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Healthcare in the USA Exam Questions And 100% Correct Answers
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Healthcare in the USA Exam Questions And100% Correct Answers
Adverse Selection - Answer A phenomenon whereby people who are more likely to
consume MORE health care services than others because they are in POOR HEALTH
enroll in health insurance plans in larger numbers relative to healthy people. Occurs
when buys and sellers have ASYMMETRIC INFORMATION, the most UNHEALTHY will be
the ones selected. It describes a situation wherein an individuals DEMANDS for health
insurance correlates with the individuals risk of LOSS
Capitation - A method of reimbursement in which the PROVIDER is paid a fixed monthly
fee per enrollee regardless of whether or NOT an enrollee sees the provider and
regardless of HOW OFTEN an enrollee sees the provider
Catastrophic Care - Medicare Care required when a patient SUFFERS a major injury or
life-threatening illness that necessitates costly long-term treatment
Case Management - Answer A coordinated process of evaluation and management of
patient care, particularly for patients with complex, potentially costly conditions
requiring numerous services from MULTIPLE providers over a LONG period
Children's Health Insurance Program (CHIP) - Answer A jointly funded federal-state
health insurance program designed for CHILDREN from LOW-income families who are
NOT otherwise eligible for Medicaid
Chronic Condition-e A disease or medical condition that persists over time; chronic
diseases can lead to a permanent medical condition that cannot be cured.
Copayment - Answer A portion of health care charges that the insured has to pay under
the terms of his or her health insurance policy; a FIXED amount that the insured person
has to pay at the TIME a service is provided. Office visit co-pays might be 15-20 dollars,
while emergency department visits might be 75 dollars.
,Deductible - Answer The amount of health care costs that the insured MUST pay
first-usually up to a yearly maximum-before insurance payments BEGIN. Extremely
HIGH deductibles are often for catastrophic coverage, whereas NO deductible means
FIRST dollar coverage.
Entitlement - A health care program to which certain people are entitled; for example,
almost everyone at 65 years of age is entitled to Medicare because of contributions
made through taxes. Guaranteed services provided to all recipients in the category who
meet eligibility criteria. Entitlement programs are FUNDED automatically; they are NOT
dependent on annual appropriations. Categorial programs - Benefits targeted at a
category of person.
Medicaid, on the other hand is a WELFARE PROGRAM
Fee-For-Service - Answer Payment of separate fees to physicians for each service
performed, such as examination, administering a test, and hospital visit; the physician
sets the fees
Formulary - Answer A list of acceptable prescription drugs approved by a health plan
Gatekeeping - Answer The use of primary care physicians to coordinate health care
services needed by an Enrollee in a Managed Care Plan (MCO)
Health Maintenance Organization - Answer A managed care organization responsible
for providing COMPREHENSIVE medical care for a pre-determined annual fee per
enrollee
Health Reimbursement Arrangement (HRA) - Answer An account established and
funded entirely by an employer that may be used by an employee or retiree to pay for
health care expenses
Managed Care - Answer A system that integrates the functions of financing, insurance,
delivery, and payment and uses mechanisms to control costs and utilization of services
,Medicaid - Answer A joint federal-state program of health insurance for the POOR
Medicare - Answer A federal program of health insurance for the elderly, certain
disabled individuals, and people with end-stage renal disease
Moral Hazard - Answer Consumer behavior that leads to HIGHER utilization of health
care services because people are COVERED by insurance. IT occurs when a party is
INSULATED from financial risk and so behaves differently than it would behave if it were
FULLY exposed to all the financial risk.
Out-of-Pocket Costs - Answer Costs of health care paid by the recipients of care. For an
individual covered by health insurance, these costs generally include the deductible,
copayments, costs of excluded services, and costs in excess of what the insurer has
determined to be customary, prevailing and reasonable. These expenses are NOT
reimbursed by insurance
Preferred Provider Organization PPO - A managed care organization, having a panel of
preferred providers who are paid on a discounted fee schedule basis. Enrollees DO
have the option of going to out-of-network providers but at a higher level of cost sharing.
Premium - The amount the insurer charges for insurance; the PRICE for an insurance
plan. What you pay to BUY insurance. If you have EMPLOYER-based insurance, money
comes out of paycheck; if individual insurance, you will get a MONTHLY BILL
PPO-Prepaid Plan - Answer A contractual arrangement whereby a provider agrees to
provide all necessary services to a group of members in return for a predetermined
monthly fee paid in advance to the provider on a per-member basis. They SPREAD
during the Great Depression because HOSPITALS had such low occupancy rates; this
was a way of increasing them
Reimbursement - Answer The amount insurers PAY to providers; the payment may only
be a portion of the actual charge
, Underwriting - Answer A systematic technique used by an insurer for evaluating,
selecting or rejecting, classifying and rating risks
Welfare Program - Answer A means-tested program for which only people BELOW
certain income levels qualify. Medicaid is a welfare program.
Utilization Review - The process by which an insurer reviews decisions by physicians
and other providers on HOW MUCH CARE to provide
Utilization - The extent to which health care services are actually used
Universal Coverage - Health insurance coverage for all citizens
Universal Access - Answer The ability of all citizens to obtain health care when needed.
it is a MISNOMER because timely access to certain services may still be a problem
because of supply-side rationing
Third-Party Payers - Answer In a multipayer system, the payers for covered services, for
example, insurance companies, managed care organizations and the government. They
are called THIRD parties because they are neither the PROVIDERS not the recipients of
medical services
Social Justice (FAIRNESS) - Answer A distribution principle, according to which health
care is most equitably distributed by a government-run national health care program.
Views HEALTH CARE as a social resource that requires active government involvement
in delivery. Ability to pay is inconsequential for receiving medical care; equal access to
medical services viewed as a basic right; collective responsibility for HEALTH, and
everyone is entitled to a basic package of benefits
Safety Net Programs, usually government funded, that allow individuals to obtain health
care services when they lack private resources to pay for them; without these
programs, MANY would have to go without services
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