AHIP FINAL EXAM QUESTIONS WITH
ANSWERS
1. Insurer vs Insured: - insurer is a company that provides plan
- insured are the people that buy into the plan
2. Group health insurance: Health coverage provided by employers
to members of a group.
3. Group health insurance - types of coverage: 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
4. Premium tax-credit: 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)
5. Self employed workers: can deduct health insurance premiums from their
federal taxable income - important tax savings
6. Contracts/health insurance policy: 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)
7. Covered services: insurance policy will clearly state their covered services and
their exlusions
- proactive, preventative, and reactive services
8. Cost-sharing: 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/coinsurance: Money paid out of pocket before insurance covers
the remaining costs.
% of medical bill that insured pays out of pocket
10. Copay: a fixed fee you pay for specific medical services
11. Government sponsored plans: federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney
problems - medicaid --> low-income individuals
12. Employer sponsored plans: - employer determines coverage
- 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 Philosophy: * 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
15. Managed care improves cost/access/quality: 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
16. Annual increase in premiums: - 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
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
ANSWERS
1. Insurer vs Insured: - insurer is a company that provides plan
- insured are the people that buy into the plan
2. Group health insurance: Health coverage provided by employers
to members of a group.
3. Group health insurance - types of coverage: 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
4. Premium tax-credit: 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)
5. Self employed workers: can deduct health insurance premiums from their
federal taxable income - important tax savings
6. Contracts/health insurance policy: 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)
7. Covered services: insurance policy will clearly state their covered services and
their exlusions
- proactive, preventative, and reactive services
8. Cost-sharing: 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/coinsurance: Money paid out of pocket before insurance covers
the remaining costs.
% of medical bill that insured pays out of pocket
10. Copay: a fixed fee you pay for specific medical services
11. Government sponsored plans: federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney
problems - medicaid --> low-income individuals
12. Employer sponsored plans: - employer determines coverage
- 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 Philosophy: * 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
15. Managed care improves cost/access/quality: 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
16. Annual increase in premiums: - 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
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
