AHIP - FINAL EXAM
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1. Insurer vs Insured - insurer is a company that provides plan
- insured are the people that buy into the plan
2. Group health in- Health coverage provided by employers to members of a group.
surance
3. Group health in- You can choose among several or just one depending on your employer
surance - types of * dental, vision, medical benefits, managed care, fee-for-service insurance
coverage - 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
4. Premium a subsidy that reduces the amount that consumers must pay
tax-credit * tax credit that will lower monthly premium based on income and household
info
* advanced premium tax-credit (aptc)
5. self employed can deduct health insurance premiums from their federal taxable income -
workers important tax savings
6. contracts/health between insurer and insured
insurance policy - consideration: specifically termed agreement w/ promise to do something
in return for a valuable benefit (employer/insured premium payments to the
insurer)
7. Covered services insurance policy will clearly state their covered services and their exlusions
- proactive, preventative, and reactive services
8. cost-sharing
, AHIP - FINAL EXAM
Study online at https://quizlet.com/_fc5aej
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
9. Deductible/coin- Money paid out of pocket before insurance covers the remaining costs.
surance
% of medical bill that insured pays out of pocket
10. copay a fixed fee you pay for specific medical services
11. government federal and state gov
sponsored plans * medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
12. employer spon- - employer determines coverage
sored plans - company's HR dept answers employee questions
13. excluded services services not covered in a medical insurance contract like experimental or
non-contracted providers, elective or cosmetic surgery
14. Health Care Phi- * good quality = cost effective
losophy - 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
15. cost: limited provider networks, inventing new ways to pay physicians, requiring
referrals for specialty care
, AHIP - FINAL EXAM
Study online at https://quizlet.com/_fc5aej
managed care im-
proves cost/ac- quality: credentialing providers, evidence-based medical policies, grading
cess/quality 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
16. annual increase in - result from consumer/government limitations placed on managed care
premiums - other factors: higher provider fees, increased use of tech in delivery of care,
health care fraud and other admin costs
17. Provider network * 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
addressing population health issues - focus network on certain population issues
such as obesity
- providers do this w/ communication or w/ action/outcome based payment
incentives
18. 4 most common 1) clinical quality
functions pre- 2) utilization management
formed by health 3) population health management
4) pharmacy benefit
Study online at https://quizlet.com/_fc5aej
1. Insurer vs Insured - insurer is a company that provides plan
- insured are the people that buy into the plan
2. Group health in- Health coverage provided by employers to members of a group.
surance
3. Group health in- You can choose among several or just one depending on your employer
surance - types of * dental, vision, medical benefits, managed care, fee-for-service insurance
coverage - 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
4. Premium a subsidy that reduces the amount that consumers must pay
tax-credit * tax credit that will lower monthly premium based on income and household
info
* advanced premium tax-credit (aptc)
5. self employed can deduct health insurance premiums from their federal taxable income -
workers important tax savings
6. contracts/health between insurer and insured
insurance policy - consideration: specifically termed agreement w/ promise to do something
in return for a valuable benefit (employer/insured premium payments to the
insurer)
7. Covered services insurance policy will clearly state their covered services and their exlusions
- proactive, preventative, and reactive services
8. cost-sharing
, AHIP - FINAL EXAM
Study online at https://quizlet.com/_fc5aej
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
9. Deductible/coin- Money paid out of pocket before insurance covers the remaining costs.
surance
% of medical bill that insured pays out of pocket
10. copay a fixed fee you pay for specific medical services
11. government federal and state gov
sponsored plans * medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
12. employer spon- - employer determines coverage
sored plans - company's HR dept answers employee questions
13. excluded services services not covered in a medical insurance contract like experimental or
non-contracted providers, elective or cosmetic surgery
14. Health Care Phi- * good quality = cost effective
losophy - 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
15. cost: limited provider networks, inventing new ways to pay physicians, requiring
referrals for specialty care
, AHIP - FINAL EXAM
Study online at https://quizlet.com/_fc5aej
managed care im-
proves cost/ac- quality: credentialing providers, evidence-based medical policies, grading
cess/quality 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
16. annual increase in - result from consumer/government limitations placed on managed care
premiums - other factors: higher provider fees, increased use of tech in delivery of care,
health care fraud and other admin costs
17. Provider network * 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
addressing population health issues - focus network on certain population issues
such as obesity
- providers do this w/ communication or w/ action/outcome based payment
incentives
18. 4 most common 1) clinical quality
functions pre- 2) utilization management
formed by health 3) population health management
4) pharmacy benefit
