STUDY GUIDE FOR AHIP EXAM -2025
Insurer vs Insured - answers✔✔- insurer is a company that provides plan
- insured are the people that buy into the plan
Group health insurance - answers✔✔Health coverage provided by employers to members of a
group.
Group health insurance - types of coverage - answers✔✔You can choose among several or just
one depending on your employer
* dental, vision, medical benefits, managed care, fee-for-service insurance
- dental:
* basic/preventative services, restorative services, comprehensive or stand-alone, ACA
(children, some adults)
- vision:
* basic exams and prescription glasses, ACA (children, some adults)
^ both are employer-sponsored voluntary group plans
Premium tax-credit - answers✔✔a subsidy that reduces the amount that consumers must pay
* tax credit that will lower monthly premium based on income and household info
* advanced premium tax-credit (aptc)
self employed workers - answers✔✔can deduct health insurance premiums from their federal
taxable income - important tax savings
,contracts/health insurance policy - answers✔✔between insurer and insured
- consideration: specifically termed agreement w/ promise to do something in return for a
valuable benefit (employer/insured premium payments to the insurer)
Covered services - answers✔✔insurance policy will clearly state their covered services and their
exlusions
- proactive, preventative, and reactive services
cost-sharing - answers✔✔a situation where insured individuals pay a portion of the healthcare
costs, such as deductibles, coinsurance or co-payments
- insured is reimbursed for some but not all of the costs
- reimbursement depends on policy
Deductible/coinsurance - answers✔✔Money paid out of pocket before insurance covers the
remaining costs.
% of medical bill that insured pays out of pocket
copay - answers✔✔a fixed fee you pay for specific medical services
government sponsored plans - answers✔✔federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
employer sponsored plans - answers✔✔- employer determines coverage
, - company's HR dept answers employee questions
excluded services - answers✔✔services not covered in a medical insurance contract like
experimental or non-contracted providers, elective or cosmetic surgery
Health Care Philosophy - answers✔✔* good quality = cost effective
- more expensive does not mean good healthcare
* cost vs care balance
- good benefits priced appropriately
* less cost, more quality
triangle --> cost, access, quality
*more medical care does not mean better outcomes
managed care improves cost/access/quality - answers✔✔cost: limited provider networks,
inventing new ways to pay physicians, requiring referrals for specialty care
quality: credentialing providers, evidence-based medical policies, grading providers on their
quality outcomes, comparing providers to their peers
access: reigning in premium increases and reducing unnecessary care to make additional
provider time available
annual increase in premiums - answers✔✔- result from consumer/government limitations
placed on managed care
- other factors: higher provider fees, increased use of tech in delivery of care, health care fraud
and other admin costs
Insurer vs Insured - answers✔✔- insurer is a company that provides plan
- insured are the people that buy into the plan
Group health insurance - answers✔✔Health coverage provided by employers to members of a
group.
Group health insurance - types of coverage - answers✔✔You can choose among several or just
one depending on your employer
* dental, vision, medical benefits, managed care, fee-for-service insurance
- dental:
* basic/preventative services, restorative services, comprehensive or stand-alone, ACA
(children, some adults)
- vision:
* basic exams and prescription glasses, ACA (children, some adults)
^ both are employer-sponsored voluntary group plans
Premium tax-credit - answers✔✔a subsidy that reduces the amount that consumers must pay
* tax credit that will lower monthly premium based on income and household info
* advanced premium tax-credit (aptc)
self employed workers - answers✔✔can deduct health insurance premiums from their federal
taxable income - important tax savings
,contracts/health insurance policy - answers✔✔between insurer and insured
- consideration: specifically termed agreement w/ promise to do something in return for a
valuable benefit (employer/insured premium payments to the insurer)
Covered services - answers✔✔insurance policy will clearly state their covered services and their
exlusions
- proactive, preventative, and reactive services
cost-sharing - answers✔✔a situation where insured individuals pay a portion of the healthcare
costs, such as deductibles, coinsurance or co-payments
- insured is reimbursed for some but not all of the costs
- reimbursement depends on policy
Deductible/coinsurance - answers✔✔Money paid out of pocket before insurance covers the
remaining costs.
% of medical bill that insured pays out of pocket
copay - answers✔✔a fixed fee you pay for specific medical services
government sponsored plans - answers✔✔federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
employer sponsored plans - answers✔✔- employer determines coverage
, - company's HR dept answers employee questions
excluded services - answers✔✔services not covered in a medical insurance contract like
experimental or non-contracted providers, elective or cosmetic surgery
Health Care Philosophy - answers✔✔* good quality = cost effective
- more expensive does not mean good healthcare
* cost vs care balance
- good benefits priced appropriately
* less cost, more quality
triangle --> cost, access, quality
*more medical care does not mean better outcomes
managed care improves cost/access/quality - answers✔✔cost: limited provider networks,
inventing new ways to pay physicians, requiring referrals for specialty care
quality: credentialing providers, evidence-based medical policies, grading providers on their
quality outcomes, comparing providers to their peers
access: reigning in premium increases and reducing unnecessary care to make additional
provider time available
annual increase in premiums - answers✔✔- result from consumer/government limitations
placed on managed care
- other factors: higher provider fees, increased use of tech in delivery of care, health care fraud
and other admin costs
