Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Healthcare Insurance > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What came about during the 1930s, mainly as a result of the Great Depression?

A
  1. Hospital Service Plans (evolved into Blue Cross)

2. Prepaid Group Practice Plans (evolved into Blue Shield and Managed Care)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What contributed to the early growth of health insurance in the 1940s and 1950s?

A
  1. Wage and Price Controls (imposed during WWII)
  2. Organized Labor
  3. Federal Tax Code
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

During the mid-1960s, what two government “health insurance” programs were introduced?

A

Medicare and Medicaid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

The three general forms of managed care

A
  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Point Of Service Plan (POS)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

In 2010, what law was passed that made sweeping changes to the U.S. health insurance market?

A
  • Patient Protection and Affordable Care Act (PPACA or ACA)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Briefly explain TWO advantages of Employer-Sponsored Coverage

A
  1. Tax Treatment
  2. Economies of Scale (i.e., cheaper)
  3. More Coverage Choices
  4. Richer Benefits Packages
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Different Parts of Medicare

A

Part A
- Hospital, skilled nursing, and home health coverage
- Paid for by payroll taxes
Part B
- Physician services and durable medical equipment
- Paid for by general taxes and monthly premium
Part C
- Medicare Advantage (Medicare managed care)
- Covers approximately 25 percent of beneficiaries
Part D
- Voluntary prescription drug coverage
- Paid for by an additional monthly premium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Who does Medicaid cover?

A
  1. Adults (namely pregnant women)
  2. Children
  3. Elderly
  4. Disabled
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is “churning?”

A

Churning is what happens when people move between private coverage and Medicaid or else become uninsured

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is Adverse Selection?

A

Purchasers know more about their likely use of services and use this knowledge to select a health plan that is designed for people with lower expected claims experience.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the difference between the HMO effect and Favorable Selection?

A
  1. The HMO Effect is How to keep people out of hospitals
  2. Favorable Selection is How to attract people who do not use/need hospitals and encouraging them to buy them by offering things such as gym membership
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Underwriting

A
  1. Creating a number of risk pools or risk classes
  2. Combats adverse selection
  3. It allows insurance companies to match new members to the appropriate risk pool
  4. Keys = Costs and Law
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Community Rating

A

All covered lives are placed in a single risk pool

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Experience Rating

A

Insurers seek to base premiums on the prior or current claims of individuals or groups

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Manual Rating

A

Insurers seek to identify characteristics (and thus establish premiums) of individuals or groups that are associated with higher or lower claims experience.
- Characteristics such as: Age, Gender, Occupation, health status, and industry.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Self-Insure

A

An employer group bears the underwriting risk itself. It may use a third-party administrator

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Which public insurance program implemented a risk adjustment model?

A

Medicare

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Which measure is the best predictor of healthcare expenditures?

A

Prior Utilization

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is Medicaid?

A
  • A joint federal and state program that helps with medical costs for some people with limited income and resources.
  • It also offers benefits not normally covered by Medicare, like nursing home care and personal care services.
  • Largest payer towards nursing homes
20
Q

What is Katie Beckett?

A

Home Care for Certain Disabled Children also known as Katie Beckett is a Medicaid eligibility category that provides Idaho Medicaid coverage to children under age 19 who have long-term disabilities or complex medical needs and who live at home.

21
Q

What is FreeMed?

A
  1. Designed for low income people with no prescription insurance through Pharmaceutical Company Patient Assistance Programs (PCPAP).
  2. Staffed by volunteers, receives no government funding, accepts donations
22
Q

What is PAP?

A
  1. Patient Assistance Programs

2. Run by pharmaceutical companies to provide free medications to people who can’t afford them

23
Q

Difficulties of trying to get free medications

A
  1. Hours of operation
  2. Waiting period
  3. Paperwork
  4. In person interviews and application
  5. Not publicly advertised
24
Q

What was the primary cause of growth of health insurance during the middle of the 20th century?

A
  1. Tax-exempt status of employer-sponsored health insurance. (Main Thing)
  2. Wage and price controls during World War II
  3. The rise of labor unions
  4. The declaration of health insurance as a proper focus of collective bargaining
25
Q

What is an HMO?

A

Health Maintenance Organization

  1. Network that you have to stay in and they are pretty narrow. If you go outside of the network, then insurance won’t pay anything
  2. There is a gatekeeper that is your primary care physician and they tell you if you can go and see a specialist
  3. They are insurance companies that combine the insurance function with the provision of care
26
Q

PPO

A

Preferred Provider Organization
Not all PPO’s are insurance companies
- They may just handle the contracts

27
Q

POS

A

Point of Service

  1. The least popular of the managed care types
  2. You can choose if you want to go in or out of network. Prices are generally a little better if you go in network
  3. Pay a little more to have this type of insurance
28
Q

Employer Mandate

A

Pay or Play
Employers must provide health insurance to employees if:
1. You have to have more than 50 employees
2. That work 30 or more hours per week

29
Q

Individual Mandate

A

You have to have insurance or else you have to pay PENALTIES that are increasing each year

30
Q

Kentucky Insurance

A
  • Kentucky is switching from the state to the Federal Exchange for individual plans
  • They ran out of their government grant that was funding their state exchange, but it has ran out and they now have to get onto the Federal Exchange
  • Source: New York Times
31
Q

Which Insurer is threatening to pull out of the exchange?

A
  • United Healthcare
  • They are the largest provider in the nation but they are losing too much money to make it worth it
  • Source: USA Today
32
Q

What is an Insurance Commissioner?

A
  • Each state has one that makes decisions about laws concerning insurance
  • They are attempting to make it impossible for insurance companies to be able to charge people more if they receive services out of network.
    Source: PR News Wire
33
Q

What is Pure Premium?

A

The Expected Loss

34
Q

What is the Loading Percentage?

A

The markup to cover objective risk, profit and costs of marketing, adjudicating and processing claims, coordinating benefits and providing access to networks.

35
Q

Gross Premium Calculation

A

Gross Premium = Pure Premium / (1-Loading Percentage)

36
Q

Medical Loss Ratio Calculation

A

= (Medical Claims + Quality Enhancing Efforts) / (Premiums-Taxes)

  1. ACA requires that there is an MLR of at least 80% for groups less than 100 and
  2. At least 85% for groups that are larger
  3. If these thresholds aren’t met, insurers must rebate premiums
37
Q

Prospective Experience Rating

A
  1. Premium based on prior claims of the group
  2. Credibility factor
  3. Underwriting risk borne by the insurer
38
Q

What does AAPCC stand for?

A

Adjusted Average Per Capita Costs

39
Q

Examples of Demographic Measures

A
  1. Age
  2. Gender
  3. Location
40
Q

Examples of Subjective Health Measures

A
  1. Physical health
  2. Mental health
  3. General health
  4. Disease control
41
Q

Examples of Physiologic Health Status Measures

A
  1. Health records

2. Physical and Labs

42
Q

Examples of Prior Utilization Measures

A

Outpatient and Inpatient Expense for the prior year

43
Q

What does CMS-HCC stand for

A

Centers for Medicare and Medicaid Services Hierarchical Condition Categories

44
Q

ACA uses of Risk Adjustment

A
  1. Use in adjusting risk across plans in state insurance exchanges
  2. Reduce payment to plans with disproportionately healthy enrollees
  3. Raise payment to those with less-healthy subscribers
45
Q

ERISA

A

Employee Retirement Income Security Act

this makes it so that self insurers don’t have to fallow state insurance law

Healthcare Insurance (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions