Show me the Money
The most a member/patient will pay for healthcare costs in a given year
Out of pocket Maximum
Providers submit these to the health plans to get paid for their services
Claims
Term for the fixed amount members pay for things like medications and doctor visits
Copay
A patient wants to see an out of network therapist and knows they have benefits for it - what type of plan do they have?
PPO or HDHP
Name 1 type of plan that has in AND out of network coverage
PPO/POS/HDHP
The amount a member/patient pays before the health plan starts to pay
Deductible
Providers that have a contract means they are (blank) with the health plan
In network
The term for family members who are on a plan but do not work for the company that provides it
Dependents
HMO plans require this be obtained from a primary doctor before seeing a different doctor or getting a certain test or procedure
Referral
This type of plan is the most restrictive as far as seeing different types of providers
HMO
Premium
Another term for the contracted cost for in network providers
Allowed Amount
Term for the person who carries the insurance or works for the company that provides the insurance
Subscriber
This type of plan has the most flexibility as far as seeing different providers in different areas with little issue
PPO or HDHP
This type of plan usually has the highest premium
PPO
This type of plan has a low premium or cost to have the coverage
High Deductible Health Plan (HDHP)
Process that occurs, usually by providers, to show a service or medication are medically necessary
Pre Certification or Prior Authorization
Marriages, births, deaths, and losing coverage are all examples of...
Life Events
If a service denies because the provider was out of network, what type of plan would the member have? (No out of network coverage)
EPO or HMO
This type of plan is basically a hybrid of HMO and PPO
EPO
Since out of network providers do not have a contract, they can bill above what the health plan thinks a service is worth. This is called...
Balance Billing
Facility that treats medical conditions requiring same-day, though not emergency, treatment and care
Urgent Care
A US law mandating some employees' rights to continue employer sponsored health insurance for a period of time after leaving employment
COBRA
2 part: This type of account helps pay for costs on a high deductible plan AND who can fund that account
HSA, funded by employee and employer
This type of plan typically does NOT have copays
HDHP