2 - Private Health Insurance Flashcards
Primary Methods of PRIVATE healthcare financing
3
Individual Out Of Pocket
Individual PRIVATE health insurance
Emplyer-sponsered private health insurance
Individual Out-Of-Pocket
Modes of paying for healthcare
simplest mode of financing = DIRECT PURCHASE by consumer
limite to a SINGLE TRANSACTION between indiv / provider
Third-Party PAYER
An organization that provides REIMBURSEMENT to a
healthcare provider for services rendered to a patient
Financial protection against HIGH HEALTHCARE COSTS!
Third-Party ADMINISTRATORS
PROCESS/MANAGE the health plan claims
but do NOT carry the _insurance risk_
Financial protection against HIGH HEALTHCARE COSTS!
Premium
Money paid TO AN INSURANCE COMPANY
for COVERAGE
(for a defined period)
Health Plan
ENTITY that provides for coveraage of designated health services (benefits package)
for plan members for a FIXED / PREPAID premium
Benefits
(covered services)
Medical / Health SERVICES for which
your insurance plan will pay
Benefit Design
What IS or what is NOT
COVERED
Beneficiary
INSURED INDIVIDUAL
ex.
enrolee / member / policy card holder / dependents
Deductible
Patient Cost Sharing
amount that the Insured
MUST FIRST PAY
before benefits by the plan are payable during the policy term
Copayment
Patient Cost Sharing
FIXED/SET amount of money
paid by the Beneficiary at the time of service
Coinsurance
Patient Cost Sharing
specified PERCENTAGE of
medical expenses / service that the beneficiary must PAY
Individual PRIVATE Insurance
Modes of Paying
A third party (insurer) is ADDED to the patient + health care provider
Premium paid by individual to insurance plan
is DIRECT reimbursement payment for the health plan to service the provider
SERVICE BENEFIT PLAN
ACA on Individual Private Insurance
Affordable Care ACT
Historically, age & health status were determining factors in eligibility & rates for individual health insurance plans
Now DENIAL of COVERAGE based on pre-existing consitions is BANNED under the ACA of 2010
Employer-sponsored Private health insurance
Modes of Paying
EMPLOYERS pay all or part of the premium for employee insurance
50% + people under 65 obtain healthcare coverage as an employee benefit
Empolyer group premium setting based on
experience rating or community rating
