NUR 102 Exam #2 Study Guide Exam QUESTIONS AND ANSWERS (LATEST UPDATE 2025)
ALREADY PASSED
underwriting - (answer)a systemic technique for evaluating, selecting, classifying, and rating risks.
medical loss ratio - (answer)the percentage of premium revenue spent on medical expenses
prospective reimbursement - (answer)- uses certain pre-established criteria to determine in advance the
amount of reimbursement.
- DRG, APC, RUG, HHRG
Retrospective reimbursement - (answer)-Rates are set after evaluating the cost retrospectively.
-Per diem rates based on actual costs.
-Providers had no incentive to control costs.
-Health care institutions could increase costs to increase profits, thus it has been largely replaced with
prospective reimbursement.
self-insurance - (answer)Health insurance provided by large employers that can afford to assume the
risk by budgeting funds to pay medical claims incurred by their employees.
- They assume the risk rather than pay a dividend to the insurer.
- Give the employer better control over the health plan.
- Some employers also invest in reinsurance.
gatekeeping - (answer)- arrangements that requires PCP to coordinate all health care services needed by
an enrollee.
- Controls access to costly medical services.
- Emphasizes preventative care, routine physical exams, and other primary care services.
deductible - (answer)- the portion of health care costs that the insured must pay first (generally up to an
annual limit before insurance payment kicks in
,NUR 102 Exam #2 Study Guide Exam QUESTIONS AND ANSWERS (LATEST UPDATE 2025)
ALREADY PASSED
copayment - (answer)- a portion of health care charges that the insured has to pay under the terms of
his or her health insurance policy.
coinsurance - (answer)- form of cost sharing using percentages
premium cost sharing - (answer)employee shares total cost of the premium with the employer. (On
average employee pays for 18% of coverage for individual and 29% for family)
enrollee - (answer)an individual covered under a health insurance plan, also called a member, insured,
or beneficiary.
beneficiary - (answer)a participant in a health insurance plan, also called insured or enrollee.
HMO- health maintenance organization - (answer)- provides medical care during illness while also
offering services that help people maintain health.
- emphasizes preventive and screening services through routine checkups and test.
- enrollees are allowed to use in-network providers.
- primary care gatekeepers are used to manage and coordinate the utilization of services.
PPO- preferred provider organization - (answer)- enrollees are permitted to use both in-network and
out- of network providers.
- higher copayment for non-preferred providers.
- no gatekeeping.
- unrestricted access to specialty services.
MCO- managed care organization - (answer)- single organization takes on the management of financing,
insurance, and delivery and payment
POS - (answer)- combines HMO and PPO
, NUR 102 Exam #2 Study Guide Exam QUESTIONS AND ANSWERS (LATEST UPDATE 2025)
ALREADY PASSED
- over come the drawback of restricted provider choice (many HMO's provide optional plan that allow
for out of network utilization)
- maintain tight utilization management
- type of MCO is declining in enrollment due to high out of pocket costs associate with the plan.
Ambulatory care - (answer)- health care services that do not require an overnight stay in an institution
of health care delivery.
- Used interchangeably with outpatient care.
- physician's office, outpatient departments of hospitals, and health care centers.
- outpatient services intended to serve the surrounding community.
- Certain services that are transported to the patient.
Hospital - (answer)- institution with at least six beds who primary function is to deliver patient services,
diagnostic and therapeutic, for particular or general medical conditions.
inpatient - (answer)- services delivered on the basis of overnight stay in a health care institution
inpatient day - (answer)- a night spent in the hospital by a person admitted as an inpatient
outpatient - (answer)- any health care services that are not provided based on an overnight stay in
which room and board costs are incurred
observation - (answer)- patient is admitted for a hospital stay for up to 24 hours, may or may not have
an overnight stay
Hospital Evolution - (answer)Stage 1: almshouses as primarily institutions of social welfare
Stage 2: community-owned private hospitals as charitable institutions supported by affluent donors.
