Health Systems: US

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73 Terms

1
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What is the out-of-pocket payment model in health care?

Patient pays provider directly at time of service.

2
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What are key issues with out-of-pocket payment?

Costs are unpredictable, may be unaffordable, can lead to care denial, and lack of reliable payment for providers.

3
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What is private individual insurance?

Patient pays a monthly premium to an insurer who pays medical bills.

4
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What are key issues with private individual insurance?

Higher cost per person, similar issues as employer-based plans.

5
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What is private employer-based insurance?

Employer pays a monthly premium (with employee contribution) to cover medical bills.

6
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What are key issues with employer-based insurance?

May lead to overuse, reluctance to subsidize others, and excludes unemployed or low-income individuals.

7
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What is the most common type of insurance in the U.S.?

Employer-based private insurance.

8
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What is a premium?

Monthly amount paid for insurance coverage.

9
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What is a deductible?

Amount paid out-of-pocket before insurance starts to pay.

10
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What is co-insurance?

Percentage of health care costs you pay after reaching the deductible.

11
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What is a co-pay?

Fixed out-of-pocket cost paid at time of service.

12
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What are cost-sharing mechanisms in health insurance?

Premium, deductible, co-pay, co-insurance.

13
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What is the out-of-pocket maximum?

Maximum a patient pays in a year before insurance covers 100% of costs.

14
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What are annual/lifetime maximums in insurance?

Limits on what insurance pays per year or lifetime (now banned for essential services under ACA).

15
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What is experience rating in insurance?

Premiums based on individual health risk and likelihood of using care.

16
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What is community rating in insurance?

Everyone in a group pays the same premium regardless of health status.

17
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What is managed care?

Insurance-level structures to control health care costs.

18
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What is utilization review?

Insurer reviews and authorizes or denies proposed care to control use.

19
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What is a health maintenance organization (HMO)?

Requires patients to use in-network providers and usually needs PCP referrals.

20
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What is a preferred provider organization (PPO)?

Allows out-of-network care with higher costs, usually no PCP referral needed.

21
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What is an exclusive provider organization (EPO)?

In-network only (except emergencies), does not usually require PCP referral.

22
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What is a point of service (POS) plan?

Offers out-of-network care at higher cost, may require PCP referrals for specialty care.

23
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Which managed care plan offers the most flexibility?

PPO.

24
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Which managed care plan is typically most restrictive and lowest cost?

HMO.

25
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Who is eligible for Medicare Part A?

People 65+ with work history, or younger if disabled, ESRD, or ALS.

26
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What does Medicare Part A cover?

Inpatient hospital, skilled nursing, hospice, and some home health.

27
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How is Medicare Part A funded?

Through Social Security payroll taxes.

28
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What does Medicare Part B cover?

Physician services, outpatient care, preventive services, labs.

29
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How is Medicare Part B funded?

Federal taxes and monthly premiums.

30
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What is the 2025 deductible for Medicare Part B?

$257/year.

31
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What is the typical co-insurance for Medicare Part B?

20% of service cost.

32
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What are Parts A and B of Medicare commonly called?

Original Medicare.

33
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What services are not covered by Medicare A and B?

Long-term care, dental, vision, hearing aids.

34
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What is Medicare Part C?

Medicare Advantage — private plans that replace A and B and often add benefits.

35
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What is Medicare Part D?

Prescription drug benefit with deductibles, co-pays, and co-insurance.

36
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Who manages Medicare Part D plans?

Private companies contracted by Medicare.

37
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How is Medicare Part D funded?

Federal taxes and monthly premiums.

38
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What is a key issue with Medicare Part D pricing?

Government cannot negotiate drug prices.

39
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What is Medicaid?

Government insurance for low-income individuals and families.

40
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How is Medicaid funded?

Jointly by federal and state taxes.

41
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Who administers Medicaid?

States under federal guidelines.

42
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What changed with Medicaid under the ACA?

In expansion states, eligibility extended to all under 138% of FPL regardless of category.

43
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What services does Medicaid typically cover?

Inpatient and outpatient care, prescriptions, long-term care, transport, labs, and family planning.

44
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What are Section 1115 waivers?

Allow states to modify Medicaid coverage and requirements.

45
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What are common additions to Medicaid coverage?

Physical therapy, eyeglasses, dental, behavioral health.

46
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What is a key issue with Medicaid access?

Lower provider payment leads to limited provider participation.

47
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What happened to Medicaid re-enrollment post-pandemic?

Yearly re-enrollment resumed in April 2023, leading to coverage gaps.

48
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What is CHIP?

Children’s Health Insurance Program for covering low-income children.

49
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How is CHIP funded?

Federal funds to states, currently authorized through 2027.

50
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How do states implement CHIP?

By expanding Medicaid, creating a separate CHIP, or using a hybrid.

51
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How many children are enrolled in Medicaid or CHIP?

About 40 million.

52
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How is CHIP administered in Massachusetts?

As part of MassHealth.

53
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What is the Federal Poverty Level (FPL)?

Income threshold used to determine eligibility for programs like Medicaid.

54
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What is the 2024 FPL for an individual?

$15,560.

55
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What is the 2024 FPL for a family of 4?

$32,150.

56
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How was the original poverty threshold calculated?

1963 cost of economy food plan × 3, adjusted for inflation.

57
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What is an Accountable Care Organization (ACO)?

Group of providers coordinating care to improve quality and reduce costs.

58
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How are ACOs paid?

Based on meeting quality and cost-saving benchmarks.

59
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Who can ACOs contract with?

Private insurers, Medicare, or Medicaid.

60
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Are ACOs insurer-led or provider-led?

Provider-led.

61
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What is underinsurance?

Having insurance but still facing financial barriers to care.

62
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What are effects of underinsurance?

Delayed care, less preventive services, and financial strain.

63
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Why do some people choose high-deductible plans?

Lower premiums, but higher out-of-pocket costs when care is needed.

64
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How does Medicare contribute to underinsurance?

No long-term care coverage and other service gaps.

65
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What leads to reduced access despite insurance?

High cost-sharing, limited employer coverage, and income disparities.

66
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What is uninsurance?

Lack of any health insurance coverage.

67
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How does uninsurance affect care-seeking?

Leads to delayed or skipped care due to cost.

68
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How does uninsurance affect continuity of care?

Increases likelihood of having no regular source of care.

69
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How does uninsurance affect diagnosis?

Conditions are diagnosed at later stages.

70
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How does uninsurance affect hospitalization?

Patients are often more ill when hospitalized.

71
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What is the mortality impact of being uninsured?

Increases risk of death by 40%, ~45,000 excess deaths per year.

72
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What factors were adjusted for in mortality studies on uninsurance?

Age, sex, education, health status, and smoking.

73
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What is the link between insurance and health?

Insurance alone doesn’t guarantee health, but lack of it worsens health outcomes.