HCA 2026 UPDATED EVALUATION EXAM
QUESTIONS AND ANSWERS SURE A+
✔✔medicare part d - ✔✔prescription drug coverage; it was added to the existing
medicare program under the medicare prescription drug, improvement, and
modernization act of 2003.
-available to anyone, regardless of income, who has coverage under part a or part b.
offered through two types of private plans approved by medicare:
-standalone prescription drug plans that offer only drug coverage are available to those
who want to stay in the original medicare fee-for-service program
-medicare advantage prescription drug plans are available to those who want to obtain
all health care services through MCOs participating in part C
-like part B, it is voluntary because it requires payment of a monthly premium
✔✔medicaid - ✔✔also referred to as title 19 of the SSA, it is the US's public health
insurance program for the indigent. Federal law specifies coverage for low-income
elderly, the blind, the disabled receiving supplemental security income, and some
pregnant women.
it is jointly financed by federal and state governments. The fed gov't provides matching
funds to the states based on the per capita income in each state. Each state
administers its own program so eligibility, covered services, and payments to providers
vary considerably.
, ✔✔means-tested program - ✔✔program in which people have to qualify based on
assets and income
✔✔Children's health insurance program - ✔✔codified as title 21 of the SSA and was
enacted under the balanced budget act of 1997. It offers additional federal matching
funds to states to expand Medicaid eligibility to enroll children up to 19 who otherwise
would not qualify for coverage because their families' income exceed Medicaid
threshold levels
✔✔public insurance program changes under the ACA - ✔✔1) payment cuts to managed
care plans participating in Medicare Advantage between 2012 and 2017.
2) expansion of medicaid under the penalty of losing matching funds if a state would not
expand its medicaid program with a significant part of the ACA.
3) For people whose income range between 139% and 200% of the FPL, who would
otherwise not qualify for Medicaid, the ACA allows states to set up separate Basic
Health Program.
✔✔basic health program - ✔✔enrollees obtain health insurance through the state
government,not through the exchanges even though they may qualify for exchange-
offered insurance. The cost of the program is subsidized through federal funding. States
would purchase insurance through MCOs that cover the state's Medicaid population
✔✔reimbursement - ✔✔payment made by a third-party payer to the providers of
services
✔✔fee for service reimbursement - ✔✔based on the assumption that services are
provided in a set of identifiable and individually distinct units of services. Initially,
charges were set by providers and insurers passively paid the claims. Later, insurers
started to limit reimbursement to an amount determined by each payer.
✔✔balance bill - ✔✔when providers ask patients to pay the difference between the
actual charges and the payments received from insurers
✔✔bundled payments - ✔✔aka package pricing; a number of related services are
included in one price. It can align incentives for providers to work closely together
across specialities and health care settings.
✔✔resource-based relative value scale - ✔✔implemented in 1992 by medicare; it
reimburses physicians according to a relative value assigned to each physician service.
It is based on time, skill, and intensity it takes to provide a service and the actual
reimbursement is derived by a complex formula.
✔✔reimbursement under managed care - ✔✔takes form in 3 distinct approaches:
QUESTIONS AND ANSWERS SURE A+
✔✔medicare part d - ✔✔prescription drug coverage; it was added to the existing
medicare program under the medicare prescription drug, improvement, and
modernization act of 2003.
-available to anyone, regardless of income, who has coverage under part a or part b.
offered through two types of private plans approved by medicare:
-standalone prescription drug plans that offer only drug coverage are available to those
who want to stay in the original medicare fee-for-service program
-medicare advantage prescription drug plans are available to those who want to obtain
all health care services through MCOs participating in part C
-like part B, it is voluntary because it requires payment of a monthly premium
✔✔medicaid - ✔✔also referred to as title 19 of the SSA, it is the US's public health
insurance program for the indigent. Federal law specifies coverage for low-income
elderly, the blind, the disabled receiving supplemental security income, and some
pregnant women.
it is jointly financed by federal and state governments. The fed gov't provides matching
funds to the states based on the per capita income in each state. Each state
administers its own program so eligibility, covered services, and payments to providers
vary considerably.
, ✔✔means-tested program - ✔✔program in which people have to qualify based on
assets and income
✔✔Children's health insurance program - ✔✔codified as title 21 of the SSA and was
enacted under the balanced budget act of 1997. It offers additional federal matching
funds to states to expand Medicaid eligibility to enroll children up to 19 who otherwise
would not qualify for coverage because their families' income exceed Medicaid
threshold levels
✔✔public insurance program changes under the ACA - ✔✔1) payment cuts to managed
care plans participating in Medicare Advantage between 2012 and 2017.
2) expansion of medicaid under the penalty of losing matching funds if a state would not
expand its medicaid program with a significant part of the ACA.
3) For people whose income range between 139% and 200% of the FPL, who would
otherwise not qualify for Medicaid, the ACA allows states to set up separate Basic
Health Program.
✔✔basic health program - ✔✔enrollees obtain health insurance through the state
government,not through the exchanges even though they may qualify for exchange-
offered insurance. The cost of the program is subsidized through federal funding. States
would purchase insurance through MCOs that cover the state's Medicaid population
✔✔reimbursement - ✔✔payment made by a third-party payer to the providers of
services
✔✔fee for service reimbursement - ✔✔based on the assumption that services are
provided in a set of identifiable and individually distinct units of services. Initially,
charges were set by providers and insurers passively paid the claims. Later, insurers
started to limit reimbursement to an amount determined by each payer.
✔✔balance bill - ✔✔when providers ask patients to pay the difference between the
actual charges and the payments received from insurers
✔✔bundled payments - ✔✔aka package pricing; a number of related services are
included in one price. It can align incentives for providers to work closely together
across specialities and health care settings.
✔✔resource-based relative value scale - ✔✔implemented in 1992 by medicare; it
reimburses physicians according to a relative value assigned to each physician service.
It is based on time, skill, and intensity it takes to provide a service and the actual
reimbursement is derived by a complex formula.
✔✔reimbursement under managed care - ✔✔takes form in 3 distinct approaches:
