CHFP EXAM QUESTIONS AND CORRECT
ANSWERS (A+)
Accountable Care Organization ACO ACOs are organizations of medicare providers and
suppliers that work together to coordinate care for traditional medicare patients. Their
aim is the provision of seamless, high-value care instead of the fragmented care that
many times arises from a fee-for-service payment system. The following groups of
providers can form an ACO: physicians or certain non-physician practitioners in group
practices, hospitals employing physicians, certain critical access hospitals, federally
qualified health centers and rural health clinics
Beneficiary - Answer Insurers usually refer to the patient for which services are paid as
Benefit Payment - Answer Once the insurer has determined the claim is appropriate, a
payment is made to a provider called
Bundled Payments One prospective payment from a health plan to all providers in an
episode of care, in which the providers will determine how to distribute the payment.
Centers for Medicare and Medicaid Services (CMS)-Answer The federal government,
through this organization oversees all parts of the Medicare and Medicaid programs.
This organization can waive state's requirement to participate in traditional Medicaid if
the state offers beneficiaries' plans with better benefits
Children's Health Insurance Program CHIP-Answer Signed into law in 1997, provides
health coverage to uninsured children up to age 19 in families with incomes too high to
qualify them for Medicaid
Claim- Answer Bill for healthcare services provided
,Coinsurance- Answer The percentage of the insurance payment amount that is paid by
the patient, in addition to the amount paid by the insurer
Copay - Answer Flat amount a patient pays at each time of service
Covered Benefit - Answer Services for which the insurer will pay
Deductible - Answer Pre-determined amount that the patient pays before the insurer
begins to pay for service
Denial - Answer Insurer may determine that the claim from the provider is not a covered
benefit and will not pay for the claim
Mandate of Employer: Requires the employers with 50 or more full time employees to
provide health insurance coverage
Facility Provider: Acute care hospital, long-term care hospital, inpatient rehab hospital,
psychiatric facility, skilled nursing facility, assisted living facility, home health agency,
hospice agency, clinic, or ambulatory surgery center
Fiscal Intermediary - an organization which contracts with government/CMS to pay
medicare claims and educate providers
Individual Mandate - Answer Requires individuals and families without
employer-provided insurance to purchase health insurance of pay a penalty. The
Supreme court in 2012 characterized the penalty as a tax. The penalties ranges from
$695 per year to a maximum of three times that amount ($2,085) per family of 2.5% of
household income
Insurance Exchange Federal or state-operated health insurance markets designed to
provide affordable and widely available health insurance. People who buy health
insurance may be eligible for premium subsidies. 85% of those signing up for coverage
get a subsidy.
, Medicaid - Answer Joint federal and state program for low-income and medically needy
people. Single largest source of health coverage in the US. Covers low income families,
qualified pregnant women and children and individuals receiving SSI. Includes nursing
home care and personal care services. Each state has different program
Medical Loss Ratio - Answer Refers to the percentage of premiums that insurers/health
plans must spend on clinical services and quality improvement. ACA requires health
insurance insurers to spend at least 80% to 85% of premium dollars on claims and
quality initiatives.
Medicare Cost Report-Answer Annual report that providers participating in the
Medicare program must submit to their medicare administrative contractor. For
providers paid prospectively, this determines reimbursement for certain add-on
payments but does not affect the overall payment rate. For providers paid
retrospectively, this determines the payment rate. CMS uses this data to update DRG
and APC weights and determine market basket updates
Medicare Part A - Hospital insurance. Pays for hospital inpatient, skilled nursing facility,
hospice, and some home health care. Premium-free benefit; funded by FICA payroll
deductions, the 2.9 percent payroll tax. Categorical eligibility begins when a U.S. citizen
who paid FICA taxes for at least 40 calendar quarters reaches age 65. Persons under
age 65 who are disabled and have received Social Security for 24 months also become
eligible.
Medicare Part B - Answer Supplemental medical insurance is voluntary part of
Medicare. Pays for physician services, outpatient hospital and clinic care and some
home health services. While beneficiaries over 65 pay a monthly premium tied to their
prior year income, about 75% of the total cost is paid from general tax revenues.
