Medicare & Medicaid
People aged 65+ (some under 65 with disabilities)
What does HMO stand for?
Health Maintenance Organization
The amount you pay monthly to maintain your health insurance.
Premium
What payment model pays providers after services are rendered?
Fee for service (retrospective payment)
Who is eligible for Child Health Plus?
Children under age 19, NYS residents, those not eligible for Medicaid, those not covered by other health insurance.
What is Medicare Part D?
Prescription drugs
Which plan type typically requires a referral from a primary care provider to see a specialist?
HMO
The amount you must pay before your insurance starts covering costs.
Deductible
What system pays hospitals a preset rate based on diagnosis, not actual cost?
Prospective Payment (DRGs)
True or False: Child Health Plus covers dental and vision services.
True
True or False: Medicaid coverage is the same in every state.
False - each state runs its own program under federal guidelines
What does PPO stand for, and what is its main advantage?
Preferred Provider Organization- flexibility to see out of network providers.
A fixed amount paid for each doctor’s visit.
Copay
What is a formulary?
A list of covered medications organized by cost tiers.
What services are typically covered under Child Health Plus?
Well visits, physical exams, immunizations, emergency care, prescription and nonprescription drugs, labs and imaging
Which part of Medicare covers doctor visits and outpatient care?
Part B (Medical insurance)
What type of plan requires a primary care provider (PCP) but allows specialists without referrals if in-network?
POS (Point of Service)
A percentage of healthcare costs you share with your insurer after the deductible.
Coinsurance
What type of insurance reimburses healthcare costs without using provider networks?
Indemnity plan.
Who funds and manages Medicaid programs?
Federal and state governments, managed by each state.
What does Medicare Part C include?
Parts A,B, D in one plan.
hat was the Health Maintenance Organization Act of 1973 designed to do?
Encourage managed care to reduce costs and improve prevention.
The term for payment to a provider based on a fixed amount per person, not per service.
Capitation
Making gradual changes over time.
How many states haven't expanded their Medicaid program to cover all adults with low income?
10