Exam 2 HS4300 Bowman

She is responsible for paying $1,500 of her medical expenses before her insurance policy starts to pay

A 30-year-old woman broke her arm and went to the emergency room for treatment. Her health insurance plan has a $1,500 deductible. What does this mean?

Has no gatekeeper

A PPO is a type of insurance that

Joint venture

A new corporation created by two partnering organizations that remains independent is called a (n).

Groups of people

Risk is generally predictable for what group?

Fee for Service, Package pricing, DRGs and Paying for services before they are provided

There are many ways to pay for health care services according to your readings. They are

False

There is a family coverage option for Medicare.

False

Under the Medicaid program, eligibility criteria and benefits are consistent throughout the US.

Be used by service members for non-war related health issues and be used by service members for war related issues

VHA services can

Health care services transported to patients

What are mobile health care services?

Hospital costs

What does Medicare Part A help cover?

Doctor visits, ER visits, Ambulance , renal dialysis, organ transplants

What does Medicare Part B help cover?

True

Primary care may play an important role in lessening the adverse health effects of income inequality.

Categorical programs are designed to benefit only a certain set of people and A certain set of criteria must be met to be eligible for the programs

Public programs such as Medicare and Medicaid are called categorical programs. What are categorical programs?

True

State governments are required to partially finance the Medicaid program.

To provide a seamless array of services, to diversify, to gain market share and because it makes economic sense,

The Primary purpose to utilize integration strategies in health care is

Indian Health Services, Veterans Health Administration, and Health Care for the Military

The federal government is responsible for providing health insurance for other programs. These programs include

False

The increase of health care delivery through managed care created a decreased demand for primary care physicians

Tricare

The insurance arm of military health care is called

Is highly specialized

Typically, tertiary care:

Prescription drugs

What does Medicare Part D help cover?

Medicare Part C is also called Medicare Advantage, Medicare Part C offers additional choices of insurance plans, and Medicare Part C offers managed care plans

What is Medicare Part C?

The process by which primary care physicians refer patients to specialists

What is gatekeeping?

It controls the utilization of health care

What is the main purpose of cost sharing?

Moral Hazard

What is the term for the consumer behavior that leads to a higher utilization of health care services when the services are covered by insurance?

It is a process of determining how appropriate health care services are for a given health care situation and Its main objective is to provide care that is deemed appropriate and cost effective.

What is utilization review?

Dental and Vision : Dental and Hearing aids

What services are not paid for under Medicare?

Increase

What was considered the likely impact of the ACA on primary care?

Acquisition

When an organization ceases to exist as a separate entity and is absorbed into the purchasing corporation is called a(n)

Alliance

When there is a sharing of existing resources without joint ownership of assets is called a(n).

Merger

When two organizations cease to exist, and a new corporation is formed is called a(n).

UK

Which country's health care system is founded on the principles of gatekeeping?

A specific dollar amount you pay when you receive a specific health care service

Which of the following best describes a copay?

The amount you pay before your insurance company pays benefits

Which of the following best describes a deductible?

It is the set amount you pay for your health insurance plan, usually paid every month, regardless if you don't receive medical care that month.

Which of the following best describes a premium?

The percent of the cost of medical services that the insurer pays

Which of the following describes coinsurance?

Increased morbidity

Which of the following is NOT an effect of increased primary care within a population?

Managed care, new technology and Patient preference

Which of the following is a reason for the growth in outpatient services?

Rehabilitation, Surgery and Consultation

Which of the following is an example of a secondary care service?

Increase in hospital technology budget has increased outpatient services

Which of the following is one of the reasons why outpatient services have increased in popularity over the past 20 years?

A gatekeeper is a primary care physician who delivers primary care services, A gatekeeper is the provider who has first contact with the patient and decides if a referral to a specialist is necessary, and A gatekeeper is employed by HMO plans

Who is a gatekeeper?

False

Medicare is only for the elderly.

Maintain people in the least restrictive environment as possible

Home health's basic philosophy is

Terminal illnesses

Hospice services are primarily for people with:

A primary care physician.

In the gatekeeping method, who makes referrals to specialists?

Prospective

Pre-certification(pre-authorization) is associated with which type of utilization review?

Restricts use of specialty services

An HMO is a type of insurance that

False

Anyone who claims to be an Indian can receive health care services from the IHS.

Is an insurance program for children, Is an insurance program covered under Title 21 of the Social Security act, and Is an acronym for Children's Health Insurance Program

CHIP

A fixed monthly payment per enrollee

Capitation is

Populations which are medically underserved

Community health centers serve primarily:

Copayments, Premiums and Deductibles

Cost sharing means that insured individuals will pay a portion of their health care costs. Forms of cost-sharing are

Higher satisfaction with health services among their populations

Countries whose health systems are oriented more toward primary care achieve:

Services covered by an insurance plan that are deemed medically necessary and Services covered by an insurance plan that are considered medically necessary such as hospitalization, prescriptions, maternity care and delivery of a baby

Covered services are

True

Delivery of health care with a central focus on specialization cannot maximize health.

Secondary and Tertiary

Emergency departments, in most cases, are equipped to provide:

False

Higher primary care physician supply has been associated with lower low-birth weight percentages but higher infant mortality

Point-of-service plans

It is a plan that is a hybrid between an HMO and a PPO.

Telephone triage

It is a type of outpatient service where expert opinion and advice are typically provided to a patient when a physician's office is closed

False

Long-term care services for the elderly are covered under Medicare.

Case management

MCOs use various methods to control costs. One of those methods is ___________ which is mainly recommended for patients who need secondary and tertiary care more often than primary care.

Disease Management

MCOs use various methods to control costs. One of those methods is ______________ which is focused on providing care to high-risk people with chronic illnesses which tend to be illnesses that more complicated and require more intense follow-up. This method is used to ensure that people are complying with their detailed and difficult medical regiment.

Choice restriction

MCOs use various methods to control costs. One of those methods is ______________ which means if the patient receives services from providers who are outside of the plan, they will not be covered

Practice Profiling

MCOs use various methods to control costs. One of those methods is _________________ which refers to profiling how a provider practices. It is primarily used to decide if providers have the "right fit" with the plan's managed care philosophy and goals.

True

Managed care is a way of providing health care services by a single organization that manages financing, insurance, delivery, capitation and discounted fees.

Is a means-tested program, is jointly financed by the federal and state governments, and is primarily run by the state government

Medicaid

True

Medicare and Medicaid are both financed by the government but most health care services are obtained in the private sector.

False

Medicare beneficiaries must pay a premium for Part A.

People who are eligible for Medicare have worked for at least 10 years and People who are eligible for Medicare have contributed to Medicare through the payment of taxes

Medicare is considered an entitlement program. Why is Medicare considered an entitlement program?

Women seek care more often than men

One reason women's health centers were created is:

This utilization review determines the appropriateness of care DURING the course of treatments.

Pick the statement that is true concerning Concurrent review