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Glossary

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Term Definition
Service Area

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.
Skilled Nursing Facility

A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.
Specified Low - Income Medicare Beneficiary (SLMB)

A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.

Stars

Stars for each plan show how well the plan performs in that particular category. Star ratings range from 1 star to 5 stars, where a rating of 1 star means "poor" quality and 5 stars means "excellent" quality.
Step Therapy

In some cases, plans require you to first try one drug to treat your medical condition before they will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, a plan may require your doctor to prescribe Drug A first. If Drug A does not work for you, then the plan will cover Drug B. If a drug has step therapy restrictions, you will need to work with the plan and your doctor to obtain an exception.
Summary Score for Health Plan Quality

How Well is the Health Plan Doing?

This category has a single rating that summarizes how well the health plan is doing across all areas of health plan quality and performance reported on this website.

The summary score is calculated by combining the health plan's ratings in the following categories:


  • Staying Healthy: Screenings, Tests and Vaccines. This category covers how well each health plan works to detect and prevent illness.
  • Getting Timely Care from Doctors and Specialists. This category shows how easily people in each health plan are able to get the care they need from primary care doctors and specialists.
  • Managing Chronic (Long-Lasting) Conditions. This category has information on how well each health plan helps people with chronic or long-lasting health conditions.
  • Ratings of Health Plan Responsiveness and Care. This category shows how well each health plan responds when its members need information and care.
  • How Well and Quickly Health Plans Handled Appeals. This category provides information on how well and how quickly each health plan handles appeals, and whether the health plan?s decisions are upheld by outside experts.

Why is this summary score important?

This "summary score of health plan quality" provides a quick and easy way for you to compare the overall quality and performance of health plans. You can use the separate ratings to get more details on topics of special interest to you.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

This glossary explains terms in the Medicare program, but it is not a legal document. The official Medicare program provisions are found in the relevant laws, regulations,and rulings.