Health insurance literacy
Health insurance literacy is defined as the “degree to which individuals have the knowledge, ability, and confidence to find and evaluate information about health plans, select the best plan for their own (or their family’s) financial and health circumstances, and use the plan once enrolled.”1 Ask a friend or family member about their health insurance plan. Is it provided by their employer or did they purchase it in the health insurance marketplace? What is their co-pay? What is their deductible? What type of plan is it? How much do they pay per month for their plan? Does their plan cover dental, vision, prescriptions, etc.? If so, to what extent are these things covered? Overall, are they satisfied with their plan? Feel free to add any other questions that will help you assess the level of understanding people have of their health insurance plans.
Your post is a commentary on the awareness of people of the details of their plans and how to use them. I want you to comment on the individual’s health insurance literacy. Did they seem knowledgeable of the details of their plans, were they confused by their plans, were you surprised by what you noticed? Did you learn something new about health insurance plans after talking to this individual, etc.?
Please note that the post is not a question and answer format but a summary of your assessment of the individual’s health insurance literacy. Make sure that you don’t include any names or identifying information related to the individuals you interview. Write up your commentary in around 350-450 words.
Note: You can view the rubric for the Discussion Board in My Grades.
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Chapter 8
Understanding
Health Insurance
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• Reviews the basic elements of health insurance
• Focuses on:
– How health insurance operates
• Why people buy insurance
• Basic terminology/features
– Managed care
• Cost and utilization control tools
• Common structures
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• The United States does not have a single national
health insurance program that covers the entire
population.
• In 2016, 8.8% of the U.S. population was uninsured.
• Of those with insurance, most obtain coverage
through their employer.
• Medicaid and Medicare are government health
insurance programs that cover millions of people in
the United States.
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A Brief History of the Rise of Health
Insurance in the United States
• Late 1800s–early 1900s—European social insurance
movement resulted in the creation of “sickness” insurance
throughout many countries.
• 1929—Blue Cross established its first hospital insurance plan
at Baylor University.
• 1939—Blue Shield began.
• 1954—Internal Revenue Service declared that employers
could pay health insurance premiums for their employees with
pre-tax dollars.
• 1965—Medicaid and Medicare were created.
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• Beneficiary—Consumer; the individual who is
covered by the plan
• 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
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Uncertainty and Risk
(1 of 2)
• People choose to be insured because of
uncertainty and risk.
– There is uncertainty whether an expensive and
unforeseen event that impacts their health status
will occur.
– There is risk of financial exposure due to the
unexpected event.
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Uncertainty and Risk
(2 of 2)
• Insurance companies are concerned about
uncertainty and risk because they are
businesses that need to cover the cost of their
expenditures.
• Uncertainty and risk may lead to adverse
selection.
– Unhealthy people over-select a particular plan,
making the plan more expensive.
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• Insurance companies set premiums to cover most of
their expenses.
• Experience rating
– Based on health status and claims in prior year(s)
– Also referred to as medical underwriting
• Community rating
– Based on factors unrelated to previous use of medical care,
such as geography or age
– All persons in the community rating system pay the same
amount
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• Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
– HIPAA-covered group plans may not exclude or
limit otherwise qualified individuals due to pre-
existing conditions.
– HIPAA-covered group plans may not charge
different premiums based on identified health
factors to similarly situated individuals.
• State laws on medical underwriting vary.
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• Managed care integrates the provision and
payment of healthcare services.
• Ideally, managed care contains costs while
providing necessary and high-quality health
care services.
– Some fear that managed care companies provide
fewer services than necessary or lower quality
services to save money.
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Managed Care—
Cost Containment Tools
• Performance-based salary
– Provider receives a salary as a managed care organization
employee.
– Salary is subject to bonuses or withholds.
• Discounted fee schedule
– Provider accepts less than fee-for-service rates to
participate in managed care network.
• Capitated payment
– Provider receives a per member/per month payment for all
services rendered within scope of practice.
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Managed Care—
Utilization Control Tools
• Gatekeeper
– Managed care organization uses a primary care provider to
make sure only necessary and appropriate care is provided.
• Utilization review
– Managed care organization reviews and approves or denies
services requested by provider.
• Case management
– Managed care organization manages and coordinates
patient care.
