Reimbursement Exam 3 with 100%
Correct Answers
Medicare Advantage- requirements to become a Medicare Advantage Plan - ANS--
State Licensure
-Designation as one of the following
--Coordinated care plans
--Non-Coordinated Care Plans
Coordinated Care Plans - ANS-HMOs,PPOs,POSs, adn PSOs
Non-Coordinated Care Plans - ANS-Private Fee for Service (PFFS)
Type of MA Plans: Medicare HMO - ANS--CMS delegates regulatory oversight to the
states in which the commercial company operates
-CMS accepts state certification of the commercial insurance company as sufficient
evidence that the HMO is meeting financial and market conduct standards
-Distinguish this process from Medicare's direct certification of providers under Medicare
fee-for-service (Under Traditional Medicare, providers must meet Medicare's Conditions
of Participation)
Type of MA Plans: Medicare PPO - ANS--Two designated types - local MA PPO and
regional MA PPO
--Must have a network of providers who accept negotiated rates
---Network is created by the MA PPO company.
---Negotiated rates between MA PPO and the providers
-Patients can go out-of-network; provider paid at regular Medicare rates
Type of MA Plans: Medicare PFFS - ANS--A private health insurance plan that
reimburses providers on a fee-for-service basis, and does not limit enrollees to the use
of network providers
-Beneficiary may use any Medicare-participating provider
NCQA - ANS-To demonstrate compliance with Medicare quality standards
HEDIS Data - ANS-comprehensive set of standardized performance measures
designed to provide purchasers and consumers with the information they need for
reliable comparison of health plan performance. HEDIS Measures relate to many
significant public health issues, such as cancer, heart disease, smoking, asthma, and
diabetes.
, Average Wholesale Price (AWP) - ANS-the published list price for a drug sold by
wholesalers to retail pharmacies and non-retail providers.
Tiering - ANS-Tier 1: Generic Drugs
Tier 2: Preferred brand name drugs
Tier 3: Non-preferred brand name drugs
Tier 4: Specialty drugs (some shots)
Chronic Disease - ANS--defined broadly as conditions that last 1 year or more and
require ongoing medical attention or limit activities of daily living or both.
-Chronic diseases are primarily:
--Heart disease
--Diabetes
--Glaucoma
--Asthma
--COPD
--Cancer
Disease Management - ANS--Relationship between number of chronic medical
conditions and cost
Disease Management Components - ANS--Condition selection and prioritization
-Participant identification
-Active outreach to members (recruitment and engagement)
-Interaction and management
-Active physician involvement
-Multiple modalities
--Home Visits
--Group Meetings
--Internet Education
--Special Mailings & Programs
Why Offer Wellness Benefits? - ANS-Personal responsibility is the key to decreased
medical bills
-Provide incentives and motivation to employees
-Improve employee health
-Reduce health care costs
-Reduce employee absenteeism
-Reduce on the job accidents
-Healthier workforce
-Reduce presenteeism (low productivity)
-Reduce use of health benefits
-Reduce disability claims
-Reduce complications from the disease
-Reduce medical costs through avoiding hospitalizations & decreasing ER visits
Correct Answers
Medicare Advantage- requirements to become a Medicare Advantage Plan - ANS--
State Licensure
-Designation as one of the following
--Coordinated care plans
--Non-Coordinated Care Plans
Coordinated Care Plans - ANS-HMOs,PPOs,POSs, adn PSOs
Non-Coordinated Care Plans - ANS-Private Fee for Service (PFFS)
Type of MA Plans: Medicare HMO - ANS--CMS delegates regulatory oversight to the
states in which the commercial company operates
-CMS accepts state certification of the commercial insurance company as sufficient
evidence that the HMO is meeting financial and market conduct standards
-Distinguish this process from Medicare's direct certification of providers under Medicare
fee-for-service (Under Traditional Medicare, providers must meet Medicare's Conditions
of Participation)
Type of MA Plans: Medicare PPO - ANS--Two designated types - local MA PPO and
regional MA PPO
--Must have a network of providers who accept negotiated rates
---Network is created by the MA PPO company.
---Negotiated rates between MA PPO and the providers
-Patients can go out-of-network; provider paid at regular Medicare rates
Type of MA Plans: Medicare PFFS - ANS--A private health insurance plan that
reimburses providers on a fee-for-service basis, and does not limit enrollees to the use
of network providers
-Beneficiary may use any Medicare-participating provider
NCQA - ANS-To demonstrate compliance with Medicare quality standards
HEDIS Data - ANS-comprehensive set of standardized performance measures
designed to provide purchasers and consumers with the information they need for
reliable comparison of health plan performance. HEDIS Measures relate to many
significant public health issues, such as cancer, heart disease, smoking, asthma, and
diabetes.
, Average Wholesale Price (AWP) - ANS-the published list price for a drug sold by
wholesalers to retail pharmacies and non-retail providers.
Tiering - ANS-Tier 1: Generic Drugs
Tier 2: Preferred brand name drugs
Tier 3: Non-preferred brand name drugs
Tier 4: Specialty drugs (some shots)
Chronic Disease - ANS--defined broadly as conditions that last 1 year or more and
require ongoing medical attention or limit activities of daily living or both.
-Chronic diseases are primarily:
--Heart disease
--Diabetes
--Glaucoma
--Asthma
--COPD
--Cancer
Disease Management - ANS--Relationship between number of chronic medical
conditions and cost
Disease Management Components - ANS--Condition selection and prioritization
-Participant identification
-Active outreach to members (recruitment and engagement)
-Interaction and management
-Active physician involvement
-Multiple modalities
--Home Visits
--Group Meetings
--Internet Education
--Special Mailings & Programs
Why Offer Wellness Benefits? - ANS-Personal responsibility is the key to decreased
medical bills
-Provide incentives and motivation to employees
-Improve employee health
-Reduce health care costs
-Reduce employee absenteeism
-Reduce on the job accidents
-Healthier workforce
-Reduce presenteeism (low productivity)
-Reduce use of health benefits
-Reduce disability claims
-Reduce complications from the disease
-Reduce medical costs through avoiding hospitalizations & decreasing ER visits
