INSURANCE PT I Flashcards
Self-Pay
patient/customers pays full cost
third party payer
is an agent other than the seller or the buyer who pays part of the price of a good or service
insurance claim
request for the payment of a product/service
insurance premium
is the cost of maintaining active insurance coverage; it is usually charged on a monthly basis
deductible
is the amount of $ a patient must pay out-of-pocket before the insurance benefits take effect
insurance formulary
is a list of drugs covered by an insurance policy
co-payment
is an amount of $ paid by the insured person in according to the terms of the insurance policy
HMO
– “Health Maintenance Organization”
- in-network pharmacy
- must select pcp
- need referral for specialists
- low cost
PPO
- “Preferred Provider Organization”
- in-network or out-of-network
- don’t need to select pcp
- no referral necessary
- higher cost
CMS
- “Center for Medicare and Medicaid Services”
- administrative agency within the federal Department of Health and Human Services; responsible for the operation of Medicare and Medicaid
Medicare
- federal health-care program for senior citizens
- 4 parts -
A. ] hospital insurance
B. ] outpatient medical services
• medical equipment, preventive services, supplies for diagnoses/treat medical conditions, meds that are not self-administered
C. ] “medicare advantage plans” , provides the option to have your Part A + B coverage admin. by a private insurance company
D. ] “prescription drug coverage” admin. by private insurance companies
Medicaid
is for people of any age w/ low-income & insufficient resources
- provided by federal & state governments
