Financing Health Care - Week 5 Flashcards
What did congress pass in December of 2020?
3.6% medicare payment cut
What is health Insuracne?
Policies purchased to pay for certain health-related services and goods such as medical surgical, and hospital expenses
Benefits: covered services reimbursed by the insurance policy
Who pays for Health Insurance Policies?
- Individual: purchase health insurance policy directly; out of pocket expenses
- Employer: offers health insurance coverage as a benefit to employees
• Government: federal government finances Medicare; federal and state governments finance Medicaid and the Children’s Health Insurance Program; US Department of Defense Military Health System
“entilitelment programs”
Does health insurance companies finance health care?
What do they do?
No ,
• Offer policies that assume
risk for health care costs
They,
• Process health insurance claims
• The administrative tasks add cost to health care
In the third-party payer system there are 3 players.
Who make up the first, second, and third parties?
- First party = individual seeking health care
- Second party = provider of health care
- Third party = public and private health insurers
Who finances Medicare?
federal government
Who finances Medicaid & Children’s Health Insurance Program?
federal and state government
Who pays for, or finances, health care services?
-
Health Insurance Benefit Plans are based on:
- types of services covered
- amount of services covered
- in network providers
- out of network providers
- Cost sharing: deductibles, coinsurance, co-payments, out of pocket maximum
Premium
- amount you pay for health insurance each month
- price varies on health plan or level of benefits purchased
Deductible
- amount you pay for covered health care services before your insurance plan starts to pay for services
- starts over each year
- choose plan w/ high deductible will lower the cost of monthly premium
Coinsurance
- Percentage of cost of a covered health services you pay after you pay your deductible
Co-payment
- predetermined flat rate you pay for health care services at the time of care after you met your deductible
Out of pocket maximum
- most you could have to pay in 1 year out of pocket for your health care, after you pay this then your health care pays 100% of the cost of covered services
In-Network Vs. Out-of-Network
- In-network providers contract with the insurance company to accept a specific fee for each service they bill
- Out of network providers can bill whatever they want for each service
What is the Centers for Medicare and Medicaid Services (CMS)?
What entitlement programs does it offer?
• government supported health care insurances
• Direct health insurance business
• Administration of healthcare
entitlement programs
• The largest purchaser of health insurance in the US
• administers Medicare and works w/ each state to administer Medicaid, Chip, and health insurance portability standards
Who qualifies for Medicare entitlement program?
- 65 years and older
- Persons with end-stage renal disease
- Disabled
What health care services are provided under:
Medicare Part A
- Hospital Insurance
- Mandatory
- Inpatient hospital care
- SNF
- Certain home health services
- Hospice care
- Funded by FICA & general federal revenues
What health care services are provided under:
Medicare Part B
- Supplementary Medical Insurance
- Voluntary program (option to purchase)
- Physician services, outpatient hospital services, select home health services, medical equipment & supplies, other health services
- Funded by beneficiary premium payments matched by general federal revenues
What health care services are provided under:
Medicare Part D
- Voluntary
- Prescription drug coverage
- “D” for Drugs
What health care services are provided under:
Medicare Part C
- “Medicare Advantage Plans”
- Optional
- Private insurance companies that contract with Medicare to cover Part A and Part B benefits, and usually Part D
What is Medicaid, who funds it, and do all Medicaid programs offer the same services?
- Health insurance for the indigent population
- a medicare supplement insurance policy that helps pay some health care costs that medicare part A and B doesn’t cover such as copayments, coinsurance, or deductibles.
• State creates and manages but must adhere to certain federal guidelines
- Funded by state and federal governments; can have dual eligibility for medicare and medicaid
What is MEDIGAP
• A Medicare Supplement Insurance policy that helps pay some of the health care costs that Medicare Part A, B, doesn't cover, like: • Copayments • Coinsurance • Deductibles
What is the Children’s Health Insurance Program? aka CHIP
- Mandates health insurance for uninsured children and pregnant women in families with incomes too high to be eligible for most state medicaid programs , but too low to afford private insurance
- Each state is different; good for children with special needs
Why are the uninsured and underinsured a public health issue?
- uninsured: no health insurance
- underinsured: have insurance that is inadequate to meet thier healthcare expenses
- problem when putting food on table or paying for doctor
- Less likely to seek needed medical care
- May not follow instructions for care because they cannot afford to do so
- Can turn a minor manageable health problem into a more serious and expensive chronic illness
Is access to healthcare an issue for only the uninsured?
no
AFFORDABLE CARE ACT parts?
Title I: Quality, Affordable Healthcare for All Americans
Title II: The Role of Public Programs
Title III: Improving the Quality and Efficiency of Healthcare
Title IV: Prevention of Chronic Disease and Improving Public Health
Title V: Healthcare Workforce
Title VI: Transparency and Program Integrity
Title VII: Improving Access to Innovative Medical Therapies
Title VIII: Community Living Assistance Services and Supports Act
Title IX: Revenue Provisions
Title X: Strengthening Quality, Affordable Care
Essential Health Benefits
