Mod 4 - Private Insurance

Question 1

Deductible

Answer 1

The amount you pay out of pocket for healthcare before an insurance provider will pay any expenses

Question 2

Premium

Answer 2

The amount you pay for your health insurance every month

Question 3

Copayment

Answer 3

Or “copay;” a fee you pay at the time of medical service

Question 4

Coinsurance

Answer 4

A percentage fee that you pay for medical services or supplies ONCE YOUR DEDUCTIBLE HAS BEEN PAID (sneaky)

Question 5

Health Savings Account (HSA)

Answer 5

An account that lets you save for future medical costs

Not subject to federal income tax

Not required to be spent in a single year

Question 6

Out of pocket costs

Answer 6

Your portion of the bill after insurance has covered their part

Question 7

Benefits

Answer 7

What’s covered under a health insurance plan

Question 8

Percentage of uninsured in the US (2018)

Answer 8

10.4%

Question 9

Percentage of Medicaid/Medicare/other publicly insured in the US (2018)

Answer 9

24.8%

Question 10

Percentage of individuals with non-group private insurance coverage in the US (2018)

Answer 10

7.2%

Question 11

Percentage of individuals with employer-sponsored private health insurance in the US (2018)

Answer 11

57.5%

Question 12

4 main paths to addressing the uninsured

Answer 12

1. Make employers pay for insurance
2. Expand Medicaid coverage for low-income people
3. Provide an option for people to buy their own insurance
4. Offer universal coverage

Question 13

ACA employer mandate

Answer 13

Any company with more than 50 employees must offer health insurance coverage; failure to comply results in a fee

Question 14

ACA individual mandate

Answer 14

If your employer does not offer insurance, you have to purchase it on your own; failure to comply resulted in a fee until it was removed by the 2017 Tax Cuts and Jobs Act

Question 15

National Federation of Independent Business v. Sebelius (2012)

Answer 15

5 to 4 decision
ACA individual mandate is constitutional
Part of the constitutional exercise of Congress’ taxing power

Question 16

Tax Cuts and Jobs Act (2017)

Answer 16

Passed by House and Senate
Removed the ACA individual mandate

Question 17

Texas v. California (2021)

Answer 17

Argument: If the individual mandate is unconstitutional, then the entire law is unconstitutional
Court left previous decision in place

Question 18

To qualify for middle class subsidies through your state’s Health Insurance Exchange, your income must not exceed _____ of the federal poverty level.

Answer 18

400%

Question 19

What did the ACA do regarding pre-existing conditions?

Answer 19

The ACA ensures that pre-existing conditions are covered and people with them can’t be charged more for insurance

Question 20

ACA 10 Essential Health Benefits

Answer 20

1. Pediatric services, including oral and vision
2. Ambulatory patient services
3. Emergency services
4. Hospitalization
5. Maternity and newborn care
6. Mental health and substance use disorder services
7. Prescription drugs
8. Rehabilitative and habilitative services and devices
9. Lab services
10. Preventive and wellness services and chronic disease management

Question 21

The ACA and young adults

Answer 21

All plans are required to cover dependents up to the age of 26

Question 22

The ACA and women

Answer 22

All 18 contraceptive methods included in essential benefits
Office visits for this have no copay
Pregnancy and/or DV no longer a pre-existing condition
Plans no longer permitted to use gender to determine premiums
Workplace protections for chest feeding

Question 23

Community rating

Answer 23

All pay the same premium regardless of age, sex, or health status
Dominant form of insurance pricing before the mid 1950s

Question 24

Experience rating

Answer 24

Each group pays a premium in relationship to their expected use of care, usually based on historical cost
Dominant form of pricing for most insurance today

Question 25

The sickest _____% of the population accounts for _____% of total healthcare spending

Answer 25

The sickest 5% of the population accounts for 50% of total healthcare spending

Question 26

The healthiest _____% of the population accounts for _____% of healthcare spending

Answer 26

The healthiest 50% of the population accounts for only 3% of healthcare spending

Question 27

Under the ACA, insurers can only adjust premium rates based on:

Answer 27

1. Age 2. Geographic location 3. Family composition 4. Tobacco use

Question 28

Medical loss ratio (MLR)

Answer 28

The percentage of insurance premiums that actually goes toward paying for healthcare

Question 29

The ACA requires companies to keep their medical loss ratio (MLR) at _____% for large group insurers and _____% for small group insurers

Answer 29

The ACA requires companies to keep their medical loss ratio (MLR) at 85% for large group insurers and 80% for small group insurers