Types Of Insurance Plans And Modes Of Paying For Healthcare

Question 1

What is a premium

Answer 1

Monthly fee paid to an insurance company or health plan to provide health coverage
1. Enrollee pays (you pay)
2. Often before taxes
3. Can select individual, individual + spouse, or family plan options
4. Must be paid to keep plan active
5. Copay is an additional expense

Question 2

What is a deductible

Answer 2

1. The dollar amount you pay for health care services before your insurance plans starts to pay
   *the monthly premium and copayments do not count toward the deductible

Question 3

What is coinsurance (insurance pays)

Answer 3

1. The percentage of costs your insurance pays after you’ve paid you deductible
   *typically 80/20, the insurance will cover 80% of costs beyond the deductible but patient still pays additional 20%
2. Coinsurance is a way of sharing costs between the patient and insurer

Question 4

What is a copayment

Answer 4

1. Fixed amounts for a covered medical service each time rendered
   *office visits, preventive care, prescriptions
   *amount and what they apply will differ based on plans and providers

Question 5

What are allowable costs

Answer 5

1. Maximum amount a plan will pay for a covered health care service
   *eligible expense, payment allowance, or negotiated rate
2. Often set by Center for Medicare and Medicaid Services annually

Question 6

What is an out of pocket maximum (you pay)

Answer 6

1. A predetermined cap or maximum amount a person may have incur during the calendar year if they have insurance

Question 7

What are the out of pocket maximum for family and individuals

Answer 7

I: $9,100
F: $18,200
*set by the government
*health insurance company cant force you to spend more than the max

Question 8

What are other things to know with out of pocket maximum

Answer 8

1. Plans with lower monthly premiums have higher out of pocket limits
   *plans with higher premiums have lower out of pocket maximum
2. Deductible is included in the out-of-pocket maximum
3. Out of pocket maximum is on top of the premium paid monthly

Question 9

What are the four ways to pay for healthcare

Answer 9

1. Employment based private insurance
2. Individual private insurance
3. Out of pocket
4. Government financing plans

Question 10

What patient population need private health insurance

Answer 10

1. A young adult 26
2. Unemployed
3. Part-time employee
4. Spouse or parent retires
   *no longer eligible for employer sponsored health insurance
5. Dropped by existing employer
6. An employer

Question 11

What is primary insurance

Answer 11

Insurance that pays first and up to the limits of its coverage

Question 12

What is secondary insurance

Answer 12

One that pays second and only pays if there are cost the primary insurer didn’t cover

Question 13

What type of health insurance do majority of US citizens have

Answer 13

1. Private group health insurance
   *plans vary by state, and premiums vary by zip code
   *patient needs to determine type of plan needed, deductible comfortable with, and out of pocket expense

Question 14

When is private health insurance bought

Answer 14

1. During one enrollment period
   *usually November to December
   *if someone wants insurance but it is outside the enrollment they must have a qualifying event to trigger a special enrollment period

Question 15

What are the components of open enrollment period

Answer 15

Will permit changes to plans
*must be done annually or lose coverage
1. New eligible persons can enroll

Question 16

When is the enrollment period for Medicaid, CHIP, and Medicare

Answer 16

aid: year round
CHIP: year round
Care: 3 months prior to 65th birthday

Question 17

What are the qualifying events and what does it mean

Answer 17

1. Allows for 60 day window to enroll or switch to different plan if losing existing coverage
   *birth/adoption/placement for adoption
   *permanent move
   *loss of other coverage
   *marriage (MC)

Question 18

What are the different type of health insurance plans

Answer 18

1. Health maintenance organization (HM)
2. Exclusive provider organization plan (EPO)
3. Preferred Provider Organization (PPO)
4. High deductible health plan(HDPD)
5. Point of service plan (POS)
   *1 and 3 MC

Question 19

What is health maintenance organization (HMO)

Answer 19

1. Require participants to receive health care services from an assigned provider
   *must be in network
2. PCP must provide referral to specialist
3. Tend to have lower premium

Question 20

What is an Exclusive Provider Organization (EPO)

Answer 20

1. Hybrid plan
2. PCP is not necessary
3. Services covered only if go to providers and facilities in network
4. No out of network providers are covered
5. Cost is less than HMO and PPO
   *best for people who want to save money

Question 21

What is Preferred Provider Organization (PPO)

Answer 21

1. Medical care arrangement in which medical professional and facilities provide services to subscribed clients at an agreed upon reduced rates
   *PPO medical and HCP are preferred providers
2. In exchange for reduced rate insurers pay the PPO a fee to have in network providers

