Block 2 Flashcards
Premium
amount of money paid up front to buy a policy
Cost sharing
deductable
Co-insurance
co-pay
Deductible
amount you have to reach
co-insurance
percentage of payment from insurance company and pt so like 80/20
Co-pay
flat amount paid without a deductible payed first
Annual/yearly out of pocket max
someone is required to pay a certain price then insurance company takes payments over
annual benefit maximum
the insurance company pays then nothing more
lifetime benefit maximum
anthem for 5 years and very expensive baby the insurance company wont pay anymore
Charges on a chargemaster
everything a hospital charges for it is the same regardless of if someone has insurance or not
chargemaster
highest possible level they think they will get paid
Private Pay
out of pocket
as a provider you get what you charge
need to be aware of the market supply and demand
IF you accept government payers what cant you do?
charge different payer sources different amounts
what are charges in healthcare
charges have to be the same for CPT codes however reimbursement can be different
in private pay can you create discounts based on time of service, cash pay
yes charges dont change but most private insurers negotiate a fee schedule
what are the two options for private health insurance?
- employment based- group
- individual based/individual market
Employment based insurances
group policy purchased based on employer
individual based individual market insurance
higher risk and higher premiums
more restrictive
Since ACA what have they removed from individual based insurance
no underwriting, no exclusion for existing conditions
in the past people had a fee for service plan explain what this is
could go to any doctor, hospital or provider
bill is generated for each service
the power was with the provider
to combat fee for service managed health care was created by insurance companies
controls the financing and delivery of health services to members who are enrolled in a specific health care plan
care delivered is medically necessary and appropriate for the patients condition
Did colorado pass a bill to minimize the surprise out of network bill
yes
Which can change? charges or chargemaster
charges - cannot change
chargemaster can change
low premium but high deductibles are not good for who?
people who consume alot of healthcare
Network HMO model
insurance company like anthem BC/BS develops a network of providers, most common
Staff HMO model
everyone in the HMO is employeed by the HMO can only go to them like kaiser
Network HMO fundamentals
members incentivized to see in-network providers
member selects a PCP who provides, arranges and coordinates all aspects of the members health care
typically a co-pay not co-insurance
Network HMO are the ______restrictive
______premiums
small network most restrictive
cheaper premium
low out of pocket cost to member
typically co- pay
PPO fundamentals
have a provider network- but larger than HMO
PCP- may hav pcp but not required for pre-approval
PPO are _____restrictive and ____premiums
less restrictive but higher premiums
HSA/ consumer directed health plans
created by provision in the medicare prescription drug improvement and modernization act
designed to encourage more responsible spending on healthcare
HSA fundamentals
large network
never required to go through PCP
very low restricitvve
premium low
cost sharing high deductable
HSA savings account
often the employer and the employee contribute
and does not need to be emptied out at the end of the year
FSA is for what plan
HMO and PPO
must be used within a calendar year
Whats the difference between an HSA and FSA
HSA money stays forever
FSA monely goes away after the year ends
ERISA or self funded
companies of 500 or more can self insure their employees
contract with private insurers to manage their plan
