210 Health Services And Policies

Front 1

What does the insurance mechanism do?

Back 1

1.shares and disperses the risk of the financial loss due to the occurrence of an adverse event within the population.
2. helps improve the financial stability of individuals and organizations.
3. Helps protect against unforeseen and severe financial loss

Front 2

We pay a ________ into a pool of resources that will provide income or service benefits to ____________ of an ___________.

Back 2

premium, beneficiaries, policy

Front 3

Insurance is a set of 2 contracts which are:

Back 3

1. b/w insurance co. and beneficiary
2. insurance co. and the provider

Front 4

Once you buy insurance you become part of the insurance co.'s ?

Back 4

risk pool

Front 5

How does the collection of premium relate to the amount of benefits you will receive

Back 5

the beneficiary pays premium to the co. . The co. pays claims. Most of the time the insured pays more in premium than the amount of money they receive in benefits. This is how insurance co.'s stay in business.

Front 6

some insurance programs are organized and administered by the __________ and ___________.

Back 6

gov and private companies

Front 7

Who regulates the private companies?

Back 7

state government to insure that the companies have enough financial reserves to cover the needs of their risk pool.

Front 8

How are premiums set?

Back 8

they conduct an actuarial analysis

Front 9

What do actuarial analysis consider?

Back 9

demographic factors, past medical care utilization rates and known cost data to make statistical decisions about the future utilization and costs.

Front 10

What is financially irresponsible behavior regarding insurance

Back 10

moral hazard

Front 11

who can moral hazards be caused by?

Back 11

the individual and the insurer

Front 12

How do individuals cause moral hazards?

Back 12

going to the E.R. or doctor too much
not purchasing health insurance

Front 13

Why does the cost of private insurance increase do to people being uninsured?

Back 13

If they choose not to purchase insurance then the cost for unpaid health care shifts to people who pay into the pool. If services are overused then this also raises the cost for insured people

Front 14

How are moral hazards created by insurance companies?

Back 14

actuarial analysis or actuarial adjustment

Front 15

What are the two things associated with moral hazards caused by actuarial analysis or actuarial adjustment

Back 15

1. favorable selection
2. adverse selection

Front 16

WHat results form the actuarial process that preferentially identifies people with anticipated low health care costs. Results in lower beneficiary premiums and higher profits for insurers. Trying to get low risk insureds.

Back 16

Favorable selection= trying to get low risk insureds

Front 17

What is created by favorable selection. this forces those individuals who are not in the favorable group to be in a pool of individuals with higher health care costs and higher premiums

Back 17

adverse selection= the insureds left after favorable selection

Front 18

Do insured contracts tell providers what to do?

Back 18

no, but they inform beneficiary and the provider about what services are covered and how much of the cost of care will be pd by the insurance co.

Front 19

What are the basic features of an insurance contract

Back 19

eligibility
covered events
covered services
beneficiary cost limits
provider cost limits
coordination of benefits

Front 20

What is a set of criteria. An underwriter will determine if you qualify for services.

Back 20

eligibility

Front 21

What is included under covered events

Back 21

1. medical problem diagnosed by a credentialed physician
2. contract is responsible for event precipitating the illness or injury (ex. wc is reponsible for work related accidents)
3. excludes illness or injury caused by war or riot as well as self-inflicted illness or injury

Front 22

WHat is included under covered services

Back 22

1. stated in contract (including reasonable and necessary also acceptable medical practice)
2. excludes experimental and certain elective procedures (cosmetic surgery is an ex.)

Front 23

What is covered under beneficiary cost limits

Back 23

1. plan limits: lifetime, overall limit, annual, out of pocket limit'
2. first-dollar coverage: deductible or co-pymt
3. co-insurance: shared percentage-based reimbursement b/w insurer and beneficiary up to out-of-pocket limit
4. limits on utilization:preauthorization, day-dollar visit limits, provider selection, documentation or expectation for improvement

Front 24

what is th emax dollar amount the plan will pay over the lifetime of a covered member

Back 24

overall plan limit

Front 25

what is the max amount a beneficiary is responsible to pay during a plan year?

Back 25

out-of-pocket limit

Front 26

what describes shared cost between the insurer and the ins. co until the out-of-pocket limit is reached

Back 26

co-insurance

Front 27

therapy services are usually affected by this. Physician's referral and pr-authorization for services is usally required. There may be a day, dollar, or visit limit for the plan year.

