Health 3050 Final

PCs help to coordinate _______ all hazard emergency planning and response that involves a public health threat

"on-the-ground"

Co-insurance is a

% of cost after deductible is met

Examples of entitlements

- Medicaid - Medicare

health economics

- a branch of economics focusing on issues related to efficiency, effectiveness, value and behavior in the production and consumption of health and healthcare - study the functioning of healthcare systems and health-affecting behaviors

Part C, Managed Care Advantage Plans, includes

- all coverage of A & B - some offer more services (dental, vision) - most include prescription drug coverage -premiums vary - each plan has different out of pocket costs - several options for health insurance plans - mirrors what you typically think of as insurance in the private sector

premium

- annual fee paid - monthly installments

reasons for market failure in healthcare include

- concentration of market power - imperfect information - consumption of public goods - presence of externalities

Entitlements

- everyone who is eligible for and enrolled int he program is legally entitled to receive benefits from the program

Preferred Provider Organization (PPO)

- more options and flexibility for patients - preferred providers given, but patients can see out of network providers

on-the-ground threats include

- natural disasters - CBRNE exposures - disease outbreaks

the CMS does what

- outlines mandatory and optional populations and benefits

Health Maintenance Organization (HMO)

- pays providers a salary to cover the cost of any and all services that beneficiaries need within a provider's scope of practice - greater focus on prevention - only allowed to use in-network providers

Mandatory benefits of Medicaid include

- physician services - laboratory and x-ray - inpatient hospital - outpatient hospital -EPSDT - Family planning - Nurse midwife - Nursing facility - Home health care - smoking cessation services for pregnant women - free-standing birth center - transportation to medical care

Point of Service Plans (POS)

- plans have a provider network - use a capitated rate - requires members to use a gatekeeper -most flexibility of all MCOs

Optional benefits of Medicaid include

- prescription drugs - clinic services - dental services - physical therapy & rehab - prosthetic devices - eyeglasses -Primary care case management - intermediate care facilities for the mentally disabled - inpatient psychiatric care for <21 - home health care - 'health home' services for people with chronic conditions - home and community-based attendant services & supports

under the CMS what do states do

- run programs - select optional populations and benefits

who has higher demand for healthcare?

- women <65 - people with more medical knowledge - men >65 - aging consumers - people who develop medical issues at an early age - individuals born with medical problems

What are the three branches under the Center for Medicare & Medicaid Services (CMS)?

1. States 2. District of Columbia 3. US Territories

What are the 4 factors that contribute to the determinants of health?

1. biological factors 2. psychosocial factors 3. behavioral factors 4. social factors

5 eligibility requirements of Medicaid

1. categorical 2. income level 3. resources (non-wage assets) 4. residency 5. immigration status (in country 5yrs)

two types of cost sharing are

1. co-payments 2. co-insurance

2 methods of setting premiums

1. experience rating 2. community rating

3 options for CHIP structures

1. incorporate CHIP into Medicaid program as an expansion population 2. Create separate CHIP program 3. Hybrid program: some CHIP children are in Medicaid and some are in a separate CHIP program

All plans in Part D must cover at least ____ drugs in each therapeutic category

2

beginning 2014, children ages ___ - ___ must be covered up to _____% FPL

6-19; 133

beginning 2014, all non-Medicare eligible individuals younger than _____ with incomes up to ____% FPL will be eligible for Medicaid in states that decide to expand

65; 133

What are the 4 parts of Medicare (A-D)

A : Hospital Insurance (automatically entitled) B : Supplemental Medical Insurance C : Managed Care D : Prescription Drug coverage

Medicare is administered by _______

CMS

Those dual-enrolled in Medicare and Medicaid aren't eligible for Part ___

D

What are comprehensive set of mandatory services for children under Medicaid

Early and Periodic Screening Diagnostic and Testing (EPSDT)

