CSPR - QUESTIONS BASED ON FULL COURSE | TOP
SCORES MADE SIMPLE | TRUSTED TEST SOLUTIONS!
QUALITY CONTENT YOU CAN RELY ON!
What Act shaped how commercial insurance carriers approached the concepts of paying
for medical care? Answer: HMO Act of 1973
ACA Answer: Affordable Care Act
HMO (Health Maintenance Organization) Answer: The organization is both the insurer and
provider of a set of defined services. Patients within this network must use an in-network
provider for their services to be covered.
Capitation Payment Answer: part of prospective payment in which healthcare providers
receive fixed monthly payments for services rendered regardless of whether or not services
are used
PPO (Preferred Provider Organization) Answer: A network of healthcare providers, such as
hospitals and physicians. They have entered into a contract with a third-party entitled to
deliver healthcare services to individuals covered under the plan.
POS Answer: Combines the features of both an HMO and PPO, with costs for covered
persons falling somewhere between the two. Required to have a PCP, but can self refer to
other in-network specialists.
EPO Answer: Services are covered only if patients use doctors, specialists or hospitals in
the plan's network. There are no out of network benefits.
ACO Answer: Accountable Care Organization
What employer-based insurance was first? Answer: Blue Cross
ERISA (Employee Retirement Income Security Act) Answer: Federal law that sets minimum
standards for most voluntarily established pension and health plans in private industry to
provide protection for individuals in these plans.
Government health Coverage Examples Answer: Medicare and Medicaid
Medicare Managed Care Plans Answer: These plans charge a monthly premium and a
small copayment for each office visit, but not a deductible. Like private payer managed
1
APPHIA - Crafted with Care and Precision for Academic Excellence.
, care plans, these plans often require patients to use a specific network of physicians,
hospitals, and facilities. Some plans offer the option of receiving services from providers
outside the network for a higher fee. Participants are generally required to select a primary
care provider (PCP) from within the network.
Medicaid Managed Care Answer: Plans that operate under the terms of waivers filed by the
state Medicaid agencies requesting that a program be established that varies from the
traditional Medicaid program.
Medicare Parts Answer: - part a (inpatient hospital care)
- part b (MD and outpatient care)
- part c (managed care option)
- part d (prescription drugs)
Which of the following is an anticipated change in the relationship between consumers and
providers? Answer: Providers will face many new service demands and consumers will
have virtually unfettered access to those services
Medicare provides health insurance benefits to the following individuals. Answer: All
persons age 65, individuals with permanent renal (kidney) failure, disabilities
QMBs Answer: Medicare beneficiaries who qualify for certain Medicaid benefits if they
have incomes below the FPL and resources at or below twice the standard allowed under
the SSI program.
Centers for Medicare and Medicaid Services (CMS) Answer: Administers all federally
supported healthcare financing programs
Federal Trade Commission (FTC) Answer: Examines mergers of hospitals and other
healthcare institutions
Section 501(c)3 Answer: Grants tax-exempt status and monitors compliance with
legislation.
Office of the Inspector General (OIG) Answer: Investigates organizations for violations of
the Medicare and Medicaid anti-kickback statute.
Department of Justice (DOJ) Answer: Prosecutes healthcare fraud under various federal
criminal statutes.
2
APPHIA - Crafted with Care and Precision for Academic Excellence.
SCORES MADE SIMPLE | TRUSTED TEST SOLUTIONS!
QUALITY CONTENT YOU CAN RELY ON!
What Act shaped how commercial insurance carriers approached the concepts of paying
for medical care? Answer: HMO Act of 1973
ACA Answer: Affordable Care Act
HMO (Health Maintenance Organization) Answer: The organization is both the insurer and
provider of a set of defined services. Patients within this network must use an in-network
provider for their services to be covered.
Capitation Payment Answer: part of prospective payment in which healthcare providers
receive fixed monthly payments for services rendered regardless of whether or not services
are used
PPO (Preferred Provider Organization) Answer: A network of healthcare providers, such as
hospitals and physicians. They have entered into a contract with a third-party entitled to
deliver healthcare services to individuals covered under the plan.
POS Answer: Combines the features of both an HMO and PPO, with costs for covered
persons falling somewhere between the two. Required to have a PCP, but can self refer to
other in-network specialists.
EPO Answer: Services are covered only if patients use doctors, specialists or hospitals in
the plan's network. There are no out of network benefits.
ACO Answer: Accountable Care Organization
What employer-based insurance was first? Answer: Blue Cross
ERISA (Employee Retirement Income Security Act) Answer: Federal law that sets minimum
standards for most voluntarily established pension and health plans in private industry to
provide protection for individuals in these plans.
Government health Coverage Examples Answer: Medicare and Medicaid
Medicare Managed Care Plans Answer: These plans charge a monthly premium and a
small copayment for each office visit, but not a deductible. Like private payer managed
1
APPHIA - Crafted with Care and Precision for Academic Excellence.
, care plans, these plans often require patients to use a specific network of physicians,
hospitals, and facilities. Some plans offer the option of receiving services from providers
outside the network for a higher fee. Participants are generally required to select a primary
care provider (PCP) from within the network.
Medicaid Managed Care Answer: Plans that operate under the terms of waivers filed by the
state Medicaid agencies requesting that a program be established that varies from the
traditional Medicaid program.
Medicare Parts Answer: - part a (inpatient hospital care)
- part b (MD and outpatient care)
- part c (managed care option)
- part d (prescription drugs)
Which of the following is an anticipated change in the relationship between consumers and
providers? Answer: Providers will face many new service demands and consumers will
have virtually unfettered access to those services
Medicare provides health insurance benefits to the following individuals. Answer: All
persons age 65, individuals with permanent renal (kidney) failure, disabilities
QMBs Answer: Medicare beneficiaries who qualify for certain Medicaid benefits if they
have incomes below the FPL and resources at or below twice the standard allowed under
the SSI program.
Centers for Medicare and Medicaid Services (CMS) Answer: Administers all federally
supported healthcare financing programs
Federal Trade Commission (FTC) Answer: Examines mergers of hospitals and other
healthcare institutions
Section 501(c)3 Answer: Grants tax-exempt status and monitors compliance with
legislation.
Office of the Inspector General (OIG) Answer: Investigates organizations for violations of
the Medicare and Medicaid anti-kickback statute.
Department of Justice (DOJ) Answer: Prosecutes healthcare fraud under various federal
criminal statutes.
2
APPHIA - Crafted with Care and Precision for Academic Excellence.
