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Intro to PH Policy & Mgmt > Mod 4 - Private Insurance > Flashcards

Mod 4 - Private Insurance Flashcards

1
Q

Deductible

A

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

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2
Q

Premium

A

The amount you pay for your health insurance every month

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3
Q

Copayment

A

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

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4
Q

Coinsurance

A

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

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5
Q

Health Savings Account (HSA)

A

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

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6
Q

Out of pocket costs

A

Your portion of the bill after insurance has covered their part

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7
Q

Benefits

A

What’s covered under a health insurance plan

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8
Q

Percentage of uninsured in the US (2018)

A

10.4%

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9
Q

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

A

24.8%

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10
Q

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

A

7.2%

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11
Q

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

A

57.5%

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12
Q

4 main paths to addressing the uninsured

A
  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
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13
Q

ACA employer mandate

A

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

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14
Q

ACA individual mandate

A

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

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15
Q

National Federation of Independent Business v. Sebelius (2012)

A

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

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16
Q

Tax Cuts and Jobs Act (2017)

A

Passed by House and Senate
Removed the ACA individual mandate

17
Q

Texas v. California (2021)

A

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

18
Q

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

A

400%

19
Q

What did the ACA do regarding pre-existing conditions?

A

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

20
Q

ACA 10 Essential Health Benefits

A
  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
21
Q

The ACA and young adults

A

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

22
Q

The ACA and women

A

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

23
Q

Community rating

A

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

24
Q

Experience rating

A

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

25
Q

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

A

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

26
Q

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

A

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

27
Q

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

A
  1. Age
  2. Geographic location
  3. Family composition
  4. Tobacco use
28
Q

Medical loss ratio (MLR)

A

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

29
Q

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

A

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

Intro to PH Policy & Mgmt (4 decks)

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