Medicare Advantage (Medicare Part C) - Answer Commercial insurance plans (HMOs,
PPOs, or fee-for-service plans) that offer Medicare beneficiaries an alternative to
traditional Medicare. About 30% of Medicare beneficiaries select advantage plans
because benefits exceed those of traditional medicare. Beneficiaries pay the normal
monthly Part B premiums to CMS and sometimes a seperate Medicare advantage
premium to the commercial payer. Most plans have narrower provider choices than
traditional medicare. CMS pays medicare advantage plans a fixed, risk-adjusted
monthly fee per beneficiary that slightly exceeds the estimated cost of providing similar
ANSWERS (A+)
Accountable Care Organization ACO ACOs are organizations of medicare providers and
suppliers that work together to coordinate care for traditional medicare patients. Their
aim is the provision of seamless, high-value care instead of the fragmented care that
many times arises from a fee-for-service payment system. The following groups of
providers can form an ACO: physicians or certain non-physician practitioners in group
practices, hospitals employing physicians, certain critical access hospitals, federally
qualified health centers and rural health clinics
Beneficiary - Answer Insurers usually refer to the patient for which services are paid as
Benefit Payment - Answer Once the insurer has determined the claim is appropriate, a
payment is made to a provider called
Bundled Payments One prospective payment from a health plan to all providers in an
episode of care, in which the providers will determine how to distribute the payment.
Centers for Medicare and Medicaid Services (CMS)-Answer The federal government,
through this organization oversees all parts of the Medicare and Medicaid programs.
This organization can waive state's requirement to participate in traditional Medicaid if
the state offers beneficiaries' plans with better benefits
Children's Health Insurance Program CHIP-Answer Signed into law in 1997, provides
health coverage to uninsured children up to age 19 in families with incomes too high to
qualify them for Medicaid
Claim- Answer Bill for healthcare services provided
,Coinsurance- Answer The percentage of the insurance payment amount that is paid by
the patient, in addition to the amount paid by the insurer
Copay - Answer Flat amount a patient pays at each time of service
Covered Benefit - Answer Services for which the insurer will pay
Deductible - Answer Pre-determined amount that the patient pays before the insurer
begins to pay for service
Denial - Answer Insurer may determine that the claim from the provider is not a covered
benefit and will not pay for the claim
Mandate of Employer: Requires the employers with 50 or more full time employees to
provide health insurance coverage
Facility Provider: Acute care hospital, long-term care hospital, inpatient rehab hospital,
psychiatric facility, skilled nursing facility, assisted living facility, home health agency,
hospice agency, clinic, or ambulatory surgery center
Fiscal Intermediary - an organization which contracts with government/CMS to pay
medicare claims and educate providers
Individual Mandate - Answer Requires individuals and families without
employer-provided insurance to purchase health insurance of pay a penalty. The
Supreme court in 2012 characterized the penalty as a tax. The penalties ranges from
$695 per year to a maximum of three times that amount ($2,085) per family of 2.5% of
household income
Insurance Exchange Federal or state-operated health insurance markets designed to
provide affordable and widely available health insurance. People who buy health
insurance may be eligible for premium subsidies. 85% of those signing up for coverage
get a subsidy.
, Medicaid - Answer Joint federal and state program for low-income and medically needy
people. Single largest source of health coverage in the US. Covers low income families,
qualified pregnant women and children and individuals receiving SSI. Includes nursing
home care and personal care services. Each state has different program
Medical Loss Ratio - Answer Refers to the percentage of premiums that insurers/health
plans must spend on clinical services and quality improvement. ACA requires health
insurance insurers to spend at least 80% to 85% of premium dollars on claims and
quality initiatives.
Medicare Cost Report-Answer Annual report that providers participating in the
Medicare program must submit to their medicare administrative contractor. For
providers paid prospectively, this determines reimbursement for certain add-on
payments but does not affect the overall payment rate. For providers paid
retrospectively, this determines the payment rate. CMS uses this data to update DRG
and APC weights and determine market basket updates
Medicare Part A - Hospital insurance. Pays for hospital inpatient, skilled nursing facility,
hospice, and some home health care. Premium-free benefit; funded by FICA payroll
deductions, the 2.9 percent payroll tax. Categorical eligibility begins when a U.S. citizen
who paid FICA taxes for at least 40 calendar quarters reaches age 65. Persons under
age 65 who are disabled and have received Social Security for 24 months also become
eligible.
Medicare Part B - Answer Supplemental medical insurance is voluntary part of
Medicare. Pays for physician services, outpatient hospital and clinic care and some
home health services. While beneficiaries over 65 pay a monthly premium tied to their
prior year income, about 75% of the total cost is paid from general tax revenues.
Medicare Advantage (Medicare Part C) - Answer Commercial insurance plans (HMOs,
PPOs, or fee-for-service plans) that offer Medicare beneficiaries an alternative to
traditional Medicare. About 30% of Medicare beneficiaries select advantage plans
because benefits exceed those of traditional medicare. Beneficiaries pay the normal
monthly Part B premiums to CMS and sometimes a seperate Medicare advantage
premium to the commercial payer. Most plans have narrower provider choices than
traditional medicare. CMS pays medicare advantage plans a fixed, risk-adjusted
monthly fee per beneficiary that slightly exceeds the estimated cost of providing similar
