Nurs 251 finals Questions and Correct Solutions
affordable care act
An expansion of medicaid, most of employers must provide health insurance, have insurance or
face surtax, prevents rejection based on pre-existing condition. Also referred to as "Obamacare",
signed into law in 2010.
important aspects of ACA
created state- or multistate-based insurance exchanges to help individuals and small
businesses purchase insurance. The law expanded Medicaid coverage for low-income
individuals and allows young adults to remain on parents' policies until age 26
1 primary goal of ACA
make affordable healthcare available to more people
- law provides consumers with subsidies ("premium tax credits") that lower costs for households
with incomes between 100% and 400% of the federal poverty line
2 primary goal of ACA
expand the medicaid program to cover all adults with income below 138% of the FPL
- not all states have expanded their medicaid programs
3 primary goal of ACA
support innovative medical care delivery methods designed to lower the costs of health care
generally
pre-existing conditions under ACA
,health insurance companies can't refuse to cover you or charge you more just because you have a
“pre-existing condition” — that is, a health problem you had before the date that new health
coverage starts
preventive care under ACA
must cover a set of preventive care (shots, screenings, etc.) at no cost
allowed amount
maximum payment the plan will pay for a covered health care service
- "eligible expense", "payment allowance", or "negotiated rate"
balance billing
when a provider bills you for the balance remaining on the bill that your plan doesn't cover
- amount is the difference between the actual billed amount and the allowed amount
- ex: if the provider's charge is $200 and the allowed amount is $110, the provider may bill you
for the remaining $90
- may happen when you see an out-of-network provider
claim
a request for a benefit (including reimbursement of a health care expense) made by you or your
health care provider to your health insurance or plan for items or services you think are covered
coinsurance
your share of the costs of a covered health care service, calculated as a percentage (ex: 20%) of
the allowed amount for the service
- generally pay coinsurance plus any deductibles you owe (ex: health insurance or plan's allowed
,amount for an office visit is $100 and you've met your deductible, your coinsurance payment of
20% would be $20. the health insurance or plan pays the rest of the allowed amount)
complications of pregnancy
conditions due to pregnancy, labor, and delivery that require medical care to prevent serious
harm to the health of the mother or the fetus
- morning sickness and a non-emergency C-section generally aren't complications of pregnancy
copayment
a fixed amount (ex: $15) you pay for a covered health care service, usually when you receive the
service
- amount can vary by the type of covered health care service
cost sharing
your share of costs for services that a plan covers that you must pay out of our own pocket ("out-
of-pocket) costs
- ex: copayments, deductible and coinsurance
- family cost sharing: share of cost for deductibles and out-of-pocket costs you and your spouse
and/or children must pay out of your own pocket
- not considered: premiums, penalties you have to pay, cost of a care plan
cost-sharing reductions
discounts that reduce the amount you pay for certai services covered by an individual plan you
buy through the Marketplace
, - may get a discount if your income is below a certain level, and you choose a Silver level health
plan or if you're a member of a federally-recognized tribe
deductible
an amount you could owe during a coverage period (usually one yeaR) for covered health care
services before your plan begins to pay
- overall deductible applies to all or almost all covered items and services
- plan with an overall deductible may also ave separate deductibles that apply to specific services
or groups of services
- separate deductible (ex: if your deductible is $1000, your plan won't pay anything until you've
met your $1000 deductible for covered health care services subject to the deductible)
diagnostic test
tests to figure out what your health problem is
- ex: x-ray can be a diagnostic test to see if you have a broken bone
durable medical equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use.
- may include: oxygen equipment, wheelchairs, and crutches.
emergency medical condition
An illness, injury, symptom (including severe pain), or condition severe enough to risk serious
danger to your health if you didn't get medical attention right away. If you didn't get immediate
medical attention you could reasonably expect one of the following:
1) Your health would be put in serious danger; or
affordable care act
An expansion of medicaid, most of employers must provide health insurance, have insurance or
face surtax, prevents rejection based on pre-existing condition. Also referred to as "Obamacare",
signed into law in 2010.
important aspects of ACA
created state- or multistate-based insurance exchanges to help individuals and small
businesses purchase insurance. The law expanded Medicaid coverage for low-income
individuals and allows young adults to remain on parents' policies until age 26
1 primary goal of ACA
make affordable healthcare available to more people
- law provides consumers with subsidies ("premium tax credits") that lower costs for households
with incomes between 100% and 400% of the federal poverty line
2 primary goal of ACA
expand the medicaid program to cover all adults with income below 138% of the FPL
- not all states have expanded their medicaid programs
3 primary goal of ACA
support innovative medical care delivery methods designed to lower the costs of health care
generally
pre-existing conditions under ACA
,health insurance companies can't refuse to cover you or charge you more just because you have a
“pre-existing condition” — that is, a health problem you had before the date that new health
coverage starts
preventive care under ACA
must cover a set of preventive care (shots, screenings, etc.) at no cost
allowed amount
maximum payment the plan will pay for a covered health care service
- "eligible expense", "payment allowance", or "negotiated rate"
balance billing
when a provider bills you for the balance remaining on the bill that your plan doesn't cover
- amount is the difference between the actual billed amount and the allowed amount
- ex: if the provider's charge is $200 and the allowed amount is $110, the provider may bill you
for the remaining $90
- may happen when you see an out-of-network provider
claim
a request for a benefit (including reimbursement of a health care expense) made by you or your
health care provider to your health insurance or plan for items or services you think are covered
coinsurance
your share of the costs of a covered health care service, calculated as a percentage (ex: 20%) of
the allowed amount for the service
- generally pay coinsurance plus any deductibles you owe (ex: health insurance or plan's allowed
,amount for an office visit is $100 and you've met your deductible, your coinsurance payment of
20% would be $20. the health insurance or plan pays the rest of the allowed amount)
complications of pregnancy
conditions due to pregnancy, labor, and delivery that require medical care to prevent serious
harm to the health of the mother or the fetus
- morning sickness and a non-emergency C-section generally aren't complications of pregnancy
copayment
a fixed amount (ex: $15) you pay for a covered health care service, usually when you receive the
service
- amount can vary by the type of covered health care service
cost sharing
your share of costs for services that a plan covers that you must pay out of our own pocket ("out-
of-pocket) costs
- ex: copayments, deductible and coinsurance
- family cost sharing: share of cost for deductibles and out-of-pocket costs you and your spouse
and/or children must pay out of your own pocket
- not considered: premiums, penalties you have to pay, cost of a care plan
cost-sharing reductions
discounts that reduce the amount you pay for certai services covered by an individual plan you
buy through the Marketplace
, - may get a discount if your income is below a certain level, and you choose a Silver level health
plan or if you're a member of a federally-recognized tribe
deductible
an amount you could owe during a coverage period (usually one yeaR) for covered health care
services before your plan begins to pay
- overall deductible applies to all or almost all covered items and services
- plan with an overall deductible may also ave separate deductibles that apply to specific services
or groups of services
- separate deductible (ex: if your deductible is $1000, your plan won't pay anything until you've
met your $1000 deductible for covered health care services subject to the deductible)
diagnostic test
tests to figure out what your health problem is
- ex: x-ray can be a diagnostic test to see if you have a broken bone
durable medical equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use.
- may include: oxygen equipment, wheelchairs, and crutches.
emergency medical condition
An illness, injury, symptom (including severe pain), or condition severe enough to risk serious
danger to your health if you didn't get medical attention right away. If you didn't get immediate
medical attention you could reasonably expect one of the following:
1) Your health would be put in serious danger; or
