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AHM-540 AHM Medical Management

Exam Details for AHM-540 AHM Medical Management:

Number of Questions: The AHM-540 test typically consists of 100 multiple-choice questions.

Time Limit: The test has a time limit of 2 hours (120 minutes).

Course Outline:
The AHM-540 AHM Medical Management certification test focuses on assessing the knowledge and skills required for effective medical management in the healthcare industry. The course outline covers the following key topics:

1. Introduction to Medical Management:
- Overview of medical management in healthcare organizations
- Roles and responsibilities of medical managers
- Regulatory and compliance considerations
- Ethical and legal issues in medical management
- Healthcare delivery models and systems

2. Healthcare Quality and Performance Improvement:
- Quality management principles and frameworks
- Measurement and evaluation of healthcare quality
- Performance improvement methodologies
- Patient safety and risk management
- Utilization management and cost containment

3. Medical Staff Governance and Credentialing:
- Medical staff organization and governance
- Credentialing and privileging processes
- Peer review and performance evaluation
- Medical staff bylaws and policies
- Collaboration and communication with medical staff

4. Healthcare Finance and Reimbursement:
- Financial management principles in healthcare
- Healthcare reimbursement models and payment systems
- Revenue cycle management
- Budgeting and financial forecasting
- Cost management and cost-effectiveness analysis

5. Medical Informatics and Technology:
- Electronic health records (EHR) and health information systems
- Clinical decision support tools and technologies
- Health data analytics and reporting
- Telemedicine and virtual care
- Privacy and security of health information

Exam Objectives:
The AHM-540 test aims to assess the following objectives:

1. Understanding of medical management principles, roles, and regulatory considerations in the healthcare industry.
2. Proficiency in healthcare quality management, including measurement, performance improvement, and patient safety.
3. Knowledge of medical staff governance, credentialing processes, and effective collaboration with medical staff.
4. Competence in healthcare finance and reimbursement, including financial management and cost containment strategies.
5. Familiarity with medical informatics, health information systems, and the use of technology in medical management.

Exam Syllabus:
The AHM-540 test covers the following syllabus:

1. Introduction to Medical Management
- Overview of medical management in healthcare organizations
- Roles and responsibilities of medical managers
- Regulatory and compliance considerations
- Ethical and legal issues in medical management
- Healthcare delivery models and systems

2. Healthcare Quality and Performance Improvement
- Quality management principles and frameworks
- Measurement and evaluation of healthcare quality
- Performance improvement methodologies
- Patient safety and risk management
- Utilization management and cost containment

3. Medical Staff Governance and Credentialing
- Medical staff organization and governance
- Credentialing and privileging processes
- Peer review and performance evaluation
- Medical staff bylaws and policies
- Collaboration and communication with medical staff

4. Healthcare Finance and Reimbursement
- Financial management principles in healthcare
- Healthcare reimbursement models and payment systems
- Revenue cycle management
- Budgeting and financial forecasting
- Cost management and cost-effectiveness analysis

5. Medical Informatics and Technology
- Electronic health records (EHR) and health information systems
- Clinical decision support tools and technologies
- Health data analytics and reporting
- Telemedicine and virtual care
- Privacy and security of health information
AHM Medical Management
Medical Management information source

