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M9 L1
Module 9 Lesson 1 Terms
| Term | Definition |
|---|---|
| Third-party programs | Private health benefit programs and government-run programs that pay for prescriptions on behalf of patients |
| Who are the parties involved in a third-party program? | patient (or dependent) who receives a service, person or company that provides the service (pharmacy), and group that pays for all or part of the service |
| Deductible | A form of patient cost-sharing. The amount that must be incurred and paid by the patient during a specified time period before benefits are paid by the insurance company. |
| Indemnity plan | reimburses the covered individual for incurred medical expenses |
| Traditional indemnity plan | Patient pays provider and submits claims for reimbursement (fee-for-service). Plans do not contract with health care providers and have little to no control over patient use and the cost of health care services. |
| Managed indemnity plan | Allow patients to choose any provider but may require prior approval and include deductibles and cost-sharing. The insurance typically pays only a portion of services, leaving the patient responsible for the remaining balance. |
| Managed care plan | reimburses the health care providers directly for services. Use provider networks to control costs and access to care. There are two major types of MCOs are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). However, patients pay less when using network or preferred providers. |
| Health Maintenance Organizations (HMOs) | make providers assume some of the financial risk and generally restrict patients from using providers who are not part of the network. |
| Preferred Provider Organizations (PPOs) | reimburse on a discounted fee-for-service basis. However, they do cover some expenses for providers who are not part of their network. Patients pay a smaller percentage of the cost when they use a network or preferred provider. For example, a patient may pay a $10 copayment when visiting a network physician and $25 copayment when visiting an out-of-network provider. That is known as tiered levels of coverage. |
| Tiered coverage | structure where costs to the patient vary based on the level (or “tier”) of the provider or service used. Patients pay lower out‑of‑pocket costs when they use preferred or in‑network providers and higher costs when they use non‑preferred or out‑of‑network providers. |
| Pharmacy benefit manager (PBM) | Specializes in the management of the prescription portion of a managed health care plan. PBMs contract with participating pharmacies, process claims, control costs, and manage the various elements of the pharmacy benefit, including formularies and utilization review. |
| Audit | A formal examination of an organization to verify accounts |
| TRICARE | federal health care program for uniformed service members, retirees, and their families. |
| Workers' compensation programs | offer insurance coverage for injuries employees sustain on their jobs. |
| Medicaid | administered by each state with partial funding from the federal government. Each state establishes its own eligibility criteria (usually income-based) for patients. |
| Medicare | federal program that provides health insurance for adults over age 65 and for individuals who have disabilities. |
| Medicare Part D | Prescription program is voluntary and requires beneficiaries to pay premiums plus share some of the costs for services. These premiums are reduced for low-income beneficiaries. To participate, eligible patients must enroll during limited enrollment periods. |
| Out-of-pocket expenses | Medical expenses that are not covered by insurance. They may include copayments, deductible, and coinsurance. |
Created by:
RGVCPharmily
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