01: Healthcare Policy Management

Question 1

What is the difference between healthcare policy and healthcare management?

Answer 1

Healthcare policy: Decisions, plans, and actions that are undertaken to achieve healthcare goals within society.

Healthcare management: How policy is implemented.

Question 2

Why is it important for OTs to learn about healthcare policy and management (HPM)?

Answer 2

1. “We are constantly governed by the symptoms of what kind of healthcare we receive”
2. To correct the weaknesses in the healthcare system
3. To maintain its strength, we need to understand how the system works
4. It affects our practice as OTs

Question 3

The following (italicized) are examples of…

Hospitals and healthcare practitioners

A. Purchasers
B. Providers
C. Insurers
D. Suppliers

Answer 3

B

Question 4

The following (italicized) are examples of…

Medicare, Medicaid, ACA exchanges, employer-based

A. Purchasers
B. Providers
C. Insurers
D. Suppliers

Answer 4

C

Question 5

The following (italicized) are examples of…

Individuals, businesses, government

A. Purchasers
B. Providers
C. Insurers
D. Suppliers

Answer 5

A

Question 6

The following (italicized) are examples of…

Pharmaceutical companies, medical supply companies, computer/technology industry

A. Purchasers
B. Providers
C. Insurers
D. Suppliers

Answer 6

D

Question 7

True or false: Medicaid is age-based.

Answer 7

False

Medicaid is income-based, while Medicare is age-based.

Question 8

Match the definition italicized below to the correct term.

A tax subsidy that reduces the out-of-pocket costs during the policy period; this includes the deductible, coinsurance, and copay.

A. Exchange
B. Medicare
C. Medicaid
D. Cost-sharing reduction
E. Advanced premium tax credit

Answer 8

D

Question 9

Match the definition italicized below to the correct term.

An online marketplace where consumers can compare and buy health insurance plans

A. Exchange
B. Medicare
C. Medicaid
D. Cost-sharing reduction
E. Advanced premium tax credit

Answer 9

A

Question 10

Match the definition italicized below to the correct term.

A tax subsidy that lowers monthly health insurance premiums.

A. Exchange
B. Medicare
C. Medicaid
D. Cost-sharing reduction
E. Advanced premium tax credit

Answer 10

E

Question 11

Match the definition italicized below to the correct term.

A government-subsidized insurance plan that is income-based.

A. Exchange
B. Medicare
C. Medicaid
D. Cost-sharing reduction
E. Advanced premium tax credit

Answer 11

C

Question 12

Match the definition italicized below to the correct term.

A government-subsidized insurance plan that is age-based.

A. Exchange
B. Medicare
C. Medicaid
D. Cost-sharing reduction
E. Advanced premium tax credit

Answer 12

B

Question 13

Match the definition italicized below to the correct term regarding MODES OF PAYMENT.

Cash or barter system

A. Out-of-pocket
B. Individual private insurance
C. Employment-based group private insurance
D. Government financing

Answer 13

A

Question 14

Match the definition italicized below to the correct term regarding MODES OF PAYMENT.

Medicare and medicaid

A. Out-of-pocket
B. Individual private insurance
C. Employment-based group private insurance
D. Government financing

Answer 14

D

Question 15

Match the definition italicized below to the correct term regarding MODES OF PAYMENT.

Third-party payer (insurer)

A. Out-of-pocket
B. Individual private insurance
C. Employment-based group private insurance
D. Government financing

Answer 15

B

Question 16

Match the definition italicized below to the correct term regarding MODES OF PAYMENT.

Employers pay for most of the premium for employees

A. Out-of-pocket
B. Individual private insurance
C. Employment-based group private insurance
D. Government financing

Answer 16

C

Question 17

Match the definition italicized below to the correct term.

