PUBH 6012 EXAM 2 STUDY GUIDE
2025/2026 COMPLETE QUESTIONS
WITH CORRECT DETAILED ANSWERS
|| 100% GUARANTEED PASS
<BRAND NEW VERSION>
1. Prescription drug doughnut hole - ANSWER ✓ gap in prescription drug
coverage between a limit for coverage and catastrophic coverage
2. T/F Medicare Advantage offers less choice in provider than traditional
medicare - ANSWER ✓ true because medicare advantage is similar to
managed care-- there is a preferred or required network of providers where
you can receive care, traditional medicare is fee-for-service from any
medicare provider
3. Prospective payment - ANSWER ✓ A method of reimbursement based on
payment rates that are established in advance and reflect an average of what
a service should cost. used by medicare
4. Who might be more likely to stay on traditional medicare - ANSWER ✓
someone who wants to keep their dr, someone who has more expensive care
5. Before ACA who qualified for medicaid - ANSWER ✓ low-income AND
another eligibility category (disabled, pregnant, a child)
6. How is medicaid financed - ANSWER ✓ jointly financed by state and fed,
fed chips in 50-76% depending on the state, money is attached with
conditions for different populations covered and services provided
,7. 11 15 waiver - ANSWER ✓ allows states to add populations covered by
their medicaid program, need to apply and have it be approved, would lead
to more federal funding for adding that population
8. t/f the majority of children is covered under medicaid/ CHIP - ANSWER ✓
true
9. Medicaid churn - ANSWER ✓ people getting kicked off of medicaid when
they get a new job that pays them "too much" to be on medicaid, but then
they go back on it after that job is over (i.e. in seasonal or temporary work)
10.What are the 3 pathways that make someone eligible for medicare -
ANSWER ✓ over 65, qualify for social security disability income, diagnosis
of a rapid terminal disease (i.e. late stage renal failure or ALS)
11.What was the impact of ACA on medicare part c - ANSWER ✓ bring the
cost of medicare part c down to the cost of traditional medicare (i.e. stop
giving insurance companies more money for medicare advantage plans)
12.Medicare enrollment trends - ANSWER ✓ around 30% of people now
enrolled in part c, gradually increasing, enrollment in medigap slightly
decreasing
13.What does medicare part d cover - ANSWER ✓ Outpatient prescriptions
14.Costs associated with medicare part d - ANSWER ✓ montly premium,
annual deductible, cost sharing,
15.ACA impact on part d donut hole - ANSWER ✓ gradually decrease the
amount the beneficiary has to pay within the coverage gap (because
previously once they reached the coverage gap they had to pay 100 percent
until they reached the catastrophic coverage) ; the amount of beneficiaries
falling into the coverage gap has been going down
16.Values based purchasing - ANSWER ✓ pricing based on bundled services
for everything included within a typical care episode
,17.MACRA and MIPS - ANSWER ✓ passed as a response to deficiencies in
the sustainable growth rate. How does MACRA incentivize providers to
improve quality of care?
MERIT-BASED INCENTIVE
PAYMENT SYSTEM
Doctors who prove high
quality and better outcomes
can receive large bonus
payments from CMS. Those
with poor quality are
penalized financially.
18.Sustainable Growth Rate - ANSWER ✓ set amount that says how much drs
can increase their prices each year, but it led to major reductions in
reimbursements (aka the SGR couldn't keep up with actual rise in prices,
reimbursements were low)
19.t/f medicare is an entitlement program - ANSWER ✓ true
20.t/f the number of workers per medicare beneficiary has been increasing -
ANSWER ✓ false it has been decreasing
21.t/f medicare is the primary source of coverage for long term nursing care -
ANSWER ✓ false. long term nursing care not covered by medicare,
medicaid is the primary source of coverage for this
22.What were the eligible categories for medicaid pre-2014 - ANSWER ✓ low
income AND disabled, pregnant, elderly, children, adults w/ children
23.Impact of ACA on medicaid - ANSWER ✓ expand to cover up to 133% of
FPL (expand coverage to include near-poor)
24.Woodwork effect - ANSWER ✓ increase in enrollment immediately
following expansion of medicaid, plateaued over time
25.Who predominantly falls in medicaid coverage gap - ANSWER ✓ adults in
states that did not expand medicaid (typically fall in the south) ; majority are
, working and work for small companies, or agricultural or service sectors
where employer sponsored insurance options are lacking . they can't afford
private insurance but they make too much for medicaid
26.How does federal govt enforce mandatory benefits of medicaid - ANSWER
✓ federal matching of funds requires states to offer certain benefits; there are
optional benefits that states can add that might come with more funding
27.EPSDT - ANSWER ✓ early periodic screening diagnosis treatment (defines
scope of benefits for different targeted populations of medicaid)
28.Medigap - ANSWER ✓ Supplemental insurance coverage for out of pocket
costs not covered by A and B (no addition services or benefits)
29.Medicare payment/cost structure - ANSWER ✓ Prospective payment- set
relative values for services and make adjustments; moving toward value-
based purchasing
30.Medicare trends - ANSWER ✓ Spending projected to increase, fewer
workers per beneficiary (less people paying in and more people enrolled,
people living longer), projected to run out between 2025-30
31.Cost-drivers of Medicare - ANSWER ✓ Changing demographics, increasing
prescription drug prices and use
32.Fee For Service - ANSWER ✓ Price for different health services
33.Capitation - ANSWER ✓ $ per head per month, how much money to use use
per patient a PCP sees per month
34.Benefit Package - ANSWER ✓ The sum of services provided, including
medical necessities, mandates, limits
35.Asymmetric Information - ANSWER ✓ a situation in which one side
(typically the provider) has more reliable information than the other side