Back 27

limits on utilization of services

Front 28

what is teh amount of money to be pd out-of-pocket by the beneficiary before any reimbursement by the insurance co.

Back 28

deductible

Front 29

you pay each time you utilize services

Back 29

co-pay

Front 30

What do provider cost limits include

Back 30

1. fee schedules
2. case rates
3. capitation

Front 31

what is the list of procedures and how much will be pd. on each procedure fee decided b/w provider and ins. co.

Back 31

fee schedules

Front 32

what are the three areas of case rates

Back 32

per diem- flat pymt rate per day f
per episode- for each episode
per visit- rate you get per visit.

Front 33

what is a flat fee pymt to the provider for each member in health plan

Back 33

capitation

Front 34

what is it called when some individuals are covered by more than one insurance contract.

Back 34

coordination of benefits

Front 35

Dealing with coordination of benefits what is th epolicy held by the person seeking services is considered

Back 35

primary

Front 36

How is a policy considered primary for children with dual parental cov

Back 36

the birthday-rule is used. the parent's with the birthday that comes first is the primary policy

Front 37

What are the three ways insurance is classified by

Back 37

sponsorship
methods of cost sharing
events and services covered

Front 38

what does sponsorship include

Back 38

1. private insurance
2. self-insurance
3. direct contracting

Front 39

most commonly provided as a benefit of employment. Individuals may purchase commercial insurance on their own or through a group plan

Back 39

private insurance

Front 40

some employers self-insure its employees. a company or organization chooses not to participate in a risk pool organized by an ins. co and instead establishes its own separate ins. fund internally to pay for covered events and benefits. This type of ins. is most common in businesses or labor unitions with at least 100 members

Back 40

self-insurance

Front 41

direct purchasing attemps to give employees, rather than employers, the ability to choose their health care providers by cutting out the middle-man insurance co.'s. through a competetive bidding, health care services are purchased directly from hospitals, physician groups, and other health care providers

Back 41

direct contracting

Front 42

What are the two areas listed under the method of cost sharing

Back 42

indemnity insurance and service benefit plans

Front 43

this type of insurance reimburses the beneficiary for covered health care expenses. the provider is pd by the beneficiary, who then in turn is reimburesed by the ins. company. This ins. structure is paperwork intensive and there is often a long visit for providers to be reimbursed for services. The assignment of benefits clause was created to allow the insurancce to pay the provider directly

Back 43

indemnity insurance

Front 44

Which insurance structure is paperwork intensive and there is often a long wait for providers to be reinbursed for services

Back 44

indemnity insurance

Front 45

what is a modified form of indemnity insurance

Back 45

service benefit plans

Front 46

what does service benefit plans consist of

Back 46

1. established panels of providers to deliver services
2. utilize assignment of benefits (sign a clause)
3. utilize a fee schedule to pay for providers services.

Front 47

what are some examples of covered events/services

Back 47

long-term care insurance
worker's compensation
casualty insurance

Front 48

what type of insurance provides benefits to people with physical illness, cognitive impairments, and other chronic diseases that result in impairments and functional limitations. Eligibility for benefits is based on the loss of function in ADL's or the onset of a significant cognitive impairment

Back 48

long-term care insurance

Front 49

what are the six ADL's commonly examined to determine eligibility for long-term care ins.

Back 49

1. bathing
2. continence
3. dressing
4. eating
5. toileting
6. transferring

Front 50

What usually initiates benefits concerning ADL's

Back 50

the inability to perform at least two of these tasks without assistance.

Front 51

what does long-term insurance cover

Back 51

in home care, snf, and adult day care centers. services include personal assistance and professional care

Front 52

How are services pd for usually for long-term care

Back 52

per diem rate

Front 53

What is the purpose of worker's compensation insurance

Back 53

to protect the workers, free employers from excessive litigation, and decrease the incidence of occupational injuries.

Front 54

what type of injuries is usually seen in workers comp claims

Back 54

muscloskeletal injuries and they may need therapy to return to work

Front 55

What type of insurance is no-fault

Back 55

workers compensation. employers are liable for damages due to workplace-related injuries of illness regardless of circumstances surrounding the events

Front 56

what are the 3 benefit programs that workers comp ins consists of

Back 56

1. health care ins
2. disability income replacement
3. vocational rehab

Front 57

Can workers comp benefits be permanent?

