Health Insurance Flashcards
When did Blue Cross Blue Shield begin?
1930s & 1940s
When did government programs really expand to cover healthcare costs?
1950s & 1960s
When was the ACA signed into law?
March 23rd, 2010
What is happening w/ the ACA now?
still implementing into 2018
Congress & Health & Human Services are tweaking it
U.S. Supreme Ct is weighing in on it soon
What is the purpose of the ACA?
- decrease # of uninsured (35% of pop.)
- make health insurance available to everyone
- provide gov’t assistance when ppl can’t afford health insurance (medicaid, SCHIP, exchanges/subsidies)
- regulate health insurers on how private plans are offered (min. benefits, no pre-existing limitations)
Which public programs do we have today?
Medicaid
SCHIP-Nevada Check up
Medicare
Federal & State Exchanges
Which private programs do we have today?
Federal and State Exchanges
Private individual policies
Private group policies
What are the private market positives?
Variety of options
Plan designs, provide networks, insurance companies
Competitive forces lead to better service and quality
Providers are generally compensated better > appointments easier to obtain, less waiting
Possible subsidies on the Exchange for lower income
Tax favored premiums for employers and employees
What are the private market negatives?
Can be very expensive for individuals and employers
Generally premiums are $400/month for individual $1000/month for a family
Plan designs and max out of pocket are cost prohibitive
$6600 Annually for an individual
$13,200 Annually for a family
Market place can be difficult to navigate
Compliance is very challenging. Employers > 50 employees MUST offer health insurance or face steep penalties
Premiums are not tax favored for individuals
What is fee for service? What are the requirements?
health coverage that reimburses health providers for their services
most costly for employers
no PCP, network, or referral required
What is an HMO?
health maintenance organization
covers services performed solely by providers in a network
this tends to be a low cost system, but is more restrictive than other plans
requires PCP & referrals
Can’t be covered for out of network
What is a PPO?
preferred provider organization
network of providers, allows use of medical providers outside of the plan’s network
referrals may be required
more flexible, but more expensive
What is a high deductible health plan?
paired w/ a tax-advantaged account to pay medical expenses
like a health reimbursement arrangements, health savings accounts
high deductible
no referral, PCP required
What is a health savings account?
tax-advantaged account used to pay for qualified medical expenses
used in conjunction w/ HDHP
funds remaining in account at end of plan year are rolled over into account for next year
PCP, network, referral not required
What is a point-of-service plan?
sorta HMO + PPO
more benefits if stay in network & begin w/ PCP
require PCP, network, referrals
What is a health reimbursement arrangement?
program that allows employers to set aside an amount of funds to reimburse participating employees for medical expenses.
often combined w/ another health plan
**may not require PCP, may not require network or referral
What is the health flex spending account?
account set up thru a health plan that allows employees to contribute funds that are not subject to payroll tax.
unused funds are lost after a grace period.
can carry over $500 unused funds
may not need network, PCP, referral
What is a health savings account?
**Can put money away on pre-tax basis, have high deductible, savings account
tax-advantaged account used to pay for qualified medical expenses
used in conjunction w/ HDHP
funds remaining in account at end of plan year are rolled over into account for next year
PCP, network, referral not required
Once again, what are the public insurance options?
Nevada Medicaid
Nevada Check-Up (SCHIP)
Medicare
What are the self-pay options for uninsured?
Access to Healthcare Network Medical Discount Program
Women’s Health Connection
Nevada Colorectal Cancer Control Program
Community Programs – Safety Net
What is NV medicaid?
Funded by both the federal government and state government
Administered by the state government – rates, benefits, etc.
Expanded in 2013-2014 by the Affordable Care Act
Regular Medicaid vs. emergency Medicaid
Application Process
Who is eligible for nevada medicaid?
Live between 0 – 138% of the FPL
Pregnant and lives between 0-165% of the FPL
US Citizen or Legal Resident (more than 5 years)
What are the benefits of Medicaid?
Expansion
Reduced the number of uninsured and Uncompensated care
No cost access to care
Preventive services, Specialty care services, Hospital services
WHat are issues w/ medicaid?
Reimbursement rates
Lack of providers/services
Member/patient policies – No call/no show rates, Patient Termination
Not available to everyone
What is nevada checkup? Eligibility?
Medicaid for children
Low cost access to care
Similar issues as Medicaid
Eligibility
Live between 0 – 205% of the FPL
US Citizen, Legal resident (more than 5 years)
What is medicare?
Health Insurance for Seniors and the Disabled Administered by Federal government Largest single payer source Types of Medicare Medicare and healthcare innovation
Who is eligible for medicare?
65 and Older
US Citizen, Legal resident
Paid into Social Security/Medicare
What are the benefits of medicare?
Safety Net for seniors and the disabled
Relatively low administrative costs
Driving healthcare innovation – business opportunity
What are the issues w/ medicare?
High cost of premiums and care
Not available to everyone
Reimbursement rates
Medicare Fee schedule fix
Who is eligible for medicare?
65 and Older (have to be paying into system for 7 years)
US Citizen, Legal resident
Paid into Social Security/Medicare
What constitutes 138% of FPL?
Individual - $16,243 per year, $1,354 per month, $312 per week, $7.80 per hour
Single Mom 2 kids - $27,724 per year, $2,310 per month, $533 per week, $13 per hour
What makes you eligible for the medical discount plan?
Live or work in Nevada Be uninsured (cannot qualify for Medicaid or Medicare) Must meet income guidelines – Between 138 – 250% of the FPL
What’s the deal w/ AHN medical discount plan?
pay a membership fee, $35/mo
a part of 2200 member network
What is women’s health connection?
No Cost Cervical and Breast Cancer Screening
Fast Track Medicaid for Treatment
Funded by the Federal/State Government – Administered by AHN
Care Coordination
5,000 women served each year
Eligible if:
Up to 250% of the FPL
Uninsured (screenings)
Medicaid Eligibility (Treatment)
What is the NV colorectal cancer program?
No Cost Colorectal Cancer Screenings
Funded by the Federal/State Government – Administered by AHN
Care Coordination
2,000 served each year
Eligibility
Up to 250% of the FPL
What is the ryan white program?
Program for Individuals with HIV/AIDS
No Cost Access to: Insurance Premium Assistance, Medications, Primary Care, Mental Health, Case Management
Funded by the Federal/State Government – Administered by AHN
Care Coordination
4,000 served each year
Eligibility
Diagnosed with HIV/AIDS
what are some community programs?
Safety Net for Uninsured/Underinsured Individuals
FQHC’s – Sliding Scale Fees
HAWC, Nevada Health Center
Medical Supplies, Medications, Treatment Dollars
CARE Chest, Susan G. Komen, Redfield Foundation, Nevada Diabetes Association
Vaccination Programs
Complex and Disconnected
Unreliable Year Over Year
