Final exam - Week 1 Flashcards
1
Q
What is a contract that requires a health insurer to pay some or all of an individual’s health care costs in exchange for a premium?
A
health insurance
2
Q
What is a health insurance contract also called?
A
a policy or plan
3
Q
According to the U.S. census how many people of the non-institutionalized US population had health insurance?
A
90.2%
4
Q
What is the capacity to find and evaluate information about health insurance plans, select the best plan given financial and health circumstances, and use the plan once enrolled?
A
health insurance literacy
5
Q
What are 4 risk factors associated with poor health literacy?
A
- race and ethnicity
- poverty
- education
- lack of previous health insurance coverage
6
Q
What are individual risk factors that lead to poor HIL?
A
- Unstable housing
- Limited access to phones and the internet
- Limited Experience with making decisions about health care
- Limited understanding of terminology used
7
Q
What are structural risk factors that lead to poor HIL?
A
- Limited in-person support (everything was either online or over the phone
- Too much information to process
- Information was too complicated; or presented unclearly
8
Q
who is the highest literacy amongst in the US?
A
non-hispanic whites
9
Q
Who is the lowest literacy amongst in the US?
A
racial and ethnic minorities - low income minority groups
10
Q
What is included in poverty that leads to HIL?
A
- unstable housing
2. access to phones and the internet
11
Q
What is included in education that leads to HIL?
A
- low health literacy
- low financial/math literacy
- limited literacy
12
Q
What are consequences of poor health insurance literacy?
A
- being uninsured or underinsured
- making poor insurance decisions
- inefficient use of insurance
- limiting access to are due to high out of pocket costs
- high medical bills and medical debt
- poor health outcomes
13
Q
What are 2 poor insurance decisions?
A
- not selecting the right plan for considering needs
2. frustration in using plan leading to dropping insurance
14
Q
What are the key components of an insurance plan?
A
Premium Cost Sharing --> Deductible --> Co-pays --> Co-Insurance Primary Care Provider (PCP) Preauthorization Network Preferred provider or network provider Out-of-Network Provider Maximum Out-of Pocket Limit Durable Medical Equipment (DME) Preventive Services
15
Q
what is the amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly?
A
premium
16
Q
What is your share of costs for services that a plan covers that you must pay out of your own pocket?
A
cost sharing
17
Q
What are 3 examples of cost sharing?
A
- copayments
- deductibles
- cost insurance
18
Q
What is an amount you could owe during a coverage period for covered health care services before your plan begins to pay?
A
deductible
19
Q
What is a fixed amount you pay for a covered health care service, usually when you receive the service?
A
copayment
20
Q
What is co-insurance?
A
your share of the costs of a covered health care service, calculated as a percentage of the allowed amount for the service.
21
Q
Who is a physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law and the terms of the plan, who provides, coordinates or helps you access a range of health care services?
A
primary care provider
22
Q
What is a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. Sometimes called prior authorization, prior approval or precertification?
A
preauthorization
23
Q
What is a list of drugs your plan covers?
A
formulary
24
Q
What is the facilities, the providers and suppliers your health insurer or plan has contracted with to provide health care services?
A
network
25
Who is a provider who has a contract with your health insurer or plan who has agreed to provide services to members of a plan. You will pay less if you see a provider in the network. Also called “preferred provider” or “participating provider.”
network provider (preferred provider)
26
Who is a provider who doesn’t have a contract with your plan to provide services. If your plan covers out-of-network services, you’ll usually pay more to see an out-of-network provider than a preferred provider?
out of network provider
27
What is a yearly amount the federal government sets as the most each individual or family can be required to pay in cost sharing during the plan year for covered, in-network services?
Maximum Out-of Pocket Limit
28
What is equipment and supplies ordered by a health care provider for everyday or extended use. DME may include: oxygen equipment, wheelchairs and crutches?
Durable Medical Equipment (DME)
29
What is routine health care, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems?
Preventive Services
30
What is a comprehensive health care reform law?
affordable care act
31
What is another name for affordable care act?
1. Obamacare
| 2. patient protection and affordable care act
32
What are 4 main goals for affordable care act?
1. increase access to health insurance
2. increase consumer protections
3. emphasize prevention and wellness and reduce risking health care costs
33
What does the affordable care act impact?
both private and government insurance
34
What 2 groups pay for health insurance?
