U.S. Healthcare System Review

These flashcards cover key concepts, definitions, and provisions related to the U.S. healthcare system, focusing on healthcare access, provisions of the Affordable Care Act, Health Savings Accounts, long-term care insurance, and retirement plans.

What are the main defects in the U.S. healthcare system?

High costs, lack of universal coverage, unequal access to care, and administrative inefficiencies.

What are key provisions of the Affordable Care Act (ACA)?

Coverage for pre-existing conditions, removal of lifetime/annual benefit limits, essential health benefits requirements, and allowing young adults to stay on parents' insurance until age 26.

How has the Affordable Care Act (ACA) improved healthcare access?

It has expanded insurance access, improved preventive care access, reduced uninsured rates, and eliminated denials for pre-existing conditions.

What are Health Savings Accounts (HSAs)?

Tax-advantaged savings accounts for medical expenses, paired with High Deductible Health Plans (HDHPs).

What are advantages of using Health Savings Accounts (HSAs)?

Tax savings, flexibility in spending, and unused funds roll over.

What are disadvantages of Health Savings Accounts (HSAs)?

Requirements for HDHPs, benefits skewed towards higher-income individuals, and significant out-of-pocket costs.

What is long-term care insurance and how does it function?

It pays for extended care services triggered by inability to perform Activities of Daily Living (ADLs).

What is the difference between indemnity and expense-incurred long-term care policies?

Indemnity policies pay a fixed benefit; expense-incurred policies reimburse up to a set limit.

What are Activities of Daily Living (ADLs)?

Basic self-care tasks that can trigger claims for long-term care insurance when a person is unable to perform them.

What are examples of Activities of Daily Living (ADLs)?

Bathing, dressing, eating, toileting, transferring, and continence.

How are long-term care costs typically covered in the U.S.?

Through personal savings, Medicaid for eligible individuals, or long-term care insurance policies.

What are the key elements of Individual Medical Expense Insurance?

Co-payments, out-of-pocket maximums, no lifetime or annual limits, and a selected co-insurance percentage.

What are the Ten Essential Benefits mandated by the ACA?

Preventive care, maternity care, mental health services, prescription drugs, emergency services, and more.

What is the difference between guaranteed renewable and noncancelable insurance policies?

Guaranteed renewable policies cannot be canceled if premiums are paid; noncancelable policies also cannot be canceled and cannot have their premiums increased.

What happens with nonrenewable insurance policies at expiration?

Coverage ends at the policy’s expiration date.

What is the purpose of the Uniform Individual Accident and Sickness Policy Provisions Act?

To establish standard provisions in health insurance contracts for consistency and fairness.

What is an example of a standardized provision from the Uniform Individual Accident and Sickness Policy Provisions Act?

The 'entire contract provision,' which states that the policy and attached application constitute the whole agreement.

What is the purpose of Disability Income Insurance?

To provide a portion of income if the policyholder is unable to work due to a disability.

What types of benefits are typically included in Employer-Sponsored Benefit Plans?

Health insurance, life insurance, disability insurance, retirement plans, and paid leave.

What are the sources of healthcare coverage in the U.S.?

Employer-sponsored plans, government programs like Medicare and Medicaid, and individual insurance policies.

What are the differences between individual and group benefits?

Group benefits are usually less expensive and easier to administer; individual benefits are more customizable but costlier.

What is group medical insurance and how does it operate?

Typically employer-sponsored, where the employer covers most premiums and employees pay the rest via payroll deductions.

How do deductibles, co-pays, coinsurance, and annual maximums differ?

Deductibles are paid before coverage begins; co-pays are fixed fees; coinsurance is a percentage of costs; annual maximums cap out-of-pocket expenses.

What are HMOs, PPOs, and POS plans?

HMOs require in-network care and are coordinated by a Primary Care Physician; PPOs offer flexibility to see out-of-network providers at higher costs; POS plans combine features of both.

What are examples of commercial insurers in the U.S.?

Blue Cross/Blue Shield, Aetna, and Anthem.

What are cafeteria plans and how do they function?

They allow employees to choose from a menu of benefits, with employer contributions covering part of the costs.

What are High Deductible Health Plans (HDHPs)?

Health plans with high deductibles, often paired with HSAs for tax-advantaged savings.

What is a Qualified Retirement Plan and its tax advantages?

A retirement savings plan meeting IRS requirements, offering tax-deferred growth and potential tax deductions for contributions.

What is vesting in retirement plans?

The degree to which employees own employer-contributed funds in their retirement plan.

What is the difference between a Defined Benefit and a Defined Contribution retirement plan?

Defined Benefit plans offer a predetermined payout; Defined Contribution plans' benefits depend on contributions and investment performance.

What are common problems associated with Qualified Retirement Plans?

Inadequate contributions, early withdrawals, low participation rates, and poor investment decisions.

What is the purpose of social insurance programs?

To provide economic security through basic income and benefits.

What are key characteristics of social insurance programs?

Provide a floor of income, Compulsory, Benefits prescribed by law, No means test, Full finding unnecessary, Benefits loosely related to earnings, Emphasis on social adequacy rather than individual equity

What benefits are included under OASDI (Social Security)?

Retirement benefits, survivor benefits, and disability insurance.

What is the purpose of Workers' Compensation Insurance?

To cover medical care, lost wages, rehabilitation, and death benefits for job-related injuries or illnesses.

What is 'The Great Trade-off' in workers' compensation coverage?

The compromise where workers give up the right to sue employers in exchange for guaranteed compensation for work-related injuries.