Block 2 Flashcards

1
Q

Premium

A

amount of money paid up front to buy a policy

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2
Q

Cost sharing

A

deductable
Co-insurance
co-pay

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3
Q

Deductible

A

amount you have to reach

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4
Q

co-insurance

A

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

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5
Q

Co-pay

A

flat amount paid without a deductible payed first

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6
Q

Annual/yearly out of pocket max

A

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

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7
Q

annual benefit maximum

A

the insurance company pays then nothing more

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8
Q

lifetime benefit maximum

A

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

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9
Q

Charges on a chargemaster

A

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

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10
Q

chargemaster

A

highest possible level they think they will get paid

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11
Q

Private Pay

A

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

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12
Q

IF you accept government payers what cant you do?

A

charge different payer sources different amounts

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13
Q

what are charges in healthcare

A

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

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14
Q

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

A

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

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15
Q

what are the two options for private health insurance?

A
  1. employment based- group
  2. individual based/individual market
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16
Q

Employment based insurances

A

group policy purchased based on employer

17
Q

individual based individual market insurance

A

higher risk and higher premiums
more restrictive

18
Q

Since ACA what have they removed from individual based insurance

A

no underwriting, no exclusion for existing conditions

19
Q

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

A

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

20
Q

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

A

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

21
Q

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

A

yes

22
Q

Which can change? charges or chargemaster

A

charges - cannot change
chargemaster can change

23
Q

low premium but high deductibles are not good for who?

A

people who consume alot of healthcare

24
Q

Network HMO model

A

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

25
Q

Staff HMO model

A

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

26
Q

Network HMO fundamentals

A

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

27
Q

Network HMO are the ______restrictive
______premiums

A

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

28
Q

PPO fundamentals

A

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

29
Q

PPO are _____restrictive and ____premiums

A

less restrictive but higher premiums

30
Q

HSA/ consumer directed health plans

A

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

31
Q

HSA fundamentals

A

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

32
Q

HSA savings account

A

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

33
Q

FSA is for what plan

A

HMO and PPO
must be used within a calendar year

34
Q

Whats the difference between an HSA and FSA

A

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

35
Q

ERISA or self funded

A

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