Chapter 1

Question 1

Gag clause

Answer 1

This clause or (language) in a provider contract prevents a physician from telling a patient about available clinical treatment options.
(Gag clauses are band under the ACA)

Question 2

Medically necessary

Answer 2

Policies used for benefits determinations when medical services or products may or may not be covered depending on certain criteria.

Question 3

HEDIS

Answer 3

Healthcare effectiveness data and information set

Question 4

Healthcare effectiveness data and information set

Answer 4

An ever evolving set of data reporting standards developed by NCQA with considerable input from the employer provider and managed care communities. HEDIS is designed to provide some standardization in performance reporting of financial, utilization, membership, and clinical data and more

Question 5

Health insurance exchange ( hix)

Answer 5

Under the ACA, state level health insurance exchanges where individuals and small group employers may purchase qualified health plans

Question 6

Medicare

Answer 6

The federal entitlement program under Social Security act title xviii under which health benefits coverage is provided by the federal government for citizens older than 65 as well as some other such as individuals with end-stage renal disease

Question 7

Accountable care organization (ACO)

Answer 7

And organized group of physicians possibly including a hospital that are supposed to coordinate the care for beneficiaries with high medical cost who are in traditional FFS Medicare.

Question 8

Health care

Answer 8

The service that a healthcare professional or institution provides to customers (services from my physician, at a hospital, from a physical therapist and so on) as well as medical goods such as prescription drugs and durable medical equipment.