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AHM Medical Management
Question: 155
The following statements are about chronic and disabling conditions among children eligible
for Medicaid. Three of the statements are true and one is false. Select the answer choice
containing the FALSE statement.
A. Children with chronic conditions use more physician and nonphysician professional
services than do children in the general population.
B. The majority of chronic conditions affecting children in Medicaid programs are the same
as those affecting children in the general population.
C. Medicaid-eligible children are at risk for seriousmental and physical conditions.
D. Children in Medicaid programs have a higher incidence of chronic disabling conditions
than do children in the general population.
Answer: B
Question: 156
Determine whether the following statement is true or false:
The key to successfully managing the quality and cost-effectiveness of healthcare services
for Medicaid enrollees is to merge Medicaid recipients into existing plans.
A. True
B. False
Answer: B
Question: 157
Access to services is an important issue for both fee-for-service (FFS) Medicaid and
managed Medicaid programs. Access to services under managed Medicaid is affected by the
A. lack of qualified providers in provider networks
B. lack of resources necessary to establish case management programs for patients with
complex conditions
C. unstable eligibility status of Medicaid recipients
D. inability of Medicaid recipients to change health plans or PCPs
Answer: C
Question: 158
The following statement(s) can correctly be made about medical management considerations
for the Federal Employee Health Benefits Program (FEHBP):
1. FEHBP plan members who have exhausted the health plan’s usual appeals process for a
disputed decision can request an independent review by the Office of Personnel Management
2. All health plans that cover federal employees are required to develop and implement
patient safety initiatives
A. Both 1 and 2
B. 1 only
C. 2 only
D. Neither 1 nor 2
Answer: A
Question: 159
Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located
at a military installation. Ms. Wilson serves as a primary point of contact between enrollees
and the TRICARE system and answers enrollees’ questions about plan options, eligibility,
provider selection, and claims. This information indicates that Ms. Wilson serves as a
A. lead agent
B. beneficiary services representative
C. health plan support contractor
D. primary care manager (PCM)
Answer: B
Question: 160
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Select
the term or phrase in each pair that correctly completes the paragraph. Then select the answer
choice containing the two terms or phrases you have chosen.
TRICARE enrollees have the right to challenge authorization and coverage decisions. Such
challenges are referred to as (appeals / grievances) and are typically handled by the
(TRICARE contractor / Area Field Office).
A. appeals / TRICARE contractor
B. appeals / Area Field Office
C. grievances / TRICARE contractor
D. grievances / Area Field Office
Answer: A
Question: 161
The delivery of quality, cost-effective healthcare is a primary goal of both group healthcare
and workers’ compensation programs. One difference between group healthcare and
workers’ compensation is that workers’ compensation
A. provides health and disability benefits to employees injured on the job only if the
employer is at fault for the injury
B. provides coverage for a variety of direct and indirect healthcare, disability, and workplace
C. manages costs by including employee cost-sharing features in its benefit design
D. places limits on benefits by restricting the amount of benefit payments or the number of
covered hospital days or provider office visits
Answer: B
Question: 162
For this question, if answer choices (A) through (C) are all correct, select answer choice (D).
Otherwise, select the one correct answer choice.
Ways that workers’ compensation health plans can help control the costs of job-related
injuries and illnesses include
A. applying strict definitions of medical necessity
B. developing prevention and recovery programs
C. applying out-of-network benefit reductions
D. all of the above
Answer: B
Question: 163
Occasionally, employers combine workers’ compensation, group healthcare, and disability
programs into an integrated product known as 24-hour coverage. One true statement about
24- hour coverage is that it typically
A. increases administrative costs
B. requires plans to maintain separate databases of patient care information
C. exempts plans from complying with state workers’ compensation regulations
D. allows plans to apply disability management and return-to-work techniques to
nonoccupational conditions
Answer: D
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Medical Management information source - BingNews https://killexams.com/pass4sure/exam-detail/AHM-540 Search results Medical Management information source - BingNews https://killexams.com/pass4sure/exam-detail/AHM-540 https://killexams.com/exam_list/Medical Google reveals the top 10 health searches of 2023 — and experts answer them No result found, try new keyword!Google has released its annual Year in Search, which breaks down the top searches in 2023. Below are the top 10 health-related questions of this year, along with experts’ responses to each. Thu, 28 Dec 2023 20:00:24 -0600 en-us text/html https://www.msn.com/ ‘Profitability Is the Key’: Barclays Says These 3 Health Tech Stocks Are Poised for Growth No result found, try new keyword!The healthcare sector has long been viewed by investors as a ‘recession proof’ defensive stalwart – and it is. When things turn south, consumers ... Wed, 03 Jan 2024 20:38:52 -0600 en-us text/html https://www.msn.com/ 4 Health Benefits of Lemon

Lemons (Citrus limon) are a citrus fruit known for their sour, bitter flavor and bright yellow color. They’re packed with vitamin C and antioxidants that support various aspects of health. For example, lemon water has gained a lot of popularity for helping to reduce the risk of kidney stones, promoting vitamin C intake, and supporting healthy digestion. 

Lemons are part of the Rutaceae family along with other citrus fruits. Read on to learn about the benefits and risks of lemon and tips for incorporating it into your meals and snacks.

Kidney stones are also known as renal calculi or nephrolithiasis. They're hard deposits made of minerals that build up in your urinary tract and form in your kidneys. Kidney stones affect about 10% of people. Increasing levels of a weak acid called urine citrate and making urine more alkaline can help prevent kidney stones.

Lemons contain a form of citrate called citric acid which helps increase urine citrate levels. Citric acid binds with urinary calcium to help prevent oversaturated urine. It also binds to hard clumps of minerals called calcium oxalate crystals to prevent them from growing and becoming painful kidney stones.

According to the National Kidney Foundation, daily consumption of four ounces of lemon juice concentrate mixed with water may help prevent kidney stones. However, an alkali citrate, like potassium citrate, may be better if your urine pH levels are too acidic. When in doubt, speak with your doctor about your risk for kidney stones and the best prevention options for you.

Lemons are rich in vitamin C and other antioxidants that support heart health. Consuming adequate vitamin C protects your cells from damaging free radicals—highly unstable particles that can cause damage to cells if they aren't neutralized. This can help prevent atherosclerosis (plaque buildup in the arteries), a condition that increases your risk of heart attack and stroke.

Phenolic compounds are a type of antioxidant found in lemons that support healthy blood pressure, endothelial function, and low-density lipoprotein (LDL) cholesterol levels. Endothelial function refers to how smoothly blood runs throughout your body. Hypertension (high blood pressure), high LDL cholesterol levels, and reduced endothelial function increase your risk of heart disease.

Eating lemons also increases your total fruit and vegetable intake. A large 2017 study found that higher fruit and vegetable intake was associated with reduced risk of cardiovascular disease, cancer, and all-cause mortality (risk of death due to any cause).

One lemon contains over 30% of your daily value (DV) for vitamin C. Vitamin C is important for iron absorption as well as for reducing your risk of heart disease. It helps you better absorb nonheme iron, which is found in plants and iron-fortified foods like bread and cereals.

Pairing food sources of iron with vitamin C helps you absorb iron more effectively. This can be especially beneficial if you're vegan or vegetarian and consume primarily nonheme iron. It can prevent iron deficiency anemia, a condition caused when your body does not have enough iron to produce hemoglobin. Hemoglobin is the protein in red blood cells that carries oxygen throughout your body.

Antioxidants in lemons prevent cell damage associated with health conditions like cardiovascular disease, chronic kidney disease, cancer, and chronic obstructive pulmonary disease (COPD). COPD is a group of chronic, progressive lung diseases that limit airflow to your lungs and cause difficulty breathing.

