Healthcare economics
What are the 4 most common types of managed care plans?
1. Health Maintenance Organizations 2. Preferred Provider Organizations 3. Exclusive Provider Organizations 4. Point of Service
d. Out of pocket
A medical bill that must be paid by the pt.
What is co-insurance?
A percentage paid to the doctor after your deductible has been paid
What services are provided by part A and part B Medicare?
A(Hospital Care) Hospitalization, Skilled nursing facilities, Home healthcare, Hospice care, Long-term care facilities B(Out pt Services) Medical expenses, Preventive care
What is Medicare? Who qualifies? How much of a persons health expenses does it pay?
Administered by the federal gov, is an entitlement program. Individuals 65 or older, Disabled individuals receiving Social Security Disability Benefits, Individuals with end-stage renal disease. will cover 80% of all expenses
c. Co-payment
An amount paid by the pt for a certain service
What services are typically included with Medicaid?
Inpatient and outpatient hospital services, Prenatal care, Child vaccines, Pediatric services, Physician services, Diagnostic testing/X-rays, Rehab/physical therapy, Prescription drug coverage, Home healthcare
How does a point of service (POS) plan work? What is an advantage and a disadvantage?
Your required to select a primary care provider & will need a referral from your PCP to see specialists.
The ACA requires that __ __ __ __ cover 10 essential health benefits.
health insurance companies to
What is TRICARE?
health insurance program of the Military Health System
How does an Preferred Provider Organization work? What are the benefits?
insured person can get medical care from both in-network and out-of-network providers. may receive treatment from a non-network physician
e. HIPAA
law protects pt health info & confidentiality
How does an exclusive provider organization work? What are the benefits?
managed care plans where coverage for healthcare services is limited to care from providers or hospitals in the plan's network, except in the case of an emergency
To whom does the VHA provide care for today?
non-service related to low-income veterans and those with special health needs.
What are the 2 major differences between managed-care and indemnity insurance?
payment for medical services & choosing a healthcare provider
How does a health maintenance organization (HMO) work? What is an advantage and a disadvantage?
person being insured pays a monthly fee. Then medical services are provided by a network of providers that contract with the health plan.
What concept is managed care built on? What is the goal of managed-care?
promoting good health and practicing preventive medicine. The goal is to reduce the cost of medical expenses by maintaining a healthy lifestyle.
What are public health insurance programs?
the federal government finances healthcare services received by eligible groups of the population.
What is reimbursement?
when health insurance repays what the patient has paid
What percentage of the US gross national product is made from healthcare spending?
18%
What is the difference between individual and group insurance?
Individual is when a person purchases a policy & agrees to pay the entire premium for health coverage. Group is a policy purchased through association with a larger organization such as an employer
What is Medicaid? Who typically qualifies?
Is a need-based program that was designed by the federal gov. Low-income individuals/families/ pregnant women. Families with adopted/ foster children. Blind/ disabled adults. Adults/children with certain chronic or debilitating diseases. Adults/children who receive social security benefits
Give 2 examples of public health insurance programs.
Medicaid, Medicare
What is indemnity insurance?
Pt must pay for all healthcare expenses out of pocket. Then the insurance agency will reimburse the pt for the expenses.
Who is in charge of Medicaid? All states have expanded Medicaid.
State gov False
What I had heard they go away reducing the number of uninsured individuals in the US?
The Patient Protection and Affordable Care Act of 2010 (ACA)
Define the following health insurance terms: a. Premium
The amount paid to an insurance agency for a health insurance policy. often a monthly payment.
b. Deductible
The amount that must be paid by the pt before the insurance agency will begin to make payments. paid on a yearly basis
What are 2 examples of healthcare fraud?
Using someone's health information as if it were your own Billing for medical services that were not provided
