RMIN exam 4

effect of three-party healthcare transaction

lower “user price” of healthcare

less incentive to act as traditional customer

causes over-utilization of healthcare cuz insurers pay most of it

FFS

fee-for-service

ACA

affordable care act

• guaranteed issue: insurer cannot deny coverage due to preexisting conditions

• community rating: insurers may only rate on a few variables

• minimum standard for health insurance: cannot drop policyholders, dependent remain until 26, no annual or lifetime limits, coverage for essential health benefits

• individual mandate: buy health insurance or pay a penalty

• health insurance exchanges: online marketplace where people can shop for insurance

• subsidies for low-income individuals/families

Employer mandate

firms with 50+ employees must provide health insurance or pay a fine

minimum amount HAVE to pay premiums

• requires health insurers to pay 85% of premiums in claims, other 15% can go to salaries or investments

Cost-sharing in health insurance: co-payments

amount insured must pay; medical visit; does not count toward deductible

Cost-sharing in health insurance order

Deductibles → coinsurance → OOP

deductibles

aggregate deductible that must be satisfied during the calendar yr

coinsurance

% of bill - deductible which the insured about to pay OOP; ex. 80/20 - insured has to pay 20%

Out-Of-Pocket Maximums (OOP) aka stop-loss limit

most the insured will have to pay oop in a calendar yr

individual medical expense health insurance

protects individual or family for covered hospital care, physicans’ and surgeons’ fees; helps ppl who are not able to buy group purchase

managed care plan

medical expense PLAN that provides covered services to the members in a cost-effective manner; ex. HMO, PPO, and POS plans

HMO

health maintenance organization; provides healthcare to members on prepaid basis; limited choice of providers

PPO

preferred provider organization; contracts healthcare providers to provide medical services at a discounted fee

POS

point of service plan; combines HMO and PPO; have to choose PCP but can go out of network

CDHP

consumer directed health plan; combined high-deductible health plans with HSA

HSA

health savings account; tax-exempt exclusively for paying medical expenses

FSA

flexible spending account; permits employees to pay for certain reimbursed medical expenses w/ pre-tax dollars

Legal Wrong

violation of person’s legal rights; failure to perform a legal duty owed to a person, business, or org

Tort (3)

legal wrong for which the court allows a remedy in form of monetary damages; plaintiff; tortfeaser

Intentional Tort

intentional act resulting in harm or injury to another person or damage to property; ex. assult, battery

Strict Liability Tort

liability on u even if u did not do it; ex. owning animals; no need to prove harm; responsible no matter what

negligence tort

carelessness; 4 parts; person failed to use reasonable care, ex: slip on store floor (store was careless); must prove fault

standard of care

how careful an avg, normal, and sensible person would be in the situation

elements of negligence

1. legal duty owed

2. breach of legal duty

3. damage or injury

4. proximate cause

legal duty owed

u have responsibility to act carefully toward others; ex. ur driving a car which makes you responsible for driving safely

breach of legal duty

u failed to meet that duty; ex. running a red light

damage or injury

someone suffered from harm; ex. injury

proximate cause

harm was closely connected to breach; result was foreseeable; ex. running the red is a proximate cause

compensatory damages

compensate the victim for losses actually incurred; 2: special and general

special damages

compensation for medical expenses, lost earnings, or property damages

general damages

cannot be measured; ex. emotional, pain & suffering

punitive damages

for punishment not compensation; penalize bad behavior; money awarded to punish the wrongdoer and discourage similar behavior in the future; sue for emotional distress, dumbshit; ex: manufacuter sells known damaged product to customer but did not harm them but can sue for emotional distress

legal defenses for negligence

ability to collect damages for negligence depends on state law

contributory negligence

if injured person is slightly at fault they can’t recover any damages; ex; A runs red light, B is slightly speeding then B get nothing

comparative negligence

financial burden is carried by both parties according to respective degrees of fault; ex: total damages: 100,000 & u at 30% fault → recover 70,000; pu

pure rule

can collect damages even if u are negligent; but reward is low

50 percent rule

cannot recover if u are 50% or more at fault

last clear chance rule

who had the last chance to prevent harm; even if plaintiff was negligent they can still recover if the defendant had the last opportunity to avoid the accident

assumption of risk

person knew the danger and still decided to accept it; ex: skydiving

imputed negligence

negligence of one person is legally assigned to another person; ex: employer→ employee

res ipsa loquitor

the accident is so obvious that negligence is assumed even without direct proof; 3 requirements: 1.event would happen without negligence 2.defendant had control of situation 3.injured party had no contribution to accident; ex: surgicol tool is left inside patients body after surgery

trespasser

person who enters or remains on property without the owner’s consent

licensee

person who enters or remains on property with owners permission; owner has duty to warn of harm does not need to inspect for danger

invitee

invited for owner’s benefit; ex: customers in store; duty to inspect for danger and warn them

attractive nuisance

dangerous condition that is most likely to attract children who may not understand the risk; ex: swiming pools, playgrounds; owners of land are liable if something happens to child even if they are a trespasser

respondant superior

employer responsible for employees negligence while employee is on clock; ex: delivery driver hits car then employer is liable for that

parents and children

parents can be held liable for children’s actions; child uses dangerous weapons; minor child is operating family car