Glossary of Terms

Term Definition
AARP® (formerly known as the American Association of Retired) AARP® (formerly known as the American Association of Retired). A nonprofit, nonpartisan organization that addresses the needs and interests of Americans aged 50 and older.
Agent A global term to refer to any licensed, certified, and appointed individual soliciting and selling UnitedHealthcare regulated insurance products.
Appointment (Agent) A procedure required by most states that grants limited authority to an individual, the privilege to sell a company line of products within the state. An individual is required to have an appointment in their resident state before appointments can be submitted to non-resident states. An appointment is required before an agent can sell the Company’s product.
Authorized Representative A person authorized under applicable law or identified in writing by the individual to act on behalf of the individual in making health care and related decisions for an enrollee. Same as Responsible Party.
Beneficiary Also Medicare Beneficiary. A person who is entitled to Medicare according to the Centers for Medicare & Medicaid Services definition.
Book of Business The collection of leads, contacts, and/or transactions assigned to a particular agent.
Call Monitoring A quality assurance function used to evaluate inbound and outbound calls either side-by-side or remotely; for the purposes of compliance and training (to identify areas of opportunity), while ensuring an agent’s accountability as a representative of the UnitedHealth is compliant as it pertains to CMS regulations and guidelines and Company rules, policies, and procedures.
Centers for Medicare and Medicaid Services (CMS) The federal agency responsible for administering Medicare. CMS communicates guidance and regulatory requirements and provides oversight to Medicare Advantage Organizations.
Cold Calling The act of cold calling, including but not limited to; telephone calls, emailing, text messaging and leaving voice mail are all prohibited. The Centers for Medicare & Medicaid Services (CMS) has specific Regulations in relation to marketing through unsolicited contacts. Agents may not engage in any direct unsolicited contact with consumers, including consumers who are aging-in. (See also Unsolicited Contact).
Community See Sales Event. All Community Events/Meetings are ‘Formal Marketing/Sales Events.’
Complaint A written grievance received from a consumer or member, or any person or organization acting on a consumer or member’s behalf, including written grievances from any Department of Insurance or other regulatory or governmental agency.
Consumer An individual who may be eligible for UnitedHealthcare products (e.g. Medicare consumer, customer, client).
Coordinated Care In Part C, the health care plans that coordinate a consumer’s care by the physicians and hospitals visited. These plans may have some restrictions on the physicians and hospitals used for care. These plans are also referred to as “managed care” plans. PFFS and MSA Plans are not coordinated care plans.
Copayment An amount the member may be required to pay as their share of the cost for a medical service or supply, like a physician’s visit or a prescription. A copayment is usually a set amount, rather than a percentage.
Cost-Sharing The amounts that a member has to pay when drugs or services are received. The most common types of cost-sharing are coinsurance, copayments and deductibles.
Coverage Gap Most Medicare prescription drug plans have a coverage gap. This means that after the member and plan have spent a certain amount of money for covered drugs, the member has to pay all costs out-of-pocket for their drugs up to a limit. The member’s yearly deductible, coinsurance or copayments, and what they pay in the coverage gap all count toward this out-of-pocket limit. The limit does not include the drug plan’s premium. There are plans that offer some coverage in the gap. However, plans with coverage in the gap may charge a higher monthly premium. Check with the plan first, to see if the consumer’s drugs would be covered in the gap.
Credentialing Process of contracting, appointment, certification, and approval for an agent to sell any UnitedHealthcare products.
Cross-Selling CMS regulations and guidelines prohibit marketing non-health related products (e.g. annuities, life insurance, disability) to consumers during any Medicare Advantage or Part D sales activity or presentation. This
activity is prohibited.
Deductible The amount a member must pay for health care services or prescriptions, before Original Medicare, their prescription drug plan, or other insurance coverage begins to pay.
Deemed Provider A Medicare-eligible provider who agrees to accept the plan’s terms and conditions of payment for a specific member visit by virtue of the fact that the provider is aware, in advance, that the patient is a PFFS member and the provider has reasonable access to the plan’s terms and conditions of payment. Members must inform providers of PFFS Plan membership and present their ID card prior to receiving covered services. If the provider does not agree to be deemed, the PFFS member must find another provider. Providers agree to bill the plan and will not balance bill the member. A provider must agree to be deemed each time a member seeks covered medical services. The provider can decide whether or not to accept the plan’s terms and conditions of payment each time they see a PFFS member. A decision to treat one plan member does not obligate the provider to treat other PFFS members, nor does it obligate providers to accept the same member for treatment at a subsequent visit.
Deeming A provider is deemed by law to have a contract with the plan when all of the following four criteria are met:

  1. The provider is aware, in advance of furnishing health care services, that the patient is a member of the plan. (All members receive a member ID card that includes the plan logo that clearly identifies them as PFFS members).
  2. The provider either has a copy of, or has reasonable access to, the plan’s terms and conditions of payment rates.
  3. The provider furnishes covered services to a plan member.
  4. The provider agrees to submit the bill for covered services directly to the plan.