Numerous studies have shown that citrus fruits are rich in antioxidants. The antioxidants are present in the juice and flesh, but exact research shows that citrus peel contains even higher amounts of health-promoting antioxidants.

One lemon without the peel has the following nutrition profile:

  • Calories: 17 
  • Fat: 0.2 grams (g)
  • Sodium: 1 milligram (mg)
  • Carbohydrates: 5 g
  • Fiber: 1.6 g, or 6% of the DV
  • Added sugars: 0 g
  • Protein: 0.6 g 
  • Vitamin C: 31 mg, or 34% of the DV

Lemons also contain other micronutrients like potassium, vitamin B6, and thiamin. Micronutrients are vitamins and minerals needed by your body in small amounts.

Lemons are quite low in calories. Their main nutritional value comes from vitamin C, but they’re also a good source of phenolic compounds and carotenoids. These antioxidants protect against oxidative stress and cell damage linked to chronic disease.

Lemon is generally safe to eat in the amounts you typically find in food and beverages. However, experts aren’t sure about the safety of consuming it in medical amounts, such as from a lemon concentrate supplement, because we don’t have enough reliable information available.

Inhaling lemon for aromatherapy—for example, diffusing lemon essential oil—appears generally safe. However, phototoxicity is one potential risk. Phototoxicity is a harmful skin reaction to light after exposure to chemicals.

Some people may have a sensitivity to citrus fruits. Possible reactions range from mild symptoms like itchiness around your mouth to anaphylaxis, a severe and potentially life-threatening situation. Reach out to your healthcare provider if you think you may be allergic to citrus fruits. They can help you get tested for allergies and receive treatment if necessary. 

Dental erosion is another possible risk of lemons. The acid in lemons can break down tooth enamel, so it’s best to rinse your mouth with plain water after consuming lemon.

Finally, some people with acid reflux or gastroesophageal reflux disease (GERD) find that the acidity of citrus fruits makes their symptoms worse. GERD is a gastrointestinal disorder that occurs when your stomach acid repeatedly flows back into your esophagus (the tube that carries food from your mouth to your stomach).

Adding some lemon throughout your day and week may help you increase your vitamin C intake and antioxidant consumption to support health. Here are some tips to eat more lemons and maximize their freshness:

  • Store lemons in the crisper section of your fridge to maximize freshness
  • Freeze cut or whole lemons that you’re not going to use to prevent them from going to waste
  • Add lemon juice or a lemon wedge to water or tea
  • Marinate meat, fish, or tofu in lemon juice and garnish with lemon slices
  • Make a simple legume (e.g., chickpea) salad with lemon dressing to enhance absorption of nonheme iron
  • Use lemon or lemon zest to add flavor to soups, grains, or pastries

Lemons can add bright flavor and nutritional value to your meals and beverages. They’re packed with vitamin C and antioxidants that promote heart health, help prevent kidney stones and cell damage, and enhance iron absorption.

Try adding lemon to your water or tea, or use the juice and zest of lemons to flavor foods like meats, seafood, legumes, or grains.

Some people have a sensitivity to citrus fruits. The acidity of lemons can also erode tooth enamel and cause gastrointestinal symptoms. Pay attention to possible negative side effects of consuming lemons and reach out to your healthcare provider if you have questions or concerns.

Sun, 31 Dec 2023 10:00:00 -0600 en text/html https://www.health.com/lemon-8414390
Veradigm acquires revenue cycle management company Koha Health No result found, try new keyword!Healthcare data and technology solutions provider Veradigm (MDRX) said on Tuesday that it has acquired Koha Health, a revenue cycle management company. Tue, 02 Jan 2024 07:09:01 -0600 en-us text/html https://www.msn.com/ N. Hamgyong Province launches harsh inspection of hospitals’ management of medical supplies

At the end of last year, North Hamgyong Province launched an unprecedently harsh inspection focused on how hospitals and other facilities manage their supplies of medicines and other medical products, Daily NK has learned. 

Speaking on condition of anonymity for security reasons, a source in North Hamgyong Province told Daily NK on Dec. 26 that the provincial branch of the Ministry of Public Health began the inspection on Dec. 12 to review the practices of “local medical supply management offices and provincial, municipal, and county-level hospitals and clinics.” 

While inspections and reviews of agencies that handle medical supplies occur every December, “the authorities are carrying out a much harsher inspection this year, with cases related to two agencies already being turned over to prosecutors for punishment,” he said. 

In particular, the provincial branch of the Ministry of Public Health closely examined if public health agencies and facilities correctly managed the drugs in their possession and accurately recorded their use in their ledgers.

Local hospital staff and medical teams expressed fear they might get caught up in the unprecedentedly harsh inspection.

“Because medical supplies are always in short supply, hospitals paid little attention to managing their drugs – and many places didn’t keep up their ledgers – so hospitals and medical teams are frightened following the sudden launch of this intense inspection,” the source said.

In fact, the managers of one medical supply office in Chongjin faced an investigation after the authorities discovered they used drugs from a pharmaceutical factory without verifying their quality or efficacy and falsified medicine use records.

The inspection found that local pharmaceutical factories had sold drugs deemed unusable to pharmacies and hospitals at low prices, and local hospitals were found to be failing to store medicines in designated locations.

During the course of the inspection, the provincial branch of the Ministry of Public Health regularly reported the investigation’s results to the provincial party committee, and provincial and city prosecutors used the results to launch their own probes.

