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Things I Should Know > U.S. Health Insurance Terms > Flashcards

U.S. Health Insurance Terms Flashcards

1
Q

U.S. Health Insurance

Name the term that meets the following definition: groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated, high-quality care.

A

Accountable Care Organization (ACO)

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2
Q

U.S. Health Insurance

Name the term that meets the following definition: the person that receives any of the benefits of the insurance coverage.

A

Beneficiary

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3
Q

U.S. Health Insurance

Name the term that meets the following definition: the payment of a fee to a healthcare provider providing services to a number of people, such that the amount paid is determined by the number of total patients.

A

Capitation

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4
Q

U.S. Health Insurance

Name the term that meets the following definition: the amount a beneficiary must pay for medical care after they have met their deductible.

For instance, the insurance company may pay for 80% of an approved amount, and the patient’s __________ will be for 20%.

A

Coinsurance

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5
Q

U.S. Health Insurance

Name the term that meets the following definition: the flat fee that a beneficiary must pay each time they receive medical care.

For example, a patient may pay a $10 ______ for every doctor visit, while the insurance plan covers the rest of the cost.

A

Copayment

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6
Q

U.S. Health Insurance

Name the term that meets the following definition: the maximum amount that a health insurance plan may pay for certain healthcare services. Some health insurance policies may also have a maximum annual or lifetime coverage amount. After any of these limits are reached, then the policyholder may have to pay for all remaining costs.

A

Coverage limits

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7
Q

U.S. Health Insurance

Name the term that meets the following definition: the amount the beneficiary must pay each year before their health insurance coverage plan begins paying.

A

Deductible

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8
Q

U.S. Health Insurance

Name the term that meets the following definition: services that are not covered by the specific insurance plan. These must be clearly defined in the plan literature.

A

Exclusions / limitations

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9
Q

U.S. Health Insurance

Name the term that meets the following definition: a payment system where healthcare services are unbundled and paid for separately.

A

Fee-for-service

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10
Q

U.S. Health Insurance

Name the term that meets the following definition: an insurance provider’s list of covered drugs.

A

Formulary

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11
Q

U.S. Health Insurance

Name the term that meets the following definition: a form of managed care in which all care is received from participating providers within the network. A referral from a primary care provider needs to be obtained prior to seeing specialists.

A

Health maintenance organization (HMO)

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12
Q

U.S. Health Insurance

Name the term that meets the following definition: an account established by an employer to pay an employee’s medical expenses. Only the employer can contribute to a ___.

A

Health reimbursement account (HRA); HRA

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13
Q

U.S. Health Insurance

Name the term that meets the following definition: an account established by an employer or an individual to save money toward medical expenses on a tax-free basis.

A

Health savings account (HSA)

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14
Q

U.S. Health Insurance

Name the term that meets the following definition: a plan that provides comprehensive coverage for high-cost medical events but features a high deductible coupled with a limit on annual out-of-pocket expense.

A

High-deductible health plan (HDHP)

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15
Q

U.S. Health Insurance

Name the term that meets the following definition: insurance coverage purchased independently (as opposed to as part of a group), usually directly from an insurance company.

A

Individual health insurance

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16
Q

U.S. Health Insurance

Name the term that meets the following definition: a federal program administered by individual States to provide healthcare for certain poor and low-income individuals and families.

A

Medicaid

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17
Q

U.S. Health Insurance

Name the term that meets the following definition: a federal insurance program that provides healthcare coverage to eligible individuals aged 65 and older and certain disabled people (such as those with end-stage renal disease).

A

Medicare

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18
Q

U.S. Health Insurance

Name the term that meets the following definition: a group of physicians, hospitals, and other providers who participate in a particular managed care plan.

A

Network

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19
Q

U.S. Health Insurance

Name the term that meets the following definition: the maximum amount that an insured person can pay, after which the insurance plan pays all further covered costs. Out-of-pocket maxima may be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.

A

Out-of-pocket maxima

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20
Q

U.S. Health Insurance

Name the term that meets the following definition: a form of managed care in which insurance policyholders have more flexibility in choosing physicians and other providers than in an HMO. Both participating and nonparticipating providers may be seen, however the out-of-pocket expenses paid by the policyholder will vary.