1. private sources
| 2. government sources
35
What is group health insurance?
employer/employee
36
What is individually purchased health insurance?
purchased directly from an insurance company
37
Who do you purchase individually purchased health insurance from?
insurance agents or broken; through a government (ACA) Health Insurance Marketplace or Exchange
38
What are the 2 most common insurance plans?
1. HMOs
| 2. PPOs
39
What do HMO's usually only cover?
cover only care provided by doctors and hospitals inside the HMO’s network
40
Who do members sign up with who have HMO's plan?
PCP; and they become the gatekeeper
41
What is the benefit of HMO? the downside?
a. expensive
| b. restrictive
42
What do PPO's usually have higher of? but offer what?
premiums and deductibles; greater flexibility
43
What do you not need with PPO's
referrals
44
Where do POs and EPO plans lie?
fall somewhere in between a HMO and PPO; seem to vary depending on who offers it
45
What private insurance plan limits providers to those in network, and a POS, covers providers out of network, but at an increased cost?
EPO
46
Which private insurance plans has the lowest premium?
High deductible health plans (HDHP)
47
What happens in HDHP?
People have $ deducted from their paychecks into an account which they can be used to pay for out of pocket medical and dental bills.
48
What are 7 select provisions affecting individuals with private insurance?
1. Requires individuals to have insurance, with some exceptions (individual mandate).
2. Plans must cover young adults on parents policies until age 26
3. Pre-existing conditions: One’s health; medical history and gender can’t affect premiums
4. Ends lifetime and yearly dollar limits on coverage of essential health benefits
5. Mandates essential health benefits that all plans must cover (including MH and SA)
6. No copays or coinsurance for certain preventive services.
7. Insurers can no longer cancel health insurance because an individual got
49
What are government sources of health insurance?
1. Medicare
2. Medicaid
3. Children’s Health Insurance Program (CHIP)
4. ACA Subsidies
5. Government as an employer
- -> TriCare
50
What is a federal health insurance program for:
1. People who are 65 and older
2. Certain younger people with disabilities
3. People with End-Stage Renal Disease requiring dialysis or transplant
medicare
51
What is medicare part A?
hospital insurance
52
What is medicare part B?
medical insurance
53
What is medicare part D?
prescription drugs
54
what is supplemental policies - medigap?
pay for deductibles, services and copays not
55
What are some other key provisions impacting medicare include?
1. reduced payments to Medicare Advantage plans
| 2. increased premiums for higher income beneficiaries
56
What is a joint federal and state health insurance program for people with low income (feds match state spending)?
medicaid
57
What is unique about medicaid state and state?
Eligibility and covered services vary state to state
58
Who does medicaid cover?
1. nursing home residents
| 2. low income families
59
What is our medicaid program called in Arizona?
Arizona Health Care Cost Containment System
60
What did the affordable care act do for medicaid?
1. gave states the $ to expand Medicaid through increased eligibility
2. As of 2018, 34 states have adopted the expansion.
61
What is CHIP?
Health insurance for low income children whose family has income above the cut-off for Medicaid eligibility
62
What are 3 facts about CHIP?
1. Administered by state
2. based on federal guidelines
3. funded by state & feds
63
Benefits may what in CHIP?
vary state to state
64
What is CHIP program called in Arizona?
KidsCare
65
What is one key provision of ACA subsidies?
involves offering people with low to moderate incomes discounts (called tax credits) on health insurance.
66
Who are government ACA subsidies for?
For people with low or moderate incomes who purchase their own health insurance
67
What must health insurance be purchased through in order to have a government ACA subsidy?
Health insurance must be purchased through a government-sponsored health insurance marketplace (exchange).
68
What do ACA subsidies not impact?
Does not impact people on Medicare or those with employee sponsored health insurance
69
What was tricare formerly known as?
CHAMPUS
70
What is a health insurance program for active duty and retired uniformed service members and their families (similar to private employer insurance)?
tricare
71
What kind of options does tricare have?
managed care and preferred-provider options
72
Where is care provided for tricare?
provided at military treatment facilities or by private health care providers, depending on the plan
73
How many people does tricare cover?
9.4 million people
74
What are both government and private alternatives to health insurance?