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• Health Maintenance Organization (HMO)
– Pays providers a salary or capitation
– Beneficiaries may only use in-network providers
– HMO coordinates and controls receipt of services
• Preferred Provider Organization (PPO)
– Pays provider on a discounted fee schedule
– Beneficiary may use in- or out-of-network providers
• Point of Service Plans (POS)
– Combines features of HMO and PPO
– Pays providers with capitation or other risk-sharing arrangement
– Has a provider network; beneficiaries may use out-of-network provider
for designated services
– Has a gatekeeper to control and coordinate care
- Slide Number 1
- A Brief History of the Rise of Health Insurance in the United States
- Uncertainty and Risk�(1 of 2)
- Uncertainty and Risk�(2 of 2)
- Managed Care—�Cost Containment Tools
- Managed Care—�Utilization Control Tools
Chapter Overview
Insurance Coverage Overview
Basic Terminology
Setting Premiums
Legal Issues
Managed Care
Managed Care—Common Structures
Rubric Detail
A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this
item and made it available to you. Select Grid View or List View to change the rubric’s layout.
Exemplary Proficient
Needs
Improvement
Poor
Name of
local public
health
department
10 (10.00%)
–
10 (10.00%)
Name of
health
department
fully and
clearly
identified.
0 (0.00%) – 0
(0.00%)
–
0 (0.00%) – 0
(0.00%)
–
0 (0.00%) – 0
(0.00%)
Name of
health
department is
not identified.
Website 10 (10.00%) –
10 (10.00%)
Website of
health
department is
clearly
identified with
a functional
link.
0 (0.00%) – 0
(0.00%)
–
0 (0.00%) – 0
(0.00%)
–
0 (0.00%) – 0
(0.00%)
Website of
health
department is
not included.
Public
health
services
36 (36.00%) –
40 (40.00%)
Two services
are clearly
identified with
the correct
corresponding
core function
and essential
public health
service.
32 (32.00%) –
35.6 (35.60%)
Two services
are clearly
identified with
1-2 incorrect
corresponding
core function
/ essential
public health
service.
26 (26.00%) –
31.6 (31.60%)
Only one
service is
clearly
identified with
the correct
corresponding
core function
and essential
public health
0 (0.00%) – 25.6
(25.60%)
No service is
clearly
identified with
the correct
corresponding
core function
and essential
public health
service.
Name: Week 3 – Discussion Board
Exit
Grid View List View
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service. service. public health
service.
service.
Reflection –
Overall
impression
22.5 (22.50%) –
25 (25.00%)
Student
directly
addresses
main
question(s) or
issue(s) and
adds new
insight to the
subject not
provided in
lectures,
readings, or
class
discussions.
20 (20.00%) –
22.25 (22.25%)
Student
directly
addresses
main
question(s) or
issue(s) but
does not add
much new
insight into
the subject.
That said, it is
clear that the
student has
learned a
great deal in
class and is
able to
communicate
this
knowledge to
others.
16.25 (16.25%)
– 19.75
(19.75%)
Student
attempts to
address main
question(s) or
issue(s), but
fails. The
student has
retained some
information
from the
course, but
does not fully
understand its
meaning or
context and
cannot clearly
convey it to
others.
0 (0.00%) – 16
(16.00%)
Post does
NOT address
main
question(s) or
issue(s), and it
is obvious that
student has
not retained
any
information
from the
course.
Writing and
organization
9 (9.00%) – 10
(10.00%)
Post is
coherently
organized and
the logic is
easy to follow.
Writing is
clear, concise
and
persuasive.
8 (8.00%) – 8.9
(8.90%)
.Post is
generally well
organized and
most of the
argument is
easy to follow.
Writing is
mostly clear
but may lack
conciseness.
6.5 (6.50%) –
7.9 (7.90%)
Post is
somehow
poorly
organized and
difficult to
read – barely
flows logically
from one part
to another.
Writing lacks
clarity and
conciseness.
0 (0.00%) – 6.4
(6.40%)
Post is poorly
organized and
difficult to
read – does
not flow
logically from
one part to
another.
Writing lacks
clarity and
conciseness.
Grammar
and spelling
4.5 (4.50%) – 5
(5.00%)
There are no
spelling or
grammatical
errors and
terminology is
clearly
4 (4.00%) – 4.45
(4.45%)
There are only
a few minor
spelling or
grammatical
errors, or
terms are not
3.25 (3.25%) –
3.95 (3.95%)
There are
several
spelling
and/or
grammatical
errors;
0 (0.00%) – 3.2
(3.20%)
There are
many spelling
and/or
grammatical
errors;
technical
clearly
defined.
terms are not
clearly
defined.
errors;
technical
terms may
not be
defined or are
poorly
defined.
technical
terms may
not be
defined or are
poorly
defined.
Name:Week 3 – Discussion Board
Exit