Quizzes Review Flashcards
Which of the following best describes the status of the United States healthcare system?
A. The United States spends more on healthcare per capita than any other nation, but this increased spending is offset by superior health outcomes.
B. Similar to the United States, most counties of comparable economic status have not achieved near universal health coverage of their populations.
C. Health care spending increased steadily over the last five decades, and it is projected to reach about 25% of gross domestic product (GDP) in 2030.
D. After substantial growth, healthcare spending has stabilized around 18% of gross domestic product (GDP), but it is still slowly rising.
D
Which statement is NOT true about the evolution of health insurance in the United States?
A. Major health care reform efforts were omitted or blocked as part of Franklin D Roosevelt’s “New Deal,” Harry Truman’s “Fair Deal,” and Lyndon B Johnson’s “The Great Society.”
B. The Baylor Hospital Partnership exchanged a set number of hospital days for a prepaid fee.
C. Early forms of health insurance were more similar to current disability coverage because they focused on lost wages rather than medical care expenses.
D. Passage of the Affordable Care Act represented the largest legislative expansion of health care since creation of Medicare and Medicaid.
A
Which statement correctly uses insurance terminology?
A. The out-of-pocket maximum is calculated using the amount a beneficiary spends on premiums, deductibles, copayments, and coinsurances.
B. Members are charged different monthly premiums depending on their age in community-rated plans.
C. Beneficiaries on a health insurance policy are either subscribers or dependents.
D. A coinsurance is a fixed dollar amount that a beneficiary pays each time a covered service is received.
C
Which statement correctly describes employer-sponsored insurance?
A. If an employer is fully insured, then they are regulated by the federal government.
B. Individuals can keep their employer-sponsored insurance for up to 18 months post-employment through the Health Insurance Portability and Accountability Act.
C. Most employers offering health insurance are required to offer at least one preferred provider organization (PPO)-type plan.
D. As health insurance costs rise, employers are shifting more costs to employees, primarily by increasing the cost sharing burden to employees
D
Profit is distributed to shareholders in which hospital ownership structure?
A. Religious not-for-profit hospitals
B. For-profit hospitals
C. Secular not-for-profit hospitals
D. Physician-owned hospitals
B
A patient has been hospitalized for severe burns following a house fire. His condition has stabilized. However, he will require several weeks of sophisticated wound care, including daily dressing changes with sedation. What type of facility is he most likely to receive this care upon discharge?
A. Long term acute care hospital
B. Inpatient rehab facility
C. Skilled nursing facility
D. Assisted living facility
A
Select the correct pairing:
A. Specialty care: Internal medicine
B. Primary care: Cardiology
C. Specialty care: Pediatrics
D. Primary care: Family medicine
D
Which type of model is known for providing all patient services (e.g., medical office, labs, imaging) in a single location?
A. Network model HMO
B. Group model HMO
C. Preferred provider organization
D. Point of service
B
This agency within the US Department of Health and Human Services administers the Medicare program.
A. ACL
B. ATSDR
C. CMS
D.HRSA
C
Use the PetPlan insurance plan and information below to answer the following 6 questions. Please provide your rationale or show your work as appropriate.
Insurance Policy Details:
Deductible: $750
Copayment: $25 (primary care visits); $50 (specialist visits)
Coinsurance: 10% (outpatient surgery)
Please note: In the scenario below, please assume: (1) all terms and conditions of the policy have been met (i.e., these are valid insurance claims), (2) the scenario begins with the first claims on the policy, and (3) the benefit period is the calendar year. Do not over-complicate the question.
Question 10:
Alamo is a 3-year-old lab mix who is covered by the insurance policy described above. Alamo loves his tennis ball and guards it from other dogs. One afternoon in March, while guarding his ball, he swallows it requiring surgery to remove it from his stomach. The surgery costs $2300. How much will the owner pay?
Answer:
First, the deductible is payed ($750).
The remaining cost is $1550.
The owner pays 10% of the remaining cost.
10% of $1550 is $155.
Thus, the owner pays $905 (deductible plus 10% of cost after deductible is met).
Question 11:
Alamo recovers well from the surgery and is soon back to chasing tennis balls. Unfortunately, in October, he lands awkwardly after a jump and begins limping. The owner takes him to his primary care veterinarian. The visit costs $175. How much will the owner pay?
Answer:
The owner is still under the same beneficiary period from last March so the deductible is paid. According to the pet insurance plan, the owner pays $25 for primary care visits.
Question 12:
Alamo’s primary care veterinarian thinks that he has torn his anterior cruciate ligament (ACL) in his knee and refers him to an orthopedist. The owner follows up with an appointment with the specialists, and this visit costs $250. How much will the owner pay?
Answer:
Deductible is assumed to still have been met for this question. Therefore, the owner pays $50 for specialist visits.