1. Government
- -> Veteran’s Health Care System
- -> Indian Health Service
2. Private
- -> Health Care Cost Sharing Ministries
75
What determines who is eligible for VA health benefits?
is determined by how much money congress sets aside for it each year.
76
What is considered in order for someone to be eligible for the VA?
based on a priority system which considers military service, disability rating, income level, and other criteria.
77
true or false: members of the va. Care for some is free; for others there are copays
true
78
Where do veterans receive care at the VA?
VA medical centers and outpatient clinics. Some care is provided by community health care providers under limited conditions.
79
How many people does the VA serve?
9 million veterans per year
80
What is a health care system for members of one of the 573 federally recognized American Indian and Alaska Native tribes in the United States?
Indian health service
81
What is the Indian health service not?
health insurance system
82
What does the Indian health service consist of?
Consists of 26 hospitals, 59 health centers, 32 health stations, and 33 urban health projects.
83
Who takes care of patients in the Indian health service?
Most personal and public health care is provided directly by IHS staff at their facilities.
84
Who can provide some care of patients in the Indian Health service?
Some care can be provided by tribal facilities contracted by IHS, and very occasionally by non-native contracted health services
85
How many people does the Indian health service serve?
2.2 million
86
What are faith-based organizations that facilitate sharing of health care costs among members?
healthcare cost sharing ministries
87
What do members of healthcare cost sharing ministries do every month?
pay their fair share
88
How do healthcare cost sharing ministries work?
usually self-pay for health care; plans then reimburse members after the fact
89
Who are healthcare cost sharing ministries open to?
members who follow the practices of their faith community
90
What are healthcare cost sharing ministries used to replace?
health insurance or medicare supplemental plans
91
what are members of healthcare cost sharing ministries exempted from?
1. HCSM members exempted from the individual mandate
| 2. May deny enrollment based on health status; may exclude care for preexisting conditions
92
What are there no guarantees or protection of in healthcare cost sharing ministries?
No guarantees for reimbursement; no consumer protection
93
What are 4 reasons why people remain uninsured?
1. high cost of insurance
2. ineligible for work-sponsored insurance
3. ineligible for government programs
4. poor health insurance literacy
94
Who would be ineligible for work-sponsored insurance?
the working poor
95
Who would be ineligible for government programs?
1. Live in states that did not expand Medicaid
| 2. Unauthorized (illegal; undocumented) immigrants
96
What may someone have poor health insurance literacy of?
1. About eligibility
2. Process
3. Confidence in selecting a plan
97
What are the pros of healthcare cost sharing ministries?
1. Usually lower out of pocket costs (although they are not called premiums and deductibles).
2. People report feeling better about paying their monthly share, which goes towards health care costs another member in the system, rather than a premium to a for profit insurance company (not all insurance companies are for profit)
98
What are the cons of healthcare cost sharing ministries?
1. No consumer protections of ACA: Not regulated by the sate as insurance companies
2. May exclude care for pre-existing conditions, may deny enrollment based on health status
3. No guarantee of payment; no recourse for consumers; may not cover essential services such as preventive care; vaccines; prescription drugs. And for most of the plans, cost sharing is limited to health problems that do not conflict with Christian Values.
4. According to an article in science based medicine, some companies limit maternity care to married women; do not cover problems that arise due to substance abuse, sex outside of marriage, and suicide.
5. And finally, on a bigger picture, advocates of both ACA and insurance companies claim that these ministries are pulling healthy people out of the health insurance pool, and leaving a higher percentage of those who require more care, driving up the costs for all in insurance.
99
What are the nurses role in health insurance literacy?
1. assessment
2. health teaching
3. referral and follow-up
4. advocacy
5. case management
100
What is important for referral and follow-up?
1. for help with insurance
| 2. for low or no cost health care
101
What are community resources for people who are uninsured?
1. Emergency rooms (1985 Federal Law)
2. Federally Qualified Health Centers (FQHC)
- Community Health Centers; Rural Health
Clinics; Migrant Health Centers, Health
Care for the Homeless
- Sliding scale
- Tucson: El Rio, St. Elizabeth’s; Marana Health Centers
3. Free clinics (Clinica Amistad)
4. Pima County Health Department
5. Family Planning Clinic
6. Vaccines for Children program
7. Pima Community Access Program (PCAP)
102
What are key responsibilities for nurses?
1. referral
| 2. advocacy
