Presentation Flashcards
Urgent care
When you need urgent attention and perhaps cannot see your primary care physician
Emergency care
When you require emergency attention/resources
Aetna T1A drugs
Value drugs
Aetna T1 drugs
Generic drugs
Aetna T2 drugs
Preferred brand
Aetna T3 drugs
Non-preferred brand drug/generic drug
Aetna T4 drugs
Specialty drug
Virtual visit
Access to care virtually for non-emergency conditions like the cold, flu, allergies
What is an embedded plan?
An embedded plan is when members have their own individual deductible or out of pocket maximum that you have to meet
What is a non-embedded plan or a true individual family plan?
When more than just the employee is enrolled in a plan and the members have to meet the family deductible and/or out of pocket maximum. There is no individual deductible if more than just the employee is enrolled in the plan
What does COC stand for?
Certificate of Coverage
What does SBC stand for?
Summary of benefits and coverage
Mail order benefit
- Allows you to receive medications to your home automatically
- Can save money because you can receive a 90 day subscription while paying for a 60 day co-payment
What is balanced billing?
The difference between the in-network contracted rate and out-of-network negotiated rate
Preventative medication for conditions such as
- Hypertension
- High cholesterol
- Diabeties
- Asthma
- Osteoporosis (condition in which bones become weak and brittle)
With a high deductible plan, everything is subject to a deductible. True or False?
True
Describe health advocate
- Health advocate is a program available for employees who enroll into a medical plan. The service is also available to dependents, spouses, parents, and parents-in-law.
- Can help with scheduling doctors appointments and tests
- Can help resolve issues with Billings and claims
How does dental rollover work?
- It works like an incentive to stay healthy
- If your claims do not reach the threshold during the calendar year, you will get the rollover dollars added to the next year
How does dental preventative care work?
Dental preventative care is covered at 100% meaning you will not have to pay out-of-pocket, but it is being deducted from the dental benefits maximum
What does a dental benefits maximum mean?
This is the maximum that the dental insurance will cover for that plan year
How does dental orthodontic services work?
For new orthodontic service
How does the dental lifetime maximum work?
You have a maximum per person enrolled in the dental plan.
Vision plans with ADP run on a calendar year or plan year?
Plan year
For in-network vision services members must choose one service, either prescription glasses, contact lenses, or laser vision care per calendar year. True or false?
True
Who is eligible to enroll in a health savings account (HSA)?
- WSE who enroll in a high deductible health plan
Does the HSA run on a plan year or calendar year?
Calendar year with IRS limits
What expenses qualify under a HSA?
Medical, dental, vision expenses
Do unused HSA funds roll over?
Yes, unused HSA funds get rolled over
What is considered dental preventative care?
- Cleanings
- Oral exams (looking at teeth, mouth, and throat to identify problems like cavities, swelling, broken teeth)
- Fluoride treatments
- Sealants
- X-rays
- Space maintainers
- Emergency palliative treatment
What are dental oral exams?
Oral exams (looking at teeth, mouth, and throat to identify problems like cavities, swelling, broken teeth)
What is dental basic care?
- Diagnostic consultations
- Fillings
- Periodontal services (gum disease services)
- Endodontic services (root canals)
- Oral surgery like simple and complex extractions
- General anesthesia
- Repair & maintenance of crowns, bridges, dentures
What is dental major care?
- Bridges and dentures
- Crowns & veneers
- Inlays & onlays
What are medical advanced imaging examples?
- CT/PET Scans
2. MRIs
What are the medical plan types?
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Point of Service (POS)
- Exclusive Provider Organization (EPO)
- High Deductible Health Plan (HDHP) or Consumer Driven Health Plan
Do HMO’s offer in network or Out of network coverage?
In network coverage only
Do PPO’s offer in network or Out of network coverage?
In and out of network coverage
Do POS plans offer in or out of network coverage?
In and out of network coverage
Do EPO’s offer in network or Out of network coverage?
In network coverage only
Do HDHP or consumer driven health plans offer in network or Out of network coverage?
Can be in or out of network coverage
What is a dental passive PPO?
Deductible, coinsurance, and/or plan maximum amounts are the same, whether members get care in or out of the network.
What is an active dental PPO?
Deductible, coinsurance, and/or plan maximum amounts can be different for in-and out-of-network care.
What is a dental health maintenance organization?
- Works like an HMO, where the dentist must be in the DHMO network.
- This type of plan gives you lower cost for coverage
What is considered a highly compensated employee for DCFSA?
$135,000+ year