For example, prosecutors investigated all medical supply management offices, pharmacy, and hospital employees found to have sold cold medicine, antibiotics, and other medications to market sellers. Furthermore, prosecutors were handed cases of doctors who arbitrarily prescribed narcotic pain medication such as morphine without prescriptions.

“The arbitrary management of medical supplies is certainly a problem that directly impacts patient safety, but cases of hospitals pilfering medicines in violation of regulations is particularly bad,” provincial public health officials said, according to the source. “We’ll uncover all these acts and severely punish them.”

“The situation in Chongjin, the province’s biggest city, is this bad, so it goes without saying what other cities, counties, and villages are like,” the source said. “The inspection will likely lead to punishments for officials in facilities and agencies that have failed to manage their medical supplies properly.”

Translated by David Black. Edited by Robert Lauler. 

Daily NK works with a network of sources who live inside North Korea, China and elsewhere. Their identities remain anonymous due to security concerns. More information about Daily NK’s reporting partner network and information gathering activities can be found on our FAQ page here.  

Please direct any comments or questions about this article to dailynkenglish@uni-media.net.

Read in Korean

Thu, 04 Jan 2024 18:00:00 -0600 en-US text/html https://www.dailynk.com/english/n-hamgyong-province-launches-harsh-inspection-of-hospitals-management-of-medical-supplies/
Exercise prescription: Pioneering the 'third pole' for clinical health management

Professor Chen Shiyi's team at Huashan Hospital of Fudan University has commented on the concept, policy, development and prospect of exercise prescription in the context of "Health for All."

The work, titled "Exercise Prescription: Pioneering the 'Third Pole' for Clinical Health Management," is published in the journal Research.

Modern lifestyles have led to reduced physical activity and a rise in chronic diseases from a young age. Exercise has emerged as a key component in , not only integrating medical and sports models but also enhancing , treating and preventing chronic diseases, and improving the elderly's self-care abilities. Exercise, as a natural and side-effect-free treatment, has been proven effective against numerous chronic diseases.

Professor Chen Shiyi's team has found that exercise can enhance immunotherapy in treating certain cancers and slow down physiological aging. An increasing body of evidence suggests that exercise emerges as the "third pole" (which means sports medicine occupies a unique and indispensable position in clinical practice, and it is as important as medication and surgery).

Exercise prescriptions, akin to medical prescriptions, offer personalized exercise recommendations for treating or preventing diseases and enhancing physical fitness. These prescriptions, crafted by specialists, detail exercise types, frequency, intensity, and duration, catering to a wide range of individuals, from youths to the elderly, and those with .

The future of exercise prescriptions lies in their detailed and systematic application as comprehensive health management plans. Key development areas include personalized services, integration with modern medical equipment, professional training, and public awareness. As prescriptions gain traction, they are set to contribute significantly to public health, with China poised to cooperate with other countries in research globally.

More information: Zhiwen Luo et al, Exercise Prescription: Pioneering the "Third Pole" for Clinical Health Management, Research (2023). DOI: 10.34133/research.0284

Provided by Research

Citation: Exercise prescription: Pioneering the 'third pole' for clinical health management (2023, December 21) retrieved 5 January 2024 from https://medicalxpress.com/news/2023-12-prescription-pole-clinical-health.html

This document is subject to copyright. Apart from any fair dealing for the purpose of private study or research, no part may be reproduced without the written permission. The content is provided for information purposes only.

Wed, 20 Dec 2023 10:00:00 -0600 en text/html https://medicalxpress.com/news/2023-12-prescription-pole-clinical-health.html
Margins Ring Alarm Bells As 160 Health Readies IPO

Key Takeaways:

  • Gross margins have been falling at 160 Health, which gets more than 60% of its revenue from wholesaling medical and health supplies
  • The online healthcare service provider is still in the red but rising revenues and cost-cutting measures have helped to narrow its losses  

By Li Shi Ta

Digital healthcare has been booming in China, offering a remedy for some of the deep-rooted maladies of the country’s medical system.

Online platforms connecting patients with medical services or products can help to alleviate the uneven distribution and the limited supply of quality provision that plague the Chinese healthcare system.

And the government’s plan to boost the population’s health by 2030 has the potential to generate even more business for market leaders in digital healthcare such as 160 Health International Ltd..

Seeking capital to ride an anticipated wave of demand, 160 Health became the latest company in the sector to file for a Hong Kong share listing on Dec. 15, following in the footsteps of ClouDr Group Ltd. (9955.HK) and Medlive Technology Co., Ltd. (2192.HK).

The IPO candidate will be hoping that the rapid growth of digital healthcare will be a draw for investors. 

China’s digital healthcare industry grew from 28.9 billion yuan ($4.05 billion) in 2017 to 135.2 billion yuan in 2022, representing a compound annual growth rate (CAGR) of 36.2% during the period, according to a Frost & Sullivan study. The market is predicted to reach 1.4 trillion yuan in 2030, marking a CAGR of 33.9% from 2022.

The 160 Health platform connects healthcare organizations, medical professionals, individual users and third-party suppliers. According to the listing application, the company ranked as China’s biggest platform for integrated digital healthcare services in 2022 by number of registrations and partner hospitals.

The company was founded in 2005 by Luo Ningzheng, a computer engineering graduate with a professional background in education and health management. After heading up the information and education department at a Shenzhen hospital, he jumped into the digital healthcare business by setting up Shenzhen Ningyuan, the predecessor of 160 Health.

Big Marketing Drive 

Collaboration with healthcare organizations is one of the company’s core businesses, through digital solutions to help the institutions better manage their medical information and monitor diseases. 

