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Flashcards in 4) Insurance Concepts Deck (42)
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1
Q

Classify coverage exclusion for the following conditions:

  • Cancer
  • HIV/AIDS
  • DM
  • MS
  • CVA
  • Pregnancy
A

Always Denied

2
Q

What are some qualities of Medicaid?

A
  • Pays a lot of money towards long-term care
  • Almost half of enrollees are kids, but the majority of money goes towards ____ care
  • If you’re above the federal poverty line, you can’t qualify unless you accept the expansion
  • PT coverage isn’t a mandated requirement in every state
  • Serves as its own high-risk pool
  • Most money is spent in the northeast
3
Q

What are the risk options for insurance

A
  • Guaranteed Issue
  • Experience Rating
  • Community Rating
4
Q

Guaranteed Issue

A

Requirement that insurance can be sold to an individual, regardless of their health status

5
Q

Community Rating

A

Risk is spread among members, premiums are set w/out regard to health status, and determined by utilization experience or a larger community

  • Everybody is equal and pays the same
6
Q

Classify coverage exclusion for the following conditions:

  • Acne
  • Hay Fever
A

Sometimes Denied

7
Q

Who can benefit from entitlement programs?

A
  • Those who completed service to the country
  • At-risk peeps who can’t access employer-based health care (Elderly or Poor)
8
Q

Balance Billing

A

Provider bills pt for the difference between what the amount that insurance covered and the remaining amount

  • Cannot do this when you sign a contract
9
Q

Risk

A

The potential for a substantial financial loss from an event where the probability of loss is relatively small

10
Q

What does cost of insurance depend on?

A
  • Who’s being covered → Age, Gender, Health Status
  • What’s covered → Benefits, Cost Sharing/Deductible, Terms, Pre-existing conditions
  • Insurer Profits & Administration
  • Subsidies
  • Underlying health care costs; Inflation
11
Q

What is adverse selection and what causes it?

A

People who have a higher chance of needing health care are more likely than those who have a lower chance to get health insurance

  • Occurs when less healthy individuals are disproportionately enrolled in a risk pool
12
Q

State Children’s Health Insurance Program (sCHIP)

A

Partnership between the federal govt and states created during the Balanced Budget Act to provide health insurance coverage for targeted low-income kids <19y/o who are not eligible for Medicaid

  • Based on the belief that if kids are given a good start in life, they’ll see the importance of being healthy
13
Q

What are the Fundamental Principles of Insurance?

A

1) Risk is unpredictable to insured
2) Risk can be predicted w/some accuracy for a certain group/population
3) Pooling of resources transfers risk from individuals to a group of individuals
4) All members of the insured group share the actual losses on some equitable basis

14
Q

Who are the key players in insurance?

A
  • Pt’s/Consumers
  • Providers
  • Insurance companies
  • Employers
15
Q

Pre-Existing Condition Exclusions

A

Denies pt coverage bc the condition will cost the insurance company too much money

16
Q

Where do most individuals over 65y/o get health insurance from? Where do the remaining non-elderly individuals get health insurance?

A
  • Medicare
  • Medicaid
  • Private (Group or Individual)
  • Uninsured
17
Q

Provider Network

A

Group of providers that have a contract w/an insurance company

  • Can create a discount for the buyer
  • Not every plan has a network
18
Q

Describe Veteran’s Coverage

A
  • For veterans and their families
  • Veterans are eligible to enroll
  • Through the US Dept of Veteran’s Affairs → Is a closed system funded by the government
  • Access to services is determined by an assigned priority level
  • Is an integrated health system
19
Q

Deductible

A

Amount a pt has to pay out-of-pocket until insurance kicks in

  • Includes copay & coinsurance
20
Q

Who can utilize military coverage?

A

Active duty, Military Personnel, and their Families

21
Q

Classify coverage exclusion for the following conditions:

  • Overweight
  • Cancer Hx
  • HTN
  • Asthma
A

Often Denied

22
Q

Who assumes risk in insurance models?

A

Insurer

23
Q

Premium

A

Monthly payment

24
Q

Where do high costs of health care come from?

A

Secondary & Tertiary Care

25
Q

COBRA

A

Federal law that states that companies with >20 full-time employees are required to give job-sponsored health insurance

  • Requires that company provide temporary continuation of coverage after a qualifying event
26
Q

How are Medicare and Medicaid different?

A
  • Coverage
  • Funding
  • Administration
27
Q

Copay

A

What pt is responsible for paying at the time of care

  • Higher for specialties to prevent overutilization
  • Still have to pay after you meet your deductible
28
Q

What can cause coverage options to change?

A
  • Loss/change of job
  • Change in family status (new widow)
  • Birthday
  • Moving
  • Change in health status
29
Q

True or False: Health insurance is designed to spread the risk

A

True

30
Q

TRICARE

A

Managed health care plans that have a lot of rules

31
Q

Why is health insurance different from other types of insurance?

A
  • Its not required but still 100% a necessity
  • Everybody has health
  • People have chronic problems
  • No pooled payments
32
Q

What are the problems w/military and Veteran’s Coverage?

A
  • They’re 2 different systems → Transitioning btwn active duty to veteran is not seamless
  • There’s issues w/sharing data
33
Q

What is the purpose of health insurance?

A

To pool many people together into groups to share (spread) the costs generated by this small number of people

34
Q

Indian Health Services

A

Through Indian health care provider

35
Q

Experience Rating

A

Premiums that are determined by the medical group’s own medical claims experience

36
Q

Federal Employee Health Benefits Program (FEHBP)

A

Health plan for current and retired govt employees as well as their families

37
Q

Coinsurance

A

Pt is responsible for a certain percent of the charges, no matter what

38
Q

What do medical underwriting, pre-existing condition exclusions, and risk-based rating have in common?

A

They’re ways of dealing w/adverse selection

39
Q

Risk-Based Rating

A

Charging premiums based on a pt’s probable health care needs

40
Q

Medical Underwriting

A

Process that insurers use to evaluate the risk of an applicant → Figures out a pt’s risk in comparison to other pt’s and then uses this to determine the pt’s costs

41
Q

True or False: COBRA does not require that a company to keep paying for coverage after a qualifying event, but it does still require access for the pt

A

True

42
Q

Out-Of-Pocket Maximum

A

Maximum amount a pt will be required to pay out of pocket annually