Back 57

yes or temporary

Front 58

when do med beneifts start

Back 58

immediately after the injury and are unlimited.

Front 59

How long are benefits provided

Back 59

until maximal medical improvement or a return to employment has occured

Front 60

what is the dominant mode of medical care delivery in wc programs

Back 60

outpatient services

Front 61

what is a source of contention in wc law

Back 61

choice of physician and provider

Front 62

is the injured employee always allowed to choose their physician or proveder

Back 62

no, in some states they are and in others they are not

Front 63

if a person is to receive the income replacement benefit they have to receive a

Back 63

disability classification by the physician.

Front 64

How much of their pre-injury income will a person recieve through wc

Back 64

66%

Front 65

What are the 5 categories of disability

Back 65

1. fatal
2. permanent total
3. permanent partial
4. temporary total
5. temporary partial

Front 66

why has there been abuse of workers compensation insurance and the cost for employers has been rising.

Back 66

1. generous benefit pkgs in wc plans provide incentives for employees to file false claims or to exaggerate symptoms
2. the high costs of the program have given employers incentives to aggressively manage these costs and jeopardize the medical care of persons with legitimate injury or illness
3. the presence of insurance tends to make employers more safety conscious and employees less safety conscious
4. the fee-for-service reimbursement mechanism of some worker's compensation plans give incentives to providers to overtreat conditions.

Front 67

what type of insurance includes automobile and homeowners insurance will include a medical care benefit.

Back 67

casualty insurance

Front 68

if a person is injured in a home or auto accident then they will be coverd by

Back 68

policies on their home and cars

Front 69

each state has an insurance dept. that __________ and _________ the activities of insurance companies doing business in that state.

Back 69

licenses and regulates

Front 70

what are the 2 primary areas of state insurance regulation

Back 70

1. maintain solvency requirements
2. market regulation

Front 71

insurance companies are required to maintain capital reserves and financial strategies to cover their anticipated losses

Back 71

maintain solvency requirements

Front 72

some states regulate the premiums charged by insurers and all states monitor the marketing and eligibility determination practices of ins. companies

Back 72

market regulation

Front 73

what is a federal statute that was enacted to standardize the regulation of pension and employee benefit plans. It provides protection against loss of benefits to retired works. protection is not absolute. a pension plan can be terminated if the company goes out of business or the company merges with another company

Back 73

Employee Retirement Income Security Act of 1974 (ERISA). prior to this people pd into pension plans and b/f could make claim they were fired

Front 74

what was enacted to deal with the problems of the loss of health care insurance due to a change in life status or employment.

Back 74

The consolidated budget reconciliation act of 1985 (cobra)

Front 75

cobra mandates that those who lose employment-based health care ins. for reasons other than gross misconduct are eligible to continue cov. for _____ mnts at full cost to themselves

Back 75

18 mnts

Front 76

in the event of an employee death, divorce, or a child no longer maintaining eligible-dependent status, the spouse or dependents can purchase cov. for up to _____---

Back 76

3 years

Front 77

this provides rights and protections for participants and beneficiaries in group health plans

Back 77

The Health Insurance Portability and Accountability Act (HIPAA)

Front 78

HIPAA includes what protections for coverage under group health plans

Back 78

exclusions for preexisting conditions, prohibit discrimination against employees and dependents based on their health status; and allow a special opportunity to enroll in a new plan to individuals in certain circumstances.

Front 79

How does HIPAA protect workers and their families

Back 79

1. limiting exclusios for preexisting medical conditions
2. providing credit against max. preexisting condition exclusion periods for prior health cov. and a process for providing certificates showing periods of prior cov. to a new group health plan or health ins. issuer
3. providing new rights that allow individuals to enroll for health cov. when they lose other health cov., get married or add a new dependent
4. prohibiting discrimination in enrollment and in premiums charged to employees and their dependents based on health status-related factors
5. guaranteeing availability of health ins. cov. for small employers and renew ability of health ins. cov. for both small and large employers
6. preserving the states' role in regulating health ins., including the states' authority to provide greater protections than those available under federal law.