Chapter 15

Question 1

what is the healthcare three party system in the US?

Answer 1

• provider/ seller
• consumer
• third party

Question 2

who are the provider/ seller?

Answer 2

• doctors
• hospitals
• drug companies

Question 3

who are consumers?

Answer 3

• patient
• insured
• employee

Question 4

who are third parties?

Answer 4

• insurers
• self insured employee
• government (medicare/ medicaid)

Question 5

what is the effect of a three party healthcare transaction for patient/ insured/ employee?

Answer 5

• lower “user” price
• less incentive to act as a traditional consumer

Question 6

what is the effect of three party healthcare transaction for healthcare providers?

Answer 6

• payment of system based on fee-for-service
• for service, a separate fee is paid

Question 7

what percent of people are covered by private healthcare or public healthcare?

Answer 7

91.7%

Question 8

how much is US national health expenditures?

Answer 8

4.3 trillion dollars

Question 9

what are the global contributions to high costs?

Answer 9

• advances in technology
• aging population
• behavioral factors
• third party financing

Question 10

what are the US contributions to high costs?

Answer 10

• employer sponsored health insurance
• fee for fee service providers
• high administration costs
• lack of transparency in cost and quality
• cost shifting in Medicare and Medicaid
• defensive medicine

Question 11

what are major defects in the US healthcare system?

Answer 11

• rising healthcare expenditures
• large number of uninsured
• considerable waste and inefficiency
• harmful insurer practices

Question 12

what is the guaranteed issue with ACA?

Answer 12

insurers cannot deny coverage due to preexisting conditions

Question 13

what is community rating in ACA?

Answer 13

insurers may only rate on a few variables

Question 14

what are the minimum standards for health insurance under ACA?

Answer 14

• cannot drop policy holders
• dependents can remain on policy until age 26
• no annual or lifetime benefits
• coverage for essential health benefits

Question 15

what is individual mandate under ACA?

Answer 15

buy health insurance or pay a penalty (has been repealed)

Question 16

what is employer mandate under ACA?

Answer 16

firms with 50+ employees must provide health insurance or pay a fine

Question 17

what percent of premiums is required by health insurers to pay in claims under ACA?

Answer 17

85%

Question 18

what are cost sharing methods in medical insurance?

Answer 18

• copayments
• deductibles
• coinsurance
• out of pocket maximum limits

Question 19

what is a co payment?

Answer 19

a flat amount the insured must pay for certain benefits such as an office visit or generic drug

Question 20

what does not count towards annual deductible?

Answer 20

co payment

Question 21

what is a calendar year deductible?

Answer 21

an aggregate deductible that must be satisfied during the policy/ calendar year

Question 22

what is the amount the insured is responsible for in total (over all claims during the policy periods)?

Answer 22

calendar- year deductible

Question 23

what is coinsurance?

Answer 23

The percentage of the bill in excess of the deductible, which the insured must pay out of pocket up to some maximum

Question 24

what helps prevent over utilization of plan benefits?

Answer 24

coinsurance

Question 25

what is the out of pocket (OOP) maximum limit?

Answer 25

The most the insured will have to pay out of pocket in a calendar year

Question 26

after the OOP limit is met, the insurer pays what percent of all eligible expenses?

Answer 26

100%

Question 27

what is another name for OOP limit?

Answer 27

stop loss

Question 28

what are the largest healthcare insurers in the US?

Answer 28

• United Healthcare Group ($286)
• Anthem Blue Cross ($138)
• Cantene ($126)
• Kaiser Permanente ($89)

Question 29

what percent is covered under individual plans?

Answer 29

12%

Question 30

what percent is covered under group plans?

Answer 30

88%