Health Systems: US
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73 Terms
What is the out-of-pocket payment model in health care?
Patient pays provider directly at time of service.
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.
What is private individual insurance?
Patient pays a monthly premium to an insurer who pays medical bills.
What are key issues with private individual insurance?
Higher cost per person, similar issues as employer-based plans.
What is private employer-based insurance?
Employer pays a monthly premium (with employee contribution) to cover medical bills.
What are key issues with employer-based insurance?
May lead to overuse, reluctance to subsidize others, and excludes unemployed or low-income individuals.
What is the most common type of insurance in the U.S.?
Employer-based private insurance.
What is a premium?
Monthly amount paid for insurance coverage.
What is a deductible?
Amount paid out-of-pocket before insurance starts to pay.
What is co-insurance?
Percentage of health care costs you pay after reaching the deductible.
What is a co-pay?
Fixed out-of-pocket cost paid at time of service.
What are cost-sharing mechanisms in health insurance?
Premium, deductible, co-pay, co-insurance.
What is the out-of-pocket maximum?
Maximum a patient pays in a year before insurance covers 100% of costs.
What are annual/lifetime maximums in insurance?
Limits on what insurance pays per year or lifetime (now banned for essential services under ACA).
What is experience rating in insurance?
Premiums based on individual health risk and likelihood of using care.
What is community rating in insurance?
Everyone in a group pays the same premium regardless of health status.
What is managed care?
Insurance-level structures to control health care costs.
What is utilization review?
Insurer reviews and authorizes or denies proposed care to control use.
What is a health maintenance organization (HMO)?
Requires patients to use in-network providers and usually needs PCP referrals.
What is a preferred provider organization (PPO)?
Allows out-of-network care with higher costs, usually no PCP referral needed.
What is an exclusive provider organization (EPO)?
In-network only (except emergencies), does not usually require PCP referral.
What is a point of service (POS) plan?
Offers out-of-network care at higher cost, may require PCP referrals for specialty care.
Which managed care plan offers the most flexibility?
PPO.
Which managed care plan is typically most restrictive and lowest cost?
HMO.
Who is eligible for Medicare Part A?
People 65+ with work history, or younger if disabled, ESRD, or ALS.
What does Medicare Part A cover?
Inpatient hospital, skilled nursing, hospice, and some home health.
How is Medicare Part A funded?
Through Social Security payroll taxes.
What does Medicare Part B cover?
Physician services, outpatient care, preventive services, labs.
How is Medicare Part B funded?
Federal taxes and monthly premiums.
What is the 2025 deductible for Medicare Part B?
$257/year.
What is the typical co-insurance for Medicare Part B?
20% of service cost.
What are Parts A and B of Medicare commonly called?
Original Medicare.
What services are not covered by Medicare A and B?
Long-term care, dental, vision, hearing aids.
What is Medicare Part C?
Medicare Advantage — private plans that replace A and B and often add benefits.
What is Medicare Part D?
Prescription drug benefit with deductibles, co-pays, and co-insurance.
Who manages Medicare Part D plans?
Private companies contracted by Medicare.
How is Medicare Part D funded?
Federal taxes and monthly premiums.
What is a key issue with Medicare Part D pricing?
Government cannot negotiate drug prices.
What is Medicaid?
Government insurance for low-income individuals and families.
How is Medicaid funded?
Jointly by federal and state taxes.
Who administers Medicaid?
States under federal guidelines.
What changed with Medicaid under the ACA?
In expansion states, eligibility extended to all under 138% of FPL regardless of category.
What services does Medicaid typically cover?
Inpatient and outpatient care, prescriptions, long-term care, transport, labs, and family planning.
What are Section 1115 waivers?
Allow states to modify Medicaid coverage and requirements.
What are common additions to Medicaid coverage?
Physical therapy, eyeglasses, dental, behavioral health.
What is a key issue with Medicaid access?
Lower provider payment leads to limited provider participation.
What happened to Medicaid re-enrollment post-pandemic?
Yearly re-enrollment resumed in April 2023, leading to coverage gaps.
What is CHIP?
Children’s Health Insurance Program for covering low-income children.
How is CHIP funded?
Federal funds to states, currently authorized through 2027.
How do states implement CHIP?
By expanding Medicaid, creating a separate CHIP, or using a hybrid.
How many children are enrolled in Medicaid or CHIP?
About 40 million.
How is CHIP administered in Massachusetts?
As part of MassHealth.
What is the Federal Poverty Level (FPL)?
Income threshold used to determine eligibility for programs like Medicaid.
What is the 2024 FPL for an individual?
$15,560.
What is the 2024 FPL for a family of 4?
$32,150.
How was the original poverty threshold calculated?
1963 cost of economy food plan × 3, adjusted for inflation.
What is an Accountable Care Organization (ACO)?
Group of providers coordinating care to improve quality and reduce costs.
How are ACOs paid?
Based on meeting quality and cost-saving benchmarks.
Who can ACOs contract with?
Private insurers, Medicare, or Medicaid.
Are ACOs insurer-led or provider-led?
Provider-led.
What is underinsurance?
Having insurance but still facing financial barriers to care.
What are effects of underinsurance?
Delayed care, less preventive services, and financial strain.
Why do some people choose high-deductible plans?
Lower premiums, but higher out-of-pocket costs when care is needed.
How does Medicare contribute to underinsurance?
No long-term care coverage and other service gaps.
What leads to reduced access despite insurance?
High cost-sharing, limited employer coverage, and income disparities.
What is uninsurance?
Lack of any health insurance coverage.
How does uninsurance affect care-seeking?
Leads to delayed or skipped care due to cost.
How does uninsurance affect continuity of care?
Increases likelihood of having no regular source of care.
How does uninsurance affect diagnosis?
Conditions are diagnosed at later stages.
How does uninsurance affect hospitalization?
Patients are often more ill when hospitalized.
What is the mortality impact of being uninsured?
Increases risk of death by 40%, ~45,000 excess deaths per year.
What factors were adjusted for in mortality studies on uninsurance?
Age, sex, education, health status, and smoking.
What is the link between insurance and health?
Insurance alone doesn’t guarantee health, but lack of it worsens health outcomes.