WGU C428 OA ACTUAL EXAM
2025/2026 COMPLETE QUESTIONS
WITH CORRECT DETAILED ANSWERS
|| 100% GUARANTEED PASS
<BRAND NEW VERSION>
1. Covered benefit - ANSWER ✓ The services for which the insurer will pay
are usually referred to as a covered benefit.
2. Deductible - ANSWER ✓ A deductible is a pre determined amount that the
patient pays before the insurer begins to pay for service
3. Denial - ANSWER ✓ The insurer may determine that the claim from the
provider is not a covered benefit and will not pay for the claim.
4. Employer mandate - ANSWER ✓ The employer Mandate requires
employers with 50 or more full time equivalent employees to offer health
insurance coverage.
5. Facility Provider - ANSWER ✓ A facility provider is an 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.
6. Fiscal Intermediary. - ANSWER ✓ A fiscal intermediary is an organization
that contracts with CMS to pay medical claims and educate providers.
A newer term is Medicare Administrative Contractor (MAC)
,7. Individual Mandate - ANSWER ✓ The individual Mandate Requires
individuals and families without employer-provided insurance top purchase
health insurance or pay a penalty.
The Supreme Court in 2012 characterized the penalty as a tax.
The penalty ranges from 695$ per year to three times that amount (2,085$)
per family or 2.% of household income.to
8. Insurance Exchange - ANSWER ✓ Insurance Exchanges are federal or state-
run health insurance markets designed to make health insurance affordable
and broadly available.
They are more correctly referred to as Health Insurance Marketplaces.
Individuals who purchase health Insurance on an exchange (in the
marketplace) may qualify for premium subsidies.
85% of enrollees receive such a subsidy.
The subsidies are not available on the individual market.
9. Medicaid - ANSWER ✓ Medicaid is a joint federal-state program
established by Title XIX of the Social Security Act in 1965 for low-income
and medically needy people.
It is the single largest source of health coverage in the United States.
Medicaid Covers low-income families, qualified pregnant women and
children, and individuals receiving Supplemental Security Income (SSI).
Medicaid includes benefits not usually covered by Medicare, such as nursing
home care and personal care services.
Each state has different rules about eligibility and applying for Medicaid.
10.Medical Loss Ratio - ANSWER ✓ Medical Loss Ratio refers to the
percentage of premiums that insurers/health plans must spend on clinical
services and quality improvement.
The Affordable Care Act Requires health insurance Issuers to spend at least
80% to 85% of premium dollars on claims and quality intiatives.
11.Medicare Cost report - ANSWER ✓ A Medicare Cost Report is an annual
report that institutional providers participating in the Medicare program must
submit to their Medicare Administrative Contractor.
For providers paid prospectively, the cost report determines reimbursement
for specific add-on payments but does not affect the overall payment rate.
, For Providers paid retrospectively, the cost report determines the payment
rate.
CMS uses cost report data to update DRG and APC weights and determine
market basket updates.
12.Medicare Part A - ANSWER ✓ Medicare Part A (Hospital Insurance) is one
of two parts of the original Medicare program established by Title XVIII of
the Social Security Act in 1965.
It pays for hospital inpatient, skilled nursing facilities, hospice, and some
home health care.
Part A is a premium-free benefit funded by FICA payroll deductions (2.9%
payroll tax)
Categorical Eligibility starts when a US citizen who paid FICA taxes for at
least 40 calendar quarters turns 65.
Disabled individuals under 65 who have received Social Security for 24
Months also qualify for Medicare.
13.Medicare Part B - ANSWER ✓ Medicare Part B (Supplemental Medical
Insurance) is the voluntary part of the original Medicare.
It 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.
Since Part B is voluntary and not everyone may qualify for Part A, it is
possible for a patient to have Medicare Part B but not Medicare Part A or
vice versa.
14.corporate bonds - ANSWER ✓ issued by for profit industry
15.municipal bonds - ANSWER ✓ state/federal, allows public to invest in
municipal area w/o raising taxes
16.NPV - ANSWER ✓ uses discounted cash flows and discount rate
17.IRR - ANSWER ✓ is used in the npv calculation and measures the internal
rate of return for a set of cash flows
, 18.break-even analysis - ANSWER ✓ used to determine the point at which the
project investment will generate a positive return
19.payback method - ANSWER ✓ used to determine how long it will take you
to recoup or breakeven on an investment
20.post-audit - ANSWER ✓ this process is used after a project has been
executed to check for outcomes to ensure that the project produced accurate
results
21.Variance - ANSWER ✓ compare what you budgetted vs. what you actually
spent
22.comparative - ANSWER ✓ existing to new
23.horizontal - ANSWER ✓ looking across mulitple years
24.cash accounting - ANSWER ✓ paying a copay
25.accrual accounting - ANSWER ✓ recognize revenue as soon as it happens
26.managing liquidity - ANSWER ✓ looking at revenue cycles
27.fixed costs - ANSWER ✓ remain the same regardless of sales
28.variable costs - ANSWER ✓ costs change based on your sales activity
29.direct costs - ANSWER ✓ expenses that directly go into producing goods or
providing services (direct labor, direct materials, manufacturing supplies)
30.indirect costs - ANSWER ✓ general business expenses that keep you
operating (rent, utilities, general office expenses)
31.Income statement - ANSWER ✓ Paycheck, revenue, expenses
32.Balance sheet - ANSWER ✓ statement of net worth, assets, liabilities, equity
2025/2026 COMPLETE QUESTIONS
WITH CORRECT DETAILED ANSWERS
|| 100% GUARANTEED PASS
<BRAND NEW VERSION>
1. Covered benefit - ANSWER ✓ The services for which the insurer will pay
are usually referred to as a covered benefit.
