Chapter 15 Flashcards
what is the healthcare three party system in the US?
- provider/ seller
- consumer
- third party
who are the provider/ seller?
- doctors
- hospitals
- drug companies
who are consumers?
- patient
- insured
- employee
who are third parties?
- insurers
- self insured employee
- government (medicare/ medicaid)
what is the effect of a three party healthcare transaction for patient/ insured/ employee?
- lower “user” price
- less incentive to act as a traditional consumer
what is the effect of three party healthcare transaction for healthcare providers?
- payment of system based on fee-for-service
- for service, a separate fee is paid
what percent of people are covered by private healthcare or public healthcare?
91.7%
how much is US national health expenditures?
4.3 trillion dollars
what are the global contributions to high costs?
- advances in technology
- aging population
- behavioral factors
- third party financing
what are the US contributions to high costs?
- 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
what are major defects in the US healthcare system?
- rising healthcare expenditures
- large number of uninsured
- considerable waste and inefficiency
- harmful insurer practices
what is the guaranteed issue with ACA?
insurers cannot deny coverage due to preexisting conditions
what is community rating in ACA?
insurers may only rate on a few variables
what are the minimum standards for health insurance under ACA?
- cannot drop policy holders
- dependents can remain on policy until age 26
- no annual or lifetime benefits
- coverage for essential health benefits
what is individual mandate under ACA?
buy health insurance or pay a penalty (has been repealed)
what is employer mandate under ACA?
firms with 50+ employees must provide health insurance or pay a fine
what percent of premiums is required by health insurers to pay in claims under ACA?
85%
what are cost sharing methods in medical insurance?
- copayments
- deductibles
- coinsurance
- out of pocket maximum limits
what is a co payment?
a flat amount the insured must pay for certain benefits such as an office visit or generic drug
what does not count towards annual deductible?
co payment
what is a calendar year deductible?
an aggregate deductible that must be satisfied during the policy/ calendar year
what is the amount the insured is responsible for in total (over all claims during the policy periods)?
calendar- year deductible
what is coinsurance?
The percentage of the bill in excess of the deductible, which the insured must pay out of pocket up to some maximum
what helps prevent over utilization of plan benefits?
coinsurance
what is the out of pocket (OOP) maximum limit?
The most the insured will have to pay out of pocket in a calendar year
after the OOP limit is met, the insurer pays what percent of all eligible expenses?
100%
what is another name for OOP limit?
stop loss
what are the largest healthcare insurers in the US?
- United Healthcare Group ($286)
- Anthem Blue Cross ($138)
- Cantene ($126)
- Kaiser Permanente ($89)
what percent is covered under individual plans?
12%
what percent is covered under group plans?
88%