Question 13:
The specialist confirms the diagnosis of an ACL tear and recommends surgery, which happens shortly thereafter. The surgery costs $3750. How much will the owner pay?
Answer:
The owner pays 10% of the surgery.
10% of $3750 is $375.
Thus, the owner pays $375 for the surgery.
Question 14:
Alamo needs follow-up care from the specialist at 2 and 6 weeks post-surgery. Each of these visit costs $150. If they happened in December and January, then how would the cost to the owner change? Why?
Answer:
If the first follow-up occurs in December, then the owner pays $50 for the specialist appointment. If the second follow-up occurs in January, then the owner pays $150 for the specialist appointment since the deductible has reset.
.
What information is currently found on a beneficiary’s Medicare Card? (Note: This question may have more than one answer)
A. Medicare Advantage member ID (if applicable)
B. Month and year the beneficiary started Part A and/or Part B
C. First and last name
D. Social security number
B and C
Which group of individuals would automatically receive their Medicare card in the mail a few months before turning age 65?
A. Low income individuals who are receiving medical benefits through their state’s Medicaid program.
B. Non-citizen, legal residents of the United States who have lived in the United States for a minimum of 5 years.
C. All United States citizens who have paid Medicare payroll taxes for at least 40 quarters.
D. Individuals who are already receiving Social Security retirement benefits.
D
Which statement is true for an individual turning age 65, but who is still working and covered by an employer group health plan (EGHP) with creditable prescription drug coverage?
A. They must continue with their EGHP and defer enrolling in Medicare until they retire if their employer has more than 20 employees.
B. They must enroll in both Part A and B when they turn age 65 because their EGHP is not an acceptable substitute for Medicare.
C. They can voluntarily enroll in Part A and/or Part B while still covered by their EGHP, but they are allowed to defer either without penalty.
D. They can enroll in Part A while covered by their EGHP, but they must defer enrolling in Part B until they retire.
C
If an individual misses their initial enrollment period (and is not actively working), then they can enroll in Medicare Parts A and B during which enrollment period?
A. General enrollment period
B. Special enrollment period
C. Open enrollment period
D. Annual enrollment period
A
Medicare Part B…
A. Covers influenza and pneumococcal vaccines.
B. Does not have an annual deductible.
C. Will pay 50% of costs for chemotherapy drugs administered at a doctor’s office or approved infusion center.
D. Has the same monthly premium for all recipients unless they qualify for free or reduced premiums due to low income.
A
Which group of individuals might qualify for premium-free Medicare Part B?
A. Low income individuals who qualify for financial assistance through their state’s Medicaid program.
B. A person who qualifies for Medicare due to disability, irrespective of the number of quarters they have paid Medicare payroll taxes.
C. Any United States citizen who has paid Medicare payroll taxes for a minimum of 40 quarters.
D. Non-citizen, legal residents of the United States who have lived in the United States for a minimum of 5 years.
A
Which of the following is true about physician charges under Medicare Part B?
A. If a physician accepts “Medicare assignment,” then they can charge the patient an additional amount if the Medicare-approved amount is lower than their usual charge for a service, but this amount is capped at 15% of the Medicare-approved amount.
B. If the physician does not accept Medicare assignment, but agrees to see a patient and bill Medicare, then they can receive a payment of up to 20% more than the standard Medicare-approved payment amount.
C. If a physician accepts “Medicare assignment,” then they are restricted to serving beneficiaries enrolled in Original Medicare and cannot serve patients enrolled in Medicare Advantage plans.
Correct!
D. If a physician accepts “Medicare assignment,” then they agree to accept the Medicare-approved payment amount for services provided even if it is less than their usual charge for that service.
D
All Medigap plans fully cover….
A. Hospital deductible
B. Part B co-insurance
C. Hospital cost share after the first 60 days
D. Skilled nursing facility cost share
C
A patient, who is now 70, enrolled in Medicare Part A and B plus a Medigap Plan F at age 65. Which of the following correctly applies to this situation?
A. They will pay a 20% co-pay for chemotherapy administered in a physician’s office or infusion center.
B. They will have no co-insurance for Medicare Part B services regardless of whether the provider accepts assignment.
C. They should transition to a different Medigap plan immediately to prevent a gap in coverage because Plan F was discontinued in January 2020.
D. They will pay a Part D deductible annually for outpatient services.
B
Which of the following is FALSE about drug coverage under Medicare?
A. All stand-alone prescription drug plans charge a monthly premium.
B. The medications covered often varies across prescription drug plans.
C. Medicare Advantage plans available for a $0 monthly premium cannot offer prescription drug coverage.
D. Prescription drug plans can have a deductible that is lower than the standard deductible.
C
Which of the following is FALSE true about drug coverage under Medicare?