(typically the patient)
2025/2026 COMPLETE QUESTIONS
WITH CORRECT DETAILED ANSWERS
|| 100% GUARANTEED PASS
<BRAND NEW VERSION>
1. Prescription drug doughnut hole - ANSWER ✓ gap in prescription drug
coverage between a limit for coverage and catastrophic coverage
2. T/F Medicare Advantage offers less choice in provider than traditional
medicare - ANSWER ✓ true because medicare advantage is similar to
managed care-- there is a preferred or required network of providers where
you can receive care, traditional medicare is fee-for-service from any
medicare provider
3. Prospective payment - ANSWER ✓ A method of reimbursement based on
payment rates that are established in advance and reflect an average of what
a service should cost. used by medicare
4. Who might be more likely to stay on traditional medicare - ANSWER ✓
someone who wants to keep their dr, someone who has more expensive care
5. Before ACA who qualified for medicaid - ANSWER ✓ low-income AND
another eligibility category (disabled, pregnant, a child)
6. How is medicaid financed - ANSWER ✓ jointly financed by state and fed,
fed chips in 50-76% depending on the state, money is attached with
conditions for different populations covered and services provided
,7. 11 15 waiver - ANSWER ✓ allows states to add populations covered by
their medicaid program, need to apply and have it be approved, would lead
to more federal funding for adding that population
8. t/f the majority of children is covered under medicaid/ CHIP - ANSWER ✓
true
9. Medicaid churn - ANSWER ✓ people getting kicked off of medicaid when
they get a new job that pays them "too much" to be on medicaid, but then
they go back on it after that job is over (i.e. in seasonal or temporary work)
10.What are the 3 pathways that make someone eligible for medicare -
ANSWER ✓ over 65, qualify for social security disability income, diagnosis
of a rapid terminal disease (i.e. late stage renal failure or ALS)
11.What was the impact of ACA on medicare part c - ANSWER ✓ bring the
cost of medicare part c down to the cost of traditional medicare (i.e. stop
giving insurance companies more money for medicare advantage plans)
12.Medicare enrollment trends - ANSWER ✓ around 30% of people now
enrolled in part c, gradually increasing, enrollment in medigap slightly
decreasing
13.What does medicare part d cover - ANSWER ✓ Outpatient prescriptions
14.Costs associated with medicare part d - ANSWER ✓ montly premium,
annual deductible, cost sharing,
15.ACA impact on part d donut hole - ANSWER ✓ gradually decrease the
amount the beneficiary has to pay within the coverage gap (because
previously once they reached the coverage gap they had to pay 100 percent
until they reached the catastrophic coverage) ; the amount of beneficiaries
falling into the coverage gap has been going down
16.Values based purchasing - ANSWER ✓ pricing based on bundled services
for everything included within a typical care episode
,17.MACRA and MIPS - ANSWER ✓ passed as a response to deficiencies in
the sustainable growth rate. How does MACRA incentivize providers to
improve quality of care?
MERIT-BASED INCENTIVE
PAYMENT SYSTEM
Doctors who prove high
quality and better outcomes
can receive large bonus
payments from CMS. Those
with poor quality are
penalized financially.
18.Sustainable Growth Rate - ANSWER ✓ set amount that says how much drs
can increase their prices each year, but it led to major reductions in
reimbursements (aka the SGR couldn't keep up with actual rise in prices,
reimbursements were low)
19.t/f medicare is an entitlement program - ANSWER ✓ true
20.t/f the number of workers per medicare beneficiary has been increasing -
ANSWER ✓ false it has been decreasing
21.t/f medicare is the primary source of coverage for long term nursing care -
ANSWER ✓ false. long term nursing care not covered by medicare,
medicaid is the primary source of coverage for this
22.What were the eligible categories for medicaid pre-2014 - ANSWER ✓ low
income AND disabled, pregnant, elderly, children, adults w/ children
23.Impact of ACA on medicaid - ANSWER ✓ expand to cover up to 133% of
FPL (expand coverage to include near-poor)
24.Woodwork effect - ANSWER ✓ increase in enrollment immediately
following expansion of medicaid, plateaued over time
25.Who predominantly falls in medicaid coverage gap - ANSWER ✓ adults in
states that did not expand medicaid (typically fall in the south) ; majority are
, working and work for small companies, or agricultural or service sectors
where employer sponsored insurance options are lacking . they can't afford
private insurance but they make too much for medicaid
26.How does federal govt enforce mandatory benefits of medicaid - ANSWER
✓ federal matching of funds requires states to offer certain benefits; there are
optional benefits that states can add that might come with more funding
27.EPSDT - ANSWER ✓ early periodic screening diagnosis treatment (defines
scope of benefits for different targeted populations of medicaid)
28.Medigap - ANSWER ✓ Supplemental insurance coverage for out of pocket
costs not covered by A and B (no addition services or benefits)
29.Medicare payment/cost structure - ANSWER ✓ Prospective payment- set
relative values for services and make adjustments; moving toward value-
based purchasing
30.Medicare trends - ANSWER ✓ Spending projected to increase, fewer
workers per beneficiary (less people paying in and more people enrolled,
people living longer), projected to run out between 2025-30
31.Cost-drivers of Medicare - ANSWER ✓ Changing demographics, increasing
prescription drug prices and use
32.Fee For Service - ANSWER ✓ Price for different health services
33.Capitation - ANSWER ✓ $ per head per month, how much money to use use
per patient a PCP sees per month
34.Benefit Package - ANSWER ✓ The sum of services provided, including
medical necessities, mandates, limits
35.Asymmetric Information - ANSWER ✓ a situation in which one side
(typically the provider) has more reliable information than the other side
(typically the patient)
