4) Insurance Concepts Flashcards
Classify coverage exclusion for the following conditions:
- Cancer
- HIV/AIDS
- DM
- MS
- CVA
- Pregnancy
Always Denied
What are some qualities of Medicaid?
- Pays a lot of money towards long-term care
- Almost half of enrollees are kids, but the majority of money goes towards ____ care
- If you’re above the federal poverty line, you can’t qualify unless you accept the expansion
- PT coverage isn’t a mandated requirement in every state
- Serves as its own high-risk pool
- Most money is spent in the northeast
What are the risk options for insurance
- Guaranteed Issue
- Experience Rating
- Community Rating
Guaranteed Issue
Requirement that insurance can be sold to an individual, regardless of their health status
Community Rating
Risk is spread among members, premiums are set w/out regard to health status, and determined by utilization experience or a larger community
- Everybody is equal and pays the same
Classify coverage exclusion for the following conditions:
- Acne
- Hay Fever
Sometimes Denied
Who can benefit from entitlement programs?
- Those who completed service to the country
- At-risk peeps who can’t access employer-based health care (Elderly or Poor)
Balance Billing
Provider bills pt for the difference between what the amount that insurance covered and the remaining amount
- Cannot do this when you sign a contract
Risk
The potential for a substantial financial loss from an event where the probability of loss is relatively small
What does cost of insurance depend on?
- Who’s being covered → Age, Gender, Health Status
- What’s covered → Benefits, Cost Sharing/Deductible, Terms, Pre-existing conditions
- Insurer Profits & Administration
- Subsidies
- Underlying health care costs; Inflation
What is adverse selection and what causes it?
People who have a higher chance of needing health care are more likely than those who have a lower chance to get health insurance
- Occurs when less healthy individuals are disproportionately enrolled in a risk pool
State Children’s Health Insurance Program (sCHIP)
Partnership between the federal govt and states created during the Balanced Budget Act to provide health insurance coverage for targeted low-income kids <19y/o who are not eligible for Medicaid
- Based on the belief that if kids are given a good start in life, they’ll see the importance of being healthy
What are the Fundamental Principles of Insurance?
1) Risk is unpredictable to insured
2) Risk can be predicted w/some accuracy for a certain group/population
3) Pooling of resources transfers risk from individuals to a group of individuals
4) All members of the insured group share the actual losses on some equitable basis
Who are the key players in insurance?
- Pt’s/Consumers
- Providers
- Insurance companies
- Employers
Pre-Existing Condition Exclusions
Denies pt coverage bc the condition will cost the insurance company too much money
Where do most individuals over 65y/o get health insurance from? Where do the remaining non-elderly individuals get health insurance?
- Medicare
- Medicaid
- Private (Group or Individual)
- Uninsured
Provider Network
Group of providers that have a contract w/an insurance company
- Can create a discount for the buyer
- Not every plan has a network
Describe Veteran’s Coverage
- For veterans and their families
- Veterans are eligible to enroll
- Through the US Dept of Veteran’s Affairs → Is a closed system funded by the government
- Access to services is determined by an assigned priority level
- Is an integrated health system
Deductible
Amount a pt has to pay out-of-pocket until insurance kicks in
- Includes copay & coinsurance
Who can utilize military coverage?
Active duty, Military Personnel, and their Families
Classify coverage exclusion for the following conditions:
- Overweight
- Cancer Hx
- HTN
- Asthma
Often Denied
Who assumes risk in insurance models?
Insurer
Premium
Monthly payment
Where do high costs of health care come from?
Secondary & Tertiary Care
COBRA
Federal law that states that companies with >20 full-time employees are required to give job-sponsored health insurance
- Requires that company provide temporary continuation of coverage after a qualifying event
How are Medicare and Medicaid different?
- Coverage
- Funding
- Administration
Copay
What pt is responsible for paying at the time of care
- Higher for specialties to prevent overutilization
- Still have to pay after you meet your deductible
What can cause coverage options to change?
- Loss/change of job
- Change in family status (new widow)
- Birthday
- Moving
- Change in health status
True or False: Health insurance is designed to spread the risk
True
TRICARE
Managed health care plans that have a lot of rules
Why is health insurance different from other types of insurance?
- Its not required but still 100% a necessity
- Everybody has health
- People have chronic problems
- No pooled payments
What are the problems w/military and Veteran’s Coverage?
- They’re 2 different systems → Transitioning btwn active duty to veteran is not seamless
- There’s issues w/sharing data
What is the purpose of health insurance?
To pool many people together into groups to share (spread) the costs generated by this small number of people
Indian Health Services
Through Indian health care provider
Experience Rating
Premiums that are determined by the medical group’s own medical claims experience
Federal Employee Health Benefits Program (FEHBP)
Health plan for current and retired govt employees as well as their families
Coinsurance
Pt is responsible for a certain percent of the charges, no matter what
What do medical underwriting, pre-existing condition exclusions, and risk-based rating have in common?
They’re ways of dealing w/adverse selection
Risk-Based Rating
Charging premiums based on a pt’s probable health care needs
Medical Underwriting
Process that insurers use to evaluate the risk of an applicant → Figures out a pt’s risk in comparison to other pt’s and then uses this to determine the pt’s costs
True or False: COBRA does not require that a company to keep paying for coverage after a qualifying event, but it does still require access for the pt
True
Out-Of-Pocket Maximum
Maximum amount a pt will be required to pay out of pocket annually
