Block 2

Question 1

Premium

Answer 1

amount of money paid up front to buy a policy

Question 2

Cost sharing

Answer 2

deductable
Co-insurance
co-pay

Question 3

Deductible

Answer 3

amount you have to reach

Question 4

co-insurance

Answer 4

percentage of payment from insurance company and pt so like 80/20

Question 5

Co-pay

Answer 5

flat amount paid without a deductible payed first

Question 6

Annual/yearly out of pocket max

Answer 6

someone is required to pay a certain price then insurance company takes payments over

Question 7

annual benefit maximum

Answer 7

the insurance company pays then nothing more

Question 8

lifetime benefit maximum

Answer 8

anthem for 5 years and very expensive baby the insurance company wont pay anymore

Question 9

Charges on a chargemaster

Answer 9

everything a hospital charges for it is the same regardless of if someone has insurance or not

Question 10

chargemaster

Answer 10

highest possible level they think they will get paid

Question 11

Private Pay

Answer 11

out of pocket
as a provider you get what you charge
need to be aware of the market supply and demand

Question 12

IF you accept government payers what cant you do?

Answer 12

charge different payer sources different amounts

Question 13

what are charges in healthcare

Answer 13

charges have to be the same for CPT codes however reimbursement can be different

Question 14

in private pay can you create discounts based on time of service, cash pay

Answer 14

yes charges dont change but most private insurers negotiate a fee schedule

Question 15

what are the two options for private health insurance?

Answer 15

1. employment based- group
2. individual based/individual market

Question 16

Employment based insurances

Answer 16

group policy purchased based on employer

Question 17

individual based individual market insurance

Answer 17

higher risk and higher premiums
more restrictive

Question 18

Since ACA what have they removed from individual based insurance

Answer 18

no underwriting, no exclusion for existing conditions

Question 19

in the past people had a fee for service plan explain what this is

Answer 19

could go to any doctor, hospital or provider
bill is generated for each service
the power was with the provider

Question 20

to combat fee for service managed health care was created by insurance companies

Answer 20

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

Question 21

Did colorado pass a bill to minimize the surprise out of network bill

Answer 21

yes

Question 22

Which can change? charges or chargemaster

Answer 22

charges - cannot change
chargemaster can change

Question 23

low premium but high deductibles are not good for who?

Answer 23

people who consume alot of healthcare

Question 24

Network HMO model

Answer 24

insurance company like anthem BC/BS develops a network of providers, most common

Question 25

Staff HMO model

Answer 25

everyone in the HMO is employeed by the HMO can only go to them like kaiser

Question 26

Network HMO fundamentals

Answer 26

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

Question 27

Network HMO are the ______restrictive ______premiums

Answer 27

small network most restrictive cheaper premium low out of pocket cost to member typically co- pay

Question 28

PPO fundamentals

Answer 28

have a provider network- but larger than HMO PCP- may hav pcp but not required for pre-approval

Question 29

PPO are _____restrictive and ____premiums

Answer 29

less restrictive but higher premiums

Question 30

HSA/ consumer directed health plans

Answer 30

created by provision in the medicare prescription drug improvement and modernization act designed to encourage more responsible spending on healthcare

Question 31

HSA fundamentals

Answer 31

large network never required to go through PCP very low restricitvve premium low cost sharing high deductable

Question 32

HSA savings account

Answer 32

often the employer and the employee contribute and does not need to be emptied out at the end of the year

Question 33

FSA is for what plan

Answer 33

HMO and PPO must be used within a calendar year

Question 34

Whats the difference between an HSA and FSA

Answer 34

HSA money stays forever FSA monely goes away after the year ends

Question 35

ERISA or self funded

Answer 35

companies of 500 or more can self insure their employees contract with private insurers to manage their plan