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Ch 12 Insurance
Financial Mgmt and Health Insurance
| Question | Answer |
|---|---|
| 3 Components that determine the price of a prescription | 1. Cost of drug dispensed; 2. Cost of dispensing thej drug; 3. Net income from dispensing the drug |
| The cost of the drug is usually referred to as... (2) | Ingredient cost; Product cost |
| Markup Method based on | Price and dollar margin on the ingredient cost of the product dispensed |
| As ingredient costs increase, so do... | price and margin increase proportionately |
| Assignment of benefits | authorization to an insurance co to make payments directly to the pharmacy or physician |
| Overpayment | Payment by the insurer or patient of more that the amt due |
| Contract | An insurance policy; legally enforceable |
| Subscriber | The individual or organization protected under the terms of an insurance policy. |
| Subscriber AKA (4)... | Insured, member, policyholder, recipient |
| In group insurance, the employer is known as the ___________ and the employees are ______________. | Insured; Risks |
| Dependents | Spouse and children of the insured who are also covered |
| Policy Limitations, with examples (5) | Exclusion policies; AIDs, suicide attempt, cancer, job injury, pregnancy |
| Waiting Period | Time a person must wait to become eligible before coverage starts, or for a specific benefit (ex. nine months before pregnancy is covered) |
| Time Limit | Amt of time from the date of service to the deadline a claim can be filed |
| Eligibility | The determination of the exact coverage the insured is entitled to. Often checked by tech via phone, computer, or printed list |
| Preauthorization | Certain requirements that must be met before an insurance co will approve certain testing, medications, admissions, and procedures |
| Premium | Cost of the coverage; could be paid by employer/employee/combo |
| Beneficiary | Person designated by an insurance policy to receive death benefits |
| Deductible | A specific amt of money that must be paid before the policy benefits begin. Higher deductible = lower policy cost; Lower deductible = higher policy cost |
| Coinsurance | An arrangement in which the insured must pay a percentage of the cost of medical services covered by the insurer |
| Co-payment | The insured makes a specified payment at the time of treatment or purchase of a prescription |
| Coordination of benefits | When someone has more than one insurance plan, this avoids double payment and has the second company kick in after the first company. |
| Group Plan | A group of employees is insured under a single policy; usually provides better benefits and lower premiums than individual plans |
| Third-party Payer | An individual or corporation that makes a payment on an obligation or debt, but is not a party to the contract that created the obligation or debt. 1st party=person insured; 2nd party=provides the service; 3rd party pays (insurance co) |
| Blue Cross-Blue Shield | Nationwide federation of local non-profit service organizations that offer prepaid health care services to subscribers |
| Blue Cross covered | hospital, outpatient, home care, institutional care; Both offer health care coverage for subsrcibers |
| Blue Shield covered | physician, dental, vision; oth offer health care coverage for subsrcibers |
| Kaiser | Prepaid group practice HMO; began in CA in 1933; owns its own facilities and directly employees physicians and other providers |
| Medicare | The largest single medical benefits program in the US, nationwide and offers the same benefits in all states |
| Medicare was authorized by _____________ and administrated by ___________________________________. Became law in _______ as part of _______________. | Congress; CMS (Centers for Medicare and Medicaid Services); 1965; Social Security |
| Medicare provides health insurance to... | citizens aged 65+ and to younger patients who are blind, widowed, disabled due to long-term illness |
| Medicare Part B does/doesn't cover prescriptions; optional/not optional | doesn't; optional |
| Universal Claim for for Rx is called... | CMS-1500 claim form |
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