Question 22

What do PPO offer in comparison to HMO plan

Answer 22

PPO are more comprehensive in their coverage and offer a wider range of providers than HMO plans
1. PPO is a higher cost than HMO
*charge a higher premium
2. Offer more flexibility, since PPO networks are large and in many cities and states

Question 23

What are the pros and cons of HMO (health maintenance organization)

Answer 23

P: lower premium, low or no deductible
C: usually required to select a Primary Care Physician (PCP), PCP referral required for care from a specialist, no non-emergency coverage outside of network

Question 24

What are the pros and cons of PPO (Preferred provider Organization)

Answer 24

P:
1. No need to select a primary care physician
2. No referral needed to see a specialist
3. Usually some out of network coverage
C
1. Higher premiums
2. Usually have a deductible

Question 25

What is a HDHP (high Deductible health plan)

Answer 25

1. Monthly premium usually lower
2. Has a high minimum deductible for medical expenses
3. Allows for a Health Savings Account
   *free from medical taxes

Question 26

What is the minimum deductible for a HDHP

Answer 26

I: $1,500
F: $3,000

Question 27

What is a HSA (Health Savings Account)

Answer 27

1. Only available to US taxpayers who are enrolled in high deductible health plan
2. Can be used for medical costs that HDHPs dont cover
   *funds are not subject to federal income taxes

Question 28

What are some of the medical expenses that are qualified for HSA

Answer 28

1. Deductibles
2. Dental services
3. Vision care
4. Prescription drugs
5. Co pays
6. Psychiatric treatments

Question 29

What happens if there is a withdrawal for a non qualified expense

Answer 29

1. Income tax will occur on the amount spent

Question 30

What happens to the unused contributions for a HSA

Answer 30

1. They can be rolled over to the following yea r
   *an alternative is a flexible savings account, but they dont roll over to the following year

Question 31

Who would benefit from a high deductible health plan (HDHP)

Answer 31

1. For younger, healthier people who dont expect to need healthcare coverage
2. Or wealth individuals and families who can afford to pay the high deductible out of pocket and want benefits of an HSA

Question 32

What does a higher deductible allow for? (HDHP)

Answer 32

1. For lower insurance premiums thus coverage more affordable
   *but comes with a annal catastrophic limit on out of pocket expenses
   I: $7,500 individually
   F: $15,00
   *once the out of pocket is reached the plan will pay for 100% of expenses in network

Question 33

What is a Point of Service Plan (POS)

Answer 33

1. Represents a small share of health insurance market
2. Combines features of the two most common health insurance plans
   *HMO aspect
   *PPO aspect

Question 34

What is HMO aspect

Answer 34

Policy holder chooses an in networkPCP and gets referrals from doctor if need to see specialist

Question 35

What is PPO aspect

Answer 35

Provides out of network services, but have to pay more r

Question 36

What do the Point of Service Plans (POS) cover

Answer 36

1. Have lower costs, but list of providers are limited in scope
2. Premiums fall between lower premiums offered by HMO and higher premiums of PPO
   *middle of the road (POS 50% cheaper than PPOs, premiums can cost 50% more than HMOs)
3. Patient must file all paperwork if visit an out of network provider
4. Reduce in network copayments
5. Often non deductibles for in-network services
6. Nationwide coverage

Question 37

What are the components of out of pocket payment

Answer 37

1. Cash payment for care if uninsured
2. Expense not reimbursed even if have insurance

Question 38

What is COBRA

Answer 38

1. If someone loses a job, have hours reduced, death of employee, divorce or legal separation some may be eligible to continue employers health insurance plan under COBRA
   *provides continuing group health insurance coverage for some employees and their families after job loss

Question 39

How does COBRA work

Answer 39

1. An employer must offer private sector insurance and have at least 20 employees to offer COBRA
2. Coverage lasts 18 months but can extend to 36
3. Employees must pay the fully cost of insurance plus small administrative premium
   *expensive

Question 40

What are the advantages of COBRA

Answer 40

1. May still be less expensive than buying an individual health plan
2. Coverage doesnt change
3. Available to full time and some part time employees
4. Given 60 days to decide whether to accept or decline

Question 41

What are the disadvantages of COBRA

Answer 41

1. Isn’t free
2. Pay both their share and the share the employer previously paid
3. If the company doesnt offer group health benefits then they are exempt from offering COBRA