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CHFP Cards A+ Graded
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CHFP Cards A+ Graded ...
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CHFP Cards A+ Graded 2024-2025Facility Providers - Answer Hospitals
Skilled Nursing Facilities
Assisted Living Facilities
Home Health Agencies
Ambulatory Surgery Center
Professional Providers - Answer Physicians
Pharmacists
Nurses
Allied Professional Providers (APPs) - PT, clinical social work, & others
Primary Care Physicians - Usually trained in: - Answer Family Practice
General Practice
General Internal Medicine
Pediatrics
Primary Care Physicians role is viewed as: - Answer Coordinator of a patients care
Assessing a patient's condition
Referring a patient to a specialist physician
Specialists - Care Concentrate on intensive training in specialty diseases, organ
systems, or delivery of health services.
With their practice confined to a hospital, radiology, anesthesiology, and pathology are
,considered specialists. In addition, emergency room physicians and hospitalists are
also categorized as a type of specialist. - Answer Hospital-based Physicians
Types of out-of-pocket payments by patients that may be required in a health insurance
plan include: Response Deductibles
Co-payments
Coinsurance
Deductible - Response the amount that the insured is required to pay annually before
the insurance company will pay
Coinsurance - Response the percentage of the amount of the insurance payment that is
made by the patient, along with the amount paid by the insurer.
Copayment - A set amount that the patient pays at each time of service.
Benefit Payment - Amount paid by the insurer to the provider after the claim is
determined as appropriate.
Covered benefit - The services for which the insurer will pay.
Medicare - A federal program of health insurance for persons 65 years of age and older,
persons with disabilities, and persons with End Stage Renal Disease (ESRD).
Medicare Part A (aka Hospital Insurance or HI) - Provides hospital insurance
automatically @ age 65 (if FICA qualified) @ no fee but may have deductible & co-pay.
Categorical eligibility - Answer Persons who have paid Medicare wage taxes for at least
40 calendar quarters. Part of only Medicare Part A.
,Medicare Part A Covers - Answer Inpatient hospital services, certain organ transplants,
ESRD treatment, inpatient skilled nursing facility care, home health care and hospice
care.
Lifetime Reserve - Medicare Part A after 180 days per spell of illness, the patient has a
one-time bank of days to cover long stays.
Medicare Part A Coverage for Hospital Stays - Answer o Cost of days 2 - 60 of a spell of
illness or hospitalization
o Days 61-180 - the patient pays a coinsurance amount per day
o After 180 days, Medicare Part A stops & lifetime reserve may kick in
Medicare Part B - Answer Voluntary program where a patient that meets the age or
medical condition requirements for Medicare Part A (but not the requirement to pay
taxes for 40 calendar quarters) may participate in the insurance benefit.
Funded by a combination of premiums paid by the beneficiary and general tax revenues
from the federal government.
Part B Only- Those patients who have Medicare Part B coverage without coverage from
Medicare Part A.
Medicare Part C (Medicare Advantage)- Response •Replaces and covers expenses
found in Part A and B
•Medicare private fee-for-service plans (PFFS)
•Medicare managed care plans (HMOs and PPOs)
•Medicare specialty plans
Medicare Part D Prescription Drug Coverage - Answer a United States
federal-government program to subsidize the costs of prescription drugs and
prescription drug insurance premiums for Medicare beneficiaries.
, ***Prescription drug coverage for Medicare enrollees, which offsets some of the
out-of-pocket costs for medications.
Medicaid - Answer A federal and state assistance program that pays for health care
services for people who cannot afford them. ***Joint program between federal
government and states.
Spend-down program-Answer Program that allows patients to pay a portion of their
medical expenses each month with Medicaid available to assist with the remaining
medical expenses. This program is for persons who are at or below the state income
level. Medicaid eligibility is then determined month to month.
hospital acquired conditions (HAC) - Answer reasonably preventable conditions for
which hospitals do not receive additional payment when one of the conditions was not
present on admission
individual mandate (ACA) - Answer The Affordable Care Act requires nearly everyone to
have health insurance that meets minimum standards. With some exceptions, people
who do not maintain health insurance coverage will have to pay a tax penalty
Employer Mandate (ACA)-Answer Forcing employers with more than 50 employees to
offer health insurance benefits to employees.
Other provisions of the Affordable Care Act include: -Answer Medicaid Eligibility
Accountable Care Organizations (ACOs)
Value-Based Purchasing
Bundled Payments
Medicaid eligibility-Answer- Expanded under ACA by income limits of persons to qualify
for this program were increased.
-Decision to expand Medicaid lies with each state.
• Intent of increasing the number of persons eligible for Medicaid is to reduce the
number of persons seeking care for healthcare emergencies who have no ability to pay.
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