Insurance Flashcards
What is a network?
A panel of providers
What do Medicare and Medicaid do to offer managed care for some beneficiaries?
Contract w/ private insureres
What are some methods of cost containment?
- networks
- prior authorization
- referral requirements
- value-based payments
- negotiated rates w/ hospitals & outpatient providers through selective contracting
- addressing social determinants of health
What is the main source of coverage in the US?
Employer sponsored coverage, followed by Medicaid and medicare
what is “job lock”?
Staying in a job to keep insurance
What are some problems with employer sponsored coverage?
Increases inequality because healthy people are more likely to work -> have good insurance
Inefficiency from job lock
What is a self-funded plan?
Firms pay for some or all of the health care of their employees with their own funds rather than buying them health insurance “manage their own risk pool”
What are fully-insured plans?
Plans purchased from an insurance company at a set rate (risk taken on by insurer)
What is a health maintenance organization?
PCP referrals are usually required; out-of-network care hella expensive
What is a preferred provider organization?
PCP and referrals are not typically required; out-of-network care is still more expensive
What is a point of service plan?
Not sure, PCP and referrals may be required; sometimes referred to as “HMO without the walls” or a combination of HMO and PPO
What is an exclusive provider organization?
PCP is not typically required; a referral may be required; out-of-network is not covered
What is an indemnity plan?
No network, just see anyone
What is an HRA or HSA?
Health reimbursement arrangement
Health savings account
can be appended to high deductible health plan and are tax exempt
What is a high deductible health plan?
Deductible greater than $1,600/individual (usually has low premiums)
What is a consumer driven health plan?
HDHP + HRA/HSA
What is the hierarchy of plan generosity?
Platinum: 10%
Gold: 20%
Silver: 30%
Bronze: 40%
What is the most common plan?
PPO (preferred provider organization) followed by HDHP/SO
What is a marketplace plan?
Health insurance exchanges can be found on a website for individuals without access to affordable insurance where they can buy plans
The ACA also has subsidies for individuals between 100 and 400% of the federal poverty level
Who is Medicare for?
65 year olds, some individuals w/ disabilities, and anyone w/ end stage renal disease
Which is operated at the federal level: Medicare or Medicaid?
Medicare
What are the four parts of Medicare
Part A: inpatient insurance
Part B: outpatient insurance
Part C: Medicare advantage
Part D: drugs
How popular is Medicare Advantage?
More than half of Medicare beneficiaries
What is capitation?
Per person per capita