Share of any plan cost that the patient pays out of pocket; includes annual deductible, copays, and coinsurance but does NOT include premiums of non-covered healthcare services

A. Out-of-pocket expense
B. Premium
C. Deductible
D. Copayment
E. Coinsurance
F. Formulary
G. Out-of-pocket maximum
H. Cost-sharing
I. In-network
J. Out-of-network
K. Pre-certification
L. Open enrollment

Answer 17

H

Question 18

Match the definition italicized below to the correct term.

A lit of prescription drugs preferred by a health plan.

A. Out-of-pocket expense
B. Premium
C. Deductible
D. Copayment
E. Coinsurance
F. Formulary
G. Out-of-pocket maximum
H. Cost-sharing
I. In-network
J. Out-of-network
K. Pre-certification
L. Open enrollment

Answer 18

F

Question 19

Match the definition italicized below to the correct term.

The amount a patient spends.

A. Out-of-pocket expense
B. Premium
C. Deductible
D. Copayment
E. Coinsurance
F. Formulary
G. Out-of-pocket maximum
H. Cost-sharing
I. In-network
J. Out-of-network
K. Pre-certification
L. Open enrollment

Answer 19

A

Question 20

Match the definition italicized below to the correct term.

A fixed amount paid for a healthcare service; may or may not count toward deductible.

A. Out-of-pocket expense
B. Premium
C. Deductible
D. Copayment
E. Coinsurance
F. Formulary
G. Out-of-pocket maximum
H. Cost-sharing
I. In-network
J. Out-of-network
K. Pre-certification
L. Open enrollment

Answer 20

D

Question 21

Match the definition italicized below to the correct term.

The annual period when employees select their choice of benefits or health insurance coverage.

A. Out-of-pocket expense
B. Premium
C. Deductible
D. Copayment
E. Coinsurance
F. Formulary
G. Out-of-pocket maximum
H. Cost-sharing
I. In-network
J. Out-of-network
K. Pre-certification
L. Open enrollment

Answer 21

L

Question 22

Match the definition italicized below to the correct term.

Any provider outside of a medical plan; typically a higher cost.

A. Out-of-pocket expense
B. Premium
C. Deductible
D. Copayment
E. Coinsurance
F. Formulary
G. Out-of-pocket maximum
H. Cost-sharing
I. In-network
J. Out-of-network
K. Pre-certification
L. Open enrollment

Answer 22

J

Question 23

Match the definition italicized below to the correct term.

Limits the amount the patient pays per year for medical expenses; includes the annual deductible, medical and prescription copays, and coinsurance but does NOT include premiums or costs paid for non-covered healthcare services.

A. Out-of-pocket expense
B. Premium
C. Deductible
D. Copayment
E. Coinsurance
F. Formulary
G. Out-of-pocket maximum
H. Cost-sharing
I. In-network
J. Out-of-network
K. Pre-certification
L. Open enrollment

Answer 23

G

Question 24

Match the definition italicized below to the correct term.

Monthly amount paid by the patient to the insurance company to maintain healthcare coverage.

A. Out-of-pocket expense
B. Premium
C. Deductible
D. Copayment
E. Coinsurance
F. Formulary
G. Out-of-pocket maximum
H. Cost-sharing
I. In-network
J. Out-of-network
K. Pre-certification
L. Open enrollment

Answer 24

B

Question 25

**Match the definition italicized below to the correct term.** *Amount to pay each calendar year before insurance pays for any non-preventative expenses.* A. Out-of-pocket expense B. Premium C. Deductible D. Copayment E. Coinsurance F. Formulary G. Out-of-pocket maximum H. Cost-sharing I. In-network J. Out-of-network K. Pre-certification L. Open enrollment

Answer 25

C

Question 26

**Match the definition italicized below to the correct term.** *Providers offering service to a medical plan at a lower cost and/or negotiated rates.* A. Out-of-pocket expense B. Premium C. Deductible D. Copayment E. Coinsurance F. Formulary G. Out-of-pocket maximum H. Cost-sharing I. In-network J. Out-of-network K. Pre-certification L. Open enrollment

