Healthcare

26

The Patient Protection and Affordable Care Act allows young adults to be covered under their parent's policy up to age ____.

to create programs that promote good health and prevent disease

The Patient Protection and Affordable Care Act establishes a Prevention and Public Health Fund for what purpose?

for allowing individuals to purchase community living assistance services and support for long term care

The Patient Protection and Affordable Care Act establishes a national voluntary insurance program for what purpose?

World Health Organization

The World Health Organization (WHO) is a specialized agency of the United Nations (UN) that is concerned with international public health.

expands Medicaid eligibility to include families and individuals with incomes up to 133% of the poverty level unless a particular state opts out of this requirement

Describe the primary provision of the Patient Protection and Affordable Care Act (2010) that concerns Medicaid eligibility.

15

The cost of healthcare is more than ___% of the GDP.

wellness

Emphasis on _________ is a growing trend in healthcare; people are more aware of the need to maintain health and prevent disease because disease prevention improves the quality of life and saves costs

true

True or false: Individual pays premium for type B coverage and must also pay initial deductible for services.

true

True or false: The Patient Protection and Affordable Care Act provides additional support for medical research and the National Institutes of Health.

true

True or false: The Patient Protection and Affordable Care Act requires minimum health insurance standards and removes annual and lifetime coverage caps on benefits.

TRICARE (formally called CHAMPUS)

U.S government health insurance plan for all military personnel, provides care for all active duty members and their families, survivors of military personnel, and retired members of the Armed Forces

low income families, individuals, or very small businesses, on a sliding income scale of between 100% and up to 400% of the poverty level, to purchase through a health insurance exchange

Who are subsidies for health insurance provided to under the Patient Protection and Affordable Care Act?

ADLs

acronym for Activities of Daily Living

home health care agencies

agencies designed to provide care in patient's home, services are frequently used by elderly or disabled

Medicare supplement plans

plans offered by private insurance companies to help fill the "gaps" in Medicare coverage.

specialty hospitals

provide care for special conditions or age groups

health departments

provide health services as directed by the USDHHS, also provide specific services as needed by the state or local community such as immunization for disease control, collection of statistics and health records, inspections for environmental health and sanitation, clinics for healthcare and prevention, and other services needed in a community

university or college medical centers

provide hospital services along with research and education; can be funded by private and/or government sources

optical centers

provide vision examinations, prescribe eyeglasses or contact lenses, and check for presence of eye diseases

co-insurance

requires that specific percentages of expenses are shared by the patient and the insurance company

Allowable charge

sometimes known as the "allowed amount," "maximum allowable," and "usual, customary, and reasonable (UCR)" charge, this is the dollar amount considered by a health insurance company to be a reasonable charge for medical services or supplies based on the rates in your area.

orthopedic hospital

specialty hospital for dealing with bone, joint, and muscle disease

rehabilitative hospitals

specialty hospitals offering services such as physical and occupational therapy

co-payment

specific amount of money a patient pays for a particular service ex. $10 for each physician visit regardless of total cost of visit

Benefit year

the 12-month period for which health insurance benefits are calculated, not necessarily coinciding with the calendar year. Health insurance companies may update plan benefits and rates at the beginning of the benefit year.

Deductible

the amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.

Benefit

the amount payable by the insurance company to a plan member for medical costs.

Premium

the amount you or your employer pays each month in exchange for insurance coverage.

Coinsurance

the amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.

medical offices

Medical services obtained in _____________ can include diagnosis, treatment, examination, basic laboratory testing, minor surgery, and other similar care

80

Medicare pays for only ___% of services, individual must pay the balance or have another insurance policy cover the expenses.

diagnostic related groups, combination of services, outpatient services, mass or bulk purchasing, early intervention and preventative services, energy conservation

Name six methods of cost containment.

technological advances, aging population, health-related lawsuits

Name three reasons for rising healthcare costs

Universal healthcare

A system where every citizen is guaranteed access to a certain basic level of health services.

