Private insurance pt.2

-people contribute to a common pool an amount at least equal to the average expected cost resulting from use of covered services by the group as a whole.

risk in which loss is the only possible outcome

risk resulting in uncertain degree of gain or loss

everyone pays the same premium

premiums are based on demographic information, past medical use, family history, etc.

set limits on the amounts that insurers can vary premiums based on health status

business policies of picking out profitable customers from a large base

business policies of denying coverage to individuals that are expected to be more expensive, based on

-occupations

-past use of services

- past use of medications

between what consumers know compared to what insurers know gives consumers an advantage when looking for coverage that will meet their future demand for health care.

people are aware that the risk is transferred to the insurer so they over-consume resources

What is used to increase patient out-of-pocket costs and reduce healthcare utilization?

coverage limitation that puts a ceiling on how many benefits will covered per year

cosmetic surgeries, elective procedures, and fertility treatments not usually covered

-insurance companies can reuse to pay for services unless the beneficiary is enrolled for a certain period of time. For example, they may require patients be enrolled for 2 years before they cover maternal care costs.

-some companies will refuse to pay for conditions that were diagnosed before enrollment. This is not legal since ACA. of 2010.

requires approval from insurance before service is provided

requires an opinion from a second healthcare provider before service is provided.

requires a healthcare provider to certify that the service is needed.