Table of Contents
Prologue viii
Preface x
Contributors xi
Chapter 1 Principles of Health Insurance 1
Learning Objectives 1
Introduction 1
Development of Health Insurance in the United States 3
Principles of Insurance 9
Summary 12
Chapter 2 Public and Private Coverage in the United States 13
Learning Objectives 13
Introduction 13
Private Health Insurance 14
Public Health Insurance 16
Trends in Health Insurance Coverage 22
Comparing Private and Public Coverage 23
Summary 24
Chapter 3 The Uninsured 27
Learning Objectives 27
Introduction 27
Number of Uninsured 27
Characteristics of the Uninsured 28
Reasons for Uninsurance 30
Consequences of Uninsurance 31
Trends in Uninsurance Rates 34
What Is Underinsurance? 34
Alternative Sources of Care and Payment for the Uninsured 37
Summary 38
Chapter 4 The Affordable Care Act 41
Learning Objectives 41
Introduction 41
History of the Affordable Care Act 42
Provisions of the Affordable Care Act 43
Enforcement 56
Summary 56
Chapter 5 Covered Benefits 59
Learning Objectives 59
Introduction 59
Terms of Coverage 60
Covered Benefits 62
Benefit Design 63
Coverage of Prescription Drugs 64
Coverage of Medical Providers 66
Summary 68
Chapter 6 Consumer Financial Responsibility for Health Care 71
Learning Objectives 71
Introduction 71
Premiums 71
Cost-Sharing 73
Prescription Drugs 76
High-Deductible Health Plans 77
Narrow Networks and Tiered Networks 79
Reference Pricing (Reverse Deductible) 79
Summary 80
Chapter 7 Consumer Protections 81
Learning Objectives 81
Introduction 81
Patient Rights 81
Patient Responsibilities 87
Summary 90
Chapter 8 Payment Mechanisms 91
Learning Objectives 91
Introduction 91
Common Payment Mechanisms 91
Comparison of Payment Mechanisms 92
History of Payment 93
Payments to Providers 96
Risk Adjustment 99
Value-Based Payment and Alternative Payment Models 100
Summary 103
Chapter 9 Claims and Reimbursement for Providers 107
Learning Objectives 107
Introduction 107
Diagnosis and Procedure Coding Systems 107
Filing Claims 110
Collecting Reimbursements and Handling Disputes 112
Summary 114
Chapter 10 Benefits to People with Disabilities 117
Learning Objectives 117
Introduction 117
Defining Disability 117
Programs Administered by the Social Security Administration 119
Workers' Compensation and Federal Programs for Workers 123
Summary 125
Chapter 11 Long-Term Care 127
Learning Objectives 127
Introduction 127
What Is Long-Term Care? 127
Financing of Long-Term Care 127
Who Needs Long-Term Services and Supports? 131
Long-Term Care Reform 132
Summary 133
Chapter 12 Retiree Benefits 135
Learning Objectives 135
Introduction 135
Types of Retiree Benefits 135
Unfunded Retiree Benefit Obligations 138
Characteristics of Firms That Offer Retiree Benefits 139
Impact of Aging on the Labor Force 140
Summary 141
Chapter 13 A Global Comparison of U.S. Health Insurance 143
Learning Objectives 143
Introduction 143
Defining Health Systems 143
Health Systems in High-Income Countries 144
Health Systems in Low- and Middle-Income Countries 146
Comparing Health System Performance 149
Summary 151
Appendix A A Guide to Dental and Vision Insurance 155
Appendix B Marketplace Assister Toolkit 159
Appendix C State Insurance Regulation 187
Glossary 191
Index 199