Determinants

A determining factor; an element that determines the nature of something

Health maintenance organization (HMO)

A health care financing and delivery system that provides comprehensive health care services for enrollees in a particular geographic area. HMOs require the use of specific, in-network plan providers.

Civilian Health and Medical Programs for the Uniform Services

CHAMPUS stands for:

hospital services, physicians care, long term care services, and some therapies

Generally all State Medicaid programs provide...

Health Insurance Portability and Accountability Act

HIPAA stands for:

improves benefits for Medicare and prescription drug coverage, allows a restructuring of Medicare reimbursement from fee-for-service to bundled payments; a specific amount is paid to a group of physicians for treating an individual with a specific diagnosis instead of individual payments for each treatment provided

How did the Patient Protection and Affordable Care Act change Medicare?

mandates that insurance companies provide coverage for individuals participating in clinical trials

How does the Patient Protection and Affordable Care Act address patients participating in clinical trials?

requires insurance companies to spend at least 80% to 85% of premiums collected on medical costs or to refund excess money to the insured individuals

How is the Patient Protection and Affordable Care Act making sure that the insurance companies spend their money wisely?

Veterans Administration Hospitals

VA hospitals stand for...

All healthcare provided to a patient must have a purpose, a second opinion or verification of need is frequently required before care can be provided, preventative care is emphasized

What are some of the techniques used by the managed care approach?

physical, emotional, social, intellectual/mental, spiritual

What are the five types of wellness?

requires all insurers to charge the same premium to all applicants of the same gender, age, and geographic location, regardless of preexisting conditions, prohibits insurance companies from taking back coverage to any individual as long as premiums are paid

What are the primary provisions of the Patient Protection and Affordable Care Act (2010) concerning guaranteed issue?

alternative healthcare therapies

What does "CAM" stand for?

National Center for Complimentary and Alternative Medicine

What does "NCAAM" stand for?

eliminates co-payments for insurance benefits that have been mandated as essential coverage benefits such as those for specified preventative care services

What does the Patient Protection and Affordable Care Act do for co-payments?

gives a small business tax credit to qualified small businesses and nonprofit organizations who provide health insurance for employees

What does the Patient Protection and Affordable Care Act do for small businesses?

enforces a fine per full-time employee that must be made by any firm that employs more than 50 people and does not offer health insurance

What is the "shared responsibility payment" provision in the Patient Protection and Affordable Care Act?

mandates that all individuals secure minimum health insurance and imposes a fine on those who do not obtain insurance under the shared responsibility; special exemptions do exist such as financial hardship, religious beliefs, individuals who are American Indians, individuals for whom the lowest cost health care plan exceeds 8% of income, and individuals who have income below the lowest tax filling threshold

What is the individual mandate of the Patient Protection and Affordable Care Act?

creates affordable insurance exchanges in every state that provide a more organized and competitive market for insurance, offer a choice of plans to individuals or small businesses, and establish common rules regarding the offering and pricing of insurance

What provision of the Patient Protection and Affordable Care Act addresses the insurance exchanges?

Group health insurance

a coverage plan offered by an employer or other organization that covers the individuals in that group and their dependents under a single policy.

Centers of Disease Control and Prevention (CDC)

a division of USDHHS; concerned with causes, spread, and control of disease in populations

National Institutes of Health (NIH)

a division of USDHHS; involved in research on disease

Agency for Health Care Policy and Research (AHCPR)

a federal agency established in 1990 to research the quality of healthcare delivery and identify the standards of treatment that should be provided by healthcare facilities

Food and Drug Administration (FDA)

a federal agency responsible for regulating food and drug products sold to the public

geriatric care

a growing trend in healthcare due to growing elderly population

home health care

a growing trend in healthcare; a form of cost containment because it is usually less expensive to provide this type of care

Out-of-network provider

a health care professional, hospital, or pharmacy that is not part of a health plan's network of preferred providers. You will generally pay more for services received from out-of-network providers.

In-network provider

a health care professional, hospital, or pharmacy that is part of a health plan's network of preferred providers. You will generally pay less for services received from in-network providers because they have negotiated a discount for their services in exchange for the insurance company sending more patients their way.

