Upgrade to remove ads
Health Policy Exam 1
Terms in this set (49)
Costs you pay on your own
Out of pocket
What you pay per month to have your insurance (may be partially or fully paid by employer)
Amount of money you have to pay out of pocket prior to the insurance covering the expense
Fixed amount you pay for a visit
The most you have to pay out of pocket before your insurance starts to cover (limit)
Out of Pocket Maximum (OOP)
Documentation needed prior to getting service
Certain times that you can make changes to your benefits depending on your life status
Qualified Life Status Change
If you have a 90/10 co-insurance plan with a $400 deductible, what does this mean?
Insurance company will pay for 90% of continued services after $400 is met
Type of managed care in which you need a PCP to coordinate care (referrals); you cannot go out of network for care.
Health Maintenance Organization (HMO)
Type of managed care in which you can go in or out of network and don't have to choose a PCP or go through a PCP for referrals.
Preferred Provider Organization
Paying for each service separately
Where did HMO start?
Baylor University Hospital (1929)
In 1942, this act prevented people from making any additional wages (during WWII)
What happened as a result of the Stabilization Act of 1942?
Employee-based insurance system
T/F: HMO requires a PCP and referrals for specialists
Why did hospitals become more respectable after the 1900's?
Use of anesthesia, antiseptics, diagnostic testing improved
______ is the amount of money one needs to pay each calendar year before the insurance company starts paying
Who is at risk for fee-for-service?
Insurance company and you
Who is at risk for payment by episode of illness?
Hospital and insurance company
Federal legislation established to provide medical services for people;Le receiving cash assistance or welfare.
Title XIX of SSA (Medicaid)
This program was established to provide coverage for US and immigrant children up to 19 who are not eligible for Medicaid (low and moderate income levels)
Children's Health Insurance Program (CHIP)
Prohibits denying coverage based on pre-existing conditions, extends dependent coverage to age 26, requires full coverage of preventative care and immunization.
Title 1: Quality, Affordable Healthcare for All (ACA)
Expanded Medicaid to 133% or 138% of the federal poverty level, simplified enrollment to Medicaid
Title II: The Role of Public Programs (ACA)
What did the Medicaid expansion include?
-All adults under age 65 & with income at or below 138% FPL
-Same coverage for immigrants
-Simplified and streamlined enrollment and renewal
-Mandates PCP be paid at Medicare rates
What services are mandated for traditional Medicaid population?
-MD, inpatient/outpatient hospital services
-lab and X-rays
-early & periodic screening and diagnostic and treatment for those under 21 years
-Peds and family NP services
-family planning services and supplies
-nursing facility services for those over 21 years
-HHC for persons eligible for nursing facility services
What are the optional (state by state) Medicaid services?
-intermediate care facility for those w/ intellectual disabilities
-inpatient psych and nursing services (<21)
-personal care services
-rehab and habilitation services
-durable med equipment, prosthetic, eyeglasses
-home and comm. based services
What basic DME does Medicaid cover?
-raised toilet seat
-hospital bed (semi-electric)
T/F: Home modifications are covered by Medicaid.
In NY state, what's the cap for OT, speech, and PT per year (outpatient)?
20 visit cap
T/F: Medicaid does not cover communication devices dedicated just for communication.
False (DOES cover)
What parts of Driving Rehab does Medicaid cover?
-OT eval for driving rehab (does NOT cover: behind the wheel assessment, adaptive equipment for cars)
Prior to ACA___group of people were not eligible for Medicaid
-Low income and adults without children
Medicaid is a joint federal/state program with all states having the same benefits (T/F)
False: Medicaid is a joint federal/state program whereby the state has leeway regarding benefits as long as they provide mandatory benefits
With ACA, Medicaid expansion includes:
A. All adults under 65 and with income at or below 138% FPL are eligible
B. Simplified and streamlined enrollment and renewal process
C. No effect on immigrants
D. All of the above
Medicaid covers all of the follow except:
A. Driving rehab clinic evaluation
B. Communication devices dedicated for communication only
C. Power mobility in the house and out of house with medical necessity letter
D. A new power chair every 5 years
D. (Not necessarily, but can be provided with proof of necessity/change of function)
Who is eligible for Medicare Part A?
-Permanent legal residents w/ at least 5 yrs of continuous residence
-qualify w/out regard to med hx, pre-existing conditions or income/asset test
-People under 65 w/ permanent disabilities after receiving SSDI payments for 24 months
-People w/ ESRD/ALS- automatically eligible
What does Medicare Part A Cover?
-Inpatient hospital stays
-Short Term stays (SNF, hospice, post acute home care)
-Must be "formally" hospitalized for 3 days before Medicare will cover rehab
What does Medicare Part B Cover?
-Outpatient hospital care
-physician and prevention services
-outpatient mental health
Medicare Part B Rehab Caps
$2,010 for PT and speech combine
$2,110 for OT
What does Medicare Part C Cover?
All benefits under A & B plus extra benefits (eye glasses, hearing exams, dental, podiatry, chiropractic, gym memberships)
What is Medicare Part D for?
Prescription drug plans
What DME does Medicare cover?
-some wheelchairs and power mobility
Since Medicare has been established, it has expanded to cover the following groups except:
A. People under 65 w/ permanent disabilities
Medicare _____ covers hospitalization, while Medicare ____ covers outpatient services.
A. Part A, Part C
B. Part B, Part C
C. Part A, Part B
D. None of the above
Medicare covers the following DME:
A. Commodes, cane, walker, and low end hospital beds
B. Canes, walkers, commodes, tub bench
C. Commodes, shower chair, cane, walker
D. Canes, walkers, low end hospital beds, raised toilet seats
Medicare covers the following wheelchairs:
A. Indoor manual, outdoor power mobility
B. Indoor manual or power, and only 1 outdoor lightweight manual
C. Indoor manual or power, but only one outdoor power chair
D. Indoor power, but able to walk with a walker safely with no assistance
Medicare Part C is:
A. A voluntary program that allows individuals to enroll in private plan as an alternative to traditional Medicare
B. Covers all benefits under Medicare A and B and in most cases D
C. Receive extra benefits such as eyeglasses, hearing exams, dental, gyms
D. All of the above
Which Title of the ACA gives dependents coverage up to age 26?
Employer-sponsored health benefits whose value exceeds legally specified thresholds will be subject to a 40% excise tax, starting in 2020.
This set is often in folders with...
Health Policy Midterm
Health Policy Midterm
You might also like...
Chapter 10: Government Health Insurance Programs:…
Chapter 9 Conquering Medicare's Challenges By Roqu…
Health: Social Insurance (2:4)
Other sets by this creator
Health Policy Final 2018
Older Adults 2018 Exam
Pediatrics Midterm Spring 2018