WGU C425 / WGU C425 HEALTHCARE DELIVERY
REGULATION AND CPMPLIANCE OA EXAM PREP
COMPLETE ACTUAL EXAM QUESTIONS AND
CORRECT VERIFIED ANSWERS WITH
RATIONALES (MOST TEST QUESTIONS) A NEW
UPDATED VERSION 2024|GUARANTEED PASS A+
Medicaid - ANSWER Federal and State program that provides medical assistance
for low-income Americans
Medicare - ANSWER Administered by CMS under Department of Health and Human
Services. A federal program of health insurance for persons 65 years of age and
older, disable, end stage renal failure. Not comprehensive coverage-no vision,
dental, etc.
demand side rationing - ANSWER Prices and ability to pay ration the quantity and
type of health care services people consume
Planned rationing or supply-side rationing - ANSWER Refers to government means
to limit the availability of certain health care services by deciding, for instance, how
technology will be dispersed and who will be allowed access to certain types of high-
tech services. National health insurance enables this, U.S. hasn't
ACA mandates - ANSWER preventative and immunizations must be without cost
sharing and no lifetime limit on benefits
individual private health insurance - ANSWER for those who don't have group
coverage like farmers, early retirees, and self employed
Medicare A - ANSWER hospital insurance, covered by payroll taxes, paid equal by
employer and employee, covers things like inpatient services, home health, hospice,
benefit period begins when person is hospitalized and ends after 60 days of release
Medicare B - ANSWER supplemental medical insurance covers physician services,
outpatient, diagnostic tests, preventatives, annual deductible and coinsurance 80:20
Medicare C - ANSWER Additional coverage not covered under A or B. Often called
the advantage plan or choice plan like vision or dental, eliminates need for Medigap,
people can either be in fee for service program or have this
Medicare D - ANSWER Prescription drug coverage, available to ppl who have A or
B, monthly premium and deductible, created under Medicare Prescription Drug
improvement and modernization act of 2003 (MMA)
, Medicaid - ANSWER Title 19, finances for indigent, means tested program based on
income and per capita of state, financed by stated and federal
CHIP - ANSWER Title 21, covers kids in low income families under 19, incomes at or
below 200% of federal poverty level, states can use Medicaid or have this separate
program, fed and state financed
issues with Medicaid - ANSWER •Inadequate reimbursement and issues of
physician participation.
•Each state decides whether to expand Medicaid, which was originally required by
the ACA.
•Some evidence indicates that ACA-linked Medicaid expansion has resulted in better
access to care and utilization.
reimbursement methods - ANSWER third party payers, fee for service, bundled
payments, resource based relative value scale (reimburse according to relative value
of service based on time, skill, intensity)
reimbursement under managed care - ANSWER discounts, used by PPOS,
capitation (used by HMOS, per member per month fee, minimize provider induced
demand)
prospective reimbursement - ANSWER Used by HMOS. A method of payment in
which certain preestablished criteria are used to determine in advance the amount of
reimbursement, diagnosis related groups, ambulatory payment, resource utilization
groups, home health resource groups
ambulatory payment classification - ANSWER Hospital outpatient prospective
payment system (OPPS). The classification is a resource-based reimbursement
system, bundled rates
Resource utilization groups - ANSWER case mix method for skilled nursing facilities
to determine a fixed per day rate
New payment arrangements for Medicare to be worked out, to include: - ANSWER
bundled payments, shared savings arrangements, risk sharing arrangements
Pluralistic and Interest Group Politics - ANSWER most effective demanders of
policies, AMA, AARP, and American Hospital Association, employers, consumer
groups, manufacturers of technology, alliances
National Health Services Corps - ANSWER helps address personnel shortages in
rural areas for a limited time
Agency for healthcare research and quality - ANSWER goal is to conduct and
support research on outcomes, effectiveness, and appropriateness of services and
procedures
REGULATION AND CPMPLIANCE OA EXAM PREP
COMPLETE ACTUAL EXAM QUESTIONS AND
CORRECT VERIFIED ANSWERS WITH
RATIONALES (MOST TEST QUESTIONS) A NEW
UPDATED VERSION 2024|GUARANTEED PASS A+
Medicaid - ANSWER Federal and State program that provides medical assistance
for low-income Americans
Medicare - ANSWER Administered by CMS under Department of Health and Human
Services. A federal program of health insurance for persons 65 years of age and
older, disable, end stage renal failure. Not comprehensive coverage-no vision,
dental, etc.
demand side rationing - ANSWER Prices and ability to pay ration the quantity and
type of health care services people consume
Planned rationing or supply-side rationing - ANSWER Refers to government means
to limit the availability of certain health care services by deciding, for instance, how
technology will be dispersed and who will be allowed access to certain types of high-
tech services. National health insurance enables this, U.S. hasn't
ACA mandates - ANSWER preventative and immunizations must be without cost
sharing and no lifetime limit on benefits
individual private health insurance - ANSWER for those who don't have group
coverage like farmers, early retirees, and self employed
Medicare A - ANSWER hospital insurance, covered by payroll taxes, paid equal by
employer and employee, covers things like inpatient services, home health, hospice,
benefit period begins when person is hospitalized and ends after 60 days of release
Medicare B - ANSWER supplemental medical insurance covers physician services,
outpatient, diagnostic tests, preventatives, annual deductible and coinsurance 80:20
Medicare C - ANSWER Additional coverage not covered under A or B. Often called
the advantage plan or choice plan like vision or dental, eliminates need for Medigap,
people can either be in fee for service program or have this
Medicare D - ANSWER Prescription drug coverage, available to ppl who have A or
B, monthly premium and deductible, created under Medicare Prescription Drug
improvement and modernization act of 2003 (MMA)
, Medicaid - ANSWER Title 19, finances for indigent, means tested program based on
income and per capita of state, financed by stated and federal
CHIP - ANSWER Title 21, covers kids in low income families under 19, incomes at or
below 200% of federal poverty level, states can use Medicaid or have this separate
program, fed and state financed
issues with Medicaid - ANSWER •Inadequate reimbursement and issues of
physician participation.
•Each state decides whether to expand Medicaid, which was originally required by
the ACA.
•Some evidence indicates that ACA-linked Medicaid expansion has resulted in better
access to care and utilization.
reimbursement methods - ANSWER third party payers, fee for service, bundled
payments, resource based relative value scale (reimburse according to relative value
of service based on time, skill, intensity)
reimbursement under managed care - ANSWER discounts, used by PPOS,
capitation (used by HMOS, per member per month fee, minimize provider induced
demand)
prospective reimbursement - ANSWER Used by HMOS. A method of payment in
which certain preestablished criteria are used to determine in advance the amount of
reimbursement, diagnosis related groups, ambulatory payment, resource utilization
groups, home health resource groups
ambulatory payment classification - ANSWER Hospital outpatient prospective
payment system (OPPS). The classification is a resource-based reimbursement
system, bundled rates
Resource utilization groups - ANSWER case mix method for skilled nursing facilities
to determine a fixed per day rate
New payment arrangements for Medicare to be worked out, to include: - ANSWER
bundled payments, shared savings arrangements, risk sharing arrangements
Pluralistic and Interest Group Politics - ANSWER most effective demanders of
policies, AMA, AARP, and American Hospital Association, employers, consumer
groups, manufacturers of technology, alliances
National Health Services Corps - ANSWER helps address personnel shortages in
rural areas for a limited time
Agency for healthcare research and quality - ANSWER goal is to conduct and
support research on outcomes, effectiveness, and appropriateness of services and
procedures
