Traditional insurance concepts Flashcards
Most individuals over age 65 are covered by
government (medicare)
What are the other people who aren’t on medicare?
medicaid (for those qualified)
Uninsured
Private insurance (group/self)
Key players in insurance?
Consumers
Providers
Insurance companies
Employers
possibility of substantial financial loss from event which probability of occurrence is small?
risk
Purpose of health insurance?
to pool people together to spread cost generated by small number of ppl
Fundemental principles of insurance
1: Risk unpredictable to individual
2: risk can be predicted in group
3: risk transferred from infividual to group by pooling of resources
4: all members share losses
Requirement that insurance be sold without regard to health status?
guaranteed issue
Premiums determined by groups own medical claims experience ?
experience rating
Risk spreading among members, premiums set without regard to health status, determined by utilization experience of larger community
community rating
what are the 3 risk options for insurance?
guaranteed issue
experience issue
community rating
When less healthy people disproportionately enroll in riskk pool of health insurance?
adverse selection.
Process insurers use to evaluate risk of applicants?
medical underwriting
Charging premiums based on individuals likely healthcare needs?
risk-based rating
coverage exclusion, high cost sharing, cherry picking
benefit design
how do insurers manage adverse selection?
Medical underwriting
Pre-existing condition exclusion
Risk-based rating
Benefit design
Who are people always denied?
Cancer HIV Diabetes MS Pregnancy Stroke
Who are people often denied?
Overweight
History of cancer
HTN
Asthma
who are sometimes denied?
Acne
Hay fever
Coverage options can change with
loss/change of job change in family status Birthday Moving change in health
types of covered benefits?
ACA:Essential benefits
mandated benefits
benefit limit
Types of cost-sharing?
deductibles, co-pays, co-insurance
Terms of coverage include
Provider networks
care authorization/review
Cost of health insurance costs depend on
who is covered Whats covered Insurer profits Subsidies inflation
This applies to job-based plans sponsored by employers with >20 employees
Cobra federal law
under cobra law, what is the temporary continuation of coverage after event?
buy why does it get costly?
losing job: 18 months
change in family: 36 months
Disability: 29 months
employer premium contribution not required.
Why are there entitlement programs?
groups at risk unable to access employer-based health care
What are groups that apply for entitlement programs?
Elderly and poor
Types of military coverage
US department of defense
Military treatment facilities
TRICARE: managed HC plan
Veterans coverage covers
veterans and family .
giving access to services determined by assigned priority levels.
Military and veterans coverage are 2 different systems funded by
Congressional action.
conflict between 2
insurance for current and retired federal employees and families?
Federal employee health benefits program (FEHBP)
Indian healthcare provider?
Indian health services.
Partnership between federal and states to provide health insurance coverage for targeted low-income children under 19 who are not eligible for medicaid?
State children health insurance program (CHIP)
Who has oversight of CHIP and what do they do?
Who designs it?
CMS
establish broad eligibility and benefit guidelines.
state designs it.