Stage 3: institutions of medical practice and training serving the needs of all members of society and
able to make a profit.
ALREADY PASSED
underwriting - (answer)a systemic technique for evaluating, selecting, classifying, and rating risks.
medical loss ratio - (answer)the percentage of premium revenue spent on medical expenses
prospective reimbursement - (answer)- uses certain pre-established criteria to determine in advance the
amount of reimbursement.
- DRG, APC, RUG, HHRG
Retrospective reimbursement - (answer)-Rates are set after evaluating the cost retrospectively.
-Per diem rates based on actual costs.
-Providers had no incentive to control costs.
-Health care institutions could increase costs to increase profits, thus it has been largely replaced with
prospective reimbursement.
self-insurance - (answer)Health insurance provided by large employers that can afford to assume the
risk by budgeting funds to pay medical claims incurred by their employees.
- They assume the risk rather than pay a dividend to the insurer.
- Give the employer better control over the health plan.
- Some employers also invest in reinsurance.
gatekeeping - (answer)- arrangements that requires PCP to coordinate all health care services needed by
an enrollee.
- Controls access to costly medical services.
- Emphasizes preventative care, routine physical exams, and other primary care services.
deductible - (answer)- the portion of health care costs that the insured must pay first (generally up to an
annual limit before insurance payment kicks in
,NUR 102 Exam #2 Study Guide Exam QUESTIONS AND ANSWERS (LATEST UPDATE 2025)
ALREADY PASSED
copayment - (answer)- a portion of health care charges that the insured has to pay under the terms of
his or her health insurance policy.
coinsurance - (answer)- form of cost sharing using percentages
premium cost sharing - (answer)employee shares total cost of the premium with the employer. (On
average employee pays for 18% of coverage for individual and 29% for family)
enrollee - (answer)an individual covered under a health insurance plan, also called a member, insured,
or beneficiary.
beneficiary - (answer)a participant in a health insurance plan, also called insured or enrollee.
HMO- health maintenance organization - (answer)- provides medical care during illness while also
offering services that help people maintain health.
- emphasizes preventive and screening services through routine checkups and test.
- enrollees are allowed to use in-network providers.
- primary care gatekeepers are used to manage and coordinate the utilization of services.
PPO- preferred provider organization - (answer)- enrollees are permitted to use both in-network and
out- of network providers.
- higher copayment for non-preferred providers.
- no gatekeeping.
- unrestricted access to specialty services.
MCO- managed care organization - (answer)- single organization takes on the management of financing,
insurance, and delivery and payment
POS - (answer)- combines HMO and PPO
, NUR 102 Exam #2 Study Guide Exam QUESTIONS AND ANSWERS (LATEST UPDATE 2025)
ALREADY PASSED
- over come the drawback of restricted provider choice (many HMO's provide optional plan that allow
for out of network utilization)
- maintain tight utilization management
- type of MCO is declining in enrollment due to high out of pocket costs associate with the plan.
Ambulatory care - (answer)- health care services that do not require an overnight stay in an institution
of health care delivery.
- Used interchangeably with outpatient care.
- physician's office, outpatient departments of hospitals, and health care centers.
- outpatient services intended to serve the surrounding community.
- Certain services that are transported to the patient.
Hospital - (answer)- institution with at least six beds who primary function is to deliver patient services,
diagnostic and therapeutic, for particular or general medical conditions.
inpatient - (answer)- services delivered on the basis of overnight stay in a health care institution
inpatient day - (answer)- a night spent in the hospital by a person admitted as an inpatient
outpatient - (answer)- any health care services that are not provided based on an overnight stay in
which room and board costs are incurred
observation - (answer)- patient is admitted for a hospital stay for up to 24 hours, may or may not have
an overnight stay
Hospital Evolution - (answer)Stage 1: almshouses as primarily institutions of social welfare
Stage 2: community-owned private hospitals as charitable institutions supported by affluent donors.
Stage 3: institutions of medical practice and training serving the needs of all members of society and
able to make a profit.
