESRD or enroll in Original Medicare.
Medicare Prescription Drug Coverage - Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part B.
Member - A person with Medicare who is eligible to get covered services, who has enrolled in DaVita VillageHealth and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).
Network Pharmacy - A network pharmacy is a pharmacy where members of DaVita VillageHealth can get their prescription drug benefits. We call them "network pharmacies" because they contract with DaVita VillageHealth. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.
Non-plan Provider or Out-of-Network Provider - A provider or facility with which we have not arranged to coordinate or provide covered services to members of DaVita VillageHealth. Non-plan providers are not under contract to deliver covered services to you.
Organization Determination - The Medicare Advantage Organization (MAO) organization has made an organization determination when it, or one of its providers, makes a decision about MAO services or payment that you believe you should receive.
Original Medicare - Some people call it "traditional Medicare" or "fee-for-service" Medicare. The Original Medicare Plan is the way many people get their health care coverage. It is the national pay-per-visit program that lets you go to any doctor, hospital, or other health care 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 Pharmacy - A pharmacy that doesn't have a contract with DaVita VillageHealth to coordinate or provide covered drugs to members of DaVita VillageHealth. As explained in this Evidence of Coverage, most services you get from non-network pharmacies are not covered by DaVita VillageHealth unless certain conditions apply.
Part D - The voluntary Prescription Drug Benefit Program. (For ease of reference, we will refer to the new prescription drug benefit program as Part D.)
Part D Drugs - Drugs that Congress permitted DaVita VillageHealth to offer as part of a standard Medicare prescription drug benefit. We may or may not offer all Part D drugs. See your formulary for a specific list of covered drugs. Certain categories of drugs, such as benzodiazepines and barbiturates, and over-the-counter drugs were specifically excluded by Congress from the standard prescription drug package. These drugs are not considered Part D drugs.
Plan Provider - "Provider" is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. We call them "plan providers" when they have a contract with DaVita VillageHealth to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of DaVita VillageHealth. DaVita VillageHealth pays plan providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services.
Primary Care Provider (PCP) - A health care professional you select to coordinate your health care. Your PCP is responsible for providing or authorizing covered services while you are a plan member.
Prior Authorization - Approval in advance to get certain drugs that may or may not be on our formulary. Some drugs are covered only if your doctor or other plan provider gets "prior authorization" from us. Covered drugs that need prior authorization are marked in the formulary.
Service Area - "Service area" is the geographic area approved by the Centers for Medicare & Medicaid Services (CMS) within which an eligible individual may enroll in DaVita VillageHealth.
Urgently Needed Care - Urgently needed care refers to a non-emergency situation where you are inside the United States, you are temporarily outside of DaVita VillageHealth's authorized service area, you need medical attention right away for an unforeseen illness, injury, or condition, and it isn't reasonable given the situation for you to obtain medical care through DaVita VillageHealth's participating provider network.