If all of these conditions are met, the provider is deemed to have agreed to the plan’s terms and conditions of payment for that member specific to that visit. Note: The provider can decide whether or not to accept the plan’s terms and conditions of payment each time they see a member. A decision to treat one plan member does not obligate them to treat other plan members, nor does it obligate them to accept the same member for treatment at a subsequent visit.

Disciplinary Action Committee (DAC) A committee whose purpose is to consider recommendations for suspension or terminations of appointments of agents.
Door-to-Door Direct, unsolicited, in-person contact with a consumer. May include actual door-to-door solicitation or unauthorized in-person contact with a consumer in any public place, e.g. parking lot, senior center, etc.
Down-Line A term used to describe agents within an FMO hierarchy that are below the management/reporting level of a specific agent/agency.
Dual-Eligible Consumers and/or members receiving benefits from both Medicare and Medicaid.
Errors and Omissions (E&O) Insurance Errors and Omissions insurance covers UnitedHealthcare’s contracted agents and solicitors in the event they misrepresent a plan and its benefits to a consumer.
Educational Event Educational events are events designed to inform Medicare consumers about MA, Prescription Drug or other Medicare programs but do not steer, or attempt to steer consumers toward a specific plan or limited number of plans. Educational events may not include any sales activities such as the distribution of marketing materials or the distribution or collection of Enrollment Applications. Educational Events must be advertised as educational; otherwise they are considered marketing/sales events. Educational events are held in public venues and do not extend to personal/individual appointments. (See also Sales Event).
End-Stage Renal Disease (ESRD) Permanent kidney failure requiring dialysis or a kidney transplant.
Field Marketing Organization (FMO) An independent marketing organization that has contracted with UnitedHealthcare to solicit and sell identified UnitedHealthcare Medicare Solutions products through its network of agencies and licensed, certified, and appointed agents. They are not employed by UnitedHealthcare.
Formulary A list of medications covered within the benefit plan; often represents the level of cost-sharing associated with various groupings of medications (Generics, Preferred Brand, Non-Preferred Brands). The formulary is often published to the web or in a written document. However the document may only reference the preferred medications. (Often referred to as Preferred Drug List or PDL).
Generic Drugs A consumer who is Medicare eligible, retired from his/her previous employer and is looking to continue health care and/or prescription coverage with their previous employer. Employer Groups contract with health plans which allow them the opportunity to offer products and administer benefits through contractual agreements and arrangements. With subsidized plans, the employer contributes to the premium, but with endorsed plans the employer does not.
Health Fairs Health Fairs are defined by the venue, the room design, and the way in which the event is advertised to the consumer. These events are typically comprised of booths that are manned by staff to answer questions and hand out materials.
Hierarchy The management structure of an FMO and/or the management structure defined as part of the contracting process.
HMO Health Maintenance Organization.
In-Home Appointment A scheduled one-on-one sales presentation that takes place in a consumer’s residence. Includes a nursing home/facility resident’s room. Requires a Scope of Appointment form.
Initial CoverageElection Period (ICEP) The ICEP is the period during which a consumer newly eligible for Medicare may make an initial enrollment request to enroll in an MA plan. This period begins three months immediately before the consumer’s first entitlement to both Medicare Part A and Part B and ends on the latter of:

  1. The last day of the month preceding entitlement to both Medicare Part A and Part B, or;
  2. The last day of the consumer’s Medicare Part B initial enrollment period.

The initial enrollment period for Part B is the seven (7) month period that begins three months before the month a consumer meets the eligibility requirements for Medicare Part B, and ends three months after the month of eligibility.

Late-Enrollment Penalty (LEP) An amount added to a consumer’s monthly premium for Medicare Part A and/or Part B, or for a Medicare drug plan (Part D), if they do not elect to join when they are first eligible. Consumers pay this higher amount as long as they have Medicare. There are some exceptions.
Lead A consumer who, by their actions, has demonstrated an interest in a UnitedHealthcare Medicare Solutions product (includes current members).
License A certificate giving proof of formal permission from a governmental authority to an agent to sell insurance products within a state.
Marketing/Sales Event Formal and Informal Are defined both by the range of information provided and the way in which the content is presented. In addition, Marketing/Sales events are defined by the Plan’s ability to collect Enrollment Applications and enroll Medicare consumers during the event. A Marketing/Sales event is designed to steer, or attempt to steer, consumers toward a plan or limited set of plans.

