HCD I

Question 1

Sources of payment to providers in exchange for goods/services

Answer 1

cost-sharing
payment by insurer
governmental payment

NOT premiums — those go from patient to payer

Question 2

Most likely to happen if following conditions apply:
no guaranteed issue, no individual or employer mandate, community rating

Answer 2

individuals with pre-existing conditions will more likely be denied coverage

Question 3

common insurance company practice prior to ACA?

Answer 3

selling policies w annual benefit caps — now annual and lifetime caps are illegal under ACA!

Question 4

highest rate of pre-existing conditions in US?

Answer 4

southeast

Question 5

HMO features

Answer 5

co-pays
smaller network
cheaper premium
requires pre-auth from PCP
negotiated fee schedule
lower out of pocket costs

Question 6

PPO features

Answer 6

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

Question 7

A patient’s employer ultimately pays cost of any healthcare claims. Patient is most likely to have:

Answer 7

ERISA plan

Question 8

HSA features

Answer 8

largest network
least restrictive
cheapest premiums
no auth needed ever to see specialist
large deductible

Question 9

A beneficiary’s insurance policy is 80/20 with out of pocket cost based on provider charges. His plan is structured to pay

Answer 9

FFS

Question 10

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:

Answer 10

payment per episode

Question 11

In order to enroll in Medicare part C, individuals must be eligible for Medicare, but they do not receive their Medicare through Original Medicare

Answer 11

TRUE

Question 12

Medicare developed the 75% rule because of perceived:

Answer 12

overutilization of IRF over lower cost settings

Question 13

Which is true about the CO medicaid waiver for children?

Answer 13

the medicaid waiver “waives” a family’s income and uses the child’s income as a determinant of eligibility criteria

Question 14

the earliest US health insurance was

Answer 14

hospital based

Question 15

In a normal market, which of the following is true?

Answer 15

there is sometimes an imbalance of information, but most buyers and sellers have similar access to information about products and services

Question 16

Which of the following is most likely to lead to adverse selection for an insurer?

Answer 16

Guaranteed issue
No individual or employer mandate

Question 17

Which of the following has risen the LEAST in the past 20 years?
- health insurance premiums
- workers contribution to premiums
- overall inflation

Answer 17

overall inflation

Question 18

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?

Answer 18

total payment to the hospital increases as the patient stays in the hospital for more days

Question 19

Due to the moral hazard concept, which is expected to be the least costly for an insurance company?
- HMO
- PPO
- HSA

Answer 19

HSA

Question 20

defined contribution vs. defined benefit

Answer 20

defined benefit = employer pays for insurance plan, more risky
defined contribution = employer gives set amount towards insurance plan, less risky

Question 21

types of PT supervision

Answer 21

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