4) Insurance Concepts Flashcards
(42 cards)
Classify coverage exclusion for the following conditions:
- Cancer
- HIV/AIDS
- DM
- MS
- CVA
- Pregnancy
Always Denied
What are some qualities of Medicaid?
- 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
What are the risk options for insurance
- Guaranteed Issue
- Experience Rating
- Community Rating
Guaranteed Issue
Requirement that insurance can be sold to an individual, regardless of their health status
Community Rating
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
Classify coverage exclusion for the following conditions:
- Acne
- Hay Fever
Sometimes Denied
Who can benefit from entitlement programs?
- Those who completed service to the country
- At-risk peeps who can’t access employer-based health care (Elderly or Poor)
Balance Billing
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
Risk
The potential for a substantial financial loss from an event where the probability of loss is relatively small
What does cost of insurance depend on?
- 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
What is adverse selection and what causes it?
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
State Children’s Health Insurance Program (sCHIP)
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
What are the Fundamental Principles of Insurance?
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
Who are the key players in insurance?
- Pt’s/Consumers
- Providers
- Insurance companies
- Employers
Pre-Existing Condition Exclusions
Denies pt coverage bc the condition will cost the insurance company too much money
Where do most individuals over 65y/o get health insurance from? Where do the remaining non-elderly individuals get health insurance?
- Medicare
- Medicaid
- Private (Group or Individual)
- Uninsured
Provider Network
Group of providers that have a contract w/an insurance company
- Can create a discount for the buyer
- Not every plan has a network
Describe Veteran’s Coverage
- 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
Deductible
Amount a pt has to pay out-of-pocket until insurance kicks in
- Includes copay & coinsurance
Who can utilize military coverage?
Active duty, Military Personnel, and their Families
Classify coverage exclusion for the following conditions:
- Overweight
- Cancer Hx
- HTN
- Asthma
Often Denied
Who assumes risk in insurance models?
Insurer
Premium
Monthly payment
Where do high costs of health care come from?
Secondary & Tertiary Care
