Deductible !
DEFINE DEDUCTIBLE
The amount of money that a member or family member must pay for covered health-care services, including prescription drugs, before the health plan provides coverage for a service or prescription.
A method of reimbursement based on payment for services rendered. Payment may be made by an insurance company, the patient or a government program such as Medicare or Medicaid.
DEFINE NEGOTIATED RATES
Applies to requests for release or confirmation of a negotiated fee amount for services
DEFINE OPEN ACCESS
Aetna Open Access is an alternative benefit plan for plan sponsors interested in allowing their members more choice. We based this product off the current HMO, MC and EC products and eliminated the need for referrals.
DEFINE REASONABLE & CUSTOMARY
A method for determining payment for services based upon historical charges from the same provider or other providers in the same area for similar services/ Also known as U&C and UCR.This is a reimbursement method which typically includes a determination of prevailing fees for a particular service
WHAT ARE THE TWO TYPES OF DEDUCTIBLE CREDITS?
Who can make this payment?
insurance company
The Patient
government program such as Medicare or Medicaid
Which Health Care Program does Not Apply to Open Access?
Behavioral health care
WHEN MIGHT YOU NEED TO SEE A SPECIALIST?
PROVIDER REFERRAL
Dermatologists. ...
Infectious disease doctors. ...
Ophthalmologists. ...
Obstetrician/gynecologists. ...
Cardiologists. ...
Endocrinologists. ...
Gastroenterologists.
Is open access available for fully funded insured?
yes its for fully and self insured
WOULD A SPECIALIST EVER BE COVERED AT 100%? IF SO, THEN WHEN?
WOULD BE COVERED AFTER DEDUCTIBLE AND COINSURANCE IS PAID AS LONG ITS WITHIN A CALENDAR YEAR.
WHAT DOES THE ACRONYM PPO STAND FOR?
Preferred Provider Organization
What does the Acronym U&C and UCR stand for?
U&C (Usual and Customary)
UCR (Usual, Customary and Reasonable)
We base open access plan off which current products?
HMO
MC
EC