Midterm Exam - Lec 9-16

Question 1

what % of adults aged 19-64 are insured all year? (according to pie chart; slide 5 of 61)

Answer 1

57%

Question 2

in the _____, some hospitals offered services on a pre-paid plan

a. 1920s
b. 1930s
c. 1950s
d. 1970s

Answer 2

a. 1920s

Question 3

what year was the first employer-sponsored plan created by teachers in Dallas?

Answer 3

1929

Question 4

what year was the Social Security Act passed?

Answer 4

1935

Question 5

true or false: employer-sponsored plans as a benefit dramatically expanded during WWII as a direct result of wage controls

Answer 5

true

Question 6

which president proposed national health insurance in 1948?

Answer 6

Truman

Question 7

what occurred in 1954 in the history of health insurance?

a. Social Security Act
b. Hill Burton Act
c. tax deduction for employers in the Revenue Act

Answer 7

c. tax deduction for employers in the Revenue Act

Question 8

what act is a system for the self-employed who had to buy insurance on their own through exchanges (2010)?

Answer 8

affordable care act (ACA)

Question 9

historically, 20% of Medicare pts are readmitted within 30 days, but ___% of readmissions are preventable

Answer 9

75%

Question 10

when did Medicare begin?

Answer 10

July 1, 1966 (signed into law 1965)

Question 11

which president from 1963-1968 made the passage of Medicare his top legislative priority?

Answer 11

Lyndon B. Johnson

Question 12

Medicare and Medicaid were enacted as Title 18 and 19 of which act?

Answer 12

Social Security Act

Question 13

true or false: medicare/medicaid has no dental/eye benefits, and no drug benefit for outpatients

Answer 13

true

Question 14

what are the 4 parts of Medicare?

Answer 14

A - hospital coverage
B - medical coverage (medigap)
C - medicare advantage
D - prescription drug coverage

Question 15

when can enrollment begin for Medicare Part A?

Answer 15

3 months before 65th birthday; enrollees do not need to be retired

Question 16

medigap (Medicare supplement) is purchased through _______ _______

Answer 16

private companies

Question 17

which is not a feature of a Medicare Advantage plan?

a. administered by private companies
b. they may offer extra benefits including vision and dental
c. premiums or costs of services can be higher than in original Medicare/Medicaid with a Medigap policy
d. fewer choices

Answer 17

c. premium or costs of services can be higher than in original Medicare/Medicaid with a Medigap policy (lower)

Question 18

what was the largest change in insurance processing in retail pharmacy history?

Answer 18

Medicare Part D

Question 19

Medicare Part D is run by _______ insurance companies

Answer 19

private

Question 20

true or false: formularies for Medicare Part D are all the same

Answer 20

false

Question 21

Medicaid allows ppl with income up ____% of the federal poverty limit to qualify

Answer 21

138%

Question 22

oral methotrexate used for arthritis falls under which medicare part?

Answer 22

part D

Question 23

oral methotrexate used as an immunosuppressive/cancer treatment falls under which medicare part?

Answer 23

part B

Question 24

insulin for a pump falls under which part of medicare?

Answer 24

part B

Question 25

insulin for a syringe falls under which part of medicare?

Answer 25

part D

Question 26

what is used by CMS to measure how well Medicare Advantage and Part D plans perform?

Answer 26

Medicare STAR Rating system

(plans are reviewed annually; 1 to 5 star scale)

Question 27

what was the last state to implement Medicaid (in 1982)?

Answer 27

Arizona

Question 28

who qualifies for Medicaid? (4 groups)

Answer 28

-low income families < 138% of FPL in IN
-infants born to Medicaid-eligible pregnant women
-children < 6 yo and pregnant women with incomes < 138% of FPL (< 158% in IN)
-pregnant mothers are covered 12 months after pregnancy ends

Question 29

how many ppl are covered by Medicaid + CHIP?

Answer 29

85 million

Question 30

which of the following is NOT a mandatory service of Medicaid?

a. long term care
b. hospital
c. prenatal care
d. mental health rehab
e. family planning services

Answer 30

d. mental health rehab (optional)

Question 31

true or false: half of all children are insured through Medicaid

Answer 31

false (1/3 of all children)

Question 32

true or false: while children are eligible for dental coverage, few dentists participate

Answer 32

true

Question 33

American Rescue Plan - What are the Rx provisions? (3 in red; slide 59 of 61)

Answer 33

-require federal gov to negotiate prices for some drugs covered under part B and D with the highest total spending, beginning 2026
-require drug companies to pay rebates to Medicare if prices rise faster than inflation for drugs used by Medicare beneficiaries
-cap out-of-pocket spending for part D enrollees and make other part D benefit design changes

Question 34

when was the HMO act implemented?

Answer 34

1973

Question 35

Some goals of managed care include prevention of disease, focusing on wellness and enhanced QOL, improved clinical outcomes, and quality and accessibility of health care. There is one more goal bolded in red on the slide, what is it?

Answer 35

cost containment

Question 36

generic term applied to a managed care plan; also called HMO, PPO, or POS

Answer 36

MCO (managed care organization)

Question 37

Groups of doctors, hospitals, and other health care providers, who voluntary work together to provide coordinated high-quality care to their Medicare patients and accept financial risk/reward tied to clinical outcomes

a. MCOs
b. ACOs
c. PPOs

Answer 37

b. ACOs (accountable care organizations)

Question 38

A managed care delivery model consisting of preferred networks of providers with some out-of-network coverage

a. MCOs
b. ACOs
c. PPOs

Answer 38

c. PPOs

Question 39

3 utilization management tools used by MCOs

Answer 39

-prior auth
-step therapy
-quantity limits

Question 40

what are the 4 big health insurers merging with PBMs?

Answer 40

-Anthem
-CVS health (Caremark -PBM)
-Cigna
-United Health

Question 41

downsides of managed care (2 things in bold; slide 48 of 50)

Answer 41

-unregulated profit margin for insurers
-insurers and PBMs make navigating the system difficult

Question 42

which race has the highest percentage of people aged 65+?

a. black
b. hispanic
c. asian
d. white

Answer 42

d. white

Question 43

the amount paid to a health insurance carrier for providing coverage under a contract

a. deductible
b. premium
c. coinsurance
d. health savings account (HSA)

Answer 43

b. premium

Question 44

two types of rebates

Answer 44

-access rebate (smaller %): flat/fixed percentage off wholesale acquisition cost in exchange for formulary listing or favorable position
-performance rebate (higher %): variable percentage off wholesale acquisition cost based on achieving specific performance parameters