Preferred provider organization (PPO)

a health insurance plan that offers greater freedom of choice than HMO (health maintenance organization) plans. Members of PPOs are free to receive care from both in-network or out-of-network (non-preferred) providers, but will receive the highest level of benefits when they use providers inside the network.

Medicaid

a health insurance program created in 1965 that provides health benefits to low-income individuals who cannot afford Medicare or other commercial plans. Medicaid is funded by the federal and state governments, and managed by the states.

Pre-existing condition

a health problem that has been diagnosed, or for which you have been treated, before buying a health insurance plan.

Drug formulary

a list of prescription medications covered by your plan.

U.S Department of Health and Human Services (USDHHS)

a national agency that deals with the health problems in the United States

Health savings account (HSA)

a personal savings account that allows participants to pay for medical expenses with pre-tax dollars. HSAs are designed to complement a special type of health insurance called an HSA-qualified high-deductible health plan (HDHP). HDHPs typically offer lower monthly premiums than traditional health plans. With an HSA-qualified HDHP, members can take the money they save on premiums and invest it in the HSA to pay for future qualified medical expenses.

Claim

a request by a plan member, or a plan member's health care provider, for the insurance company to pay for medical services.

Coordination of benefits

a system used in group health plans to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans usually are limited to no more than 100% of the claim.

voluntary or nonprofit agencies

agencies that are supported by donations, membership fees, fundraisers, and federal or state grants that provide health services at national, state, and local levels

independent living and assisted living facilities

allow individuals who can care for themselves to rent or purchase an apartment in the facility; provide services such as meals, housekeeping, laundry, transportation, social events and basic medical care

deductibles

amounts that must be paid by the patient for medical services before the policy begins to pay

managed care

an approach developed in response to rising healthcare costs

World Health Organization

an international agency sponsored by the United Nations; compiles statistics and information on disease, publishes health information, and investigates and addresses serious health issues around the world

preferred provider organization (PPO)

another type of managed care health insurance plan usually provided by large industries or companies to their employees, forms a contract with certain healthcare agencies to provide certain types of healthcare at reduced rates, usually require deductible and co-payment

Dependent

any individual, either spouse or child, that is covered by the primary insured member's plan.

Provider

any person (i.e., doctor, nurse, dentist) or institution (i.e., hospital or clinic) that provides medical care.

Exclusion or limitation

any specific situation, condition, or treatment that a health insurance plan does not cover.

health maintenance organizations (HMOs)

both healthcare delivery systems and types of health insurance that provide total healthcare directed towards preventative healthcare for a fee that is usually fixed and prepaid (services include examinations, basic medical services, health education, and hospitalization or rehab as needed)

rehabilitation clinics

clinics that offer physical, occupational, speech, and other similar therapies

Rider

coverage options that enable you to expand your basic insurance plan for an additional premium. A common example is a maternity rider.

residential care facilities (nursing homes or geriatric homes)

designed to provide basic physical and emotional care to individuals who can no longer care for themselves; help individuals with activities of daily living, provide a safe and secure environment, and promote opportunities for social interactions

extended care or skilled care facilities

designed to provide skilled nursing care and rehabilitative care to prepare patients or residents for return to home environments or other long term care facilities

medicare

federal government program that provides healthcare for almost all individuals over the age of 65, for any person who has received social security benefits for atleast 2 years, and for any person with end stage renal disease

premium

fee individual pays for insurance coverage

industrial healthcare centers (or occupational health clinics)

found in large companies or industries, provide healthcare for employees of the industry or business by performing basic examinations, teaching accident prevention and safety, and providing emergency care

subacute units

found in some extended care or skilled care facilities, designed to provide services to patients who need rehabilitation to recover from a major illness or surgery, treatment for cancer, or treatments such as dialysis for kidney disease or heart monitoring

clinics (satellite clinics or satellite centers)

health care facilities found in many types of healthcare

worker's compensation

health insurance plan providing treatment for workers injured on the job, administered by state, and payments made by employers and state, also reimburses workers for wages lost because of on-the-job injury