160 Health also provides an online health service platform and healthcare management tools for medical professionals. Individual users can also enjoy a one-stop service spanning medical appointments, consultations and diagnosis, consumer healthcare packages and supplies of medicines or healthcareproducts. In addition, the company runs an online retail pharmacy.

As of the end of June this year, the platform served more than 260 Chinese cities, with a user base of more than 30,000 healthcare organizations and over 720,000 healthcare professionals, according to information in the listing document. The company had 44.9 million registered individual users, with an average of 3 million monthly active users as of the middle of this year.

Looking at the company’s finances, revenues have been rising over the past three years, but 160 Health is still making a loss.

The company brought in 280 million yuan in 2020, jumping to 420 million yuan the following year and 530 million yuan in 2022. It logged a net loss of 29.88 million yuan in 2020, surging to 150 million yuan a year later before narrowing to 120 million yuan. In the first half of this year, revenues came in at 270 million yuan, translating into a net loss of 24.78 million yuan. The online healthcare service provider is trimming its losses with higher revenues and cost-cutting.

160 Health cited the high costs of developing services and products and attracting traffic as the reasons for the persistent red ink. Notably, marketing expenses at 97.4 million yuan in 2022 were nearly double the company’s R&D spending of 54.1 million yuan that year. Clearly, the company depends on marketing to drive its sales performance.

Reliant On Drug Sales

In fact, digital healthcare solutions are not the company’s main source of revenue. The company has become increasingly reliant on its other main business – sales of pharmaceutical and health supplies. The share of revenue generated from wholesale pharmaceutical supplies has risen from 24.9% in 2020 to 63% in the first half of this year.

That shift has come with a downside. According to the listing application, 160 Health’s gross margin has dropped from 36.8% in 2020 to 24.8% in the first half of this year. The company said the decline was mainly due to an increasing proportion of revenue coming from the lower-margin sales of medical and health supplies. Gross margin on those sales has typically languished in the single digits and fell from 7.9% in 2020 to 2.1% in the middle of this year. By contrast, the gross margin for digital healthcare solutions remained at around 75%.

As online healthcare has become a national priority in China, more and more local governments have embraced digital solutions, seeking to stretch their limited resources with systems linking treatment, medicines and health insurance.

Compared with its rivals, 160 Health benefits from more than a decade of experience in developing digital healthcare in Shenzhen. By comparison, ClouDr is an online platform focusing on chronic disease management while Medlive is a doctor-focused service.

The services provided by 160 Health, such as its Cloud Hospital, Cloud Social Health and Cloud Pharmacy, have laid a foundation for a city-level healthcare service portal. If it can take advantage of more R&D investment, a rising reputation and policy support, the company may be able to boost its financial health in the future and finally turn a profit.

This article is from an external contributor. It does not represent Benzinga's reporting and has not been edited for content or accuracy.

© 2024 Benzinga.com. Benzinga does not provide investment advice. All rights reserved.

Wed, 27 Dec 2023 23:55:00 -0600 en text/html https://www.benzinga.com/23/12/36411850/margins-ring-alarm-bells-as-160-health-readies-ipo
Northwell collaborates with Envetec to become first health care system in US to implement innovative clean technology to treat regulated medical waste No result found, try new keyword!Northwell Health, New York State's largest health care provider and private employer, and Envetec Sustainable Technologies Limited ( ... Wed, 03 Jan 2024 00:00:00 -0600 https://www.businesswire.com/news/home/20240103355312/en/Northwell-collaborates-with-Envetec-to-become-first-health-care-system-in-US-to-implement-innovative-clean-technology-to-treat-regulated-medical-waste Buying Private Health Insurance

If your employer doesn’t offer you health insurance as part of an employee benefits program, you may be looking at purchasing your own health insurance through a private health insurance company. It is common to be concerned about how much it will cost to purchase health insurance for yourself. However, there are various options and prices available to you based on the level of coverage that you need.

Key Takeaways

  • You may need to purchase individual healthcare coverage if you just turned 26 years old, are unemployed or self-employed, work part time, are starting a business that will have employees, or have recently retired.
  • If you do not have the option of enrolling in an employer-sponsored health insurance plan, a good source for gaining insurance coverage is through the Health Insurance Marketplace that was created in 2014 by the Affordable Care Act (ACA).
  • If you are at least age 65 or disabled, you can enroll in Medicare, with the option to add additional coverage through a private Medigap or Medicare Advantage plan.

How Buying Private Health Insurance Works

A premium is the amount of money that an individual or business pays to an insurance company for coverage. Health insurance premiums are typically paid monthly. Employers that offer an employer-sponsored health insurance plan typically cover part of the insurance premiums. If you need to insure yourself, you’ll be paying the full cost of the premiums.

When purchasing your own insurance, the process is more complicated than simply selecting a company plan and having the premium payments come straight out of your paycheck every month. Here are some tips to help guide you through the process of purchasing your own health insurance.

Some Americans get insurance by enrolling in a group health insurance plan through their employers. Medicare also provides healthcare coverage to people 65 years or older and the disabled, and Medicaid has coverage for low-income Americans.

Medicare is a federal health insurance program for people who are age 65 or older. Certain young people with disabilities and people with end-stage renal disease may also qualify for Medicare. Medicaid is a public assistance healthcare program for low-income Americans regardless of their age.

If your company does not offer an employer-sponsored plan, and if you are not eligible for Medicare or Medicaid, individuals and families have the option of purchasing insurance policies directly from private insurance companies or through the Health Insurance Marketplace.

