policy exam 2

beneficiary

consumer, the individual who is covered by the plan, as per aca, plans should cover “essential health benefits,” benefits structured in categories

medically necessary

the determination that a healthcare service or treatment is required for the diagnosis, treatment, or prevention

premium

annual fee paid by the beneficiary to the health plan, usually in monthly installments, to secure health insurance coverage

deductible

amount of money a beneficiary must pay out-of-pocket before the insurance company assists with paying for services

cost-sharing

co-payment or co-insurance, an amount the beneficiary pays per service after the deductible is met

claim

a payment request for the health services performed

network

a group of facilities, providers, and suppliers your health insurer has contracted with to provide health care services 

stop-loss

protects against catastrophic or unpredictable losses, provides protection for the employer against a high claim on any one individual, claim must be unforeseen or emergent

otto von bismarck

german chancellor, first to recommend the idea of health insurance, “those who are disabled from work by age and invalidity have a well-grounded claim to care from the state”

hospital insurance plan

1929, blue cross established its first ___ ___ ___ at baylor university, provided 1500 teachers with 21 days of hospital care per year for $6, hospitals supported private insurance since it secured payment services during the depression

physician-based insurance plan

would provide reimbursement for physician services, blue shield began

1965

medicaid and medicare were created, coverage for disabled, elderly, and low-income

aging population

1970s healthcare costs were rising like never before, especially with an

fee-for-service (FFS) insurance system

rewarded healthcare professionals for providing high quantity of services, paid for each service they provide, from 1960-70 hospital expenditures tripled from $9.3 billion to $28 billion

21%

from 1965-70 federal and state governments collectively experienced a ___ annual rate increase in healthcare expenditures

uncertainty and risk

insurance exists because of the concepts of ___ and ___

premiums

from the insurers perspective , income =

lower, less

ideally, the insurers would like to charge ___ premiums to attract healthy individuals who are ___ likely to use their benefits

asymmetric information

when one party in a transaction has more information than the other party, carriers do not know as much as the individual does about their healthcare needs and personal habits

adverse selection

when unhealthy people over-select a particular plan, making the plan more expensive

copayment

a specific dollar amount that patients pay when they receive services or drugs

coinsurance

a percentage of service cost that patients pay when they receive services or drugs

age, location, tobacco use, individual vs family enrollment, plan category

under the health care law, insurance companies can account for 5 things when setting premiums

medical underwriting

referring to the use of medical or health information in the evaluation of an applicant for coverage

health insurance portability and accountability act of 1996

hipaa stands for

quality

insurance providers have little to no ability to improve the ___ of care provided and cannot control costs by limiting the amount or type of services provided

managed care

a healthcare delivery system organized to manage cost, utilization, and quality, became the predominant healthcare financing and delivery arrangement in the us, create incentives to provide fewer services and less expensive healthcare

network

services are offered through a ___ of providers who have a contractual relationship with the managed care organization (MCO)

large volume of patients

discounted fee schedule, provider accepts less than fee-for-service rates to participate in managed care network, in return for the ___ available through MCO

little or no measurable

research suggests there is ___ difference in the health outcomes of patients in FFS vs managed care plans

gatekeeper

primary care provider to make sure only necessary and appropriate care is provided, responsible for providing primary care, refer patients for additional care, must coordinate with the patient’s care

utilization review

managed care organization reviews and approves or denies services requested by provider

case management

managed care organization manages and coordinates patient care

health maintenance organization (HMO)

has its own network of approved healthcare professionals and facilities, can only use in-network providers, negotiates rates for services for providers (discounted rates), primary care provider is responsible for all referrals, more affordable premiums, fewer plans with deductibles, coordinated care, less flexibility, coverage does not travel, required referrals, doctors and facilities leaving hmo network

preferred provider organization (PPO)

beneficiary pays less if you use “preferred” healthcare professionals within the network, can see pros outside the plan’s network for additional costs, do not need a primary care provider to access services, more flexibility, travels with you, no referrals needed, potentially more services, higher premiums, annual deductible, responsibility for coordinating care, out-of-pocket cots

high deductible health plan (HDHP)

lower monthly premium, typically covers all preventive, in-network care in full (before deductible is met), has access, healthcare flexibility, large medical expenses, future health risks (may refrain from visiting physician, getting treatments, etc. when it is not covered), high deductibles

point of service plans (POS)

