Chapter 3 - Paying for Health Services

How are services covered by both Medicare and Medicaid paid?

• Services covered by both programs are paid first by Medicare with Medicaid filling in a difference up to the state's payment limit.

• Services are paid entirely by Medicaid with no contribution from Medicare.

• Medicare covers all services, and Medicaid does not contribute.

• Both programs split the cost equally regardless of the state's payment limit.

A High Deductible Health Plan with a Savings Option (HDHP SO) is:

• a type of health insurance plan with lower premiums and higher deductibles.

• a health plan with no deductible and high premiums.

• a government-funded health insurance plan.

• a plan that covers all medical expenses without any out-of-pocket costs.

_________ are fee-for-service systems, as opposed to _______, which are capitated ----that is insurance pays providers a set fee in advance to cover all required services that the insurance person needs. The essential elements of this plan are as follows: fee for service, contractual arrangements, organization of providers, discounts, free choice, and economic incentives.

• PPOs, HMOs

• HMOs, PPOs

__________ cover care provided both inside and outside the plans provider network.

__________ are made up of groups of physicians or a hospital that provides employers with comprehensive health services for their employees at a discount. This is the #1 employer health insurance plan. Patients have the freedom to go wherever they want, including outside the ________ system.

• HMOs

• PPOs

• EPOs

The Children's Health Insurance Program (CHIP) is:

• a federal program providing health coverage to children in families with incomes too high to qualify for Medicaid but too low to afford private coverage.

• a state program offering free education to children.

• a federal initiative to provide housing for low-income families.

• a local community service for child care.

A Medicare Advantage Plan Network is:

• A type of health insurance plan in the United States that provides Medicare benefits through a private-sector health insurer.

• A network of hospitals and doctors that only accept private insurance.

• A government-run program that offers free healthcare to all citizens.

• A plan that only covers prescription drugs.

The Health Insurance Marketplace is:

• a government-run platform for buying health insurance.

• a private insurance company.

• a type of health insurance plan.

• a medical facility.

A cost control measure used by hospitals is _______________. This system categorizes patients with similar diagnoses in order to better control hospital costs and determine payor reimbursement rates. This is how hospitals bill for their services.

• Diagnostic related groups (DRG)

• Blue Cross & Blue Shield Insurances

• Medicare & Medicare

• fee-for-services

The American Medical Association is:

• A professional association for physicians in the United States

• A government agency regulating healthcare

• A non-profit organization for medical research

• A pharmaceutical company

What are the two types of subsidies available to Marketplace enrollees?

• Premium tax credit and cost sharing subsidies.

• Medicare and Medicaid subsidies.

• Employer-sponsored insurance subsidies.

• Health savings account contributions.