HCA 101 UPDATED EXAMS SCRIPT QUESTIONS AND
SOLUTIONS GUARANTEE A+
✔✔four components in a government run system - ✔✔functions are more closely
integrated and may be indistinguishable
✔✔quad-function model: financing - ✔✔- for most privately insured Americans health
insurance is employment based --> employers finance health care as a fringe benefit
- dependent spouse or child may be covered by working spouses or working parents
employer
- in public programs, the government functions as the financier, the insurance function
may be carved out to an HMO
- medicare, medicaid,
- individual self-funding
✔✔how do most employers purchase health care for their employees - ✔✔- through an
MCO or insurance company selected by the employer
✔✔quad-function model: insurance - ✔✔- insurance protects the insured against
catastrophic risks when needing expensive health care service
- the insurance function also determines the package of health services that insured
individual is entitled to receive
- the MCO or insurance company also functions as a claims processor and manages
the disbursement of funds to the health care providers
-insurance companies
-blue cross/blue shield,
-self-insurance
✔✔quad-function model: delivery - ✔✔- "delivery" refers to the provision of health care
services by various providers
- "provider" refers to any entity that delivers health care services and can either
independently bill for those services or is tax supported
ex: physicians, dentists, optometrists, therapist, hospitals
✔✔payment - ✔✔- payment function deals with reimbursement to providers for services
delivered
- the insurer determines how much is paid for a certain services
, - funds for actual disbursement come from the premiums paid to the MCO or insurance
company
✔✔medicare - ✔✔government insurance for the elderly and certain disabled individuals
✔✔medicaid - ✔✔the program for the indigent, jointly administered by the federal
government and state governments
✔✔children's health insurance program (CHIP) - ✔✔the program for children from low-
income families, another federal/state partnership
✔✔the predominant employment-based financing system has still left some employed
individuals uninsured for two main reasons: - ✔✔1) in many states, employers are not
mandated to offer health insurance to their employees therefore some employers due to
economic constraints do not offer it ; some small businesses simply cannot get group
insurance at affordable rates and therefore are not able to offer health insurance as a
benefit to their employees to join
2) in many work settings, participants in health insurance programs is voluntary and
does not require employees to join, some employees choose not to sign up, mainly
because they cannot afford the cost of health insurance premiums
- employers rarely pay 100% of the insurance premiums; most require their employees
to pay a portion of the cost, called premium cost sharing
- people who are self-employed have to obtain health insurance on their own - individual
rates are higher than group rates
- in the Us working people earning low wages have been the most likely to be uninsured
because most cannot afford premium cost sharing and are not eligible for public
benefits
✔✔in US health care reform refers to: - ✔✔- the expansion of health insurance to cover
the uninsured those without private or public health insurance coverage
ex: affordable care act (ACA)
✔✔ACA facts - ✔✔- insurance companies were mandated to start covering children and
young adults below the age of 26 under their parents health insurance plan
- mandate for employers to provide health insurance
- requires that all US citizens and legal residents must be covered by either public or
private insurance
SOLUTIONS GUARANTEE A+
✔✔four components in a government run system - ✔✔functions are more closely
integrated and may be indistinguishable
✔✔quad-function model: financing - ✔✔- for most privately insured Americans health
insurance is employment based --> employers finance health care as a fringe benefit
- dependent spouse or child may be covered by working spouses or working parents
employer
- in public programs, the government functions as the financier, the insurance function
may be carved out to an HMO
- medicare, medicaid,
- individual self-funding
✔✔how do most employers purchase health care for their employees - ✔✔- through an
MCO or insurance company selected by the employer
✔✔quad-function model: insurance - ✔✔- insurance protects the insured against
catastrophic risks when needing expensive health care service
- the insurance function also determines the package of health services that insured
individual is entitled to receive
- the MCO or insurance company also functions as a claims processor and manages
the disbursement of funds to the health care providers
-insurance companies
-blue cross/blue shield,
-self-insurance
✔✔quad-function model: delivery - ✔✔- "delivery" refers to the provision of health care
services by various providers
- "provider" refers to any entity that delivers health care services and can either
independently bill for those services or is tax supported
ex: physicians, dentists, optometrists, therapist, hospitals
✔✔payment - ✔✔- payment function deals with reimbursement to providers for services
delivered
- the insurer determines how much is paid for a certain services
, - funds for actual disbursement come from the premiums paid to the MCO or insurance
company
✔✔medicare - ✔✔government insurance for the elderly and certain disabled individuals
✔✔medicaid - ✔✔the program for the indigent, jointly administered by the federal
government and state governments
✔✔children's health insurance program (CHIP) - ✔✔the program for children from low-
income families, another federal/state partnership
✔✔the predominant employment-based financing system has still left some employed
individuals uninsured for two main reasons: - ✔✔1) in many states, employers are not
mandated to offer health insurance to their employees therefore some employers due to
economic constraints do not offer it ; some small businesses simply cannot get group
insurance at affordable rates and therefore are not able to offer health insurance as a
benefit to their employees to join
2) in many work settings, participants in health insurance programs is voluntary and
does not require employees to join, some employees choose not to sign up, mainly
because they cannot afford the cost of health insurance premiums
- employers rarely pay 100% of the insurance premiums; most require their employees
to pay a portion of the cost, called premium cost sharing
- people who are self-employed have to obtain health insurance on their own - individual
rates are higher than group rates
- in the Us working people earning low wages have been the most likely to be uninsured
because most cannot afford premium cost sharing and are not eligible for public
benefits
✔✔in US health care reform refers to: - ✔✔- the expansion of health insurance to cover
the uninsured those without private or public health insurance coverage
ex: affordable care act (ACA)
✔✔ACA facts - ✔✔- insurance companies were mandated to start covering children and
young adults below the age of 26 under their parents health insurance plan
- mandate for employers to provide health insurance
- requires that all US citizens and legal residents must be covered by either public or
private insurance
