An amount you may be required to pay, expressed as a percentage (for example 20%) as your share of the cost for services or prescription drugs after you pay any deductibles.

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount (for example $10), rather than a percentage.

The amount you must pay for health care or prescriptions before our plan pays.

A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life (and, if you are a pregnant woman, loss of an unborn child), loss of a limb, or loss of function of a limb, or loss of or serious impairment to a bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an “outpatient.”

Physicians, hospitals and other providers in our service area that have contracted with SummaCare to provide health care services to plan members. Your network of providers is called the SCMedicare network.

The most that you pay out of pocket during the calendar year for in-network covered Part A and Part B services. Amounts you pay for our plan premiums, Medicare Part A and Part B premiums, and prescription drugs don’t count toward the maximum out-of-pocket amount.

The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Out-of-Network Provider or Out-of-Network Facility – A provider or facility that does not have a contract with our plan 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 our plan.

You’re an outpatient if you’re getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit you to a hospital as an inpatient. In these cases, you’re an outpatient even if you spend the night at the hospital.

Medicare drug coverage (also known as Medicare Part D) helps pay for the brand-name and generic drugs you need. It's optional and offered to everyone with Medicare by insurance companies and other private companies approved by Medicare. Even if you don’t take prescription drugs now, consider getting Medicare drug coverage to avoid paying a late enrollment penalty if you join a plan later.

The periodic payment to Medicare, an insurance company or a health care plan for health or prescription drug coverage.

The doctor or other provider you see first for most health problems. In many Medicare health plans, you must see your primary care provider before you see any other health care provider.

The annual quality ratings help consumers determine how well a health plan is performing in areas such as:

• How satisfied members are with the health plan.
• How effective the health plan assists its providers in prevention and detection of illnesses.
• How well the health plan maintains the overall well-being of its members.
• How quickly the health plan responds to the members’ needs in regards to receiving care and addressing members’ concerns, including appeals.

Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.