Definitions
The amount that must be paid in full, by a member, before insurance will begin to pay
What is a Deductible?
HMO
What is the acronym for health maintenance organization?
The list of contracted providers or health care facilities that are part of a health insurance plan
What are in-network providers?
An agreement that must be signed by a patient and their provider when a patient is on pain medications
What is a pain management contact?
Bronze, Silver, Gold and Platinum
What are the affordable care act coverage levels?
The fixed dollar amount that a member pays at the time services are rendered
What is a co-pay?
PPO
What is the acronym for a Preferred Provider Organization?
Providers that are not part of an insurance plan's contracted (discounted) provider list
What are out- of -network providers?
The list of a plan's pre-approved drugs
What is a Formulary?
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan
What is prior authorization?
The monthly dollar amount that member's pay for coverage- regardless of whether or not a claim has been filed
What is a premium?
ACA
What is the acronym for the Affordable Care Act?
These are copies that have exactly the same dosage, intended use, effects, side effects, route of administration, risks, safety, and strength as the original
What is a generic drug?
A written order from your primary care doctor for you to see a specialist or get certain medical services
What is a referral?
A fixed percentage that a member will pay for services rendered
What is coinsurance?
EOB
What is the acronym for an Explanation of Benefits?
An account where you can set aside pre-tax dollars for healthcare expenses
What is a Health Care Savings account?
This has a trade name and is protected by a patent (can be produced and sold only by the company holding the patent)
What is a brand name drug?
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine
What is Medical Necessity?
The total amount of out of pocket expenses you can expect to pay for the year
What is Maximum Out of Pocket?
EOC
What is the acronym for Evidence of Coverage?
Health Insurance Portability and Accountability Act
What does HIPAA stand for?
The practice begins medication for a medical condition with the most cost-effective drug therapy and progresses to other more costly or risky therapies only if necessary
What is step-therapy?
The yearly period when people can enroll in a health insurance plan
What is an open enrollment period?