A. Once a patient reaches catastrophic coverage in the standard Part D benefit, the standalone drug plan or Medicare Advantage plan pays for medications in full.
B. Delaying enrollment in Part D can lead to a penalty equaling 1% per month of the national average for Part D premiums for each month delay.
C. The term “coverage gap” or “donut hole” refers to time period where patients have historically paid higher costs for their prescriptions as compared to the initial benefit period.
D. Patient administered (i.e., self-administered) injectable drugs at home (e.g., insulin) are covered under Part D, but injectable drugs administered in a medical office or infusion center are covered under Part B.
A
During the annual enrollment period (October 15 - December 7)…
A. A person who failed to enroll in a Medicare Part D drug plan during their initial enrollment period can enroll in a stand-alone drug plan or Advantage Plan without penalty.
B. A person can change to a different Medicare Advantage or stand-alone Part D plan without underwriting or penalty.
C. A person who has a Medigap policy can change policies without underwriting.
D. A person who failed to enroll in Medicare Part B during their initial enrollment period can enroll in Part B to start January 1 of the following year.
B
When comparing PPO Advantage plans to HMO Advantage plans…
A. HMO plans often bundle limited dental, vision, and/or discounted gym memberships as part of the plan while PPO plans do not offer these extra benefits.
B. PPO plans generally have a higher monthly premium than HMO Advantage plans, but this is partially offset by a substantially lower out-of-pocket maximum.
C. While both HMO and PPO plans have limited provider networks, PPO plans allow the patient to see out-of-network providers for a higher cost share.
D. PPO plans generally provide prescription drug coverage as part of the base premium whereas HMO plans only provide prescription drug coverage for an additional cost.
C
Which program helps people with limited income by paying Part A and Part B premiums, deductibles, co-insurances, and co-pays?
A. Specified Low-income Medicare Beneficiary
B. Qualified Individual
C. Qualified Medicare Beneficiary
D. Limited Income Subsidy
C
An individual qualifies for a limited income subsidy (LIS/Extra Help). This means that their income is low enough that….
A. Medicare will pay their monthly drug plan premium and any drug plan deductible.
B. Cost sharing is capped at $3.75 and $9.20 per month for generic and brand medications, respectively.
C. Medicare pays the monthly premium for their Medicare Part B and prescription drug plan.
D. Their state Medicaid program will pay the monthly premium for their Medicare Part B and prescription drug plan.
A
Patient has a health insurance policy with a $250 deductible and a 20% coinsurance. Patient has an ultrasound that costs $350. If is this first insurance claim of the year, what is the cost to the patient?
A. $70
B. $320
C. $350
D. $270
D
Public health insurance programs include all of the following except…
A. CHIP
B. IHS
C. COBRA
D. TRICARE
C
Which of the following is driver for the shift in care from the inpatient to outpatient environment?
A. A transition away from using diagnostic-related groups (DRGs) for hospital reimbursement by CMS.
B. The growth of small group and solo practices by specialists which has made specialty care more accessible.
C. A surplus in outpatient physicians making primary care services readily available.
D. Technology advancements expanding the scope of services that can be safely provided in an outpatient setting.
D
In which model does the payer (i.e., insurance company) have the greatest control over physician actions, such as prescribing medications, requesting imaging, or placing specialist referrals?
A. Preferred provider organization
B. Network model HMO
C. Group model HMO
D. Point of service
C
In addition to CMS, this federal agency is a major funder of Oregon’s Senior Health Insurance Benefits Assistance (SHIBA) program, as well as similar programs in other states (a.k.a., SHIP)?
A. ACF
B. HRSA
C. ACL
D. CDC
C
Financing of Medicaid is the responsibility of…
A. Medicare
B. State government
C. Federal government
D. Both state and federal governments
D
Which of the following is NOT a federally-mandated eligibility category for Medicaid?
A. Pregnant women
B. Children
C. End stage renal disease
D. Old age / disabled
E. Adults with dependent children
C
Medicaid finances the majority of care for which group?
A. Nursing home residents
B. Elderly
C. Self-employed adults
D. Medicare beneficiaries
A
What differentiates the Children’s Health Insurance Program (CHIP) from standard Medicaid?
A. Financed through block grants
B. Higher income requirements (i.e., higher % FPL than standard Medicaid)
C. Higher federal matching formula
D. All of the above
D
“Dual eligible” refers to individuals who are enrolled in which two programs?
A. Medicaid & Veterans Health Administration
B. Medicaid & Indian Health Service
C. Medicaid & Medicare
D. All of the above
C
Which group became newly eligible for Medicaid in certain states in 2014?
A. Veterans
B. Anyone with an income less than 138% of the federal poverty level
C. Anyone not eligible through the state health exchanges
D. Individuals in the criminal justice system
B
