CSPR HFMA FINALS QUESTIONS AND ANSWERS
SURE A+
✔✔Exclusive Provider Organizations (EPO) -✔✔-No referral
-No PCP
-Services are covered only if patients use doctors, specialists, or hospitals in the plan's
network (except in an emergency).
-No out-of-network benefits.
✔✔Identify the various types of private health plan coverage. -✔✔-HMO
-Conventional
-PPO and POS
-(HDHP/SO) plans - high-deductible health plans with a savings option; Private - Include
higher patient out-of-pocket expenditures for treatments that can serve to reduce
utilization/costs
✔✔Identify the various types of government‐sponsored health coverage. -✔✔-Medicare
- Government; Beneficiaries enrolled in such plans, but, participation in these
plans is voluntary.
-Medicaid
-Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a
managed care plan.
-Medicare Managed Care (a.k.a. Medicare Advantage Plans)
✔✔Identify some key drivers of increasing healthcare costs -✔✔-Demographics
-Chronic Conditions
-Provider payment systems - Provider payment systems that are designed to reward
volume rather than quality, outcomes, and prevention -Consumer Perceptions
-Health Plan pressure
-Physician Relationships
-Supply Chain
, ✔✔Medicare -✔✔-Part A - provides inpatient/hospital, hospice, and skilled nursing
coverage
-Part B - provides outpatient/medical coverage
-Part C - an alternative way to receive your Medicare benefits (known as Medicare
Advantage)
-Part D - prescription drug coverage
✔✔CMS is responsible for: -✔✔-clear policy on eligibility for CMS programs, coverage
and reimbursement of healthcare services, standards for providers, and program
administration.
-Administration of comprehensive agreements with contractors and states; the
performance standards that must be met in their administration, and the programmatic
results that are to be achieved.
-Monitoring the performance of contractors and states
✔✔Medicare provides health insurance benefits to the following: -✔✔-All persons age
65 and older
-Individuals with permanent renal (kidney) failure, eligible for dialysis treatment
-Individuals with certain disabilities
✔✔Mcare Part A (Hospital Insurance) -✔✔-covers most medically necessary hospital,
skilled nursing facility, home
health, and hospice care services.
-It is free if you have worked and paid Social Security taxes for at least 40 calendar
quarters (10 years); those who have worked and paid taxes for less than 40 calendar
quarters (10 years) are required to pay a fee
✔✔Mcare Part B (Medical Insurance) -✔✔covers most medically necessary doctors'
services, preventive care, durable medical equipment, hospital outpatient services,
laboratory tests, x-rays, mental health care, and some home health and ambulance
services. An additional monthly premium is paid for this coverage.
✔✔Mcare Part C (Advantage) -✔✔-allows private health insurance companies to
provide Medicare
benefits.
-These Medicare private health plans are known as Medicare Advantage Plans. These
plans
must offer at least the same benefits as Original Medicare (those covered under Parts A
and B) but can do so with different rules, costs, and coverage restrictions.
-Medicare Part C may also offer additional health coverage benefits; you typically obtain
Part D as part of a Medicare Advantage benefits package. --You may pay a monthly
premium for this coverage, in addition to your Part B
premium.
SURE A+
✔✔Exclusive Provider Organizations (EPO) -✔✔-No referral
-No PCP
-Services are covered only if patients use doctors, specialists, or hospitals in the plan's
network (except in an emergency).
-No out-of-network benefits.
✔✔Identify the various types of private health plan coverage. -✔✔-HMO
-Conventional
-PPO and POS
-(HDHP/SO) plans - high-deductible health plans with a savings option; Private - Include
higher patient out-of-pocket expenditures for treatments that can serve to reduce
utilization/costs
✔✔Identify the various types of government‐sponsored health coverage. -✔✔-Medicare
- Government; Beneficiaries enrolled in such plans, but, participation in these
plans is voluntary.
-Medicaid
-Medicaid Managed Care - Medicaid beneficiaries are required to select and enroll in a
managed care plan.
-Medicare Managed Care (a.k.a. Medicare Advantage Plans)
✔✔Identify some key drivers of increasing healthcare costs -✔✔-Demographics
-Chronic Conditions
-Provider payment systems - Provider payment systems that are designed to reward
volume rather than quality, outcomes, and prevention -Consumer Perceptions
-Health Plan pressure
-Physician Relationships
-Supply Chain
, ✔✔Medicare -✔✔-Part A - provides inpatient/hospital, hospice, and skilled nursing
coverage
-Part B - provides outpatient/medical coverage
-Part C - an alternative way to receive your Medicare benefits (known as Medicare
Advantage)
-Part D - prescription drug coverage
✔✔CMS is responsible for: -✔✔-clear policy on eligibility for CMS programs, coverage
and reimbursement of healthcare services, standards for providers, and program
administration.
-Administration of comprehensive agreements with contractors and states; the
performance standards that must be met in their administration, and the programmatic
results that are to be achieved.
-Monitoring the performance of contractors and states
✔✔Medicare provides health insurance benefits to the following: -✔✔-All persons age
65 and older
-Individuals with permanent renal (kidney) failure, eligible for dialysis treatment
-Individuals with certain disabilities
✔✔Mcare Part A (Hospital Insurance) -✔✔-covers most medically necessary hospital,
skilled nursing facility, home
health, and hospice care services.
-It is free if you have worked and paid Social Security taxes for at least 40 calendar
quarters (10 years); those who have worked and paid taxes for less than 40 calendar
quarters (10 years) are required to pay a fee
✔✔Mcare Part B (Medical Insurance) -✔✔covers most medically necessary doctors'
services, preventive care, durable medical equipment, hospital outpatient services,
laboratory tests, x-rays, mental health care, and some home health and ambulance
services. An additional monthly premium is paid for this coverage.
✔✔Mcare Part C (Advantage) -✔✔-allows private health insurance companies to
provide Medicare
benefits.
-These Medicare private health plans are known as Medicare Advantage Plans. These
plans
must offer at least the same benefits as Original Medicare (those covered under Parts A
and B) but can do so with different rules, costs, and coverage restrictions.
-Medicare Part C may also offer additional health coverage benefits; you typically obtain
Part D as part of a Medicare Advantage benefits package. --You may pay a monthly
premium for this coverage, in addition to your Part B
premium.
