Ch 11.docx

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University of Toronto Mississauga
Multiple Professors

Ch 11 Private health insuranceActuarially fair premium an insurance premium that is set where the expected payouts equal the premiums paid by the insured plus the cost of administrationcoinsurance the percentage of a medical bill that the insured must pay after deductibles and copayments are metcommunity rating insurance premiums that are based on the pooled risk of a community All indivduals in the community pay the same premium regardless of claims experience or personal level of riskcopayment a specified amount of the insured must pay for each received service that can vary by servicedeductible a fixed amount of a health care charge that the insured must pay before the insurer begins payment for all or part of the remainder of the costsexperience rating insurance premiums are based on the claims experience or risk level such as age of each insured groupManaged care organization MCO an organization with payment or delivery arrangements to control medical care costs and quality through utilization management drug formularies and profiling participating providers according to criteria for appropriate use of medical servicesUnderwriting the insurers process of reviewing insurance applications deciding what coverage to offer and determining the applicable premiums based on the health status of the applicant Private health insurance in contextprivate health insurance is deifned as a set of health services that are financed by a third party through private nonincome related payments called premiumsenrollment in private health insurance is voluntaryFigure 111 presents private health insurance in the context of health care financing
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