Chapter 3

Question 1

Medicare

Answer 1

a federal health program that serves people over the age of 65 and certain disabled people younger than 65
- Any adult with permanent kidney failure (end-stage renal disease) or amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease)
- patients on medicare are entitiled to the same benefits as people with private insurance.

Question 2

Medicaid

Answer 2

a federal health program that was originally for low-income children and pregnant women but was expaned to include low-income adults with the introduction of the ACA 2010.

• ACA set new guidelines requiring states to cover all children and pregnant women living in households with incomes up to at least 138% of the federal poverty level (FPL).

Question 3

CHIP

Answer 3

provides healthcare coverage for low-income children who do not qualify for Medicaid

• All states have expanded children’s coverage significantly through their CHIP programs, with nearly every state providing coverage for children up to at least 200% of the FPL.

Question 4

Medicaid and Chip are both…

Answer 4

jointly funded by the federal government and individual state governments for those not eligible for insurance through an employer and for those who cannot afford to purchase health insurance through the Marketplace.

Question 5

HMOs

health maitenance organization

Answer 5

• Prepaid health insurance that only covers care provided by
  those inside the HMO network
• Patients must have a referral from a primary care provider
  to see a specialist.
• Consumer’s cost is generally less than other facilities.

Question 6

MCOs

managed care organizations

Answer 6

health insurance programs that control healthcare costs by agreeing to provide health services in exchange for a set dollar amount recieved from Medicare and Medicaid for each enrollee; MCOs use capitation to control healthcare costs.

Question 7

PPOs

preferred provider organizations

Answer 7

• PPOs cover care provided both inside and outside the plan’s provider network.
• Comprise groups of physicians or a hospital that provides companies with comprehensive health services at a discount.
• Benefits of a PPO are choice of provider and hospital and cost control.

Question 8

EPOs

exclusive provider organizations

Answer 8

• Similar to HMOs because services outside network are not covered.
• Difference between HMO and EPO is that EPO usually does not require primary care provider to make referrals to specialists.
• Biggest impact of managed care has been substantial reduction in use of hospitals.

Question 9

In 2019, total spending for Medicare was…

Answer 9

799 billion, approximately 800 billion.