CHFP EXAM QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED GRADED A++
Accountable Care Organization (ACO)
ACOs are groups of medicare providers and suppliers that work together to coordinate
care for traditional Medicare patients. Their goal is to deliver seamless, high-quality care
instead of the fragmented care that often results from a fee-for-service payment system.
The following groups of providers can form an ACO: physicians or certain non-physician
practitioners in group practices, hospitals employing physicians, certain critical access
hospitals, federally qualified health centers and rural health clinics
Beneficiary
Insurers usually refer to the patient for which services are paid as
Benefit Payment
Once the insurer has determined the claim is appropriate, a payment is made to a
provider called
Bundled Payments
Singe prospective payment by a health plan to all providers involved in a patient's
episode of care where the providers divide the payment among themselves
Centers for Medicare and Medicaid Services (CMS)
,The federal government, through this organization oversees all parts of the Medicare
and Medicaid programs. This organization can waive state's requirement to participate
in traditional Medicaid if the state offers beneficiaries plans with better benefits
Children's Health Insurance Program (CHIP)
Signed into law in 1997, serves uninsured children up to age 19 in families with incomes
too high to qualify them for Medicaid
Claim
Bill for healthcare services provided
Coinsurance
Percentage of the insurance payment amount that is paid by the patient, along with the
amount paid by the insurer
Copay
Flat amount that a patient pays at each time of service
Covered Benefit
Services for which the insurer will pay
Deductible
Pre-determined amount that the patient pays before the insurer begins to pay for
service
Denial
Insurer may determine that the claim from the provider is not a covered benefit and will
not pay for the claim
Employer Mandate
,Requires employers with 50 or more full time employees to offer health insurance
coverage
Facility Provider
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
Fiscal Intermediary
an organization that contracts with the government/CMS to pay Medicare claims and
educate providers
Individual Mandate
Requires individuals and families without employer-provided insurance to purchase
health insurance of pay a penalty. The Supreme court in 2012 characterized the penalty
as a tax. The penalties ranges from $695 per year to a maximum of three times that
amount ($2,085) per family of 2.5% of household income
Insurance Exchange
Federal or state-run health insurance markets designated to make health insurance
affordable and broadly available. Individuals who purchase health insurance may qualify
for premium subsidies. 85% of enrollees receive such a subsidy.
Medicaid
Joint federal and state program for low-income and medically needy people. Single
largest source of health coverage in the US. Covers low income families, qualified
pregnant women and children and individuals receiving SSI. Includes nursing home
care and personal care services. Each state has different program
, Medical Loss Ratio
Refers to the percentage of premiums that insurers/health plans must spend on clinical
services and quality improvement. ACA requires health insurance insurers to spend at
least 80% to 85% of premium dollars on claims and quality initiatives
Medicare Cost Report
Annual report that providers participating in the Medicare program must submit to their
medicare administrative contractor. For providers paid prospectively, this determines
reimbursement for certain add-on payments but does not affect the overall payment
rate. For providers paid retrospectively, this determines the payment rate. CMS uses
this data to update DRG and APC weights and determine market basket updates
Medicare Part A
Hospital insurance. Pays for hospital inpatient, skilled nursing facility, hospice, and
some home health care. 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
Medicare Part B
Supplemental medical insurance is voluntary part of Medicare. 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.
Medicare Advantage (Medicare Part C)
COMPLETE SOLUTIONS VERIFIED GRADED A++
Accountable Care Organization (ACO)
ACOs are groups of medicare providers and suppliers that work together to coordinate
care for traditional Medicare patients. Their goal is to deliver seamless, high-quality care
instead of the fragmented care that often results from a fee-for-service payment system.
The following groups of providers can form an ACO: physicians or certain non-physician
practitioners in group practices, hospitals employing physicians, certain critical access
hospitals, federally qualified health centers and rural health clinics
Beneficiary
Insurers usually refer to the patient for which services are paid as
Benefit Payment
Once the insurer has determined the claim is appropriate, a payment is made to a
provider called
Bundled Payments
Singe prospective payment by a health plan to all providers involved in a patient's
episode of care where the providers divide the payment among themselves
Centers for Medicare and Medicaid Services (CMS)
,The federal government, through this organization oversees all parts of the Medicare
and Medicaid programs. This organization can waive state's requirement to participate
in traditional Medicaid if the state offers beneficiaries plans with better benefits
Children's Health Insurance Program (CHIP)
Signed into law in 1997, serves uninsured children up to age 19 in families with incomes
too high to qualify them for Medicaid
Claim
Bill for healthcare services provided
Coinsurance
Percentage of the insurance payment amount that is paid by the patient, along with the
amount paid by the insurer
Copay
Flat amount that a patient pays at each time of service
Covered Benefit
Services for which the insurer will pay
Deductible
Pre-determined amount that the patient pays before the insurer begins to pay for
service
Denial
Insurer may determine that the claim from the provider is not a covered benefit and will
not pay for the claim
Employer Mandate
,Requires employers with 50 or more full time employees to offer health insurance
coverage
Facility Provider
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
Fiscal Intermediary
an organization that contracts with the government/CMS to pay Medicare claims and
educate providers
Individual Mandate
Requires individuals and families without employer-provided insurance to purchase
health insurance of pay a penalty. The Supreme court in 2012 characterized the penalty
as a tax. The penalties ranges from $695 per year to a maximum of three times that
amount ($2,085) per family of 2.5% of household income
Insurance Exchange
Federal or state-run health insurance markets designated to make health insurance
affordable and broadly available. Individuals who purchase health insurance may qualify
for premium subsidies. 85% of enrollees receive such a subsidy.
Medicaid
Joint federal and state program for low-income and medically needy people. Single
largest source of health coverage in the US. Covers low income families, qualified
pregnant women and children and individuals receiving SSI. Includes nursing home
care and personal care services. Each state has different program
, Medical Loss Ratio
Refers to the percentage of premiums that insurers/health plans must spend on clinical
services and quality improvement. ACA requires health insurance insurers to spend at
least 80% to 85% of premium dollars on claims and quality initiatives
Medicare Cost Report
Annual report that providers participating in the Medicare program must submit to their
medicare administrative contractor. For providers paid prospectively, this determines
reimbursement for certain add-on payments but does not affect the overall payment
rate. For providers paid retrospectively, this determines the payment rate. CMS uses
this data to update DRG and APC weights and determine market basket updates
Medicare Part A
Hospital insurance. Pays for hospital inpatient, skilled nursing facility, hospice, and
some home health care. 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
Medicare Part B
Supplemental medical insurance is voluntary part of Medicare. 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.
Medicare Advantage (Medicare Part C)