Answer 26

I

Question 27

**Match the definition italicized below to the correct term.** *A prerequisite to receiving special medical services or seeing specialists.* A. Out-of-pocket expense B. Premium C. Deductible D. Copayment E. Coinsurance F. Formulary G. Out-of-pocket maximum H. Cost-sharing I. In-network J. Out-of-network K. Pre-certification L. Open enrollment

Answer 27

K

Question 28

Which of the following is NOT considered a Qualified Life Status Change? A. Change in household B. Loss of health coverage C. Loss of medicare or medicaid coverage D. Release from jail E. All of the above qualify F. B and C

Answer 28

E

Question 29

True or false: A PPO requires the individual to choose a primary care physician and generally requires referrals for specialists.

Answer 29

**False** An *HMO* requires the individual to choose a primary care physician and generally requires referrals for specialists. A *PPO* does NOT require the individual to choose a primary care physician and typically does NOT require referrals.

Question 30

True or false: PPO plans generally have higher premiums than HMO plans.

Answer 30

True

Question 31

This plan has the goal of reducing duplication and unnecessary interventions, keeping people healthy, and decreasing emergency room visits and hospital stays. A. HMO (Health Maintenance Organization) B. PPO (Preferred Provider Organization) C. ACO (Accountable Care Organizations) D. PSP (Point of Service Plans)

Answer 31

C

Question 32

Who is "at risk" with **fee-for-service** reimbursement? A. The consumer B. The insurer C. The provider D. B and C

Answer 32

**A** Generally, the more a consumer is seen, the more the person will pay in copays.

Question 33

Who is "at risk" with **capitation payment** reimbursement? A. The consumer B. The insurer C. The provider D. B and C

Answer 33

**C** In this type of billing, the provider is only paid once, so if a consumer is seen multiple times, the provider loses money. The incentive with this reimbursement is for the provider to "sign on" healthy consumers.

Question 34

"Payment of a set-aside amount for all services rendered in 1 day" refers to which kind of reimbursement? A. Fee-for-service B. Payment by episode C. Per diem payment D. Capitation payment E. Payment per time

Answer 34

**C** *A*: Provider is paid for each visit. *B*: Provider is paid for all services rendered during an episode of illness. *D*: Provider is paid once per person. *E*: Provider is paid an aggregate salary of services rendered in a month.

Question 35

Suppose that under your health insurance policy, hospital expenses are subject to a $1000 deductible and $250 per day copay. You get sick and are hospitalized for 4 days, and the bill (after insurance discounts are applied) comes to $6000. **How much of this hospital bill will you have to pay yourself?** A. $0 B. $1000 C. $2000 D. $4000 E. $5000

Answer 35

**C** The deductible is $1000, meaning you must pay this amount minimum. Additionally, there is a copay of $250 per day spent in the hospital. Since you stayed 4 days, this would also be $1000. Therefore, the total you must pay would be $2000.

Question 36

Suppose your health insurance plan covers lab tests in full if you go to an in-network lab, but only pays 60 percent of allowed charges if you go to an out-of-network lab. You forget to check and go get your blood test at a lab that turns out to be out-of-network. The lab bills you $100 for the blood test. Your insurance only allows a $20 charge for this test. **How much would you have to pay out of pocket for this lab test?** A. $0 B. $40 C. $80 D. $88

Answer 36

**D** Your insurance only allows a charge of $20 for this lab test. $100 - $20 = $80. However, of this allowed charge ($20), they only cover 60%. $20 x 60% = $12 Thus, the cost of this lab would be $100, minus the 60% of $20 allowed charge insurance would pay of the test ($12), leaving you with an $88 bill to pay.

Question 37

True or false: If your health insurance plan refuses to pay for a service that you think is covered and your doctor says you need, you can appeal the denial and possibly get the insurance to pay the claim.

Answer 37

True

Question 38

True or false: If you are admitted to a hospital that accepts your insurance, then every physician within that hospital will also accept your insurance.

Answer 38

False