Terminology

3. The group of physicians, hospitals, and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members
5. In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review.
7. A fixed amount a group member must pay before the insurer will make any benefit payments.
8. A Blue Cross and Blue Shield Plan serving a specific geographic area
14. A spouse or child of a deceased federal employee or annuitant who meets the criteria of OPM to continue coverage
16. A doctor, hospital, health care practitioner, pharmacy, or healthcare facility
17. A joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals
18. A plan available to employees, former spouses or dependents who lose eligibility under the Federal Employees Health Benefits (FEHB) coverage due to a qualifying event
19. a plan's description of benefits
20. a building or place that provides a particular service

1. This is the annual enrollment period when federal employees and annuitants can change options or change their type of coverage among the various health benefits plans
2. authority must be evaluated each contact
4. A patient who receives treatment at a hospital either at a single attendance or a series of attendances
6. A federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons
9. limited to 1 year
10. acts as a member
11. a federal law that outlines the requirements that must be satisfied in order to provide health insurance coverage
12. the % the insured pays
13. Written assurance that benefits will be provided
15. The fee determined by an MCO to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. Also known as a fee allowance, fee maximum, or capped fee