Review for midterm: Health Insurance Terms and Policies: Premiums, Deductibles, ACA, HIPAA, EMTALA

What is a premium?

The amount paid to have/maintain health insurance coverage.

What is a deductible?

The amount/threshold you generally pay before the insurance plan begins paying its share.

What is an out-of-pocket maximum?

The maximum amount a member pays in covered cost-sharing during the plan year.

What's the easiest way to distinguish deductible from OOP max?

Deductible = threshold. OOP max = ceiling.

What is a copay?

A fixed dollar amount paid for a covered service.

What is coinsurance?

A percentage of the cost of a covered service that the patient pays.

What is a formulary?

The list of prescription drugs covered by a health plan.

What is a provider network?

The providers/facilities contracted with the insurance plan.

What is risk pooling?

Combining people with different levels of health risk so healthcare costs are spread across the group.

Why are healthier people important to a risk pool?

Their lower expected healthcare costs help balance the higher costs of members who need more care.

What is medical underwriting?

Evaluating an individual's health risk when determining eligibility or premiums.

Before the ACA, what could happen because of medical underwriting?

People with greater health risks/preexisting conditions could be denied coverage or charged more.

What are the three legs of the ACA's "three-legged stool"?

Subsidies + requirement to have insurance + preexisting-condition protections.

Which ACA stool component did I have trouble remembering?

SUBSIDIES.

What major insurance-market problems was the ACA designed to address?

Large numbers of uninsured people, preexisting-condition exclusions, medical underwriting, and inconsistent benefits.

Can ACA-compliant plans deny someone coverage because of a preexisting condition?

No.

What is adverse selection?

Healthier/lower-risk people leave or don't enroll, leaving a higher-risk insurance pool.

What can adverse selection lead to?

Higher average costs → higher premiums → more healthy people leave → premium spiral.

Short-Term Health Plans

What is a major attraction of short-term health plans?

Potentially lower premiums, affordability, flexibility, and consumer choice.

Are short-term plans subject to the same ACA protections as ACA-compliant plans?

No.

What protections/requirements may differ with short-term plans?

Essential Health Benefits, preexisting-condition protections, and premium-rating requirements.

What is one argument AGAINST expanding short-term plans?

They can provide fewer protections/benefits and potentially contribute to adverse selection in the comprehensive market.

What's the big short-term-plan policy tradeoff?

More regulation/protection ↔ more flexibility/potentially lower premiums.

What is the basic HIPAA Privacy Rule principle we're studying?

A covered entity generally cannot disclose PHI without consent unless the disclosure is permitted.

What is PHI?

Identifiable information related to a person's health condition, healthcare, or payment for healthcare.

What three covered entities should I know?

Healthcare providers + health plans + healthcare clearinghouses.

What does TPO stand for?

Treatment — Payment — Operations.

Are TPO disclosures automatically HIPAA violations?

No. They can be permitted disclosures.

What four questions should I ask in a HIPAA scenario?

PHI? → Covered entity? → Disclosure? → Permitted?

If medical information is involved, does that automatically mean HIPAA applies?

NO. This is a major scenario trap.

A bookstore asks a customer to show a vaccination card. Does the bookstore scenario automatically fall under HIPAA?

No. In your professor's scenario, the bookstore isn't a covered entity. SNHP 220 Fall 2026 Data Privacy...

A hospital maintains an employee's health information as an employment record. What's the HIPAA issue?

In your professor's scenario, the hospital is acting as an employer, so HIPAA does not apply to that employment record.

A dentist asks a patient for their vaccination record. Has the dentist disclosed PHI simply by asking?

No. Requesting information ≠ disclosing information. SNHP 220 Fall 2026 Data Privacy...

A hospital sends a medication list to the patient's treating physician. HIPAA violation?

Not automatically. It's a disclosure of PHI, but it can be permitted for treatment.

What problem was EMTALA created to address?

Patient dumping.

What is patient dumping?

Denying care or transferring patients because they lack insurance or cannot afford to pay.

What hospitals does EMTALA apply to in our course material?

Hospital emergency departments participating in Medicare. SNHP 220 Fall 2026 The Role of ...

What's the EMTALA sequence?

SCREEN → STABILIZE → TRANSFER.

What happens first when someone presents to a covered ED with a possible emergency?

Appropriate medical screening.

If screening identifies an emergency medical condition, what's next?

Stabilizing treatment.

What about transferring an unstable patient?

The transfer must be clinically necessary/justified under the circumstances covered in your professor's material.

Does EMTALA mean emergency treatment is free?

NO. Hospitals can still charge patients.

Why does your professor call EMTALA a "band-aid"?

It addresses emergency access/patient dumping but doesn't solve the larger problem of inadequate healthcare and insurance access. SNHP 220 Fall 2026 The Role of ...

What's our plan-comparison method?

PERSON → NEEDS → PLAN.

Is the plan with the lowest premium automatically the best plan?

No.

What should you consider for someone who rarely uses healthcare and takes no medications?

The premium may carry more weight, while still considering financial protection if unexpected care occurs.

What should you consider for someone with a chronic condition?

Medication/formulary costs, specialist costs, provider network, deductible, OOP max, and premium.

If keeping a particular specialist is important, what should you check?

Whether that provider is in-network.

If someone takes an expensive medication every month, what should you check?

The formulary and medication cost-sharing.

According to your professor's slides, how are covered preventive services treated?

No cost sharing and not subject to the deductible. SNHP 220 Fall 2026 U.S. Private...

Why can a higher-premium plan sometimes be better for someone who frequently uses healthcare?

Better coverage of their repeated medications, specialists, and other services may make the plan a better fit despite the higher monthly premium.

What's the biggest mistake to avoid on the plan questions?

Looking at one number and declaring that plan the winner instead of matching the plan to the patient's actual healthcare needs.

ACA stool?

Subsidies — Requirement — Preexisting-condition protections.

HIPAA TPO?

Treatment — Payment — Operations.

HIPAA scenario order?

PHI → Covered entity → Disclosure → Permitted.

EMTALA sequence?

Screen → Stabilize → Transfer.

Plan-comparison rule?

Person → Needs → Plan.