POL 536 Exam 1
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Activities of Daily Living (ADL)
Tasks used to measure a person's functional status, including eating, bathing, dressing, using the toilet and walking.
A method of cost-sharing in health insurance plans in which the plan member is required to pay a defined percentage of their medical costs after the deductible has been met.
Any contribution consumers make towards the cost of their health care as defined in their health insurance policy. Examples include co-payments, coinsurance, and annual deductibles.
A gap in prescription drug coverage under medicare part D, where beneficiaries enrolled in Part D plans pay 100% of their prescription drug costs after their total drug spending exceeds an initial coverage limit until they qualify for catastrophic coverage. Under the standard Part D benefit, Medicare covers 75% of total drug spending below the initial coverage limit (2,830 in 2010) and 95% of spending above the catastrophic level ($6,440 in 2010). These thresholds are indexed to increase over time. The doughnut hole or coverage gap specifically refers to the range between these two levels ($3,610 in 2010) in which beneficiaries are responsible for all costs incurred for prescription drugs. The coverage gap will gradually be phased out under health reform, so that by 2020, beneficiaries will only be responsible for 25% of all prescription drug costs up to the catastrophic level.
- A government's deficit can be measured
- with or without including the interest it pays on its debt. The primary deficit is defined as the difference between
- current government spending and total
- current revenue from all types of taxes. The total deficit (which is often just called
- the 'deficit') is spending, plus interest payments on the debt,
- minus tax revenues
- A term used to
- describe an individual who is eligible for Medicare and for some level of
- Medicaid benefits. Most dual eligibles qualify for full Medicaid benefits
- including nursing home services, and Medicaid pays their Medicare premiums and
- cost sharing. For other duals, Medicaid provides the “Medicare Savings
- Programs” through which enrollees receive assistance with Medicare premiums,
- deductibles, and other cost sharing requirements.
Fee for service (FFS)
- A traditional method of paying for health care
- services based on the actual care delivered, i.e., providers are paid for each
- service they provide
Health Maintenance Organization (HMO)
- A type of managed care plan that offers prepaid comprehensive health
- service coverage for hospital and physician services, relying on its medical
- providers to minimize the cost of providing medical services. HMOs contract with or directly employ
- participating health services providers. Enrollees must pay the full cost of
- receiving service from non-network providers.
- Health and social services for people with
- permanent disabilities or chronic illnesses. Care may be provided in a
- residential facility, at home or elsewhere in the community. Medicaid is the
- primary payer for long-term care. Many of these services are not covered by
- Medicare or private insurance
- Enacted in 1965 under Title XVII of the Social Security Act, Medicare is
- a federal entitlement program that provides health insurance coverage to 45
- million people, including people age 65 and older, and younger people with
- permanent disabilities, end-state renal disease, and Lou Gehrig’s disease.
- Medicare is organized into four parts.
Medicare Part A
- Covers inpatient hospital stays, skilled
- nursing facility stays, home health visits (also covered under Part B), and
- hospice care. Part A benefits are subject to a deductible and coinsurance.
Medicare Part B
- Covers physician visits, outpatient services, preventive services, and
- home health visits. Part B benefits are subject to a deductible and cost
- sharing generally applies.
Medicare Part C
- Refers to the Medicare Advantage program, through which beneficiaries
- can enroll in a private health plan, such as a health maintenance organization
- (HMO), and receive all Medicare-covered benefits.
Medicare Part D
- Voluntary, subsidized outpatient prescription drug benefit, with
- additional subsidies for beneficiaries with low incomes and modest assets. The
- Part D program is offered through private plans that contract with Medicare,
- both stand-alone prescription drug plans (PDPs) and Medicare Advantage
- prescription drug plans (MA-PDs).
Accountable Care Organization (ACO)
- A network of health care providers that band together
- to provide the full continuum of health care services for patients. The network
- would receive a payment for all care provided to a patient, and would be held
- accountable for the quality and cost of care. Proposed pilot programs in
- Medicare and Medicaid would provide financial incentives for these
- organizations to improve quality and reduce costs by allowing them to share in
- any savings achieved as a result of these efforts.
American Recovery and Reinvestment Act (2009) (aka the “Stimulus” or “The
- Economic stimulus package enacted by the 111th United States Congress in February 2009. The stimulus was intended to create jobs and promote
- investment and consumer spending during the recession. The rationale for the stimulus comes out of the Keynesian economic tradition that argues that government budget deficits should be used to cover the
- output gap created by the drop
- in consumer spending during a recession
- fixed payment provided to a health provider from a managed care plan for the
- care of a patient, regardless of the type or number of services actually
Insurance Program (CHIP):
- Enacted in 1997, CHIP is a federal-state program that provides health
- care coverage for uninsured low-income children who are not eligible for
- Medicaid. States have the option of administering CHIP through their Medicaid
- programs or through a separate program (or a combination of both). The federal
- government matches state spending for CHIP but federal CHIP funds are capped.
Fixed amount that must be paid by a patient before a health plan begins to cover other services.
Electronic health record (EHR)
A medical record in digital format.
Federal Medical Assistance Percentage (FMAP)
- The statutory term
- for the federal Medicaid matching rate—i.e., the share of the costs of Medicaid
- services or administration that the federal government bears. In the case of
- covered services, FMAP varies from 50 to 76 percent depending upon a state’s
- per capita income; on average, across all states, the federal government pays
- 57 percent of the costs of Medicaid. The American Recovery and Reinvestment Act
- (ARRA) provides a temporary increase in the FMAP through December 31, 2010.
Managed care organization (MCO)
- Umbrella term. Refers to a variety of healthcare
- products including: PPOs, HMOs, and POS plans. Managed care programs contract
- with a limited set of healthcare providers, often called a “network”. All
- managed care plans exert some control over how, where, when, by whom, and in
- what quantity healthcare is delivered.
- Enacted in 1965 under Title XIX of the Social Security Act, Medicaid is
- a federal entitlement program that provides health and long-term care coverage
- to certain categories of low-income Americans. States design their own Medicaid
- programs within broad federal guidelines. Medicaid plays a key role in the U.S.
- health care system, filling large gaps in the health insurance system,
- financing long-term care coverage, and helping to sustain the safety-net
- providers that serve the uninsured.
- Health care costs, such as deductibles,
- co-payments, and co-insurance that are not covered by insurance. Out-of-pocket
- costs do not include premium costs.
- The amount paid, often on a monthly basis, for
- health insurance. The cost of the premium may be shared between employers or
- government purchasers and individuals.
Non-specialty care provided by doctors, nurses and others.
People who are insured but nevertheless face big costs or limits on benefits.
Department of Health and Human Services (DHHS)
- DHHS is the U.S. government's principal agency for protecting the health of all Americans and providing essential human
Health insurance offered to employees through the workplace.
Patient Protection and Affordable Care Act (PPACA; aka ACA; aka “Obama Care”):
- On March 23, 2010, President Obama signed
- this comprehensive health reform, into law. The law, and the changes made to
- the law by subsequent legislation, focus on provisions to expand coverage,
- i.e., the individual mandate and health insurance exchanges, control health
- care costs, and improve the health care delivery system.
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