chapter 6 Flashcards
Why have costs risen?
advances in technology
specialization
aging has put strain on Medicare
Why do we purchase health insurance?
minimize risk (probability of financial loss)
What is the process of being insured?
a subscriber purchases a health insurance plan from an insurer
range of benefits
covered services and those that are reimbursed
Why was insurance developed?
could not assume that patients could afford risk or hospitals would be able to reimbursed
Who finances health care?
individual, employer, or government
first source
individual purchases policy directly from insurance company
cons: expensive (pat premium cost out of pocket)
second source
employment cased arrangement; pay premium using payroll deductions combined with employer contributions
co-insurance
cost sharing obligation under a policy
third source
tax dollars collected from individuals and corporations allocated to finance programs and services
Who is the largest purchaser of health insurance?
Centers for Medicare/Medicaid Services
Who does Medicare cover?
65+
disabled
end stage renal disease
Medicare Part A
inpatient hospital care, skilled nursing facility, some home health, and hospice care
Who finances Medicare Part A?
payroll taxes and federal revenues
Medicare Part B
voluntary
physician services, outpatient hospital, some home health, medical equipment
Who finances Medicare Part B?
beneficiary premium payments
Medicare Advantage
gain greater choice and can choose from an array of private health plan options
Medicare Part D
subsidizes cost of prescriptions and provides more choices in health care coverage
Medicaid
for indigent populations
Who funds Medicaid?
state and federal governments
Retrospective reimbursement methods
providers paid after service in full with no dispute
insurers assume risk for cost and claims
Currently how much of our GDP is going to healtcare?
16%
What are the three parts of a 3rd party system?
patient-provider-payer
What are the 8 areas covered by the CBRR?
- Information disclosure
- Choice of plans and providers
- Access to emergency service
- Participation in HC decision
- Respect and nondiscrimination
- Confidentiality of health infor
- Complaints and appeals
- Consumer responsibilites
The affordable care act is challenging what aspect of health care?
States have authority over insurance
Florida constitution as a statue: Rights of patients
Individual dignity Information Financial information and disclosure Access to health care Experimental research Patients knowledge to rights and responsibility
The individual entity covered by the health policy
Insured
The individual who has health plan coverage in virtue of being eligible on his/her own behalf rather than as a dependent
Subscriber
The entity that is assuming the risk
Insurer
Those good/services reimbursed by the insurance company, allowed by the purchased policy
Covered services
Financial term: the amount of monies reimbursed for a covered service as a part of the health policy, regardless of who is responsible for payment
Allowable
The amount the insured incurs/pays, before a health insurer will pay their portion of the remaining cost
Annual amount
Deductible
Cost sharing obligation of the member after the deductible has been met
Not predetermined, it is the percentage of allowable or fee
Coinsurance
Amount the provider charges
Not the same as what insurance will pay
Fee
The amount the subscriber must pay each time the services are used
Is predetermined
Copayment
The right or privilege based on criteria met or qualified for
Entitlment
The cost of the health insurance policy, typically paid for on a monthly basis
Employer sponsored health insurance has an amount that is deducted from paycheck and paid to the insurance company
Premium
prescribed for a patients use (crutches, commode, CPM)
Durable medical equipment (DME)
annual period designated when an employee has the opportunity to switch to a new insurance plan
Open enrollment
Vehicle used to bill the insurance company for the services provided: typically included medical condition, services provided, charges for services
Can be paper or electronic
Claim
Another word for the insurance company
Carrier
Be careful when using this verbiage
Accounting term: all expenses associated with the dispense of a service
Different from what we charge
Cost
Attempt to balance the federal deficit, entitlement programs cut and medicare/medicaid reformed
Affect the delivery of health care
Relating to PT there were gross amounts of layoffs of PTs.
Balanced budget ACT 1997
Developed due to these massive budget cuts
New way of reimbursing for healthcare services
Prospective payment system
-provided more options to medicare recipients for part C and brought forth medicare part D (for prescription drugs (2006).
added some caveats to medicare beneficiaries to those with high incomes (if you made more $ you paid more into medicare)
Medicare modernization act
Recent legislation that will expand access to healthcare to uninsured and underinsured individuals
Patient protection and affordable care act (2010)
