CPB 2023 CHAPTER 2

Question 1

Federal mandate for all persons to have minimal essential coverage for themselves and their dependents

Answer 1

Patient Protection and Affordable Care Act

Question 2

Pay a penalty as part of their income tax returns

Answer 2

Does not comply with the individual mandate for health insurance

Question 3

What was repealed in December 2017 as part of the Tax Cuts and Jobs Act and went into effect in 2019?

Answer 3

Individual mandate for health insurance

Question 4

Employer decides on the type of coverage and costs for insurance made available to eligible employees based on standard of employer.

Answer 4

Group Health Plans

Question 5

Limited exclusions for pre-existing medical conditions, followed by the pre-existing condition exclusion under the ACA.

Answer 5

HIPAA Law of 1996

Question 6

Employer contracts directly with the insurance company to hand out certificates to covered employees

Answer 6

Full Insured Employer Group

Question 7

Employer assumes financial responsibility for the enrollees’ medical claims and incurred administrative costs

Answer 7

Fully Insured Employer Group

Question 8

Payment for Fully Insured Employer Groups?

Answer 8

Employer pays a premium at a fixed rate for a year based on the number of employees enrolled in the plan..

Question 9

Insurance companies group together several small employers to form a larger group.

Answer 9

Small Employer Group

Question 10

Benefit of Small Employer Groups?

Answer 10

Enables the insurance company to better predict the cost of insurance.

Question 11

Group contracts with an insurance company and third party to handle the paperwork

Answer 11

Self-Funded ERISA

Question 12

Employer pays for each out-of-pocket claim as it is incurred instead of paying a fixed premium.

Answer 12

Self-Funded ERISA

Question 13

Signs a contract with a health plan to agree to accept assignment for all covered services furnished to its members and to submit claims for the services provided

Answer 13

Participating Provider (PAR)

Question 14

What must a participating provider write-off?

Answer 14

Any amounts billed on covered services that were above the negotiated rate

Question 15

May bill the patient for the difference between the amount billed and the amount paid by the health plan except for Medicare

Answer 15

Non-participating provider (nPAR)

Question 16

Advantage of PAR?

Answer 16

Health plan agrees to direct covered members to the provider and agrees to pay the provider directly for the services provided

Question 17

Fee schedule amount is five percent higher?

Answer 17

Medicare participating providers

Question 18

nPAR Medicare?

Answer 18

Limiting charge applies

Question 19

What is the percentage of nPAR for Medicare?

Answer 19

115% of the physician fee schedule amount

Question 20

What state has a limiting charge of 105% instead of 115%?

Answer 20

New York

Question 21

Providers not limited to any specific charge limit on their patients and do not submit claims to Medicare for their services. Patients sign private contracts regarding payment

Answer 21

Opt-out Medicare Providers

Question 22

When is the patient responsible for payment in full for services as Medicare will not pay any amount to either the patient or provider?

Answer 22

Opt-out Medicare providers

Question 23

When is provider open enrollment?

Answer 23

Mid-November to December 31st

Question 24

What is provider open enrollment?

Answer 24

Time period when providers can change participation status

Question 25

Program that offers free health benefits counseling to Medicare beneficiaries, their families, or caregivers

Answer 25

State Health Insurance Assistance Program

Question 26

Educates patients on PAR vs nPAR vs opt-out and what it means for them and free workshops

Answer 26

SHIP

Question 27

HMO

Answer 27

Health Maintenance Organization

Question 28

Contracts with a multi-specialty group that provides care to the members

Answer 28

Group Model HMO

Question 29

Pays an established rate which is distributed to the individual physicians as part of their salaries. Group is paid in bulk and group is responsible for reimbursing physician members and facilities.

Answer 29

Group Model HMO

Question 30

Employs the physicians on salary to provide care to members in the clinics and other facilities owned by the organization

Answer 30

Staff Model HMO

Question 31

Closed-panel HMO

Answer 31

Staff Model

Question 32

Physicians are contracted to provide medical services to only HMO patients

Answer 32

Staff Model HMO

Question 33

Contracts with more than one multi-specialty group, individual practice groups, or individual physicians so a variety of services may be offered to its members

Answer 33

Network Model HMO

Question 34

Allows formation of "provider __" allows care to be provided in larger geographic areas Offers the patient a choice of physicians and managed costs

Answer 34

Network Model HMO

Question 35

Contracts with independent physicians who maintain their offices and provide services to HMO and non-HMO patients

Answer 35

Independent Practice Association (IPA)

Question 36

Receive a fixed amount per patient

Answer 36

IPA

Question 37

Open-panel HMO

Answer 37

IPA

Question 38

HMO may not provide as much coverage for services out-of-network

Answer 38

IPA

Question 39

Contracts with multi-specialty group practices, IPAs, and independent physicians all together.

