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PHCY 609 Exam 1 Study Guide @ 2024
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PHCY 609 Exam 1 Study Guide @ 2024 ...
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PHCY 609 Exam 1 Study Guide @2024
define health insurance premium - Answer amount heath insurance companies charge
each month for coverage
medicaid is a government run health care delivery system, and provides enrollees
access to public health care facilities only (t/f) - Answer False - Government financed
system, federal and state contribute/pay. But can access public and private health care
facilities
services not covered by medicare (4) - Answer - dental
- eye
- hearing aids
- long term care
experience rating - Answer charging a price for insurance based on patient
risk/pre-existing conditions (think student vs. truck driver example)
community rating - Answer charging a price for insurance as an average of costs so
people pay more similar amounts despite differing needs for care
who pays for medicaid? - Answer Federal & State (federal at least 50%)
private health insurance? - Answer health insurance plans marketed by private health
insurance industry as opposed to government run insurance programs. ex: employer
sponsored insurance
medicaid - Answer public health insurance for people with low incomes, source of
financing for ~20% of US population
administered by states according to fed requirements
medicare - Answer federal insurance program consisting of 4 parts that provides
coverage to the elderly and disabled
dual eligibility - Answer disabled + low income = on medicare & medicaid
medicare eligibility (4) - Answer - 65+ years old
- ESRD
- social security disability income for at least 24 months
,- lou gehrig's disease
coverage vs. spending (comparing employer sponsored & medicare) - Answer more
people have employer sponsored insurance, but people on medicare spend more per
person than employer sponsored because they are sicker on average
role of private health insurance in medicare + medicaid - Answer collaborate with
medicare + medicaid (and employers) to provide services to varying degrees
why do companies self-insure & spend tons of money on healthcare for employees? (2) -
Answer 1) employee retention
2) tax write off (govt subsidizing program)
groups eligible for medicaid - Answer - pregnant women in poverty
- children in poverty
- parents with dependent children living in poverty
- individuals with disabilities
- low income senior citizens
what do states decide in medicaid? (4) - Answer - covered populations
- services
- healthy care delivery models
- payment methods
medicaid cost - Answer 3rd largest government program, cost per enrollee relatively
low, highest cost enrollees are those with disabilities
over half of spending attributable to 5% of enrollees
the ACA is the same in all states (t/f) explain answer - Answer False - the affordable care
act incentivizes states to cover more people, but states can choose whether or not they
want to expand
federally mandated medicaid benefits (9) - Answer - inpatient/outpatient hospital
services
- nursing facility & home health
- physician services
- rural health clinic
- lab/radiology
, - family planning
- peds & family NP
- transportation to medical care
- tobacco cessation counseling for pregnant women
state determined optional medicaid benefits (9) - Answer - prescription drugs
- clinic services
- PT/OT
- speech, hearing, language disability services
- optometry
- dental
- prosthetics
- chiropractor
- hospice
Coverage gap in states that did not expand Medicaid under ACA - Answer people that
are earning too much to qualify for medicaid, not enough to qualify for marketplace
subsidy
Medicare Part A - Answer hospital/acute care
Medicare Part B - Answer outpatient services & medical supplies
dr. visits, preventative services, drugs admin by physicians
Medicare Part C - Answer medicare advantage, prescription + medical benefits +/-
dental, eye, fitness/nutrition
Medicare Part D - Answer prescription drug coverage + MTM services
provider status - Answer being able to get reimbursed for the services that you provide
to patients - pharmacists not coded into SSA as providers of care
if pharmacists are not considered providers, how can they bill for immunizations? -
Answer they qualify as mass immunizers but only for flu, pneumococcal, hep B, and now
maybe COVID? all others through part D
how pharmacists can impact diabetes & cardio drug spend - Answer med ed,
counseling, non-pharm, evaluating social determinants and helping with those. They see
patients more frequently sometimes every month, trust, accessibility, knowledge
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