Health Insurance

Question 1

define pooled risk

Answer 1

requiring patients to assist in paying for care so the common financial risks are shared among many people

Question 2

define insurance premiums

Answer 2

a membership fee paid by subscribers

Question 3

define catastrophic cap

Answer 3

a limit on the out-of-pocket money someone is required to pay so they don’t go into debt

Question 4

define co pay

Answer 4

cost per visit

Question 5

define fee-for-service system

Answer 5

the practice of paying a care provider for specific care provided, as opposed to a capitation amount paid in advance regardless of services rendered

Question 6

define Prospective payment system:

Answer 6

a system in which reimbursements are established in advance rather than after care has been provided

Question 7

define diagnosis related groups

Answer 7

flat-rate reimbursement amounts for specified inpatient hospital procedures; meant to reward hospitals for cutting costs and expediting costs;
-helps people know what the cost of healthcare is going to be before the service: important to prospective payment system

Question 8

ways that health care is “managed” under managed care?

Answer 8

• coordinate costs and delivery of health services. Match up patients with care providers and facilities and monitor expenses
  -Limit access to providers (networks)
  Require patients to assist in paying for care
  Limit coverage of certain procedures

Question 9

define Health Managed organizations (HMO)

Answer 9

hires physicians, if you have this kind of insurance, you can only see their providers

• cheapest one
• MONTHLY PREMUIM PLUS COPAY

Question 10

define preferred provider organization (PPO)

Answer 10

Contract physicians, they cover more when you see doctors in network 

• MONTHLY PREMIUM AND ANNUAL DEDUCTIBLE
• 80% AND 20% SPLIT

Question 11

define high deductible health plans (HDHP)

Answer 11

• Low monthly premiums, deductibles are 2-3x more

- makes use of health savings account (HAS) interest

Question 12

pros and cons of managed care

Answer 12

Pros:

• Predictive budgeting
• Incentive to reduce costs
• Most affordable care
• Wellness
• Administrative assistance and teamwork
• Career jump start

Cons:

• Costs (premiums) continue to rise
• Prevention still not a priority
• Incentive to limit care: providers limit care and speed up patient visits
• Limited choices
• Red tape overload: “too much paperwork”