RMIN 4000 EDMUNDS EXAM 3
what are some major defects in the US healthcare system - ANSWERS-rising
healthcare expenditures, large number of uninsured, considerable waste and
inefficiency, and harmful insurer practices
Affordable Care Act (ACA) - ANSWERS-insurers cannot deny coverage due to
preexisting conditions, insurers may only rate on a few variables, buy health
insurance or pay penalty (been repealed), firms with 50+ employees must provide
HI, insurers pay 85% of premiums in claims
covered benefits in health insurance - ANSWERS-inpatient hospitalization,
treatment and emergency rooms, physicians, surgery, therapists,
preventative/wellness like flu shots and screenings, and prescribed drugs
typical exclusions in medical policies - ANSWERS-cosmetic surgery, dental, hearing
aides, long term, eye and foot care, and weight loss programs
copayment - ANSWERS-a flat amount the insured must pay for certain benefits,
such as an office visit or generic drug (does not count towards annual deductible)
calendar-year deductible - ANSWERS-an aggregate deductible that must be
satisfied during the calendar year (amount insured is responsible for in total
before insurer pays anything)
,coinsurance - ANSWERS-the percentage of the bill in excess of the deductible,
which the insured must pay out-of-pocket up to some maximum annual dollar
limit; usually 20-30% and helps prevent overutilizing plan benefits
Out-of-Pocket (OOP) Maximum Limit - ANSWERS-the most the insured will have
to pay out-of-pocket in a calendar year. After the out-of-pocket limit is met, the
insurer pays 100% of all eligible expenses. Also called a stop-loss limit.
largest US healthcare insurers - ANSWERS-UnitedHealthcare Group, Anthem Blue
Cross, Aetna, Humana, and Centene
what are the percentages of those covered under individual medical insurance
compared to group - ANSWERS-12% for individual and 88% for group plans
individual medical expense insurance - ANSWERS-protects an individual or family
for covered medical expenses because of sickness or injury (important for
providing to those who are not able to purchase group insurance through their
employer)
Group Medical Expense Insurance - ANSWERS-an employee benefit that pays the
cost of hospital care, physicians' and surgeons' fees, and related medical expenses
(usually provided through a managed care plan)
Managed Care Plans - ANSWERS-Medical expense plans that provide covered
services to members in a cost-effective manner. choice of physicians and hospitals
may be limited (HMO, PPO, and POS)
, health maintenance organization (HMO) - ANSWERS--System that provides
healthcare to its members on a prepaid basis in a particular area. Negotiates
rates/agreements with hospitals and physicians to provide medical services. May
own hospitals and employ physicians. Choice of providers (doctors/hospitals) is
limited.
structure of a HMO plan - ANSWERS-1. Employee enrolls in HMO plan.
2. Employee selects Primary Care Physician (PCP) from the HMO's network of
doctors.
3. PCP acts as a "gatekeeper." You must receive a referral from the PCP to see a
specialist.
how do HMO plans pay - ANSWERS-they do not pay on an FFS. instead, physicians
and medical groups are paid a fixed annual amount for each plan member
regardless of the frequency or type of service required
Advantages of HMO - ANSWERS-although premiums are high, annual costs may
be lower because cost-sharing is lower (coinsurance, deductibles) and broad care;
usually good communication between providers
disadvantages of HMO - ANSWERS-little to no out of network coverage, must get
referrals through PCP, if you join an HMO, you'll likely have to change doctors
Preferred Provider Organization (PPO) - ANSWERS-plan that contracts with
healthcare providers to provide certain medical services at discounted fees; plan
what are some major defects in the US healthcare system - ANSWERS-rising
healthcare expenditures, large number of uninsured, considerable waste and
inefficiency, and harmful insurer practices
Affordable Care Act (ACA) - ANSWERS-insurers cannot deny coverage due to
preexisting conditions, insurers may only rate on a few variables, buy health
insurance or pay penalty (been repealed), firms with 50+ employees must provide
HI, insurers pay 85% of premiums in claims
covered benefits in health insurance - ANSWERS-inpatient hospitalization,
treatment and emergency rooms, physicians, surgery, therapists,
preventative/wellness like flu shots and screenings, and prescribed drugs
typical exclusions in medical policies - ANSWERS-cosmetic surgery, dental, hearing
aides, long term, eye and foot care, and weight loss programs
copayment - ANSWERS-a flat amount the insured must pay for certain benefits,
such as an office visit or generic drug (does not count towards annual deductible)
calendar-year deductible - ANSWERS-an aggregate deductible that must be
satisfied during the calendar year (amount insured is responsible for in total
before insurer pays anything)
,coinsurance - ANSWERS-the percentage of the bill in excess of the deductible,
which the insured must pay out-of-pocket up to some maximum annual dollar
limit; usually 20-30% and helps prevent overutilizing plan benefits
Out-of-Pocket (OOP) Maximum Limit - ANSWERS-the most the insured will have
to pay out-of-pocket in a calendar year. After the out-of-pocket limit is met, the
insurer pays 100% of all eligible expenses. Also called a stop-loss limit.
largest US healthcare insurers - ANSWERS-UnitedHealthcare Group, Anthem Blue
Cross, Aetna, Humana, and Centene
what are the percentages of those covered under individual medical insurance
compared to group - ANSWERS-12% for individual and 88% for group plans
individual medical expense insurance - ANSWERS-protects an individual or family
for covered medical expenses because of sickness or injury (important for
providing to those who are not able to purchase group insurance through their
employer)
Group Medical Expense Insurance - ANSWERS-an employee benefit that pays the
cost of hospital care, physicians' and surgeons' fees, and related medical expenses
(usually provided through a managed care plan)
Managed Care Plans - ANSWERS-Medical expense plans that provide covered
services to members in a cost-effective manner. choice of physicians and hospitals
may be limited (HMO, PPO, and POS)
, health maintenance organization (HMO) - ANSWERS--System that provides
healthcare to its members on a prepaid basis in a particular area. Negotiates
rates/agreements with hospitals and physicians to provide medical services. May
own hospitals and employ physicians. Choice of providers (doctors/hospitals) is
limited.
structure of a HMO plan - ANSWERS-1. Employee enrolls in HMO plan.
2. Employee selects Primary Care Physician (PCP) from the HMO's network of
doctors.
3. PCP acts as a "gatekeeper." You must receive a referral from the PCP to see a
specialist.
how do HMO plans pay - ANSWERS-they do not pay on an FFS. instead, physicians
and medical groups are paid a fixed annual amount for each plan member
regardless of the frequency or type of service required
Advantages of HMO - ANSWERS-although premiums are high, annual costs may
be lower because cost-sharing is lower (coinsurance, deductibles) and broad care;
usually good communication between providers
disadvantages of HMO - ANSWERS-little to no out of network coverage, must get
referrals through PCP, if you join an HMO, you'll likely have to change doctors
Preferred Provider Organization (PPO) - ANSWERS-plan that contracts with
healthcare providers to provide certain medical services at discounted fees; plan
