exam 1: managed care and healthcare coverage

Question 1

what are coverage options of individuals and families under ACA and alternative plans?

Answer 1

• Higher premium (pay more per month) = lower deductible
• Lower premium (pay less per month) = higher deductible

Question 2

what is the rational for mandatory coverage (aka individual mandate) under the ACA?

Answer 2

Penalty if you don’t buy insurance (some may see it as more affordable than buying insurance)
Want everyone to buy to keep price down (if only sick ppl in pool, then it will be expensive)

Question 3

provisions for family insurance coverage for young adults/pre-existing conditions?

Answer 3

Covered until 26 under parent’s insurance
Not allowed to refuse to cover you due to pre-existing conditions

Question 4

describe the aspects of ACA’s integrated care options
- ACOs, bundles
- dual eligibles
- care transitions

Answer 4

• ACOs, bundles: innovations to help low income and sick ppl
• dual eligibles: indiv having both medicare + medicaid
• care transitions: transition of care from institutions back into the community

Question 5

describe aspects of ACA’s quality focus
- transparency and data sharing/value based payment
- fraud and abuse

Answer 5

• transparency and data sharing/value based payment: transparency in outcomes of care in the hospitals
• fraud and abuse: new tools for detecting when thieves are attempting to steal money from medicare/medicaid

Question 6

describe aspects ACA’s of innovation
- CMMI
- prevention funds
- pricing reforms
- FQHC

Answer 6

• CMMI: purpose to help foster new forms of care in america
• prevention funds: innovate better ways to improve health care
• pricing reforms: buy better care at lower costs
• FQHC: cover more people with better insurance

Question 7

what are the sources for funding for various health coverage options under the ACA/alternative plans

Answer 7

taxes, subsidies, negotiates

Question 8

explain what a care manager or gatekeeper does

Answer 8

A model of healthcare delivery in which all of the healthcare needs of a patient are funneled through one party
Attempt to keep costs down

–> FOCUS ON PREVENTION AND OUTPATIENT CARE

Question 9

fee-for-service vs managed care plans

Answer 9

fee for service: provider reimbursed for each health service delivered
- Provider may just order everything to get paid more (unnecessary overuse of care)
- Overtreatment risk

managed care plans: prepaid set fee to cover any and all health services delivered to a particular individual in that month
- No matter how much provider orders, still get paid the same amount
- incentives given to providers to limit use of high cost care

Question 10

explain the type of managed care modules
- hmo
- ppo
- pos

Answer 10

• hmo: health maintenance org; prepaid group plan and fixed fee (providers on salary basis)
• ppo: preferred provider organizations; providers give healthcare at discounted rate, but members have low out of pockets
• pos: hybrid ppo and hmo

Question 11

national committee on quality assurance (ncqa)

Answer 11

ensures that all managed care companies are providing equitable care, following all policies and protocols; independent and non profit

Question 12

what are 3 different ways the ncqa evaluates healthcare

Answer 12

1. accreditation
2. health plan employer data and information set (HEDIS): standardized measures + all info needed to measure performance of providers
3. consume assessment of health plans (CAHPS): survey sent to consumers to eval performance