Chapter 11: Health insurance systems

State Child Health Insurance Program (SCHIP)

-Administered through the Medicaid program -Additional funds the states may use to enhance the health care of children May increase income needed to receive benefits. Used taxes on cigarettes

Medicaid

A federal and state assistance program that pays for health care services for people who cannot afford them. Covers 50% births and nursing home care, and 40% of children

Worker's Compensation

A form of insurance paid by the employer providing cash benefits to workers injured or disabled in the course of employment.

Essential health benefits

A package of benefits set by the Secretary of Health and Human Services that insurers will be required to offer under the exchanges. 1) Ambulatory patient services 2) Emergency services 3) Hospitalization 4) Maternal and newborn services 5) Mental health, substance abuse treatment (includes behavioral services) 6) Prescription drugs 7) Rehabilitative and habilitative services and devices 8) Laboratory services 9) Preventative wellness services and chronic disease management 10) Pediatric services- including oral and vision care

Health insurance exchanges

A set of state-regulated and standardized health care plans in the United States, from which individuals may purchase health insurance eligible for federal subsidies.

Premium

A specific sum of money paid by the insured to the insurance company in exchange for financial protection against loss.

Factors that increase cost of health care

Aging population Technological advancements (costly but may have only small benefits) Success of medical care over last half century has increased expectations

deductible

Amount you must pay before you begin receiving any benefits from your insurance company

Downsides to capitation and fee for service

Capitation may result in underuse fee for service may result in overuse.

Efforts to control cost

Cost control through reimbursement Cost sharing Regulation Restrictions on malpractice (avoid defensive care by physicians)

Greatest negative aspect of US healthcare

Efficiency (scored 53)

Where does money spent on healthcare go?

Health insurance plans and the rest to holes coverage doesn't account for-out of pocket expenses

Uninsured fall into these groups:

Health young, choose to not purchase insurance from employer Poor or near porr who do not qualify for Medicaid Self-employed or work for small business who, despite substantial income, do not purchase health insurance.

eligible

Individual must meet certain criteria. Income level for medicaid. age and enrollment in social security for Medicare. employment status for employee benefits

Medicare part d

Medicare prescription drug reimbursement plans. monthly premium and annual deductible. gap or "doughnut hole" is being eliminated. when individual reaches catastrophic 5000 dollars a year, covers 95% of additional costs.

Framework for healthcare systems

Method of financing Method of insurance and reimbursement Methods for delivering services Comprehensiveness of insurance Cost and cost containment degree of patient choice administrative costs

Social security income

Money one receives from the government under the Social Security program. Social Security payments may be counted as income only if they are consistent. Provided for disabled adults and children who meet income level no prior contributions required. Shorter waiting period more immediate

Medicare

National Health Insurance program for the elderly and disabled who benefit from social security, also those with end stage renal disease

How do states receive funding for medicaid?

Paid by federal government based on per-capita income. 50% to 83% of cost

Social security disability insurance

Pays benefits to the individual (and certain family members) if the individual worked long enough and paid Social Security taxes. Must have had 12 months disability. Medicaid is provided for 2 years after eligibility determined

Experience rating

Rating system that bases insurance rates on claims history (replaced community rating)

Risks of uninsured individuals

Receive less preventative care, diagnosed at more advanced stages, receive less treatment More likely to use emergency department, lacking a usual source of health care Increased mortality rate

Community rating

Same insurance rate for everyone, as opposed to experience rating.

Out of pocket expenses

Specific amount of money that you pay when insurance only covers a portion of costs

How do U.S. systems compare to Canada and the UK

Spends more per person and as percentage of GDP Higher percentage of uninsured individuals More complex for patient and provider cost far more for administrative Places more emphasis on specialized healthcare providers Encourages rapid adoption of technology Places greater emphasis on giving patient choice More complex system for ensuring care and unique malpractice law system

portability

The ability to continue employer-based health insurance benefits after leaving a job. COBRA ensures 18 months of portability but requires employee pay full cost.

Medicare Part B

The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies. Most covered by tax revenue but must pay monthly premium, copayments, and deductibles.

Balance billing

The practice of billing patients for any balance left after deductibles, coinsurance, and insurance payments have been made.

Excess costs of healthcare

Unnecessary costs and overuse Inefficiently delivered services Excess administrative costs Prices that are too high Missed preventative opportunities Fraud

ACA attempts to address uninsured

Until 26 can stay on parents' insurance Expand eligibility for Medicaid Requires health insurance or fine must be paid

Cap

a limit on the total amount that the insurance will pay for a service per year, per benefit period, or per lifetime

HMOs

a network of providers for which costs are covered inside but not outside the network charged monthly fee for comprehensive care clinicians are paid by capitation for each enrolled member ex: Kaiser Permanente

PPOs

a network of providers where costs outside the network may be partially reimbursed and the patients primary care physician need not be a member (evolved from fee for service)

Medigap

a private insurance policy that pays the difference between the medical charge and the amount that Medicare pays

Covered service

a service for which health insurance will provide payment if the individual is otherwise eligible

Copayment

a small fixed fee paid by the patient at the time of an office visit

employment-based health insurance

a system in which an employer pays all or part of the health insurance premiums for the employee(largest single category of health insurance- 50% eligible)

Fee for service

a system under which doctors and hospitals receive a payment for each service they provide

Medicare Part A (Hospital Insurance)

covers Medicare inpatient care, including care received while in a hospital, a skilled nursing facility, and, in limited circumstances, at home. annual deductible required but majority paid for payroll tax- not premium

What is not covered by Medicare?

glasses, hearing aids

Point of Service (POS)

insurance plan in which a patient may choose an HMO or a non-HMO provider but must pay a deductible for using a non-HMO provider

Medicare part C

managed care health plans offered to medicare beneficiaries under the medicare advantage program

Medical loss ratio

the percentage of premium revenue spent on medical expenses. lower ratio implies larger amount of premium is retained by insurance company

Coinsurance

the percentage of the medical expenses the policyholder must pay in addition to the deductible amount

customary, prevailing, and reasonable

these standards are used by many insurance plans to determine the amount that will be paid to the provider of services.