HCD I Flashcards
Sources of payment to providers in exchange for goods/services
cost-sharing
payment by insurer
governmental payment
NOT premiums — those go from patient to payer
Most likely to happen if following conditions apply:
no guaranteed issue, no individual or employer mandate, community rating
individuals with pre-existing conditions will more likely be denied coverage
common insurance company practice prior to ACA?
selling policies w annual benefit caps — now annual and lifetime caps are illegal under ACA!
highest rate of pre-existing conditions in US?
southeast
HMO features
co-pays
smaller network
cheaper premium
requires pre-auth from PCP
negotiated fee schedule
lower out of pocket costs
PPO features
larger network
less restrictive, don’t need PCP pre-auth
more expensive premiums
coinsurance and deductible
less costly to go out of network, but higher out of pocket costs
negotiated fee schedule
A patient’s employer ultimately pays cost of any healthcare claims. Patient is most likely to have:
ERISA plan
HSA features
largest network
least restrictive
cheapest premiums
no auth needed ever to see specialist
large deductible
A beneficiary’s insurance policy is 80/20 with out of pocket cost based on provider charges. His plan is structured to pay
FFS
A hospital negotiates with an insurer based on reduced fee schedule to provide all services for an individual after an ACL reconstruction, including surgery, hospitalization, and post-operative care. This payment method is called:
payment per episode
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
Medicare developed the 75% rule because of perceived:
overutilization of IRF over lower cost settings
Which is true about the CO medicaid waiver for children?
the medicaid waiver “waives” a family’s income and uses the child’s income as a determinant of eligibility criteria
the earliest US health insurance was
hospital based
In a normal market, which of the following is true?
there is sometimes an imbalance of information, but most buyers and sellers have similar access to information about products and services
Which of the following is most likely to lead to adverse selection for an insurer?
Guaranteed issue
No individual or employer mandate
Which of the following has risen the LEAST in the past 20 years?
- health insurance premiums
- workers contribution to premiums
- overall inflation
overall inflation
An acute care hospital is in a provider network for a private insurer and is paid a per diem rate. The insurance company does not use case management. What happens to total payment?
total payment to the hospital increases as the patient stays in the hospital for more days
Due to the moral hazard concept, which is expected to be the least costly for an insurance company?
- HMO
- PPO
- HSA
HSA
defined contribution vs. defined benefit
defined benefit = employer pays for insurance plan, more risky
defined contribution = employer gives set amount towards insurance plan, less risky
types of PT supervision
direct: PT physically in building— aides, other professions
immediate: PT physically in building and can provide immediate response — SPT
general: PT may not be in building but available to be contacted— PTAs
