Principles of Health Science Test Review for Health Insurance Healthcare systems-Key.pdf

Principles of Health Science Test Review for Health Insurance Healthcare systems Make sure to type your answers in a different color 1. PPO-A type of medical plan in which coverage is provided to participants through a network of selected health care providers, such as hospitals and physicians. Enro...

Principles of Health Science Test Review for Health Insurance Healthcare systems Make sure to type your answers in a different color 1. PPO-A type of medical plan in which coverage is provided to participants through a network of selected health care providers, such as hospitals and physicians. Enrollees may seek care outside the network but pay a greater percentage of the cost of coverage than within the network. 2. POS-POS stands for “point of service,” which refers to the provider of the healthcare services. They’re called point-of-service insurance plans because at each point you need healthcare services, you can decide whether or not to stay in the network. With this type of insurance, your costs all depend on that “point” of service, referring to the healthcare provider or medical facility. A Point of Service (POS) plan has some of the qualities of HMO and PPO plans with benefit levels varying depending on whether you receive your care in or out of the health insurance company’s network of providers. 3. HMO -A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness. 4. EPO-A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency). 5. HSA-A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in an HSA to pay for deductibles, copayments, coinsurance, and some other expenses, you may be able to lower your out-of-pocket health care costs. HSA funds generally may not be used to pay premiums. While you can use the funds in an HSA at any time to pay for qualified medical expenses, you may contribute to an HSA only if you have an HSA-eligible plan (sometimes called a High Deductible Health Plan (HDHP)) — generally a health plan (including a Marketplace plan) that only covers preventive services before the deductible. An HSA may earn interest or other earnings, which are not taxable. Banks, credit unions, and other financial institutions offer HSAs 6. FSA-An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, insulin, and medical devices. You decide how much to put in an FSA, up to a limit set by your employer. You aren't taxed on this money. If money is left at the end of the year, the employer can offer one of two options (not both): You get 2.5 more months to spend the left over money. You can carry over up to $640 to spend the next plan year. Flexible Spending Accounts are sometimes called Flexible Spending Arrangements. 7. OSHA-The Occupational Safety and Health Administration (OSHA) assures safe and healthful working conditions by setting and enforcing standards, and by providing training, outreach, education and assistance. 8. FDA-The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food safety, tobacco products, caffeine products, dietary supplements, prescription and over-the-counter pharmaceutical drugs (medications), vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), cosmetics, animal foods & feed and veterinary products. 9. CDC-CDC is the nation’s leading science-based, data-driven, service organization that protects the public’s health. For more than 70 years, we’ve put science into action to help children stay healthy so they can grow and learn; to help families, businesses, and communities fight disease and stay strong; and to protect the public’s health. 10. WHO- Founded in 1948, WHO is the United Nations agency that connects nations, partners and people to promote health, keep the world safe and serve the vulnerable – so everyone, everywhere can attain the highest level of health. WHO leads global efforts to expand universal health coverage. We direct and coordinate the world’s response to health emergencies. And we promote healthier lives – from pregnancy care through old age. Our Triple Billion targets outline an ambitious plan for the world to achieve good health for all using science-based policies and programmes. 11. PPACA- The first part of the comprehensive health care reform law enacted on March 23, 2010.The law was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is usually used to refer to the final, amended version of the law. (It’s sometimes known as “PPACA,” “ACA,” or “Obamacare.”)The law provides numerous rights and protections that make health coverage more fair and easy to understand, along with subsidies (through “premium tax credits” and “cost-sharing reductions”) to make it more affordable. 12. HIPAA-The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule. 13. Medicaid- Medicaid is a joint federal and state program that provides free or low-cost health coverage to millions of Americans, including some low-income people, families and children, pregnant women, the elderly, and people with disabilities. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. Medicaid programs vary from state to state. They may also have different names, like “Medical Assistance” or “Medi-Ca is a government national health insurance program in the United States, begun in 1965 under the Social Security Administration (SSA) and now administered by the Centers for Medicare and Medicaid Services (CMS). It primarily provides health insurance for Americans aged 65 and older, but also for some younger people with disability status as determined by the SSA, including people with end stage renal disease and amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease). In 2022, according to the 2023 Medicare Trustees Report, Medicare provided health insurance for 65.0 million individuals—more than 57 million people aged 65 and older and about 8 million younger people. According to annual Medicare Trustees reports and research by