block 1, 2 and 5 old quiz Flashcards
what are the primary players in health care marketplace
patients
providers
payers
which are following examples of cost sharing
deductibles
co pay
co-insurance
what is an example of gov as a payer
medicare
medicaid
tricare
which of the following may be sources of payment to providers in exchange for good/service
cost sharing
payment by insurer
goverment payment
What is most likely to happen if the following conditions apply?
No Guaranteed Issue
No Individual or employer mandate
Community Rating
individual with pre-exisiting conditions will be more likely to be denied coverage
Which of the following is most financially risky for insurance companies?
large and sick pool
The goal of underwriting is to:
minimize risk for the insurer
Which of the following is MOST likely to occur in a state with a single health insurance company offering policies?
higher premiums
Which of the following is a cultural belief that has contributed to challenges with reforming the US Healthcare system?
distrust in large gov
Which of the following was common insurance company practice prior to the ACA?
selling policies with annual benefit caps
States in which region of the United States are most likely to have the highest rates of pre-existing conditions?
southeast
During which era were physicians essentially the only provider of healthcare?
pre-industrial
When a patient visits her physical therapist, she is required to pay a percentage of the bill out of pocket. She is MOST LIKELY to have:
PPO
A patient’s employer ultimately pays the cost of any healthcare claims. She is MOST LIKELY to have:
ERISA plan
Which of the following is NOT TRUE about Consumer Directed Health Plans, or High Deductible Plans with a Health Savings Account (abbreviated HSA’s)?
HSA tend to cost more in premiums than PPOs
Which of the following is TRUE regarding HMO’s compared to PPO’s?
HMO a patient almost always must obtain a PCP referral to see a specialis, but not in a PPO
Which of the following are true about Health Maintenance Organizations (HMO’s)? Typically:
lower out of pocket costs at time of service than a PPO
A beneficiary’s insurance policy is 80/20 with out of pocket cost based on provider charges. His plan is structured to pay:
fee for service
If a patient’s insurance plan is an HMO, are they MORE LIKELY to pay a co-payment or co-insurance?
co-payment
Every time a patient is seen in a physical therapy clinic, the clinic receives a flat contracted amount. This is called:
payment per diem
A hospital negotiates with an insurer based on a reduced fee schedule to provide all services for an individual after an ACL reconstruction, including surgery, hospitalization and post-operative care. This is called:
payment per episode
Jason works for a small employer (25 employees), and purchased a family health insurance policy through the company. He chose a plan with a $100,000 per person Annual Maximum Benefit. The plan had no yearly out of pocket maximum. Jason was cleaning his gutters and fell off the ladder at home, sustaining a severe traumatic brain injury. The total bills in the first 2 months were $150,000. Who will be responsible for paying the bills over $100,000? CONSIDER THE CONCEPT OF THE ANNUAL MAXIMUM BENEFIT ONLY. DO NOT CONSIDER ANY CHANGES THAT HAVE OCCURRED AS A RESULT OF HEALTHCARE REFORM
jason and his family
A public health insurance program that provides both hospital insurance and supplemental medical insurance
medicare
Providers that submit claims for Medicare Part A services include:
hospital
Medicare is a Federal health insurance program following qualify:
age 65 and older
under 65 but considered disabled by cms
end stage kidney disease
In order to enroll in Medicare Part C, individuals must be eligible for Medicare, but they do not receive their Medicare through Original Medicare.
true
Original, also called Traditional Medicare, includes which of the following Parts
part a and b
Medigap helps pay some (or sometimes all) of the cost-sharing that Part A and Part B doesn’t cover
true
Medicare beneficiaries may choose to have their Hospital and Medical benefits administered through a private company if they enroll in:
part c
Choose the type of care that is NOT covered by Medicare Part B:
inpatient hospital facility services
medicare open enrollment is a time period when individuals ca
enroll in orginal medicare and choose to enroll in medicare advantage
which may include vision and perscription drugs
part c
An individual who enrolls in Medicare Advantage must also enroll in a Medigap plan.
false
why was the 75% rule developed
overutilization of inpatient rehav services over lowering cost settings
did the 75% rule become implimented
no stoped at 60%
which of the following applies to financing of medicare part b
premiums are collected from beneficiaries and cover 25% of the plan remainder comes from general tax revenue
Which of the following is TRUE for a Medicare beneficiary who signs up for a Part C plan?
Part C insurers often provide additional covered bundled benefits like Dental and Vision.
is custodial care covered by medicare
no
Which of the following is true about the Colorado Medicaid waiver for children example discussed in class/module?
The Medicaid waiver “waive” a family’s income, and use the child’s income as a determinant of eligibility criteria