Scenarios When You Might Need Private Health Insurance

There are certain circumstances that make it more likely that you will need to purchase your own health insurance plan, including:

A Young Adult 26 Years of Age or Older

Under provisions of the Affordable Care Act (ACA) of 2010, young people can be covered as dependents by their parents’ health insurance policy until they turn 26 years old. After that, they must seek out their own insurance policy.


If you lose your job, you may be eligible to maintain coverage through your employer’s health insurance plan for a period of time through a program called the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA allows eligible employees and their dependents the option to continue health insurance coverage at their own expense. 

While coverage through COBRA can be maintained for up to 36 months (under certain circumstances), the cost of enrolling in COBRA is very high. This is because the formerly employed person pays the entire cost of the insurance. Typically, employers pay a portion of healthcare premiums on behalf of their employees.

A Part-Time Employee

Part-time jobs rarely offer health benefits. A part-time job is any position that requires employees to work a lower number of hours than would be considered full time by their employer, or 40 hours per week. If you work part time, you usually must enroll in your own health insurance.


A self-employed person may work as a freelancer or own a business. Some self-employed people can get health insurance through a spouse’s plan. If not, they must provide their own health insurance.

A Business Owner Who Has Employees

If you start a business and you have employees, you might be required to offer them health insurance. Even if it’s not required, you might decide to offer health insurance to be a competitive employer that can attract qualified job candidates. In this situation, you will be required to purchase a business health insurance plan, also known as a group plan.

If You Retire (or Your Spouse/Parent Retires)

When you retire, you will likely no longer be eligible for employer-sponsored health insurance. If you are under age 65 and not disabled, you will need to purchase individual private health insurance until you turn 65 and can apply for Medicare. Many retirees choose to purchase private Medigap or Medicare Advantage plans in addition to Medicare as a way of guaranteeing more comprehensive coverage. Some retired people may also decide to completely replace Medicare coverage with a private Medicare Advantage plan.

It is important to note that Medicare, Medigap, and Medicare Advantage plans are only for the individual—your spouse, partner, and any dependents cannot be insured through your Medicare plan. This means that if your family was previously insured through your employer’s plan, and you retire, your family members may need to enroll in individual insurance plans.

Dropped by Your Existing Insurer

Although the ACA prevents insurers from canceling your coverage—or denying you coverage due to a preexisting condition or because you made a mistake on your application—there are other circumstances when your coverage may be canceled. It’s also possible that your insurance may become so expensive that you can’t afford it.

Why You Should Purchase Health Insurance

If you find yourself in one of the above situations and lack health insurance coverage, it’s important to enroll in an individual plan as soon as possible. (The fine for failing to obtain coverage was canceled in 2019.)

Even though you’re not required to have insurance, you cannot predict when an accident will occur that will require medical attention. Even a minor broken bone can have major financial consequences if you’re uninsured.

If you purchase insurance through the Health Insurance Marketplace, you may be eligible for income-based premium tax credits or cost-sharing reductions. The marketplace is a platform that offers insurance plans to individuals, families, and small businesses.

The ACA established the marketplace as a means to achieve maximum compliance with the mandate that all Americans be enrolled in health insurance. Many states offer their own marketplaces, while the federal government manages an exchange open to residents of other states.

While you may not be able to afford the same kind of plan that an employer would offer you, any amount of coverage is more advantageous than none. In the event of a major accident or a long-term illness, you will be prepared.

Choosing the Best Insurance Plan for You

There are several different kinds of health insurance plans, and each of these plans has a number of unique features.

Health Maintenance Organization (HMO)

A health maintenance organization (HMO) is a company with an organizational structure that allows them to provide insurance coverage for their subscribers through a specific network of healthcare providers.

Typical HMO features include paying for insurance coverage for a monthly or annual fee. Premiums tend to be lower for HMOs because health providers have patients directed at them, but the disadvantage is that subscribers are limited to accessing a network of doctors and other healthcare providers who are contracted with the HMO.

Preferred Provider Organization (PPO)

A preferred provider organization (PPO) is a type of insurance plan in which medical professionals and facilities provide services to subscribed clients at reduced rates. Healthcare providers that are part of this network are called preferred providers or in-network providers. 

Subscribers of a PPO plan have the option of seeing healthcare providers outside of this network of providers (out-of-network providers), but the rates for seeing these providers are more expensive.

Exclusive Provider Organization (EPO)

An exclusive provider organization (EPO) is a hybrid of HMO and PPO plans. With an EPO plan, you can only receive services from providers within a certain network. However, exceptions can be made for emergency care.

Another characteristic of an EPO plan is that you may be required to choose a primary care physician (PCP). This is a general practitioner who will provide preventive care and treat you for minor illnesses. In addition, with an EMO plan, you usually do not need to get a referral from your PCP to see a specialist physician.

High-Deductible Health Plan (HDHP)

A high-deductible health plan (HDHP) has a couple of key characteristics. As its name implies, it has a higher annual deductible than other insurance plans. A deductible is the portion of an insurance claim that the subscriber covers themselves. HDHPs typically have lower monthly premiums.

This type of plan is ideal for young or generally healthy people who don’t expect to demand healthcare services unless they experience a medical emergency or an unexpected accident.

The last defining feature of a high-deductible health plan is that it offers access to a tax-advantaged Health Savings Account (HSA).

HSA subscribers can contribute funds that can later be used for medical costs that their HDHP doesn’t cover. The advantage of these accounts is that the funds are not subject to federal income taxes at the time of the deposit.