Congress' MedPAC group, Medicare covers about half of healthcare expenses of those enrolled. Enrollees almost always cover most of the remaining costs by taking additional private insurance and/or by joining a public Medicare Part C and/or Medicare Part D health plan. In 2022, spending by the Medicare Trustees topped $900 billion per the Trustees report Table II.B.1, of which $423 billion came from the U.S. Treasury and the rest primarily from the Part A Trust Fund (which is funded by payroll taxes) and premiums paid by beneficiaries. Households that retired in 2013 paid only 13 to 41 percent of the benefit dollars they are expected to receive. No matter which of those supplemental options the beneficiaries choose—private insurance or public health plans—to make up for the shortfall of what Medicare covers (or if they choose to do nothing), beneficiaries also have other healthcare-related costs. These additional costs can include but are not limited to Medicare Part A, B and D deductibles and Part B and C co-pays; the costs of long-term custodial care (which Medicare does not consider health care); the cost of annual physical exams (for those not on Part C health plans almost all of which include physicals); and the costs related to basic Medicare's lifetime and per-incident limits. Medicare is divided into four Parts: A, B, C and D. Part A covers hospital, skilled nursing, and hospice services. Part B covers outpatient services. Part D covers self-administered prescription drugs. Additionally, Part C is an alternative that allows patients to choose their own plans with different benefit structures and that provide the same services as Parts A and B, almost always with additional benefits. The specific details on these four Parts are as follows: Part A covers hospital (inpatient, formally admitted only), skilled nursing (only after being formally admitted to a hospital for three days and not for custodial care), home health care, and hospice services. Part B covers outpatient services including some providers' services while inpatient at a hospital, outpatient hospital charges, most provider office visits even if the office is "in a hospital", durable medical equipment, and most professionally administered prescription drugs. Part C is an alternative often called Managed Medicare by the Trustees (and almost all of which are deemed Medicare Advantage plans), which allows patients to choose health plans with at least the same service coverage as Parts A and B (and most often more), often the benefits of Part D; Part C's key difference with Parts A and B is that C plans always include an annual out-of-pocket expense limit in an amount between $1500 and $8000 of the beneficiary's choosing; Parts A and B lack that protection. A beneficiary must enroll in Parts A and B first before signing up for Part C. Part D covers mostly self-administered prescription drugs. 14. TriCare-TRICARE is the health care program for almost 9.6 million beneficiaries worldwide—including active duty service members, National Guard and Reserve members, retirees, their families, survivors, certain former spouses and others registered in the Defense Enrollment Eligibility Reporting System (DEERS). 15. Veterans Administration-The Department of Veterans Affairs runs programs benefiting veterans and members of their families. It offers education opportunities and rehabilitation services and provides compensation payments for disabilities or death related to military service, home loan guaranties, pensions, burials, and health care that includes the services of nursing homes, clinics, and medical centers. 16. General Hospital-Offers services, facilities, and beds for use for more than 24 hours for two or more unrelated individuals requiring diagnosis, treatment, or care for illness, injury, deformity, abnormality, or pregnancyRegularly maintains, at a minimum, the following: a. Clinical laboratory services b. Diagnostic x-ray services c. Treatment facilities including surgery or obstetrical care, or both d. Other definitive medical or surgical treatment of similar extent 17. Charity Hospital- A charitable hospital, or charity hospital, is a non-profit hospital that provides treatment for poor and uninsured people who can not purchase treatment. An example would be St. Jude Children's Hospital that provides assistance to children and funds research for pediatric ailments.Ex. St. Jude’s Children’s Hospital. 18. Non-Profit Hospital-Nonprofit hospitals are driven by a commitment to community service and a mission to provide accessible healthcare to all, regardless of a patient’s ability to pay. These facilities are often founded by charitable organizations, religious groups, or community initiatives, or may be affiliated with a medical school. Nonprofit hospitals are sometimes known as not-for-profit or NFP 19. Speciality Hospital-means a hospital or the specialty unit of a general hospital that is licensed by the state. It must be designed to care for patients with injuries or special illnesses. This includes, but is not limited to, a long-term acute care unit, an acute mental health or acute short-term rehabilitation unit or hospital. Hospital does not mean: convalescent home; rest home; nursing home; home for the aged; school and college infirmary; residential treatment facility; long-term care facility; urgent care center or freestanding ambulatory surgical center; facility providing mainly custodial, educational or rehabilitative care; or a section of a hospital used for custodial, educational or rehabilitative care, even if accredited by the JCAHO or listed in the AHA directory 20. Deductible-The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest. Many plans pay for certain services, like a checkup or disease management programs, before you've met your deductible. Check your plan details. All Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible. Some plans have separate deductibles for certain services, like prescription drugs. Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members. Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles. Premium-The amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance. If you have a Marketplace health plan, you may be able to lower your costs with a premium tax credit. When shopping for a plan, keep in mind that the plan with the lowest monthly premium may not be the best match for you. If you need much health care, a plan with a slightly higher premium but a lower deductible may save you a lot of money. After you enroll in a plan, you must pay your first premium directly to the insurance company — not to the Health Insurance Marketplace®. 21. Open Enrollment-The yearly period when people can enroll in a health insurance plan. 22. Qualifying Life Events-Loss of health coverage a. Losing existing health coverage, including job-based, individual, and student plans b. Losing eligibility for Medicare, Medicaid, or CHIP c. Turning 26 and losing coverage through a parent’s plan Changes in household d. Getting married or divorced e. Having a baby or adopting a child f. Death in the family Changes in residence g. Moving to a different ZIP code or county h. A student moving to or from the place they attend school i. A seasonal worker moving to or from the place they both live and work j. Moving to or from a shelter or other transitional housing Other qualifying events k. Changes in your income that affect the coverage you qualify for l. Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder m. Becoming a U.S. citizen n. Leaving incarceration (jail or prison) o. AmeriCorps members starting or ending their service 23. Worker’s Compensation-An insurance plan that employers are required to have to cover employees who get sick or injured on the job. 24. Hospice-Hospice care focuses on a person's quality of life as they near the end of life. Hospice treats the person and the symptoms of cancer, rather than the cancer itself. A team of health care professionals work together to manage symptoms, distress, and spiritual issues 25. Home Healthcare-Home health care is a wide range of health care services that can be given in your home for an illness or injury. Home health care is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility (SNF). 26. University/College Medical Center-Academic medical centers (AMCs) are hospitals that provide patient care and educate healthcare providers in partnership with at least one medical school accredited by the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association (AOA) 27. CHIPS-Children's Health Insurance Program (CHIP) covers children in families that earn too much money to qualify for Medicaid but cannot afford to buy private insurance The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value 28. Joint Commission- 29. Satellite Health Clinic-a freestanding outpatient facility that is physically separate from but administratively attached to a parent medical facility. Staff interaction and delivery of services occur between the clinic and parent facility 30. Preventive Care-Regular checkups are separate from any other doctor’s visit for sickness or injury. In addition to physical exams, these visits focus on preventive care, such as: Screening tests, which are medical tests to check for diseases early, when they may be easier to treat. Services, like vaccines (shots), that improve your health by preventing diseases and other health problems. Dental cleanings. Education and counseling to help you make informed health decisions. 31. Maximum Out of Pocket-The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits 32. In-Network/Out of Network-What we are talking about is the difference between in-network and out-of-network health insurance. In-network just means that your health care provider signed an agreement with your health insurance carrier to accept a discounted rate. And out-of-network just means that there's no signed agreement in place 33. Co-Pay-A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible. Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20. If you've paid your deductible: You pay $20, usually at the time of the visit. If you haven't met your deductible: You pay $100, the full allowable amount for the visit. Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists. Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments. 34. Co-Insurance-The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%. If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest. If you haven't met your deductible: You pay the full allowed amount, $100. 35. Medigap-Medigap (Medicare Supplement Health Insurance) A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn't cover 36. USDHHS-The mission of the U.S. Department of Health and Human Services (HHS) is to enhance the health and well-being of all Americans, by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services. 37. AHRQ-The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of healthcare for all Americans. AHRQ develops the knowledge, tools, and data needed to improve the healthcare system and help consumers, healthcare professionals, and policymakers make informed health decisions. 38. Assisted Living Facilities-Assisted living facilities provide individualized health and personal care assistance in a homelike setting with an emphasis on personal dignity, autonomy, independence and privacy. Facilities can be large apartment-like settings or private residences. Services provided include meals, bathing, dressing, toileting and administering or supervising medication. 39. Residential Care Facilities-Residential Care provides a 24-hour living arrangement in a licensed facility that provides: Personal care Home management Escort Social and recreational activities Transportation 24-hour supervision Supervision of/assistance with or direct administration of medication