Prof quiz 3 hints, part 1

Question 1

Definition of a hospital

Answer 1

An institution with at least 6 beds whose function is to deliver pt svcs that include diagnostics and tx

Question 2

Expenditure formula

Answer 2

E = P X Q
Expenditures = price x utiilization

Question 3

Definition of insured (beneficiary)

Answer 3

An individual protected by insurance

Question 4

Insurer definition

Answer 4

An insurance agency that assumes the risk

Question 5

Underwriting definition

Answer 5

Evaluation, selection (or rejection), classification, and rating of risk

Question 6

Definition of premium

Answer 6

Amt charged by insurer to insure against risk

Question 7

What is risk rating?

Answer 7

The actuarial assessment of risk

Question 8

Benefits definition

Answer 8

Svcs covered by an insurance plan

Question 9

Details about MLR

Answer 9

MLR = % of premium revenue spent on medical expenses
The rest = administration, marketing, and profits
85% for large grp insurance plans
80% for individual/small grp insurance plans

Question 10

How many tiers are there of marketplace plans?

Answer 10

4

Question 11

What is the minimum value test?

Answer 11

At least equivalent to the Bronze plan offered through the exchanges

Question 12

What is the affordability test?

Answer 12

Employer’s share of the premium for a single plan is less than or equal to 9.5% of the HH income

Question 13

What are the three groups of Medicare beneficiaries?

Answer 13

65 yrs and older
Disabled entitled to social security
Those with end stage renal dz

Question 14

What are the parts of Medicare?

Answer 14

A
B
C
D

Question 15

What is Medicare part A

Answer 15

Hospital insurance

Question 16

How is Medicare part A financed?

Answer 16

mandatory payroll taxes
Employer and employee pay equally into the Hospital Insurance Trust Fund

Question 17

When are no premiums required for Medicare part A?

Answer 17

If a person or spouse has worked and earned 40 credits

Question 18

Medicare part A benefits

Answer 18

90 days of inpatient hospital care per benefit period
Lifetime care of 190 days in a psych hospital
Up to 100 days of care in a Medicare-certified SNF subsequent to inpt hsopitalization
Home health care through a Medicare-certified agency
Hospice care

Question 19

What is Medicare part B generally?

Answer 19

Supplemental medical insurance
Covers various outpt svcs

Question 20

Means-testing and Medicare part B

Answer 20

Started in 2007
A higher income threshold triggers Income Relative Monthly Adjustment Amount (IRMAA)
Results in higher premium

Question 21

What is Medicare part C?

Answer 21

Medicare advantage

Question 22

Hx of Medicare part C

Answer 22

Began as Medicare + Choice in 1997 then renamed Medicare Advantage in 2003
-No additional svcs, but additional health plan choices
-To channel into managed care for Parts A and B
-Can choose to remain in original Medicare program

Question 23

Aspects of Medicare part C

Answer 23

Pay additional premiums
Additional benefits
No need for Medigap
Lower out of pocket costs

Question 24

What is Medicare part D?

Answer 24

Prescription drug coverage

Question 25

What can enrollees choose between for Medicare part D?

Answer 25

Stand-alone plans for prescriptions only
Part C (all svcs through managed care)

Question 26

Payment in Medicare part D

Answer 26

Requires payment of a deductible

Question 27

Three levels of out-of-pocket costs after deductible in Medicare part D

Answer 27

Basic level
Coverage gap (doughnut hole)
Catastrophic level

Question 28

What is another component of part D, that’s also a component of part B?

Answer 28

Higher income leads to paying more, IRMAA

Question 29

Who does Medicaid finance?

Answer 29

Indigent as determined by each state (means tested)

Question 30

Who are dual eligible beneficiaries?

Answer 30

Eligible for both Medicare and Medicaid

Question 31

Full duals for Medicare and Medicaid

Answer 31

Qualified for all benefits under both Medicare and Medicaid

Question 32

Partial duals for Medicare and Medicaid

Answer 32

Some of the costs paid by Medicaid