Health Insurance Terminology Quiz

Health Insurance Terms and Definitions

HMO (Health Maintenance Organization): Usually restricts patients to a network of local providers for care, leading to limited options for outside services.
PPO (Preferred Provider Organization): Allows patients to seek care outside their network but incurs higher costs for out-of-network services.
Medicaid: A state and federal program providing health coverage primarily for individuals with low income.
Medicare Part A: Automatic enrollment at age 65 for individuals who have paid premiums; covers inpatient hospitalization, hospice care, home health care, and skilled nursing facility services. Does not cover custodial care.
Medicare Part B: Covers outpatient services, physician services, medical equipment, and preventive care.

Medicare Enrollment and Coverage

Automatic Enrollment: Medicare Part A enrollment is automatic at age 65; regulated by the federal government.
Coverage Specifics: Part A covers hospital stays and home health care, while Part B covers doctor visits and outpatient services.
Cost for Medicare Part A: Most beneficiaries do not pay a premium for Part A.

Long-Term and Specialized Care

Primary Payer for Long-Term Care: Medicaid serves as the primary payer for long-term services for older adults with low income.
Dialysis Coverage: Patients with end-stage renal disease are typically covered by Medicare regardless of age.

Managed Care

Characteristics of Managed Care: Managed care entails restrictions on provider access, with a primary care provider often acting as a gatekeeper.
Limitations: Unlimited access to specialty providers is not a feature of managed care.

Health Prevention Strategies

Types of Prevention:
- Primary Prevention: Engaging in healthy activities to prevent disease onset.
- Secondary Prevention: Early diagnosis and interventions to prevent progression of a disease.
- Tertiary Prevention: Actions to minimize damage once a disease has progressed, focusing on rehabilitation.

Health Assessments and Risk Factors

Fall Risk in Elderly: Falls are the leading cause of fatal and non-fatal injuries in individuals over 65, with one-third of seniors falling each year.
Elder Abuse Risk: Higher incidence of abuse seen in elderly females with mental impairment or dependency.
Safe Pediatric Practices: Key strategies to prevent infant suffocation include removing soft bedding and supervised play.

Health Metrics

Epidemiology: The study of disease incidence and distribution within populations.
Incidence vs. Prevalence:
- Incidence: Refers to the number of new cases of a disease.
- Prevalence: Refers to the total number of existing cases of a disease.

Behavioral Change Models

Transtheoretical Model Stages: The stages of behavior change include precontemplation, contemplation, preparation, action, maintenance, and termination.
Legal Considerations in Workers' Compensation: Workers' Compensation typically does not cover legal assistance for suing employers but provides several benefits pursuant to employment-related injuries.

Patient Identification and Safety

Patient Identification: Healthcare workers should verify patient identity using at least two unique identifiers as per WHO guidelines.
Prevention of Falls: D.A.M.E. acronym emphasizes assessing drugs, age-related issues, medical problems, and environment to evaluate fall risks.

Important Biological Tests

Pap Smear: A test for cervical cancer.
Sigmoidoscopy: A procedure to check for colorectal cancer.
Oral Glucose Tolerance Test: Used to diagnose diabetes.
Guthrie Test: A test for phenylketonuria (PKU) in newborns following protein ingestion.

These study notes encapsulate essential health insurance terms and concepts, focusing on coverage specifics, preventive measures, and health assessments critical for understanding health insurance systems and their impact on patient care.