Individual health insurance

health insurance plans purchased by individuals to cover themselves and their families. Different from group plans, which are offered by employers to cover all of their employees.

medigap

health insurance plans that help pay expenses not covered by Medicare, offered by private insurance companies, require payment of premium by enrollee, and must meet specific federal guidelines

long term care facilities (LTCs or LCTFs)

mainly provide assistance and care for elderly patients, also provide care for individuals with disabilities or handicaps and individuals with chronic or long term illness

health department clinics

may offer clinics for pediatric healthcare, treatments of STDs, and respiratory disease, immunizations, and other special services

medicaid

medical assistance program that is jointly funded by the federal government and state government but operated by individual states, in most states it pays for the healthcare of individuals with low incomes, children who qualify for public assistance, and individuals who are physically disabled or blind

Copayment

one of the ways you share in your medical costs. You pay a flat fee for certain medical expenses (e.g., $10 for every visit to the doctor), while your insurance company pays the rest.

government hospitals

operated by federal, state, and local government agencies; include the many facilities located throughout the world that provide care for government service personnel and their dependents ex. VA hospitals, state psychiatric hospitals, state rehabilitation centers

pandemic

outbreak of disease which occurs over a wide geographic area and affects a large proportion of the population

surgical clinics (surgicenters)

perform minor surgical procedures, frequently called "one day" surgical centers because patients are sent home immediately after they recover from their operation

Effective date

the date on which a policyholder's coverage begins.

Medicare

the federal health insurance program that provides health benefits to Americans age 65 and older. Signed into law on July 30, 1965, the program was first available to beneficiaries on July 1, 1966 and later expanded to include disabled people under 65 and people with certain medical conditions. Medicare has two parts; Part A, which covers hospital services, and Part B, which covers doctor services.

Network

the group of doctors, hospitals, and other health care providers that insurance companies contract with to provide services at discounted rates. You will generally pay less for services received from providers in your network.

Payer

the health insurance company whose plan pays to help cover the cost of your care. Also known as a carrier.

Explanation of benefits

the health insurance company's written explanation of how a medical claim was paid. It contains detailed information about what the company paid and what portion of the costs you are responsible for.

Benefit level

the maximum amount that a health insurance company has agreed to pay for a covered benefit.

Out-of-pocket maximum

the most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.

Waiting period

the period of time that an employer makes a new employee wait before he or she becomes eligible for coverage under the company's health plan. Also, the period of time beginning with a policy's effective date during which a health plan may not pay benefits for certain pre-existing conditions.

Underwriting

the process by which health insurance companies determine whether to extend coverage to an applicant and/or set the policy's premium.

telemedicine

the use of video, audio, and computer systems to provide medical and/or healthcare services

general hospitals

treat a wide range of conditions and age groups, usually provide diagnostic, medical, surgical, and emergency services

mental health facilities

treat patients with mental disorders and diseases

true

true or false: Healthcare costs are increasing much faster than other costs of living.

cost containment

trying to control the rising costs of healthcare and achieving the maximum benefit for every dollar spent

type A

type of medicare that covers hospital services, care provided by an extended care facility or home-healthcare agency after hospitalization, and hospice care for people with terminal illness

type D

type of medicare that covers pharmaceutical expenses

type B

type of medicare that offers additional coverage for doctor's services, outpatient treatment, therapy, clinical laboratory services, and other healthcare

medical center clinics

usually located in colleges or universities, offer care and treatment and provide learning experiences for medical students

outpatient clinics

usually operated by hospitals or large medical groups; provide care for outpatients

State Children's Health Insurance Program (SCHIP)

was established in 1997 to provide healthcare to uninsured children of working families who earn too little to afford private insurance but too much to be eligible for Medicaid

genetic counseling centers

where counselors work with couples or individuals who are pregnant or considering a pregnancy, they perform prenatal screening tests, check for genetic abnormalities, and birth defects