AHIP - FINAL EXAM WITH CORRECT ANSWERS
Insurer vs Insured -correct ans-- insurer is a company that provides plan
- insured are the people that buy into the plan
Group health insurance -correct ans-Health coverage provided by employers to members of a group.
Group health insurance - types of coverage -correct ans-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 -correct ans-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 -correct ans-can deduct health insurance premiums from their federal taxable
income - important tax savings
contracts/health insurance policy -correct ans-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 -correct ans-insurance policy will clearly state their covered services and their exlusions
,- proactive, preventative, and reactive services
cost-sharing -correct ans-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 -correct ans-Money paid out of pocket before insurance covers the remaining
costs.
% of medical bill that insured pays out of pocket
copay -correct ans-a fixed fee you pay for specific medical services
government sponsored plans -correct ans-federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
employer sponsored plans -correct ans-- employer determines coverage
- company's HR dept answers employee questions
excluded services -correct ans-services not covered in a medical insurance contract like experimental or
non-contracted providers, elective or cosmetic surgery
Health Care Philosophy -correct ans-* 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 -correct ans-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 -correct ans-- 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
Provider network -correct ans-* to assure quality/cost control and addressing population health issues
1. closed network (specific providers)
2. open network (not set of providers)
3. defined network w/ out-of-network coverage
(specific providers but any out-of-network services = larger portion of costs)
quality control - credentialing providers (Verify and review licenses to avoid malpractices)
cost control - negotiate fee payments w/ in-network providers = high patient volume for lower per-unit
costs
* makes costs of plans more predictable
Insurer vs Insured -correct ans-- insurer is a company that provides plan
- insured are the people that buy into the plan
Group health insurance -correct ans-Health coverage provided by employers to members of a group.
Group health insurance - types of coverage -correct ans-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 -correct ans-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 -correct ans-can deduct health insurance premiums from their federal taxable
income - important tax savings
contracts/health insurance policy -correct ans-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 -correct ans-insurance policy will clearly state their covered services and their exlusions
,- proactive, preventative, and reactive services
cost-sharing -correct ans-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 -correct ans-Money paid out of pocket before insurance covers the remaining
costs.
% of medical bill that insured pays out of pocket
copay -correct ans-a fixed fee you pay for specific medical services
government sponsored plans -correct ans-federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
employer sponsored plans -correct ans-- employer determines coverage
- company's HR dept answers employee questions
excluded services -correct ans-services not covered in a medical insurance contract like experimental or
non-contracted providers, elective or cosmetic surgery
Health Care Philosophy -correct ans-* 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 -correct ans-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 -correct ans-- 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
Provider network -correct ans-* to assure quality/cost control and addressing population health issues
1. closed network (specific providers)
2. open network (not set of providers)
3. defined network w/ out-of-network coverage
(specific providers but any out-of-network services = larger portion of costs)
quality control - credentialing providers (Verify and review licenses to avoid malpractices)
cost control - negotiate fee payments w/ in-network providers = high patient volume for lower per-unit
costs
* makes costs of plans more predictable