A

Preferred provider organization (PPO)

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21
Q

U.S. Health Insurance

Name the term that meets the following definition: the amount the insurance policyholder pays to belong to a health plan. In general under employer-sponsored health insurance, the employee’s share of premiums is usually deducted from their pay.

A

Premium

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22
Q

Define the following health insurance term:

Accountable Care Organization (ACO)

A

Name the term that meets the following definition: groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated, high-quality care.

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23
Q

Define the following health insurance term:

Beneficiary

A

The person that receives any of the benefits of insurance coverage.

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24
Q

Define the following health insurance term:

Capitation

A

The payment of a fee to a healthcare provider providing services to a number of people, such that the amount paid is determined by the number of total patients.

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25
Q

Define the following health insurance term:

Coinsurance

A

The amount a beneficiary must pay for medical care after they have met their deductible. For instance, the insurance company may pay for 80% of an approved amount, and the patient’s coinsurance will be for 20%.

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26
Q

Define the following health insurance term:

Copayment

A

The flat fee that a beneficiary must pay each time they receive medical care. For example, a patient may pay a $10 copay for every doctor visit, while the insurance plan covers the rest of the cost.

27
Q

Define the following health insurance term:

Coverage limits

A

The maximum amount that a health insurance plan may pay for certain healthcare services. Some health insurance policies may also have a maximum annual or lifetime coverage amount. After any of these limits are reached, then the policyholder may have to pay for all remaining costs.

28
Q

Define the following health insurance term:

Deductible

A

The amount the beneficiary must pay each year before their health insurance coverage plan begins paying.

29
Q

Define the following health insurance term:

Exclusions / limitations

A

Services that are not covered by the specific insurance plan. These must be clearly defined in the plan literature.

30
Q

Define the following health insurance term:

Fee-for-service

A

A payment system where healthcare services are unbundled and paid for separately.

31
Q

Define the following health insurance term:

Formulary

A

An insurance provider’s list of covered drugs.

32
Q

Define the following health insurance term:

Health maintenance organization (HMO)

A

A form of managed care in which all care is received from participating providers within the network. A referral from a primary care provider needs to be obtained prior to seeing specialists.

33
Q

Define the following health insurance term:

Health reimbursement account (HRA)

A

An account established by an employer to pay an employee’s medical expenses. Only the employer can contribute to an HRA.

34
Q

Define the following health insurance term:

Health savings account (HSA)

A

An account established by an employer or an individual to save money toward medical expenses on a tax-free basis.

35
Q

Define the following health insurance term:

High-deductible health plan (HDHP)

A

A plan that provides comprehensive coverage for high-cost medical events but features a high deductible coupled with a limit on annual out-of-pocket expense.

36
Q

Define the following health insurance term:

Individual health insurance

A

Insurance coverage purchased independently (as opposed to as part of a group), usually directly from an insurance company.

37
Q

Define the following health insurance term:

Medicaid

A

A federal program administered by individual States to provide healthcare for certain poor and low-income individuals and families.

38
Q

Define the following health insurance term:

Medicare

A

A federal insurance program that provides healthcare coverage to eligible individuals aged 65 and older and certain disabled people (such as those with end-stage renal disease).

39
Q

Define the following health insurance term:

Network

A

A group of physicians, hospitals, and other providers who participate in a particular managed care plan.

40
Q

Define the following health insurance term:

Out-of-pocket maxima

A

The maximum amount that an insured person can pay, after which the insurance plan pays all further covered costs. Out-of-pocket maxima may be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.

41
Q

Define the following health insurance term:

Preferred provider organization (PPO)

A

A form of managed care in which insurance policyholders have more flexibility in choosing physicians and other providers than in an HMO. Both participating and nonparticipating providers may be seen, however the out-of-pocket expenses paid by the policyholder will vary.

42
Q

Define the following health insurance term:

Premium

A

The amount the insurance policyholder pays to belong to a health plan. In general under employer-sponsored health insurance, the employee’s share of premiums is usually deducted from their pay.

43
Q

U.S. Health Insurance

What are the two broadest categories of healthcare delivery modality (in terms of how long a person is in care)?

What defines each?

A

Inpatient (patient stays ≥ 2 midnights);

outpatient (patient doesn’t stay overnight)

44
Q

U.S. Health Insurance

Describe what percentages of U.S. hospitals are not-for-profit, for-profit, public, etc.

