Employer Sponsored Health Insurance Flashcards
What is preferred provider organization?
- people who enroll can get medical treatment form in network physicians
- most common
- fee for service is how providers are paid
What are the cons of a PPO?
- increased premiums
- increased deductibles
What does PPO stand for?
preferred provider organization
What is Point of Service (PPO)?
- has characteristics of HMO and PPO
- may need a PCP to be a gatekeeper
- it is possible to see non-network doctors, but could lead to increased out of pocket payments
What does PPO stand for?
point of service
What are the pros of PPOs?
- no referral
- out of network coverage
What are the cons of POS?
- a claim will be filled
- increased deductible than PPO and HMO
High Deductible Health Plans
- decreased premiums
- high deductibles
- required to have health savings account
Who can be an agent?
PCP or employers
What is an agent?
someone who works on behalf of another using their expertise
What is the National Committee for Quality Assurance (NCQA)?
non-profit since 1990 that has worked with federal, state, consumer and business leaders to improve the quality of health
How does the NCQA want to quantify health?
- Measurement
- Transparency
- Accountability
What are the pros of accreditation?
- access/experience of care
- quality improvement initiatives
- verifying provider credentials
- appropriate denial and appeal practices
- helping enrollees manage their own health and healthcare
What companies are responsible for accreditation?
- HEDIS
- CAHDS
What are preventative services?
Provided by the ACA to provide services to prevent disease
Who recommends the required preventative services?
- USPSTF
- ACIP
- HRSA
- IOM
What are examples of cost-sharing?
- Deductibles
- Coinsurance (80/20)
- Copayment
- Prescription coverage
What are the 10 essential health benefits that plans offer?
- Ambulatory services
- Emergency services
- Hospitalizations
- Pregnancy, maternity, and new born care
- Substance abuse and mental health services
- Prescription drugs
- Rehabilitative and habilitative services
- Laboratory Services
- Preventative and Chronic Disease
- Pediatric Services
What is a cadillac tax?
excise tax that is to be assigned to plans w/ increased premiums
- has been delayed
- would impact the type of health coverage and cost-sharing
What are the various ways that employers have gotten involved with the opioid crisis?
- employee assistance programs
- modified coverage to incorporate utilization
- providing education on opioid use
- expanding networks to include substance abuse experts
How are High Deductible Plans described?
“consumer driven health plans”
What are the negatives of a High Deductible Health Plans?
- increased responsibility due to high deductibles
- decreased adherence due to increased prices
What are the positives of a High Deductible Health Plans?
- decreased premiums
- more cost effective plans
- employees are more aware of costs and can more informed decisions
What is HSA?
- help individuals save for future qualified medical and retiree health expenses on a tax-free basis
- alternative way to pay for health care
- money that employees save can be put into an HSA
- regulated by the IRS
- not taxable
What is a qualified expense?
- determination of whether an expense is for “medical care”
- application: think of Ms. Laurie
- uses facts and circumstances
- can only be prevention
- have longer relative effects on pharmacy
What is economics?
how society allocates scarce resources and goods
What are resources?
inputs (labor, capitals, and land) that society uses to produce output
What are goods?
provided by barbers, doctors, and police can be clothes, food, or housing
What is production?
converting inputs to outputs
What is the driving force of economics?
scarcity
