prior authorization

Insurance Speak [Show Notes]

 in Podcasts  tagged coinsurance / copay / costs / deductible / definitions / formulary / FSA / healthcare / HRA / HSA / insurance / netoworks / out of pocket / premium / prior authorization / terminology by

Coverage Terminology

  • Formulary – a list of medications that insurance decides they will pay for.  They can change this whenever they feel like it.
  • Prior Authorization – insurance requires the payment of a particular medication or service to be authorized prior to them paying for it and/or you receiving it.  Usually require documentation and justification from your doctor.
  • Networks – Providers in the Network usually have a negotiated discount or other beneficial contract with the insurance, which will translate to lower costs for you.

Payment Terminology

  • Premium – paying dues to be in the club.  And being in the club means that the insurance company will have to pay for your care if you get sick or hurt.
  • Deductible – a portion of costs that you are 100% responsible for before the insurance company chips in.  Low premium = high deductible.
  • Copay – Co = together, pay = payments.  You and your insurance are paying the total bill together.  Copays are usually standardized, and are a price predetermined by the insurance company.  Medication copays are broken down into Tiers.
  • Coinsurance – rather than a set price, it’s a set percentage.  Based on the total cost of the service, the price you pay may change.
  • Out Of Pocket (OOP) – some companies keep track of all the money you pay and they have a limit (called Lifetime Maximum or Lifetime Limit).  If your costs reach that limit, the insurance company will take care of everything after that.

Your Money

  • Health Savings Account (HSA) – YOUR money that you put back to use to pay for healthcare costs in the future.  This money will roll over.
  • Health Reimbursement Account (HRA) – an incentive from your employer or insurance for you do things to prevent illness, and then THEY will give you money to pay for your healthcare costs.  This money will roll over as well.
  • Flex Spending Account (FSA)-  YOUR money that you put into an account to pay for healthcare costs or health related items (some OTC things are approved).  They usually require receipt submission to prove you purchased approved items.  But if that money is not used by the deadline, it does NOT roll over, you do not get it back.

 

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Music Credits:  “Radio Martini” Kevin MacLeod (incompetech.com)  Licensed under Creative Commons: By Attribution 3.0  http://creativecommons.org/licenses/by/3.0/