2023 AHIP FINAL EXAM 2
| Passed | A+ Rated Guide | New Full Exam
• Insurer vs Insured:
- insurer is a company that provides plan
- insured are the people that buy into the plan
• Group health insurance:
Health coverage provided by employers to members of a group.
• Group health insurance - types of coverage:
You can choose among several or just one depending on your employer
- dental, vision, medical benefits, managed care, fee-for-service insurance
- dental:
- basic/preventative services, restorative services, comprehensive or stand-alone,
ACA (children, some adults)
- vision:
- basic exams and prescription glasses, ACA (children, some adults)
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^ both are employer-sponsored voluntary group plans
• Premium tax-credit:
a subsidy that reduces the amount that consumers must pay
- tax credit that will lower monthly premium based on income and household info
- advanced premium tax-credit (aptc)
• self employed workers:
can deduct health insurance premiums from their federal taxable income - important tax savings
• contracts/health insurance policy: between insurer and insured
- consideration:
specifically termed agreement w/ promise to do something in return for a valuable benefit (employer/insured premium payments to the insurer)
• Covered services:
insurance policy will clearly state their covered services and their exlusions
- proactive, preventative, and reactive services
• cost-sharing:
a situation where insured individuals pay a portion of the health- care costs, such as deductibles, coinsurance or co-payments 2 / 4
- insured is reimbursed for some but not all of the costs
- reimbursement depends on policy
• Deductible/coinsurance:
Money paid out of pocket before insurance covers the remaining costs.% of medical bill that insured pays out of pocket
• copay:
a fixed fee you pay for specific medical services
• government sponsored plans:
federal and state gov
- medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
• employer sponsored plans:
- employer determines coverage
- company's HR dept answers employee questions
• excluded services:
services not covered in a medical insurance contract like experimental or non- contracted providers, elective or cosmetic surgery 3 / 4
• Health Care Philosophy:
- good quality = cost effective
- more expensive does not mean good healthcare
- cost vs care balance
- good benefits priced appropriately
- less cost, more quality
triangle --> cost, access, quality *more medical care does not mean better outcomes
• managed care improves cost/access/quality:
cost: limited provider net- works, inventing new ways to pay physicians,
requiring referrals for specialty care
quality: credentialing providers, evidence-based medical policies, grading
providers on their quality outcomes, comparing providers to their peers
access: reigning in premium increases and reducing unnecessary care to make
additional provider time available
• annual increase in premiums:
- result from consumer/government limitations placed on managed care
- other factors: higher provider fees, increased use of tech in delivery of care, health
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