Term
| name the three components of the healthcare system |
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Definition
| consumer, provider, delivery system |
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Term
| a healthy people 2020 goal that we are not currently meeting is what |
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Definition
| to improve access to quality, comrehensive healthcare services |
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Term
| when a client is charged for what they recieve |
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Definition
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Term
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Definition
| a set amount of money per member per month |
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Term
| capitation is contracted how |
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Definition
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Term
| by using capitation, there is more incentive to do what |
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Definition
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Term
| administrative costs are lower with which type |
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Definition
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Term
| quality of care may be an issue with what type |
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Definition
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Term
| what is a problem with fee for service |
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Definition
| they may charge for unneeded tests |
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Term
| who adminsiters medicaid and medicare |
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Definition
| the centers for medicaid and medicare or CMS.gov |
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Term
| cms will not reimburse for what |
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Definition
| hospital aquired infections and incidents |
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Term
| this is federally mandated and the same in every state |
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Definition
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Term
| name 3 qualifiers for medicare |
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Definition
| people over 65, under 65 with certain disabilities, and those with ESRD |
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Term
| how do you apply for medicare |
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Definition
| online or at the social security office |
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Term
| name and define the parts of medicare |
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Definition
| A-hospitalization, B- medical, C-supplemental, D-medicine/prescriptions |
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Term
| this is federally mandated and different from state to state |
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Definition
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Term
| to get medicaid, you must eventually go where |
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Definition
| the department of human services (DHS) |
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Term
|
Definition
| managed care organizations |
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Term
| three MCO's of tenncare are |
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Definition
| amerigroup, blue cross blue sheild(VSHP), and united healthcare |
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Term
| this is when income is weighed against medical expenses |
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Definition
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Term
| managed care organizations all work through what |
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Definition
|
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Term
| this is when a 45 day window is given before going to DHS |
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Definition
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Term
| name who is eligible for medicaid |
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Definition
| pregnant, children, income at poverty level, disabled, if you draw SSI, if part of DCS, women with breast or cervical cancer |
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Term
| the problem with CMS reimbursment is that |
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Definition
| sometimes providers are not reimbursed |
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Term
| case management helps alleviate what |
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Definition
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Term
| with capitation, what is more important than care |
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Definition
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Term
| name the three ways private insurance can be provided |
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Definition
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Term
| the two types that use capitation are |
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Definition
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Term
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Definition
| fee for service so it does not require referrel |
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Term
| EPSDT must be provided by medicaid and medicare because of what |
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Definition
| the John B lawsuit in which children were not recieving this care |
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Term
| the group who began providing EPSDT were |
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Definition
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Term
| the greatest influence on national healthcare expense is going to be |
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Definition
| the aging of the population |
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Term
| the biggest barrier to getting health insurance is what |
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Definition
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Term
| what is EMTALA and what does it mandate |
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Definition
| emergency medical treatment and labor act; it requires that people who enter an ER recieve treatment or referel, they must at least be seen and evaluated |
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Term
| demographic changes that effect healthcare include |
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Definition
| aging of the population, change of minorities |
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Term
| socioeconomic factors include |
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Definition
| older nurses returing to work, |
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Term
| name some components of the patient protection and affordable healthcare act |
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Definition
| medicaid expansion by raising the poverty ceiling, fraud and abuse programs, accountable care organizations, under 26 are insured, dual eligibility (for medicaid and medicare), exchange subsidies |
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Term
| this is a program to improve label understanding |
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Definition
| nuval (assign one number to every item) |
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Term
| this is a grant designed to improve quality, access, coverage, healthy behavior and realistic expectations |
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Definition
| community transsformation grant |
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Term
| the major driving force of healthcare costs in this country are r/t to |
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Definition
|
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Term
| this delivers healthcare to children who do not qualify for medicaid |
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Definition
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Term
| a community health center that provides comprehensive care to an underserved area and is based on income is what |
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Definition
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Term
| a system in which care is delivered by a specific network of providers and in which gatekeepers are used to control access to providers |
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Definition
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Term
| why has the government used managed care for medicare and medicaid |
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Definition
|
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Term
| access to healthcare for the poor is provided by |
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Definition
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Term
| access is affected by what barriers |
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Definition
| preexisting conditions, physician not accepting the insurance, communication problems, childcare needs, refusal of services by providers, lack of time or info, long travel distance |
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Term
| community providers that offer services to the uninsured or underinsured |
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Definition
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Term
| when reimburment to health care providers is made by someone other than the client (insurance, government, employer) |
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Definition
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Term
| part B of medicare is available with what |
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Definition
|
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Term
| this is a patient classification scheme based on illness that outlines what can be covered by medicare |
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Definition
|
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Term
| medicaid provides financial services to who |
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Definition
| poor older adults, blind, disabled, and families with dependent children |
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Term
| managed care uses what philosophies |
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Definition
| health promotion, disease prevention, wellness and consumer education |
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Term
| name two common types of managed care |
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Definition
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Term
| when comprehensive care is provided through a per member per month fee |
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Definition
|
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Term
|
Definition
| capitation, designated providers |
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Term
| an arrangement where predetermined rates are established for services to be delivered to members |
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Definition
|
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Term
|
Definition
| discounted rate setting, hospital and physician providers, financial incentives |
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Term
| capitation uses what type of reimbursement |
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Definition
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Term
| fee for service uses what type of reimbursment |
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Definition
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Term
| when a set rate is offerred for a service such as a physical |
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Definition
|
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Term
| when the consumer is charged for each aspect of care such as culture, blood test, office visit, etc. |
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Definition
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Term
|
Definition
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|
Term
| with POS, they must choose a primary care provider as their point of service but then have the option of what |
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Definition
| being referred outside the network |
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