Consumer-Driven Health Plan (CHDP)

Consumer-driven health plans (CDHPs) are a type of HDHP. A portion of services that subscribers receive is paid for with pretax dollars. Like other HDHPs, CDHPs have higher annual deductibles than other health insurance plans, but the subscriber pays lower premiums each month.

Point-of-Service (POS) Plan

A point-of-service (POS) plan provides different benefits to subscribers based on whether or not they use preferred providers (in-network providers) or providers outside of the preferred network (out-of-network providers). A POS plan includes features of both HMO and PPO plans.

Short-Term Insurance Policy

A short-term insurance policy covers any gap that you might experience in coverage if, for example, you change jobs and your new company plan doesn’t kick in immediately.

It typically lasts for three months. Term lengths vary by state, and in some U.S. states, you may be eligible for a short-term plan for up to 12 months.

Short-term health insurance is also called temporary health insurance or term health insurance. It can be useful if you’re changing jobs, waiting to become eligible for Medicare coverage, or waiting out the designated open enrollment period for a plan.

Under a short-term insurance plan, your spouse and other eligible dependents may also be covered. However, one important caveat of a short-term insurance plan is that in some cases, preexisting conditions can disqualify you from coverage. The definition of a preexisting condition varies depending on the state where you live, but it is usually defined as something you have been diagnosed with or received treatment for within the last two to five years.

Catastrophic Coverage

Catastrophic health insurance is a type of insurance plan that is typically only available to adults ages 30 or younger. To qualify, you must receive a hardship exemption from the government. Catastrophic health insurance typically has lower premiums than other health insurance plans.

These types of plans are intended for people who cannot afford to spend much money every month on insurance premiums but don’t want to be without insurance in the event of a serious accident or illness.

While catastrophic health insurance plans may have low monthly premiums, they typically have the highest possible deductibles.

Choosing a Deductible

Once you’ve decided on the type of plan that is best for you, you’ll need to determine how much you can afford to pay as a deductible. This is the predetermined amount that you pay for covered healthcare services before your insurance plan starts to pay.

What can you afford to pay in out-of-pocket medical expenses each year? With most health insurance plans, the higher your deductible is, the lower your monthly premium will be. If your monthly cash flow is low, you might have to opt for a higher deductible.

Another key consideration when selecting an insurance plan is the plan’s out-of-pocket maximum. After you’ve spent this amount on deductibles and medical services through co-payments and co-insurance, your health plan will pay the entire cost of covered benefits.

How Much Does Private Health Insurance Cost?

While many people are scared by the prospect of purchasing their own insurance versus enrolling in an employer-sponsored plan, some studies have shown that it can end up being more affordable than employer-sponsored plans.

A study from the Kaiser Family Foundation found that the average annual premium for an employer-sponsored insurance plan for individual coverage in 2023 was $8,435 per year. This total increases to $23,968 per year for family coverage.

In addition, if you end up purchasing coverage through the Health Insurance Marketplace, you may qualify for a Cost-Sharing Reduction subsidy and Advanced Premium Tax Credits. These can lower your premium payment amounts, your deductible, and any co-payments and co-insurance for which you are responsible.

Where to Go to Buy Private Health Insurance

You have several options when it comes to buying private health insurance.


If you are (or are soon to be) retired, you can begin on the Medicare website. It is recommended that you see what the standard Medicare plan covers and then look at options for ways to supplement Medicare through Medigap and Medicare Advantage policies.

When considering Medigap or Medicare Advantage coverage, it’s important to understand how both work types of coverage work in conjunction with standard Medicare coverage.


As a result of the ACA, the Health Insurance Marketplace was created in 2014. You can visit the Health Insurance Marketplace website to find out more about the options for health insurance coverage that are available where you live. You can also determine if you qualify for any subsidy and apply for it.

The marketplace has a specific open enrollment period. Typically, it is from Nov. 1 to Dec. 15 every year, although various events may lead to the open enrollment period being extended or reopened.

The website includes information about private plans that are available for purchase outside of the marketplace. However, if you purchase a plan outside of the marketplace, whether during open enrollment or not, then you will not be eligible for any subsidies available under the ACA.

Under certain circumstances, an individual may be eligible to purchase a healthcare plan through the exchange even if it is outside of the specified open enrollment period. This is called a Special Enrollment Period. You may be eligible for a Special Enrollment Period if you experience a household change, including getting married or divorced, having or adopting a child, a death in your family, moving, losing your health insurance, being in a national catastrophe, or experiencing a disability.

The American Rescue Plan of 2021 increased subsidies for ACA plans for lower-income Americans and broadened subsidies to include some subsidies at higher income levels.

Private Health Insurance Companies

You can visit the websites of major health insurance companies in your geographic region and browse available options based on the type of coverage that you prefer and the deductible that you can afford to pay.

The types of plans available and the premiums will vary based on the region where you live and your age. It’s important to note that the plan price quoted on the website is the lowest available price for that plan and assumes that you are in excellent health. You won’t know what you’ll really pay per month until you apply and provide the insurance company with your medical history.

Pricing and the type of coverage can vary significantly based on the health insurance company. Because of this, it can be difficult to truly compare the plans to determine which company has the best combination of rates and coverage. It can be a good idea to identify which plans offer the most of the features that you require and are within your price range, then to read consumer reviews of those plans.

If you are choosing a family plan or are an employer who is choosing a plan that you’ll provide to your employees, then you’ll also want to consider the needs of others who will be covered under the plan.