combines features of hmo and ppo, has a provider network; beneficiaries may use out-of-network provider for designated services, has a gatekeeper to control and coordinate care, lower cost than ppo, more flexibility than an hmo, no deductible in-network, potential for high costs (deductible for out-of-network care ), red tape (out-of-network care), more visits or calls to you pcp

life insurance

a type of contract in which you make regular payments to an insurance company, the company pays a sum of money to your chosen beneficiaries upon death, premiums are determined by factors like the policyholder’s age, health, and lifestyle, with younger and healthier individuals paying lower rates

health savings account

tax-advantaged saving account used with high-deductible health plans to pay for qualified medical expenses

public health preparedness

includes the ways in which nations, states, and communities identify, prepare for, respond to contain, and recover from emergencies

9/11 and the ensuing anthrax attacks

government leaders engaged in a series of legislative and regulatory forms including specific classify and define PHEs, authorize public and private sector responses, coordinate efforts across federal and state governments after this event

local level

public health professionals recognize that most public health activities occur at the

states

have a responsibility for developing their own emergency preparedness plans, and all have some level of planning and preparedness training in place

preemption

prevents states from taking contradictory action whenever the federal government has the sole authority to act or chooses to act in areas of overlapping authority with states

quarantine

separation of persons who are reasonably believed to have been exposed to a communicable disease but who are not known to be ill from others during the incubation period of the disease to prevent disease spread should they develop the disease

isolation

refers to the separation of individuals who are known to be ill and contagious from those who are well from the period of infectiousness

robert t stafford disaster relief and emergency assistance act (stafford act)

state governor requests federal assistance from the president, president must declare an emergency, after the emergency is declared, this allows the federal government to provide support

national emergencies act (NEA)

president must specify which statutory powers will be used and report to congress, allows for congress to terminate a national emergency through a joint resolution

public health service (PHSA)

serves as a foundation for public health and health services in the us, as it relates to emergencies, allow the secretary of health and human services the authority to develop strategies for public health emergencies

cbrn threats

release of chemical, biologic, radiologic, or nuclear threats

tokyo subway sarin attack 1995

largest cbrn threat

biologic warfare

the military use of biologic agent to cause death or harm to humans, animals, or plants

bioterrorism

the threat or use of biologic agent to harm or kill humans, plants, or animals

traditional 

naturally occurring microorganisms or toxins

enhanced

traditional agents that have been offered to circumvent MCM

emerging

any naturally occurring organism

advanced

novel pathogens that are engineered to inflict harm

community resilience

helps ensure that individuals and communities can recover more quickly from health emergencies and how we’ve learned from prior experiences

sheppard-towner act 1941

provided matching funds to states for prenatal and child health centers

social security act of 1935

includes grants for maternal and child health- restored what was established under the shepard-towner act, extended the role of the children’s bureau to include other child welfare services

economic bill of rights

fdr outlines new bill of rights, included the right to adequate medical care and the opportunity to achieve and enjoy good health

hill-burton act

expanded hospital infrastructure, largely successful (more beds and improved access), prohibited discrimination based on race, religion, or national origin, required hospitals to provide and “reasonable volume” of charitable care

kerr-mills act

uses federal funds to support state programs providing medical care to the poor and elderly

medicare and medicaid were incorporated under the social security act signed by johnson with truman at his side

what happened in 1965

medicare

a federally funded health insurance program for the elderly and some persons with disabilities

10 years

eligible for social security by having worked and contributed to social security (pay taxes) for at least

24 months

disabled requirements, individual is totally and permanently disabled and has received social security disability insurance for at least

part d: prescription drug coverage

may receive through private drug plans or managed care arrangement

medicaid

a federal-state public health insurance program for the indigent

per capita income

rate is tied to each state’s __ __ __ with poorer states receiving a higher federal match

provider participation, coverage limitation, administrative complexity, stigma and discrimination

cons of medicaid

insures 72 million americans, financial protection, improved health outcomes, comprehensive benefits

pros of medicaid

1986

year consolidated omnibus budget reconciliation act was passed (COBRA)

18-36 months

cobra gives the same health coverage the employee had while employed, can last from 

above

childen’s health insurance program (CHIP) designed to provide health insurance to low-income children whose family income is __ the medicaid eligibility level in their state

enhanced match

chip will always be higher than the state’s medicaid match

independent business v sebelius

challenged the legality of the ACA