A Formal Sales Event is structured in an audience/presenter style with sales personal or plan representative formally providing specific sponsor information via a presentation on the products being offered. An Informal Sales Event is conducted with a less structured presentation or in a less formal environment like a retail booth, kiosk, table, recreational vehicle or food banks where an agent can discuss plan information when approached by a consumer.

Master General Agent (MGA) An independent contractor, with a direct contract with UnitedHealthcare at the MGA level that is part of the FMO hierarchy. May refer agents and solicitors for certification and appointment. The specific hierarchy level is based upon the production of contracted agents and solicitors; they are not employed by UnitedHealthcare.
Medicaid A program that pays for medical assistance for certain individuals and families with low incomes and resources. Medicaid is jointly funded by the Federal and State governments to assist states in providing assistance to people who meet certain eligibility criteria. Medigap cannot be sold to consumers who receive assistance from Medicaid unless assistance is limited to help with Part B premiums, or Medicaid buys the Medigap Plan for the individual.
Medicare A federal government health insurance program for:

  1. People age 65 and older.
  2. People of all ages with certain disabilities.
  3. People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or kidney transplant).
Medicare Advantage Disenrollment Period- MADP January 1 – February 14
The 45-day period when Medicare Advantage members may disenroll from their current plan, but only return to Original Medicare (they may also select a PDP for Part D coverage).
Medicare Advantage Plan – MA Only A Medicare Advantage Plan with only medical coverage. It does not have an integrated Part D prescription medication benefit.
Medicare Advantage A Medicare Advantage Plan that integrates Part D prescription drug benefits with the medical coverage.
Medicare Part A The part of Medicare that provides help with the cost of hospital stays, skilled nursing services following a hospital stay, and some other kinds of skilled care.
Medicare Part B The part of Medicare that provides help with the cost of physician visits and other medical services.
Medicare Part B Premium The premium amount deducted from a Medicare consumer’s Social Security check. The Part B Premium varies from year to year.
Medicare Part C Medicare Part C Plans are referred to as Medicare Advantage Plans.

