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
Is Medicare solvent? Why?
Nope
- Aging population increases pool
- Healthcare costs are increasing more than inflation
- Funding is mainly from payroll taxes and premiums which cant keep up w/ growing demand
What are ways to target solvency in Medicare?
- introduce other payroll taxes
- increase age of eligibility
- increase premiums more for higher-income beneficiaries
- increase deductibles
- implement more cost sharing
- restructure Medigap and other supplemental coverage
What is Medicaid?
Health insurance for low income and disabled people
What do 1115 waivers do?
Focus on specific groups and extend benefits to them
How much did the Federal government pay for Medicaid spending?
100% which slowly decreased with years
How is the federal medical assistance percentage determined?
State per capita incomes (between 50-83%)
How is Medicaid reimbursement?
Crazy low
How is Medicaid reimbursement?
Crazy low
Medicaid is the primary payer of __ ___ ___
Long term care
What are Medicaid managed care organizations?
Contract managed companies that take the financial risk for services in their contracts, accounts for 2/3s of Medicaid beneficiaries
What does capitation incentivize insurers to do regarding utilization?
Keep it low
What are social determinants of health? What do they have to do with Medicaid?
Societal and environmental conditions, Medicaid and their MCOs target SDoH
How many dual-eligible of Medicare and Medicaid are there?
1 in 7 Medicaid enrollees and 1 in 5 Medicare enrollees
What is defined as being underinsured?
Out of pocket healthcare costs being equal to greater than 10% of household income
Did the ACA eliminate being uninsured?
Helped it, didnt save it
What determines premiums?
85% is claims experience and 15% is loading charge
What are 5 levels of reimbursement? What do they rank by?
1-5, by complexity
What is community rating and how does it affect premiums?
All patients in given area must pay similar premiums, this can lead to too high of premiums which drives individuals out of the market
What is guaranteed issue?
A ban against insurers denying patients w/ pre-existing conditions
What is experience rating?
Charge different things based on a patients experiences such as smoking, age, location, individual v family enrollment, plan category
Based on the Rand Health Insurance Experiment, how does cost sharing impact risky behaviors?
It doesnt
What are the three threats to internal validity pointed out by Aron-Dine et al regarding Rand Experiment?
- no random assignment
- differential participation across plans (more free care group participated)
- differential reporting across plans (med spending reported more by free care group)
What did Finkelstein find using The Oregon Lottery regarding the efficiency of Health Insurance?
No improvement in physical health outcomes was detected, use of health care services and diabetes detection and management increased, depression and financial strain decreased
