chapter 6

Question 1

Why have costs risen?

Answer 1

advances in technology
specialization
aging has put strain on Medicare

Question 2

Why do we purchase health insurance?

Answer 2

minimize risk (probability of financial loss)

Question 3

What is the process of being insured?

Answer 3

a subscriber purchases a health insurance plan from an insurer

Question 4

range of benefits

Answer 4

covered services and those that are reimbursed

Question 5

Why was insurance developed?

Answer 5

could not assume that patients could afford risk or hospitals would be able to reimbursed

Question 6

Who finances health care?

Answer 6

individual, employer, or government

Question 7

first source

Answer 7

individual purchases policy directly from insurance company

cons: expensive (pat premium cost out of pocket)

Question 8

second source

Answer 8

employment cased arrangement; pay premium using payroll deductions combined with employer contributions

Question 9

co-insurance

Answer 9

cost sharing obligation under a policy

Question 10

third source

Answer 10

tax dollars collected from individuals and corporations allocated to finance programs and services

Question 11

Who is the largest purchaser of health insurance?

Answer 11

Centers for Medicare/Medicaid Services

Question 12

Who does Medicare cover?

Answer 12

65+
disabled
end stage renal disease

Question 13

Medicare Part A

Answer 13

inpatient hospital care, skilled nursing facility, some home health, and hospice care

Question 14

Who finances Medicare Part A?

Answer 14

payroll taxes and federal revenues

Question 15

Medicare Part B

Answer 15

voluntary

physician services, outpatient hospital, some home health, medical equipment

Question 16

Who finances Medicare Part B?

Answer 16

beneficiary premium payments

Question 17

Medicare Advantage

Answer 17

gain greater choice and can choose from an array of private health plan options

Question 18

Medicare Part D

Answer 18

subsidizes cost of prescriptions and provides more choices in health care coverage

Question 19

Medicaid

Answer 19

for indigent populations

Question 20

Who funds Medicaid?

Answer 20

state and federal governments

Question 21

Retrospective reimbursement methods

Answer 21

providers paid after service in full with no dispute

insurers assume risk for cost and claims

Question 22

Currently how much of our GDP is going to healtcare?

Answer 22

16%

Question 23

What are the three parts of a 3rd party system?

Answer 23

patient-provider-payer

Question 24

What are the 8 areas covered by the CBRR?

Answer 24

1. Information disclosure
2. Choice of plans and providers
3. Access to emergency service
4. Participation in HC decision
5. Respect and nondiscrimination
6. Confidentiality of health infor
7. Complaints and appeals
8. Consumer responsibilites

Question 25

The affordable care act is challenging what aspect of health care?

Answer 25

States have authority over insurance

Question 26

Florida constitution as a statue: Rights of patients

Answer 26

Individual dignity
Information
Financial information and disclosure
Access to health care
Experimental research
Patients knowledge to rights and responsibility

Question 27

The individual entity covered by the health policy

Answer 27

Insured

Question 28

The individual who has health plan coverage in virtue of being eligible on his/her own behalf rather than as a dependent

Answer 28

Subscriber

Question 29

The entity that is assuming the risk

Answer 29

Insurer

Question 30

Those good/services reimbursed by the insurance company, allowed by the purchased policy

Answer 30

Covered services

Question 31

Financial term: the amount of monies reimbursed for a covered service as a part of the health policy, regardless of who is responsible for payment

Answer 31

Allowable

Question 32

The amount the insured incurs/pays, before a health insurer will pay their portion of the remaining cost
Annual amount

Answer 32

Deductible

Question 33

Cost sharing obligation of the member after the deductible has been met
Not predetermined, it is the percentage of allowable or fee

Answer 33

Coinsurance

Question 34

Amount the provider charges

Not the same as what insurance will pay

Answer 34

Fee

Question 35

The amount the subscriber must pay each time the services are used
Is predetermined

Answer 35

Copayment

Question 36

The right or privilege based on criteria met or qualified for

Answer 36

Entitlment

Question 37

The cost of the health insurance policy, typically paid for on a monthly basis
Employer sponsored health insurance has an amount that is deducted from paycheck and paid to the insurance company

Answer 37

Premium

Question 38

prescribed for a patients use (crutches, commode, CPM)

Answer 38

Durable medical equipment (DME)

Question 39

annual period designated when an employee has the opportunity to switch to a new insurance plan

Answer 39

Open enrollment

Question 40

Vehicle used to bill the insurance company for the services provided: typically included medical condition, services provided, charges for services
Can be paper or electronic

Answer 40

Claim

Question 41

Another word for the insurance company

Answer 41

Carrier

Question 42

Be careful when using this verbiage
Accounting term: all expenses associated with the dispense of a service
Different from what we charge

Answer 42

Cost

Question 43

Attempt to balance the federal deficit, entitlement programs cut and medicare/medicaid reformed
Affect the delivery of health care
Relating to PT there were gross amounts of layoffs of PTs.

Answer 43

Balanced budget ACT 1997

Question 44

Developed due to these massive budget cuts

New way of reimbursing for healthcare services

Answer 44

Prospective payment system

Question 45

-provided more options to medicare recipients for part C and brought forth medicare part D (for prescription drugs (2006).
added some caveats to medicare beneficiaries to those with high incomes (if you made more $ you paid more into medicare)

Answer 45

Medicare modernization act

Question 46

Recent legislation that will expand access to healthcare to uninsured and underinsured individuals

Answer 46

Patient protection and affordable care act (2010)