Unit 2 Financing Health Care Flashcards
Who pays for, or finances, health care services?
the people (through taxes and private health insurance companies)
Health insurance companies do not finance health care. What do they do?
They offer policies that assume the risk for health care costs.
In the third-party payer system there are 3 players. Who make up the first, second, and third parties?
- individual seeking health care
- the provider of health care
- public and private health insurers
Who pays for Health Insurance Policies? List the 3 possibilities:
- individual: out of pocket expenses
- employer: offers health insurance as a benefit
- government: federal = medicare, federal/state = medicaid and Children’s health insurance program, US department pf defense military health system
Health Insurance Benefit Plans are based on:
*_____________ of services covered
*_____________ of services covered
*_____________ providers
*_____________ providers
*_____________: deductibles, coinsurance, co-payments, out of pocket maximum
Define the following:
*Premium-
*Deductible-
*Coinsurance-
*Co-payment-
*Out of Pocket Maximum-
*Premium- amount you pay for health insurance per month
*Deductible- the amount you pay for covered health care services before the insurance plan will start to pay for health care services (starts over each year)
*Coinsurance- percentage of cost of covered health care services you pay after the deductible has been met
*Co-payment- predetermined flat rate you pay for health care services at the time of care
*Out of Pocket Maximum- most you will have to pay in one year out of pocket for your health care (health plan covers 100% after this has been met)
Answer the question to the practice case: Peter is covered by a health insurance policy that has a $1000 deductible, 80/20 coinsurance, $20 copay for routine visits, $40 copay for specialty (PT) visits, and an out-of-pocket max for in-network providers of $5000.
He saw his PCP for back pain on January 10th. That visit cost $100. Who referred him to PT.
The in-network OT treats him for 12 session and each visit is $100 for 1 hour of therapy.
How much money will Peter have to pay for all of his medical care?
PCP visit and 9 PT session = $1000
20% coinsurance for 3 PT session = $60
$40 copay for 3 PT session = $120
total = $1180
What is the Centers for Medicare and Medicaid Services (CMS)? What entitlement programs does it offer?
-a direct health insurance business that administers health entitlement programs
-Medicare, Medicaid, CHIP and health insurance portability standards
Who qualifies for Medicare entitlement programs?
-65 years or older
-persons with end-stage renal disease
-any disabled and entitled to social security benefits
What health care services are covered under:
*Medicare Part A
*Medicare Part B
*Medicare Part D
*Medicare Part C
*Medicare Part A: hospital insurance that provides mandatory coverage for inpatient hospital care; includes acute care, LTACH, inpatient rehab, SNF, certain home health services and hospice care; funded by FICA and general federal revenues
*Medicare Part B: supplementary medical insurance, voluntary program available for purchase to those that qualify for part A; covers physician services, outpatient hospital services, select home health services, medical equipment and supplies, and other health services (PT); funded by beneficiary premium payments matched by general federal revenues
*Medicare Part D: voluntary program for Medicare beneficiaries; subsidizes the cost of prescription drugs
*Medicare Part C: Medicare advantage plans; optional health plan; plans approved by Medicare that beneficiaries can purchase; offered by private insurance companies that contract with Medicare to cover Part A and B benefits, and usually D.
What is Medicaid, who funds it, and do all Medicaid programs offer the same services?
-a health insurance program for the indigent population
-funded jointly by state and federal governments
-state creates and manages but must adhere to certain federal guidelines
What is the Children’s Health Insurance Program?
state and federal partnership that targets uninsured children and pregnant women in families with incomes too high to be eligible for most state Medicaid programs, but too low to afford private insurance
Why are the uninsured and underinsured a public health issue?
-may have to choose between cost of food or medical care
-these people are less likely to seek needed medical care
-may not follow instructions for care because they cannot afford to do so
-can turn a minor manageable health problem into a more serious and expensive chronic illness
Is access to healthcare an issue for only the uninsured?
no, it affects everybody
For each of the provisions under the ACA, write one sentence on the purpose of the provision. See Chapter 4 in Dr. Page’s book.
1.Title I: Quality, Affordable Healthcare for All Americans
2.Title II: The Role of Public Programs
3.Title III: Improving the Quality and Efficiency of Healthcare
4.Title IV: Prevention of Chronic Disease and Improving Public Health
5.Title V: Healthcare Workforce
6.Title VI: Transparency and Program Integrity
7.Title VII: Improving Access to Innovative Medical Therapies
8.Title VIII: Community Living Assistance Services and Supports Act
9.Title IX: Revenue Provisions
10.Title X: Strengthening Quality, Affordable Care
11.Essential Health Benefits