  1. Include both Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
  2. Private insurance companies approved by Medicare provide this coverage.
  3. In most plans, members need to use plan physicians, hospitals and other providers or they pay more.
  4. Members usually pay a monthly premium (in addition to their Medicare Part B premium) and a copayment for covered services.
  5. Costs, extra coverage and rules vary by plan.
Medicare Part D Known as Medicare Prescription Drug Plans. The part of Medicare that provides coverage for outpatient prescription medications. These plans are offered by insurance companies and other private companies approved by Medicare. Consumers can get Part D coverage as part of a Medicare Advantage Plan (if offered where a consumer lives), or as a Stand-alone Prescription Drug Plan.
Medicare Private Fee-For-Service Plan (PFFS) Medicare Advantage Plans offered by private insurance companies that allow members to go to any Medicare eligible provider who agrees to accept the PFFS Plan’s terms and conditions of payment rates. The PFFS Plan pays instead of Original Medicare. PFFS Plans may or may not offer Part D coverage.
Medigap Policy Medicare Supplement insurance sold by private insurance companies to fill “gaps” (deductibles, coinsurance, copayments) in Original Medicare. A Medigap Policy cannot be sold to a Medicare Advantage member unless the member is switching to Original Medicare. A Medigap Policy can be sold to members in Part D (not MA-PD) Plans.
Network Group of physicians, hospitals and pharmacies who have contracts with a health insurance plan to provide care/services to the plan’s members. The Part D prescription drug plan’s network of pharmacies may help members save money on medications.
NIPR National Insurance Producer Registry. NIPR developed and implemented the Producer Database (PDB) which provides the following benefits: Financial/Time savings, reduction in paperwork, real time information, verify license and status in all participating states, ease of access via the internet, and single source of data vs. multiple websites.
National Marketing Alliance FMO (NMA) NMA is a higher level contract given to a select group of FMOs. These companies must adhere to comprehensive compliance, marketing and recruiting goals.
Outbound Enrollment Verification Call (OEV) An outbound call to recent enrollees which evaluates agent performance in making full benefit and network disclosures and benefit descriptions.
Original Medicare An outbound call to recent consumers who enrolled in a Medicare Advantage plan which evaluates agent performance in making full benefit and network disclosures and benefit descriptions.
Out-of-Network Provider A licensed physician or hospital that is not contracted with a Plan to provide medical services to its members. With Medicare Advantage PPO and POS plans, members can access out-of-network providers for covered services, generally at a higher cost than with in-network providers.
Out-of-Pocket Maximum An annual limit that some plans set on the amount of money a member will have to spend out of their own pocket for benefits.
Party ID A number assigned by Agent On-Boarding that provides primary identification of an agent. All writing numbers assigned to the agent are tied to their Party ID.
Pledge of Compliance A document signed (electronically) annually by agents pledging compliance with Center for Medicare and Medicaid Services (CMS) regulations.
Point-of-Service (POS) An HMO option that lets members use physicians and hospitals outside the plan’s contracted provider network subjected to increased cost sharing, POS benefits are available for selected benefits.
Preferred Provider Organization (PPO) A type of Medicare Advantage Plan in which the member can use either preferred physicians or hospitals, or go to non-preferred physicians and hospitals. If the member uses non-preferred providers, they will usually pay a larger share of the cost of their care.
Prescription Drug Plan (PDP) A stand-alone plan that offers Part D prescription medication coverage only.
Primary Care Physician (PCP) A physician seen first for most health problems. The PCP may also coordinate a member’s care with other physicians and health care providers. In some Medicare Advantage Plans, members must see their PCP before seeing any other health care provider.
Provider Any individual who is engaged in the delivery of health care services in a state and is licensed or certified by the state to engage in that activity, and any entity that is engaged in the delivery of health care services in a state and is licensed or certified to deliver those services if such licensing or certification is required by state law or regulation.
Regional Preferred Provider Organization (RPPO) A type of Medicare Advantage Plan. Regional PPO plans were introduced in an effort to expand the reach of Medicare managed care to Medicare consumers, including those in rural areas. The RPPOs can only be offered in an MA Region which is defined by CMS.
Resident Agent An agent who is licensed to sell in their state of primary residency.
Responsible Party A person authorized under applicable law or identified in writing by the individual to act on behalf of the individual in making health care and related decisions for a consumer. Also known as ‘Authorized Representative.’
Sales Event Any sales or marketing activity and/or event that can be used to market to consumers and steer them toward specific plans, but does not include scheduled face-to-face individual/personal sales presentations. All sales events must be reported in accordance with CMS reporting regulations and guidelines. CMS also outlines specific regulations and guidelines in regard to the marketing, facilitation, and cancellation of sales events.
Scope of Appointment A document or recorded agreement, received prior to the related scheduled appointment, which specifies the products the consumer has agreed that the sales agent may present at the one-on-one sales presentation.
Service Area The geographic area approved by CMS within which an eligible consumer may enroll in a certain plan.
Service Request The documentation of all inbound and outbound contacts between the PHD and the producer community.
Solicitor A licensed, certified, and appointed independent contractor who sells any one of the UnitedHealth products through a contract with an agency (FMO, SGA, MGA and GA), but does not have a direct contract with UnitedHealth Group.
Special Election Period (SEP) A period when a Medicare consumer may sign up or make changes to their Medicare coverage outside of a general enrollment period. These periods are available under specified circumstances defined by Medicare.
Super General Agent (SGA) An independent contractor, with a direct contract with UnitedHealthcare at the SGA level that is part of the FMO hierarchy. May refer agents and solicitors for certification and appointment. The specific hierarchy level is based upon the production of contracted agents and solicitors. They are not employed by UnitedHealthcare.
Telemarketer/ing A firm or individual who contacts consumers, via the telephone, on behalf of UnitedHealthcare for the purpose of soliciting or selling any of the products listed above. Telemarketing activities may include lead generation, appointment setting, and/or product marketing.
Tier Covered medications have various levels of associated member cost-sharing. Example: Tier One (primarily Generics); Tier Two (primarily Preferred Branded Medications); Tier Three (primarily Non-Preferred Branded Medications); Tier Four (Specialized High Cost Medications).
Unsolicited Contact Unsolicited contact includes, but is not limited to: door-to-door solicitation; email solicitation; text message solicitation and cold-calling (telephone solicitation). Products affected are Medicare Advantage (MA), Prescription Drug Plan (PDP) and any UnitedHealthcare product that carries the AARP name. If the consumer asks to no longer receive calls, you must discontinue contact and update your book of business in regard to MA/PDP and all products carrying the AARP name.
Up-Line Agents within an FMO hierarchy that are above the management/reporting level of a specific agent/agency.
Writing ID number A Company generated number, assigned to a contracted, licensed, and appointed agent used for submitting business, tracking commissions, and other agent-specific sales statistics.