A
46
Q

U.S. Health Insurance

What are the two main types of hospital according to function?

A

General (teaching hospitals are in this category);

specialty (e.g. children’s, psychiatric, cardiology, etc.)

47
Q

U.S. Health Insurance

If a health system performs many different types of services (e.g. insurer, hospital owner, outpatient clinic owner, employer of physician), what type of network is it?

If a health system performs only one type of services (e.g. a system only owns a number of pediatric hospitals), what type of network is it?

A

A vertical network (e.g. Kaiser Permanente);

a horizontal network (e.g. Shriners hospitals)

48
Q

U.S. Health Insurance

A higher primary care : specialist ratio will lead to what effects?

A

More preventative medicine, better health outcomes, fewer hospital administrations, less overall cost

49
Q

U.S. Health Insurance

True/False.

There is a current (and worsening) shortage of both primary care providers and nurses in the U.S.

A

True.

50
Q

U.S. Health Insurance

What type of insurance plan involves strict regulation of which providers can be seen and which procedures are pre-authorized?

What type of insurance plan involves making deals for discounted rates with certain providers that cost the insuree less to see?

A

Health maintenance organizations (HMOs);

preferred provider organizations (PPOs)

51
Q

U.S. Health Insurance

What percentage of U.S. citizens accounts for 50% of all healthcare spending?

What healthier 50% of U.S. citizens accounts for what percentage of all healthcare spending?

A

The sickest 5%;

3%

52
Q

U.S. Health Insurance

Describe where most Americans get their insurance.

A
53
Q

U.S. Health Insurance

What percentage of Americans get their insurance through either Medicare, Medicaid, CHIP, Tricare, or the VA?

A

31%

54
Q

U.S. Health Insurance

What are the three main types of insurance plan offered by employers?

A

Preferred provider organizations (56%);

consumer-driven (e.g. health savings accounts) (20%);

health maintenance organizations (14%)

58
Q

U.S. Health Insurance

Describe Medicare Parts A - D.

A

A - inpatient costs

B - outpatient costs

C - medicare advantage plans

D - drugs

59
Q

U.S. Health Insurance

The Medicaid expansion includes what people?

A

Any U.S. citizen at ≤ 138% of the FPL

60
Q

U.S. Health Insurance

If not a fee-for-service system, what are the three criteria for how physicians can be paid?

(I.e. if not paid per service, a physician can be paid per ________)

A
  1. Paid per diagnosis (episode of illness)
  2. Paid per patient (capitation)
  3. Paid per year (salary)
61
Q

U.S. Health Insurance

What is the difficulty of pay-for-performance health systems?

A

Quality of care is difficult to measure;

different systems serve different populations (with different baseline health levels)

62
Q

U.S. Health Insurance

Describe health lobbying in terms of main players.

A
63
Q

U.S. Health Insurance

What system does Medicare use to keep inpatient costs down in relation to a new diagnosis?

How does it work?

A

Diagnosis-Related Groups (DRGs);

a flat fee is paid for the management of a new diagnosis

(the hospital gets to keep whatever isn’t used in managing the disorder)

64
Q

U.S. Health Insurance

What system does Medicare use to keep outpatient costs down in relation to a new diagnosis?

How does it work?

A

Relative Value Units (RVU);

each procedure is given a certain number of ‘points’ based on required labor, costs to the physician, and malpractice insurance

(E.g. a diagnostic colonoscopy is worth about 6 RVUs, while surgically removing part of the colon is ~40 RVUs)

65
Q

U.S. Health Insurance

What percentage of the U.S. GDP goes towards healthcare?

What are U.S. per capita healthcare expenditures?

What is this total (not per capita)?

A

17.2%

$9,000

$2.8 trillion

66
Q

U.S. Health Insurance

What percentage of Medicare spending goes towards the last year of life?

A

25%

68
Q

U.S. Health Insurance

Expanding Medicaid access so anyone could enroll (while also leaving private insurance as an option) would be an example of what type of healthcare reform?

A

Public option

69
Q

U.S. Health Insurance

Under the ACA, all insurance plans must cover which essential benefits?

A

Ambulatory, emergency, hospitalization, maternity and newborn, mental health and substance abuse, prescription drugs, laboratory, prevention and wellness, chronic disease management, rehabilitation and devices, and pediatric services

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