AHIP FINAL EXAM 2022/2023 UPDATED VERSION QUESTIONS
AND 100%CORRECT ANSWERS+ ELABORATIONS
Insurer vs Insured - ANSWER: - insurer is a company that provides plan
- insured are the people that buy into the plan
Group health insurance - ANSWER: Health coverage provided by employers to
members of a group.
Group health insurance - types of coverage - ANSWER: 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)
^ both are employer-sponsored voluntary group plans
Premium tax-credit - ANSWER: 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 - ANSWER: can deduct health insurance premiums from their
federal taxable income - important tax savings
contracts/health insurance policy - ANSWER: 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 - ANSWER: insurance policy will clearly state their covered services
and their exlusions
- proactive, preventative, and reactive services
cost-sharing - ANSWER: a situation where insured individuals pay a portion of the
healthcare costs, such as deductibles, coinsurance or co-payments
- insured is reimbursed for some but not all of the costs
- reimbursement depends on policy
Deductible/coinsurance - ANSWER: Money paid out of pocket before insurance
covers the remaining costs.
% of medical bill that insured pays out of pocket
, copay - ANSWER: a fixed fee you pay for specific medical services
government sponsored plans - ANSWER: federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
employer sponsored plans - ANSWER: - employer determines coverage
- company's HR dept answers employee questions
excluded services - ANSWER: services not covered in a medical insurance contract
like experimental or non-contracted providers, elective or cosmetic surgery
Health Care Philosophy - ANSWER: * 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 - ANSWER: cost: limited provider
networks, 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 - ANSWER: - result from consumer/government
limitations placed on managed care
- other factors: higher provider fees, increased use of tech in delivery of care, health
care fraud and other admin costs
Provider network - ANSWER: * to assure quality/cost control and addressing
population health issues
1. closed network (specific providers)
2. open network (not set of providers)
3. defined network w/ out-of-network coverage
(specific providers but any out-of-network services = larger portion of costs)
AND 100%CORRECT ANSWERS+ ELABORATIONS
Insurer vs Insured - ANSWER: - insurer is a company that provides plan
- insured are the people that buy into the plan
Group health insurance - ANSWER: Health coverage provided by employers to
members of a group.
Group health insurance - types of coverage - ANSWER: 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)
^ both are employer-sponsored voluntary group plans
Premium tax-credit - ANSWER: 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 - ANSWER: can deduct health insurance premiums from their
federal taxable income - important tax savings
contracts/health insurance policy - ANSWER: 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 - ANSWER: insurance policy will clearly state their covered services
and their exlusions
- proactive, preventative, and reactive services
cost-sharing - ANSWER: a situation where insured individuals pay a portion of the
healthcare costs, such as deductibles, coinsurance or co-payments
- insured is reimbursed for some but not all of the costs
- reimbursement depends on policy
Deductible/coinsurance - ANSWER: Money paid out of pocket before insurance
covers the remaining costs.
% of medical bill that insured pays out of pocket
, copay - ANSWER: a fixed fee you pay for specific medical services
government sponsored plans - ANSWER: federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
employer sponsored plans - ANSWER: - employer determines coverage
- company's HR dept answers employee questions
excluded services - ANSWER: services not covered in a medical insurance contract
like experimental or non-contracted providers, elective or cosmetic surgery
Health Care Philosophy - ANSWER: * 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 - ANSWER: cost: limited provider
networks, 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 - ANSWER: - result from consumer/government
limitations placed on managed care
- other factors: higher provider fees, increased use of tech in delivery of care, health
care fraud and other admin costs
Provider network - ANSWER: * to assure quality/cost control and addressing
population health issues
1. closed network (specific providers)
2. open network (not set of providers)
3. defined network w/ out-of-network coverage
(specific providers but any out-of-network services = larger portion of costs)
