HSC 111 Final Exam - Questions and Answers (Complete Solutions)

HSC 111 Final Exam - Questions and Answers (Complete Solutions) What is the central role of health services financing in the United States? a. Fund health insurance b. Underwrite medical risk c. Support managed care d. Balance the supply of health care professionals What is the primary mechanism that enables people to obtain health care services? a. Availability of services b. Health insurance c. Payment for services d. Control of expenditures The phenomenon called 'moral hazard' results directly from a. the uninsured status of segment of the U.S. population b. inadequate payment to providers c. managed care enrollment d. health insurance coverage Controlling total health care expenditures by restricting financing for health insurance. a. top-down control b. demand-side rationing c. underwriting d. underutilization IN national health care systems, total expenditures are controlled mainly through a. cost shifting b. underwriting c. supply-side rationing d. demand-side rationing In a general sense, what is the primary purpose of insurance? a. Predicting risk b. Risk assessment c. Protection against risk d. Underwriting Private health insurance is also referred to as a. mandatory health insurance b. public insurance c. employee health insurance d. voluntary health insurance Under community rating a. premiums are based on risk rating b. premiums are based on a group's utilization of health care services c. high-risk individuals pay a higher premium that low-risk individuals d. both high-risk and low-risk people are charged the same premium Which method of risk assessment is required by the ACA for individual and small-group health insurance? a. experience rating b. pure community rating c. adjusted community rating d. risk selection Under experience rating, a. costs shift from people in poor health to people in good health b. favorable risk groups pay a lower premium than high-risk groups c. premiums rise for every one regardless of risk d. deductibles and copayments are eliminated What is the main advantage of group insurance? a. More people can obtain insurance from a single insurer b. Risk is spread out among a large number of insured c. More comprehensive services can be covered than under an individual plan d. The employer has to deal with only one insurance company Cost is shifted from people in poor health to the healthy when a. premiums are based on experience rating b. people purchase individual private health insurance policies instead of group policies c. first-dollar coverage is predominant d. premiums are based on community rating A health insurance plan pays for medical care only after the insured has first paid $1,000 out of pocket on an annual basis. The $1,000 annual cost is called a. first-dollar coverage b. coinsurance c. premium d. deductible A copayment is generally paid a. once a year b. each time the insured receives health care services c. in form of a deduction from payroll checks d. by the employer to purchase health insurance on behalf of each covered employee Medigap policies are sold by a. private insurance companies b. the government c. HMO's d. Medicare The ACA specifies that ___________ can be covered under their parents' health insurance plans. a. Children attending college b. Children who are unemployed c. Children up to the age of 19 d. Children under the age of 26 How are preexisting medical conditions covered under the Affordable Care Act? a. They will continue to be covered under a special federal program. b. States are mandated to have risk pools to cover preexisting conditions. c. Private insurance plans have to cover them starting 2014. d. There is no provision in the law to cover preexisting conditions. In general, how do bronze, silver, gold, and platinum health plans differ? a. They differ according the benefits offered. b. They differ according to cost sharing c. They differ according to both benefits and cost sharing d. They differ according to the length of service with an employer The majority of beneficiaries receiving health care through Medicare are a. elderly b. disabled c. financially poor d. those suffering from end-stage renal disease To finance Medicare Part A, a. enrollees are required to pay a subsidized premium b. only employers are required to pay a payroll tax c. all income earned by a working person is subject to Medicare tax d. employee wages are taxed up to a certain ceiling that is raised each year Skilled nursing care is covered under ____________ of Medicare. a. Part A b. Part B c. Part C d. Part D The HI portion of Medicare is financed through a. Premiums from enrollees b. General taxes c. Payroll taxes d. None of the above For Medicare beneficiaries, the maximum stay in a SNF during a benefit period cannot exceed a. 30 days b. 60 days c. 100 days d. None of the above For hospitalizations, Medicare beneficiaries must pay a deductible a. each time they are admitted to a hospital b. once per benefit period c. on discharge from a hospital d. None of the above Medicare Part B premiums are a. standard for everyone b. market-based c. income-based d. None of the above SMI provides a. hospital coverage b. skilled nursing facility coverage c. prescription drugs d. physician services Part C of Medicare specifically covers a. rehabilitation services b. preventive care c. prescription drugs d. none of the above The primary criterion to become eligible for Medicaid is a. age b. medical necessity c. financial status d. family emergency The insurance arm of military health care is called a. CHAMPUS b. VISN c. VHA d. TRICARE To receive payment for services delivered, providers must file a _______ with third-party payers. a. bill b. claim c. fee-schedule d. charge ____________ reimbursement is based on the assumption that health care is provided in a set of identifiable and individually distinct units of services. a. bundled-fee b. cost-plus c. prospective d. fee-for-service When a fixed monthly fee per enrollee is paid to a provider, it is called a. bundled fee b. charge c. capitation d. retrospective reimbursement Capitation removes the incentive to a. control costs b. provide unnecessary services c. file a reimbursement claim d. underutilize health care The amount of reimbursement is determined before the services are delivered. a. retrospective reimbursement b. cost-plus reimbursement c. prospective reimbursement d. fee-for-service A DRG represents a. cumulative days of care b. a group of principle diagnoses c. bundled fees established prospectively d. number of discharges from the hospital An MS-DRG is a refined DRG that includes a. patient severity b. costs incurred in treating a patient c. adjustment from treating patients on Medicaid d. adjustment from readmissions within 30 days of discharge Under the DRG method of reimbursement, an acute care hospital is paid a. a per-diem rate based on the DRG classification b. a fixed amount for a particular DRG classification c. a fixed amount for each day of care d. an amount based on the use of resources in treating a patient How is case mix determined for an inpatient facility? a. A comprehensive assessment of each patient is done b. Patients are classified according to case-mix groups c. A case-mix index is created d. Case mix is determined by the principle diagnosis of each patient What is the Minimum Data Set (MDS)? a. It is a data collection instrument used mainly for clinical research b. It facilitates the determination of case-mix groups in rehabilitation hospitals c. It is a patient assessment instrument for skilled nursing facilities d. It facilitates the determination of ambulatory payment classifications in outpatient centers. The largest share of national health expenditures is attributed to: a. Structures and equipment b. Personal health care c. Net cost of private health insurance d. Public health activities Adverse selection makes health insurance less affordable for a. those in poor health b. those covered by public insurance c. those in good health d. high-risk individuals Managed care was initially welcomed by a. employers b. workers c. private insurance d. the government A managed care organization functions like a. a provider b. an insurer c. a regulator d. a financier What is the purpose of risk sharing with providers? a. it makes providers immune to costs b. it makes providers cost conscious c. it rewards providers for quality d. it keeps insurance premiums low Capitation is best described as a. monthly lump sum payment regardless of utilization b. monthly lump sum payment regardless of cost c. fixed monthly fee per member d. payments capped to a maximum cost for delivering services Under which payment method is a fee schedule used? a. prospective payment b. capitation c. discounted fees d. fee for service Discounted fees are a. discounted capitated fees b. used to shift risk from the financiers to the insurers c. used to share maximum risk with providers d. a modified form of fee for service In the term, managed care, 'manage' refers to a. management of utilization b. management of premiums c. management of risk d. management of the supply of services Fee for service promoted a. price controls b. moral hazard c. provider-induced demand d. both moral hazard and provider-induced demand Gatekeeping heavily depends on the services of a a. primary care physician b. case manager c. disease consultant d. nurse practitioner Gatekeeping ___________ secondary care services. a. bypasses b. encompasses the delivery of c. requires a referral for d. does not control