Answer 39

Mixed Model HMO

Question 40

Offer the biggest variety of choices, largest coverage area, more choices of clinics, labs, pharmacies, and hospitals

Answer 40

Mixed Model HMO

Question 41

Organizations that are affiliated with or own hospitals, physician groups, and other providers that provide a wide range of coordinated health services

Answer 41

MCO

Question 42

MCO

Answer 42

Managed Care Organizations

Question 43

Combine the functions of health insurance, delivery of care, and admin

Answer 43

MCO

Question 44

Manage benefits and develop participating provider networks

Answer 44

MCO

Question 45

Types of MCO's

Answer 45

EPO, HMO, IDS, PPO, TOP

Question 46

Offer provisions that provide insurers with ways to manage the cost, use, and quality of the healthcare services received by group members

Answer 46

MCO

Question 47

Process of reviewing the appropriateness and quality of care provided to patients

Answer 47

Utilization review - MCO

Question 48

Authorization for hospital admissions given by a healthcare provider to a group member prior to hospitalization

Answer 48

Preadmission certification - MCO

Question 49

Requirement designed to encourage patients to obtain routine outpatient services prior to non-emergent admissions, reduces LOS

Answer 49

Preadmission testing - MCO

Question 50

If the member does not receive services through an in-network provider or facility, the member pays for all costs incurred, unless an emergency

Answer 50

Exclusive Provider Organization (EPO)

Question 51

Members choose a PCP upon enrollment and pay a percentage of every medical bill up to a yearly maximum out-of-pocket

Answer 51

EPO

Question 52

Earn more money by charging an access fee to the insurer for use of the network

Answer 52

EPO

Question 53

Negotiate with the providers of the organization to set fee schedules, help resolve differences, and contract with others to strengthen the network

Answer 53

EPO

Question 54

Network of affiliated facilities and providers that work together to offer joint healthcare services to members

Answer 54

Integrated Delivery Services

Question 55

PHO MSO GPWW

Answer 55

Types of IDS'

Question 56

Owned by hospitals and physician groups to develop improved methods of delivery

Answer 56

Physician-Hospital Organization (PHO)

Question 57

Contract with managed care organizations or directly to employers with joint risk sharing and developing standards of care

Answer 57

PHO

Question 58

Organized way for physicians and hospitals to work together on utilization management and quality improvement

Answer 58

PHO

Question 59

Organization that provides: Administrative duties Collaborate with managed care companies Establish physician reimbursement and risk-sharing amounts

Answer 59

PHO

Question 60

Business that provides nonclinical services to providers like practice management to IPPs

Answer 60

Management Service Organizations (MSO)

Question 61

Provides a menu of services for providers to select from to meet their needs

Answer 61

MSO

Question 62

Includes: Hiring employees, billing and coding personnel, IT personnel, monitoring, implementing policies, compliance, claims submission, appeals, auditing services, managed care contracting and negotiations

Answer 62

MSO

Question 63

Medical practice formed to share economic risk, expenses, and marketing efforts

Answer 63

Group Practice Without Walls (GPWW)

Question 64

Several small practices trade under a common tax identification number but retain separate offices and finances

Answer 64

GPWW

Question 65

Allows providers to jointly negotiate fees and avoid antitrust issues federally

Answer 65

GPWW

Question 66

Common fee schedule, standardized benefits, and equally shared ancillary service revenue

Answer 66

GPWW

Question 67

Coporate umbrella for the management of diversified healthcare delivery system

Answer 67

Integrated Provider Organization (IPO)

Question 68

Physicians practice as employees of the organization or in a closely affiliated physician group

Answer 68

IPO

Question 69

Can perform services such as: Evaluate new payer arrangements Negotiate risk contracts Credentialing agreements Annual budgets

Answer 69

IPO

Question 70

Insurance plan that allows members to choose the doctors and hospitals they prefer within network

Answer 70

Preferred Provider Organization (PPO)

Question 71

Members can choose not to see a preferred provider but will pay more out-of-pocket costs if provider is nPAR

Answer 71

PPO

Question 72

Operated by a single insurance plan or a joint venture among two or more insurance payers

Answer 72

Triple option plan

Question 73

Allows insurers to offer members three different healthcare plans to select the services they want

Answer 73

Triple option plan

Question 74

What are the three different healthcare plans offered in a triple option plan?

Answer 74

Straight indemnity, HMO, and PPO

Question 75

Allows the patient to choose any physician and facility of their choosing, the health plan then pays a set portion of the total charges

Answer 75

Straight indemnity plan

Question 76

usual, customary, and reasonable rates

Answer 76

UCR rates

Question 77

What are UCR rates utilized for?

Answer 77

To base the reimbursement percentage for payment

Question 78

The amount that providers in the area where the services were rendered typically charge for the same service

Answer 78

UCR rate

Question 79

Costlier but gives the patient the most choices

Answer 79

indemnity plan