ACA signed into law on

March 23, 2010

CHIP starts at the level where _____ ends

Medicaid

Children who are eligible for _____ must be enrolled in that, not CHIP

Medicaid

Part B, Supplemental Medical Insurance, includes

Physician services, outpatient services, limited preventive services

Examples of Block grants

SCHIP

What has been the DHHS focus since 2010 at the state and local gov't level

Social Determinants of Health (SDOH)

CHIP

a 10-year, $40 billion block grant program designed to provide health insurance to low-income children whose family income is above the Medicaid eligibility level in their state

Block grants

a defined sum of money (often from the fed gov't to the states) that is allocated for a particular program over a certain amount of time

Medicaid

a federal-state public health insurance program for the indigent

Medicare

a federally-funded health insurance program for the elderly and some persons with disabilties

health equity

a situation in which everyone has the opportunity to attain his or her full health potential

behavioral factors

alcohol/drug use, smoking, unprotected sex

under CHIP, ____ participate; it is a _____ matching program; and it cannot exclude ________

all states; fed/state; children based on pre-existing condition

About how often do the counties conduct risk assessments?

approx. every 4 years

"modified" community rating

can take into account age and gender but is illegal for the most part now with ACA

demand elasticity

change in demand when you increase the good by 1%

social factors

conditions in which people are born and that affect their daily lives and overall well-being as they move through various stages of life

psychosocial factors

conflicts within one's family that may lead to stress, anger, and/or depression

cost sharing

costs of services or drugs that are shared between company and individual seeking care

health care disparity

denotes differences in access to health care services or health insurance or in the quality of care actually received

PCs coordinate _______ for the community and public health staff

emergency preparedness education

Under ____ beneficiaries may not be refused service for lack of funds or other reasons. However, under ______ beneficiaries CAN be refused service for lack of funds or other reasons

entitlements; block grants

as long as health disparities exist, a society cannot achieve health _____

equity

Medicaid covers _____ care and _____ benefits

extensive acute; Long-Term Care

Managed Care provides incentives to provide_______ and _____ while maintaining ______

fewer services; less expensive care; quality

Co-payments have a _______

flat rate

biological factors

genetic mutation that could increase chances of developing a disease (i.e. sickle cell anemia)

community rating uses only what to set rates

geography and family composition to set rates

experience rating is based on

health status and claims in prior year(s)

Beneficiary

individual buying health insurance

Part A, Hospital Insurance, includes

inpatient hospital, skilled nursing facility, hospice

How is medicaid financed

jointly by the federal (57%) and the state governments

under block grants, there is no _________ to the benefits

legal entitlement

PCs are acutely aware of

local resources and partnerships

case management

managed care organization manages and coordinates patient care

utilization review

managed care organization reviews and approves or denies services requested by provider

gatekeeper

managed care organization uses a primary care provider to make sure only necessary and appropriate care is provided

Part D, Prescription Drug Coverage:

may receive through private drug plans or managed care arrangement

disequilibrium

occurs when there is extra supply (surplus)

Fee for Service

providers charge fee for every service rendered

Health care reformed aimed to

reduce number of uninsured

market failure

resources are not produced or allocated efficiently

benefits

services covered by health insurance plan

Every _____ chooses to participate in the Medicaid program, and each has a different __________

state; Medicaid system

Under Medicare, there is no _____ administration and _____ rules apply in ______

state; national; all states

__________ implement the Medicaid programs

states

supply

the amount of goods and services that producers are able and willing to sell at a given price over a given period of time

deductible

the amount of money you pay first before insurance kicks in

the two main groups covered by medicare are

the elderly and the disabled

out of pocket maximum

the highest amount you will have to pay during a plan year before insurance covers 100% of medical costs

equity

the quality of being fair (i.e. flu vaccine)

demand

the quantity of goods and services that a consumer is willing and able to purchase over a specified time

How is emergency preparedness funded?

through the CDC Public Health Emergency Preparedness grant

inelasticity

when change in price is not good enough to effect demand

health disparity

when one population or group experiences a higher burden of disability or illness than another group

equilibrium

when people are buying at the same rates as production