Key Factors for Choosing a Plan

Health insurance plans offer a variety of different features. While it may be hard to find a plan that offers everything you desire, consider which of the following features are the most medically and financially necessary. Here are some questions to consider when you are researching plans:

  • Does the plan offer prescription drug coverage? Does it only cover generic versions of prescription drugs? What is the co-payment (also referred to as the co-pay) on generics and name-brand drugs? Check the medicines you’re already taking, if any.
  • What is the office visit co-payment, and does the plan have instituted a maximum number of office visits that it will cover per year?
  • What is the co-payment for specialized services, such as X-rays, lab tests, and surgery? How about for an emergency room visit?
  • Do you want a plan that allows you to add vision and dental coverage?
  • Do you need pregnancy benefits?
  • Do you already have a doctor who you like? If so, you might want to find a plan that includes your doctor in its insurance company’s provider network.
  • Do lifetime and annual maximum benefits apply? The ACA effectively eliminated lifetime and annual maximums for essential medical services, but this does not include dental and vision coverage, for example.
  • Does the plan offer free or discounted services for preventive care, such as an annual checkup? Most plans under the ACA provide free coverage for most preventive care services. Short-term insurance plans and catastrophic coverage may not.
  • Does the plan cover specialty services such as physical therapy, chiropractic, and acupuncture visits?
  • What hospitals are included in the network?
  • For PPOs, what is the cost for out-of-network services, should you want or need them? Can you afford this?

When Can I Buy Private Health Insurance?

Most types of health insurance have an open enrollment period during which you can sign up for private health insurance. This is true whether you buy insurance via the Affordable Care Act (ACA) health insurance exchange in your state, sign up directly through the insurer, enroll in the plan that your employer offers, or sign up for Medicare.

Certain life events can trigger a special enrollment period, which will allow you to change your health insurance coverage outside of the normal enrollment period. These events include getting married or divorced, having a baby, losing your job-based health insurance, or moving out of your health plan’s service area.

What Does Private Health Insurance Cost?

In 2023, the average national cost for health insurance per year was $8,435 for single coverage and $23,968 for family coverage. However, this cost can vary considerably depending on your healthcare needs, the state where you live, and what level of coverage you require.

Where Can I Buy Private Health Insurance?

A good place to start looking for coverage is the Health Insurance Marketplace created in 2014 by the ACA. On the marketplace for your state, you can look through the details of private health insurance plans and compare the cost and benefits of each. If your state does not have its own marketplace, use HealthCare.gov.

The Bottom Line

Getting your own health insurance policy is not as easy as signing up for an employer’s plan, but at least you have control over the plan that you get. Once you figure out what you need and become familiar with the terminology used to describe health insurance plans, your research will become easier. With the number of options available, you can probably find a plan that meets both your needs and your budget.

Mon, 21 Sep 2015 10:04:00 -0500 en text/html https://www.investopedia.com/articles/pf/08/private-health-insurance.asp
Electrostim Medical Services Notifies Consumers of exact Data Breach Impacting Their Personal Information

On December 28, 2023, Electrostim Medical Services, Inc. (“EMSI”) filed a notice of data breach with the Attorney General of Vermont after discovering that an unauthorized party was able to access its computer system. In this notice, EMSI explains that the incident resulted in an unauthorized party being able to access consumers’ sensitive information, which includes their names, addresses, email addresses, phone numbers, diagnosis information, insurance information, subscriber numbers, and order histories. Upon completing its investigation, EMSI began sending out data breach notification letters to all individuals whose information was affected by the exact data security incident.

If you received a data breach notification from Electrostim Medical Services, Inc., it is essential you understand what is at risk and what you can do about it. A data breach lawyer can help you learn more about how to protect yourself from becoming a victim of fraud or identity theft, as well as discuss your legal options following the Electrostim Medical Services data breach. For more information, please see our exact piece on the topic here.

What Caused the Electrostim Medical Services Data Breach?

The Electrostim Medical Services data breach was only recently announced, and more information is expected soon. However, EMSI’s filing with the Attorney General of Vermont provides some important information on what led up to the breach. According to this source, on May 13, 2023, EMSI detected suspicious activity within its computer network. In response, EMSI secured its systems and launched an investigation with the help of third-party data security specialists.

Ultimately, the EMSI investigation confirmed that an unauthorized party accessed the company’s IT network between April 27, 2023 and May 13, 2023. EMSI also determined that the unauthorized party accessed certain files containing confidential consumer information.

After learning that sensitive consumer data was accessible to an unauthorized party, Electrostim Medical Services reviewed the compromised files to determine what information was leaked and which consumers were impacted. While the breached information varies depending on the individual, it may include your name, address, email address, phone number, diagnosis information, insurance information, subscriber number, and order history.

On December 28, 2023, Electrostim Medical Services sent out data breach letters to anyone who was affected by the exact data security incident. These letters should provide victims with a list of what information belonging to them was compromised.

More Information About Electrostim Medical Services, Inc.

Electrostim Medical Services, Inc. is a medical device manufacturing company based out of Tampa, Florida. EMSI is an affiliate of Validus Group, a private investment firm which is also based in Tampa, Florida. Affiliates of Validus Group include Strategic Capital Fund Management, Validus Group Properties, Validus Senior Living, Electrostim Medical Services Inc. (EMSI), and SC Distributors. Electrostim Medical Services employs more than 356 people and generates approximately $71 million in annual revenue.

Wed, 03 Jan 2024 10:00:00 -0600 en text/html https://www.jdsupra.com/legalnews/electrostim-medical-services-notifies-2215745/

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