2. Deductible - ANSWER ✓ A deductible is a pre determined amount that the
patient pays before the insurer begins to pay for service
3. Denial - ANSWER ✓ The insurer may determine that the claim from the
provider is not a covered benefit and will not pay for the claim.
4. Employer mandate - ANSWER ✓ The employer Mandate requires
employers with 50 or more full time equivalent employees to offer health
insurance coverage.
5. Facility Provider - ANSWER ✓ A facility provider is an 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.
6. Fiscal Intermediary. - ANSWER ✓ A fiscal intermediary is an organization
that contracts with CMS to pay medical claims and educate providers.
A newer term is Medicare Administrative Contractor (MAC)
,7. Individual Mandate - ANSWER ✓ The individual Mandate Requires
individuals and families without employer-provided insurance top purchase
health insurance or pay a penalty.
The Supreme Court in 2012 characterized the penalty as a tax.
The penalty ranges from 695$ per year to three times that amount (2,085$)
per family or 2.% of household income.to
8. Insurance Exchange - ANSWER ✓ Insurance Exchanges are federal or state-
run health insurance markets designed to make health insurance affordable
and broadly available.
They are more correctly referred to as Health Insurance Marketplaces.
Individuals who purchase health Insurance on an exchange (in the
marketplace) may qualify for premium subsidies.
85% of enrollees receive such a subsidy.
The subsidies are not available on the individual market.
9. Medicaid - ANSWER ✓ Medicaid is a joint federal-state program
established by Title XIX of the Social Security Act in 1965 for low-income
and medically needy people.
It is the single largest source of health coverage in the United States.
Medicaid Covers low-income families, qualified pregnant women and
children, and individuals receiving Supplemental Security Income (SSI).
Medicaid includes benefits not usually covered by Medicare, such as nursing
home care and personal care services.
Each state has different rules about eligibility and applying for Medicaid.
10.Medical Loss Ratio - ANSWER ✓ Medical Loss Ratio refers to the
percentage of premiums that insurers/health plans must spend on clinical
services and quality improvement.
The Affordable Care Act Requires health insurance Issuers to spend at least
80% to 85% of premium dollars on claims and quality intiatives.
11.Medicare Cost report - ANSWER ✓ A Medicare Cost Report is an annual
report that institutional providers participating in the Medicare program must
submit to their Medicare Administrative Contractor.
For providers paid prospectively, the cost report determines reimbursement
for specific add-on payments but does not affect the overall payment rate.
, For Providers paid retrospectively, the cost report determines the payment
rate.
CMS uses cost report data to update DRG and APC weights and determine
market basket updates.
12.Medicare Part A - ANSWER ✓ Medicare Part A (Hospital Insurance) is one
of two parts of the original Medicare program established by Title XVIII of
the Social Security Act in 1965.
It pays for hospital inpatient, skilled nursing facilities, hospice, and some
home health care.
Part A is a premium-free benefit funded by FICA payroll deductions (2.9%
payroll tax)
Categorical Eligibility starts when a US citizen who paid FICA taxes for at
least 40 calendar quarters turns 65.
Disabled individuals under 65 who have received Social Security for 24
Months also qualify for Medicare.
13.Medicare Part B - ANSWER ✓ Medicare Part B (Supplemental Medical
Insurance) is the voluntary part of the original Medicare.
It 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.
Since Part B is voluntary and not everyone may qualify for Part A, it is
possible for a patient to have Medicare Part B but not Medicare Part A or
vice versa.
14.corporate bonds - ANSWER ✓ issued by for profit industry
15.municipal bonds - ANSWER ✓ state/federal, allows public to invest in
municipal area w/o raising taxes
16.NPV - ANSWER ✓ uses discounted cash flows and discount rate
17.IRR - ANSWER ✓ is used in the npv calculation and measures the internal
rate of return for a set of cash flows
, 18.break-even analysis - ANSWER ✓ used to determine the point at which the
project investment will generate a positive return
19.payback method - ANSWER ✓ used to determine how long it will take you
to recoup or breakeven on an investment
20.post-audit - ANSWER ✓ this process is used after a project has been
executed to check for outcomes to ensure that the project produced accurate
results
21.Variance - ANSWER ✓ compare what you budgetted vs. what you actually
spent
22.comparative - ANSWER ✓ existing to new
23.horizontal - ANSWER ✓ looking across mulitple years
24.cash accounting - ANSWER ✓ paying a copay
25.accrual accounting - ANSWER ✓ recognize revenue as soon as it happens
26.managing liquidity - ANSWER ✓ looking at revenue cycles
27.fixed costs - ANSWER ✓ remain the same regardless of sales
28.variable costs - ANSWER ✓ costs change based on your sales activity
29.direct costs - ANSWER ✓ expenses that directly go into producing goods or
providing services (direct labor, direct materials, manufacturing supplies)
30.indirect costs - ANSWER ✓ general business expenses that keep you
operating (rent, utilities, general office expenses)
31.Income statement - ANSWER ✓ Paycheck, revenue, expenses
32.Balance sheet - ANSWER ✓ statement of net worth, assets, liabilities, equity
