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Health Care Delivery > Employer Sponsored Health Insurance > Flashcards

Employer Sponsored Health Insurance Flashcards

1
Q

What is preferred provider organization?

A
  • people who enroll can get medical treatment form in network physicians
  • most common
  • fee for service is how providers are paid
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2
Q

What are the cons of a PPO?

A
  • increased premiums
  • increased deductibles
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3
Q

What does PPO stand for?

A

preferred provider organization

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4
Q

What is Point of Service (PPO)?

A
  • 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
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5
Q

What does PPO stand for?

A

point of service

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6
Q

What are the pros of PPOs?

A
  • no referral
  • out of network coverage
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7
Q

What are the cons of POS?

A
  • a claim will be filled
  • increased deductible than PPO and HMO
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8
Q

High Deductible Health Plans

A
  • decreased premiums
  • high deductibles
  • required to have health savings account
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9
Q

Who can be an agent?

A

PCP or employers

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10
Q

What is an agent?

A

someone who works on behalf of another using their expertise

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11
Q

What is the National Committee for Quality Assurance (NCQA)?

A

non-profit since 1990 that has worked with federal, state, consumer and business leaders to improve the quality of health

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12
Q

How does the NCQA want to quantify health?

A
  1. Measurement
  2. Transparency
  3. Accountability
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13
Q

What are the pros of accreditation?

A
  1. access/experience of care
  2. quality improvement initiatives
  3. verifying provider credentials
  4. appropriate denial and appeal practices
  5. helping enrollees manage their own health and healthcare
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14
Q

What companies are responsible for accreditation?

A
  1. HEDIS
  2. CAHDS
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15
Q

What are preventative services?

A

Provided by the ACA to provide services to prevent disease

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16
Q

Who recommends the required preventative services?

A
  1. USPSTF
  2. ACIP
  3. HRSA
  4. IOM
17
Q

What are examples of cost-sharing?

A
  1. Deductibles
  2. Coinsurance (80/20)
  3. Copayment
  4. Prescription coverage
18
Q

What are the 10 essential health benefits that plans offer?

A
  1. Ambulatory services
  2. Emergency services
  3. Hospitalizations
  4. Pregnancy, maternity, and new born care
  5. Substance abuse and mental health services
  6. Prescription drugs
  7. Rehabilitative and habilitative services
  8. Laboratory Services
  9. Preventative and Chronic Disease
  10. Pediatric Services
19
Q

What is a cadillac tax?

A

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

20
Q

What are the various ways that employers have gotten involved with the opioid crisis?

A
  1. employee assistance programs
  2. modified coverage to incorporate utilization
  3. providing education on opioid use
  4. expanding networks to include substance abuse experts
21
Q

How are High Deductible Plans described?

A

“consumer driven health plans”

22
Q

What are the negatives of a High Deductible Health Plans?

A
  • increased responsibility due to high deductibles
  • decreased adherence due to increased prices
23
Q

What are the positives of a High Deductible Health Plans?

A
  • decreased premiums
  • more cost effective plans
  • employees are more aware of costs and can more informed decisions
24
Q

What is HSA?

A
  • 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
25
Q

What is a qualified expense?

A
  • 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
26
Q

What is economics?

A

how society allocates scarce resources and goods

27
Q

What are resources?

A

inputs (labor, capitals, and land) that society uses to produce output

28
Q

What are goods?

A

provided by barbers, doctors, and police can be clothes, food, or housing

29
Q

What is production?

A

converting inputs to outputs

30
Q

What is the driving force of economics?

A

scarcity

Health Care Delivery (9 decks)

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