Health Insurance Plans
Which type of managed care organization(s) require a primary care physician (PCP) and referrals for specialist care?
HMOs and POS
Premiums can be up to 3 times higher for older people than for younger ones
Age
the percentage of the cost of covered healthcare services that a policyholder must pay after meeting their deductible.
what is a coinsurance
When was the Health Insurance Exchange (Marketplace) enacted?
2010 with the Affordable Care Act
Is the state of someone having health insurance coverage that is insufficient to cover necessary medical expenses, often resulting in high out-of-pocket costs that can lead to financial strain.
Underinsured
Under this type of insurance, patients can choose any healthcare provider and are reimbursed after paying out-of-pocket, with no network restrictions.
indemnity plan / fee for service
Insurers can charge higher premiums in regions, states, or ZIP codes with higher medical costs
Location
How many possible tiers are medications divided into order for an insurance to approve it?
4
How many health benefits do Marketplace health plans offer and what are 3 of them?
10: ambulatory, emergency services, hospitalization, OB care, mental health, prescriptions, rehab, labs, preventative/wellness/chronic disease management, pediatric
Is the state of someone not having any health insurance coverage, leaving individuals to pay for medical expenses out of pocket without financial assistance.
Uninsured
Linda is 68 years old and has Medicare coverage. Her plan covers hospital stays, doctor visits, and some preventive services. However, she also needs coverage for prescription drugs and has recently signed up for a plan that covers her prescriptions and some additional benefits, like wellness programs.
Medicare Part C (Medicare Advantage) or Medicare Part D
Smokers can pay up to 50% more in premiums than non-smokers
Tobacco Use
applying changes in policy more slowly; in healthcare, it would apply the changes to only certain groups.
What is Incrementalism
What do you total together to know your total cost per month for health insurance?
Add your premium + deductible + out-of-pocket costs + any co-payments or co-insurance
An example of a recreational intervention for those underinsured or uninsured.
Any right answer
Tina, a 32-year-old woman, has been working for a company that offers a health insurance plan with a high degree of flexibility. She can see any specialist or doctor she wants without needing to get approval from a PCP. However, she is aware that her costs will be lower if she stays within her insurer’s network of providers, though she doesn’t have to.
PPO (Preferred Provider Organization)
Insurance companies can charge more for plans that covers spouse and/or dependent children than individual policies
Family Status
payments that are predetermined by insurance companies for care provided by healthcare organizations based on the diagnosis at admission.
What is a prospective payment
What is a Special Enrollment Period?
A period where people who have experienced special circumstances are allowed to get health insurance after the open enrollment deadline has passed
An example of an educational intervention for those underinsured or uninsured.
Any right answer
Carlos, a 29-year-old man, recently lost his job and is struggling financially. He has a chronic health condition that requires regular doctor visits and medications. With limited income, he applies for assistance to help cover his medical expenses, and he is approved for a program that helps pay for doctor visits, prescriptions, hospital care, and even some preventive services. His young child also qualifies for coverage under this program, making sure they both get the care they need.
Medicaid
Marketplace plans are categorized by metals: bronze, silver, gold, and platinum
Plan Type
he payment of a fee or grant to a doctor, school, or other person or body providing services to a number of people, such that the amount paid is determined by the number of patients, students, or customers.
What is capitation
What are the 4 metals and what is the relationship between how much your insurance pays and how much you pay?
Bronze, Silver, Gold, Platinum
With bronze your plan pays 60% and you pay 40% and your deductibles are high. As you move up in the metals you pay less and your deductible amount decreases
An example of a health and social service intervention for those underinsured or uninsured.
Any right answer