Health Insurance (Semester 2)

Question 1

Adjudication

Answer 1

the process by which insurance companies review healthcare claims

-they pay in full OR
-pay a partial amount OR
-deny

Question 2

Approvals

Answer 2

A decision by the health insurer if a health care service, treatment plan, or drug is medically necessary

Question 3

Premium

Answer 3

Amount paid to the insurance (carrier) for coverage (in a period, f.e. from employer paycheck)

Question 4

Copayment

Answer 4

Fixed amount to pay for a service

Question 5

Co-insurance

Answer 5

The percentage to pay for a service

Question 6

Deductible

Answer 6

An amount that needs to be paid before the insurance kicks in

Question 7

Medicare Donut Hole

Answer 7

-Deductible phase: pay 100% of the prescription cost until the plan deductible is reached
-initial coverage phase: just pay a set amount of copay(coinsurance (set by the drug plan, + depends on the tier rank of the drug)
-Donut/gap phase: pay 25% of the cost for generics and brand drugs
-catastrophic coverage phase: pay 5% of the cost of medications

Question 8

Out of pocket costs

Answer 8

Amount paid for health care service by the enrollee

Question 9

Reimbursement

Question 10

Prior Authorization

Answer 10

medical services that need to be approved before being performed

Question 11

Formulary / Preferred drug list

Answer 11

A list of prescription drugs the insurance will pay for

Question 12

Pharmacy Benefits Manager

Answer 12

thrid-party-administrator of a drug program for processing drug claims