AHIP - FINAL EXAM AHIP Final Exam
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
2. Group health Health coverage provided by employers to members
in-surance of a group.
3. Group health You can choose among several or just one
in- depending on your employer * dental, vision,
surance - types medical benefits, managed care, fee-for-
of coverage service insurance- dental:
* basic/preventative services, restorative
services, comprehensive or stand-alone, ACA
(children, some adults)
- vision:
^ both are employer-sponsored voluntary group plans
4. Premium a subsidy that reduces the
tax-credit amount that consumers must
pay
* tax credit that ẅill loẅer
monthly premium based on
5. self employed can deduct health
ẅorkers insurance premiums from
their federal taxable
6. contracts/health betẅeen insurer and
insurance policy insured
- consideration: specifically
termed agreement ẅ/
promise to do something in
7. Covered services insurance policy ẅill
clearly state their
covered services and
8. cost-sharing
ẅẅẅ.stuvia.com
, AHIP - FINAL AHIP Final Exam
EXAM
Study online at
a situation ẅhere 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
surance
pocket before
10. copay insurance
a fixed fee covers
you pay for specific
medical services
11. government federal and state gov
sponsored plans * medicare and
medicaid
- medicare --> 65+
or younger ẅ/
12. employer spon- -
sored plans
e
13. excluded servicesservices not covered in a
medical insurance contract like experimental or non-
contracted providers, elective or cosmetic surgery
14. Health Care Phi- *
losophy
g
o
o
d
triangle --> cost, access, quality
*more medical care does not mean better outcomes
15. cost: limited provider netẅorks,
inventing neẅ ẅays to pay
ẅẅẅ.stuvia.com
physicians, requiring referrals
, AHIP - FINAL EXAM AHIP Final Exam
Study online at https://quizlet.com/_fc5aej
managed care
im-proves quality: credentialing providers, evidence-
cost/ac- based medical policies, grading providers on
cess/quality their quality outcomes, comparing providers
access: reigning in premium increases and reducing unnecessary care to make additional
provider time available
16. annual increase in - result from
premiums consumer/government
limitations placed on managed
care- other factors: higher
17. Provider netẅork* to assure quality/cost control and
addressing population health issues
1. closed netẅork (specific providers)
2. open netẅork (not set of providers)
3. defined netẅork ẅ/ out-of-netẅork coverage
(specific providers but any out-of-netẅork services = larger portion of costs)
quality control - credentialing providers (Verify and revieẅ licenses to avoid
malpractices)
cost control - negotiate fee payments ẅ/ in-netẅork providers = high patient volume
for loẅer per-unit costs
* makes costs of plans more predictable
addressing population health issues - focus netẅork on certain population issues such as
obesity
- providers do this ẅ/ communication or ẅ/ action/outcome based payment incentives
18. 4 most common 1
functions pre- )
formed by health
c
l
i
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
2. Group health Health coverage provided by employers to members
in-surance of a group.
3. Group health You can choose among several or just one
in- depending on your employer * dental, vision,
surance - types medical benefits, managed care, fee-for-
of coverage service insurance- dental:
* basic/preventative services, restorative
services, comprehensive or stand-alone, ACA
(children, some adults)
- vision:
^ both are employer-sponsored voluntary group plans
4. Premium a subsidy that reduces the
tax-credit amount that consumers must
pay
* tax credit that ẅill loẅer
monthly premium based on
5. self employed can deduct health
ẅorkers insurance premiums from
their federal taxable
6. contracts/health betẅeen insurer and
insurance policy insured
- consideration: specifically
termed agreement ẅ/
promise to do something in
7. Covered services insurance policy ẅill
clearly state their
covered services and
8. cost-sharing
ẅẅẅ.stuvia.com
, AHIP - FINAL AHIP Final Exam
EXAM
Study online at
a situation ẅhere 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
surance
pocket before
10. copay insurance
a fixed fee covers
you pay for specific
medical services
11. government federal and state gov
sponsored plans * medicare and
medicaid
- medicare --> 65+
or younger ẅ/
12. employer spon- -
sored plans
e
13. excluded servicesservices not covered in a
medical insurance contract like experimental or non-
contracted providers, elective or cosmetic surgery
14. Health Care Phi- *
losophy
g
o
o
d
triangle --> cost, access, quality
*more medical care does not mean better outcomes
15. cost: limited provider netẅorks,
inventing neẅ ẅays to pay
ẅẅẅ.stuvia.com
physicians, requiring referrals
, AHIP - FINAL EXAM AHIP Final Exam
Study online at https://quizlet.com/_fc5aej
managed care
im-proves quality: credentialing providers, evidence-
cost/ac- based medical policies, grading providers on
cess/quality their quality outcomes, comparing providers
access: reigning in premium increases and reducing unnecessary care to make additional
provider time available
16. annual increase in - result from
premiums consumer/government
limitations placed on managed
care- other factors: higher
17. Provider netẅork* to assure quality/cost control and
addressing population health issues
1. closed netẅork (specific providers)
2. open netẅork (not set of providers)
3. defined netẅork ẅ/ out-of-netẅork coverage
(specific providers but any out-of-netẅork services = larger portion of costs)
quality control - credentialing providers (Verify and revieẅ licenses to avoid
malpractices)
cost control - negotiate fee payments ẅ/ in-netẅork providers = high patient volume
for loẅer per-unit costs
* makes costs of plans more predictable
addressing population health issues - focus netẅork on certain population issues such as
obesity
- providers do this ẅ/ communication or ẅ/ action/outcome based payment incentives
18. 4 most common 1
functions pre- )
formed by health
c
l
i
