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PHAR 7273 Healthcare Final iRATs

Terms in this set (60)

True or False? Prescription drug payment is always a part of health insurance plans.
a) True
b) False
b) False
If prescription drug coverage on health plans offer a relatively small benefit at a high administrative cost, why are prescription drugs covered on health plans?
a) Prescription drugs are sold at a loss to attract customers.
b) The law imposes a tax penalty on health plans who fail to have the required prescription drug coverage.
c) Drug therapy can be preventive, and mitigate and/or delay the expense of other more costly therapies.
c) Drug therapy can be preventive, and mitigate and/or delay the expense of other more costly therapies.
Fill in the blank with the term that BEST completes the sentence. "A PBM is a specialized company that adjudicates prescription drug claims and manages the prescription drug coverage for _____ by containing costs and influencing the quality of services provided."
a) specialty hospitals
b) a third-party payer
c) prescribers
b) a third-party payer
The process of reviewing or screening prescription drug claims to determine payment is known as:
a) Drug Utilization Evaluation (DUE)
b) Formulary Management
c) Adjudication
c) Adjudication
True or False?
The insurance company pays the PBM to manage its drug costs.
a) True
b) False
a) True
The PBM negotiates with the pharmacy over reimbursement for drugs and dispensing fees.
a) True
b) False
a) True
Fill in the blank with the term that BEST completes the sentence.
"In a Participating Pharmacy Agreement (PPA), pharmacies enter into a contract with a _____ to provide specific services for a specified reimbursement to the pharmacy.
a) doctor
b) lending agency, such as a bank
c) PBM (insurer)
c) PBM (insurer)
Reimbursement (pharmacy payment) in a Participating Pharmacy Agreement (PPA) is based on 3 factors:
1) Dispensing fee (cost of dispensing), 2) Ingredient costs, and 3)_____.
(Fill in the blank with the term that BEST completes the sentence.)
a) Taxes
b) Competition
c) Patient cost sharing
c) Patient cost sharing
Consider the services of a Pharmacy Benefit Manager (PBM). One service is to maintain a drug formulary. Which of the following is the BEST definition of a drug formulary?
a) Financial incentives for patients to avoid using unnecessary health care services by making them pay a portion of the cost of the service.
b) A list of medicines whose main function is to specify which medicines are approved to be prescribed under a particular PBM contract.
c) Review of physician prescribing, pharmacist dispensing, and patient use of drugs.
b) A list of medicines whose main function is to specify which medicines are approved to be prescribed under a particular PBM contract.
Consider the services of a Pharmacy Benefit Manager (PBM). One service is Drug Utilization Review (DUR). Which of the following is the BEST definition of Drug Utilization Review (DUR)?
a) Review of physician prescribing, pharmacist dispensing, and patient use of drugs.
b) Financial incentives to use preferred drugs on a PBM drug formulary.
c) A pharmacist-initiated act by which a different brand or an unbranded drug product is dispensed instead of a drug brand that was prescribed by the physician.
a) Review of physician prescribing, pharmacist dispensing, and patient use of drugs.
The major goal of Medicare is to:
a) provide health care to older Americans, age 65 and over.
b) cut the rate of increase in health care costs.
c) provide health care to low-income families.
a) provide health care to older Americans, age 65 and over.
Which organization administers the Medicare program?
a) The Centers for Healthcare Financial Assistance (CHFA)
b) The Centers for Medicare & Medicaid Services (CMS)
c) The U.S. Social Security Administration (SSA)
b) The Centers for Medicare & Medicaid Services (CMS)
How many parts is Medicare made up of?
a) Five
b) Four
c) Three
d) Two
e) One
b) Four
True or False? Medicare does NOT have a provision to cover patients with disabilities.
a) True
b) False
b) False
Which part of Medicare covers inpatient hospital care?
a) Part A
b) Part B
c) Part C
d) Part D
a) Part A
Medicare Part A is funded primarily by:
a) state lottery contributions
b) general revenues of the federal government
c) payroll taxes
c) payroll taxes
Which part of Medicare covers physician services?
a) Part A
b) Part B
c) Part C
d) Part D
b) Part B
In which part of Medicare can patients choose to get their benefits from an insurance company that contracts with Medicare?
a) Part A
b) Part B
c) Part C
d) Part D
c) Part C
Which part of Medicare covers payment for prescription drugs?
a) Part A
b) Part B
c) Part C
d) Part D
d) Part D
A patient decides to pay for an insurance plan that will pay many of the charges for which Medicare-covered patients normally would be responsible. Which type of insurance plan is this?
a) Medicare Extra
b) Medicare Advantage
c) Medigap
c) Medigap
What type of insurance is Medicare Part D?
a) Hospital coverage available to all Medicare beneficiaries
b) Physician coverage requiring monthly premiums to all Medicare beneficiaries
c) Prescription drug coverage available to all Medicare beneficiaries
c) Prescription drug coverage available to all Medicare beneficiaries
A person is eligible for Medicare Part D if they:
a) Turn 62
b) Turn 64½
c) Turn 65
c) Turn 65
True or False?
When a patient signs up for Medicare, they are automatically enrolled in Medicare Part D.
a) True
b) False
b) False
Regarding Medicare Part D, which organization provides the insurance coverage?
a) A private company approved by Medicare provides the coverage
b) The federal government
c) The U.S. Food and Drug Administration
a) A private company approved by Medicare provides the coverage
With Medicare Part D, there are two ways to receive coverage: 1) to add drug coverage to original Medicare through a private insurance company, or 2) to enroll in a/an:
a) Medicare contract
b) Medicare Advantage Plan
c) Pharmacy Benefit Management Company (PBM)
b) Medicare Advantage Plan
When a patient is enrolled in Medicare Part D, the amount that an individual must pay the Part D plan for coverage, usually on a monthly basis, is known as the:
a) premium
b) co-pay
c) deductible
a) premium
How many Medicare Part D coverage stages are there?
a) Four
b) Three
c) Two
a) Four
In the Medicare Part D coverage gap or "donut hole", the patient's drug costs are typically higher than the previous stage. How much will a patient typically pay for brand-name or generic drugs?
a) 25% or less
b) 50% or less
c) 100% or less
a) 25% or less
Regarding Medicare Part D, each prescription drug plan has its own list of covered drugs, known as the plan's _______.
a) formulations
b) drug tier
c) formulary
c) formulary
In general, which Medicare Part D drug tier has the lowest co-pay amount?
a) Tier 3
b) Tier 2
c) Tier 1
c) Tier 1
The major goal of Medicaid is to:
a) provide health care to older, retired Americans.
b) make basic health care available to all Americans.
c) provide health care to low-income families.
c) provide health care to low-income families.
Medicaid is funded and financed by:
a) The Federal Government
b) State governments
c) The Federal and State governments
c) The Federal and State governments
What is the Federal Medical Assistance Percentage (FMAP)?
a) A map that shows the number of Medicaid patients in each state.
b) A map that shows the percentage of Medicaid patients in each state.
c) The federal government's portion of Medicaid programs' costs.
c) The federal government's portion of Medicaid programs' costs.
What is the Federal Poverty Level (FPL)?
a) A person who is extremely poor, lacking the basic resources of a normal life.
b) The lowest hourly amount an employer may legally pay an employee.
c) An economic measure that is used to decide whether the income level of an individual or family qualifies them for Medicaid.
c) An economic measure that is used to decide whether the income level of an individual or family qualifies them for Medicaid.
True or False? If an individual is below the Federal Poverty Level, they automatically qualify to receive Medicaid benefits.
a) True
b) False
b) False
For which of the following does Medicaid provide health insurance coverage?
a) 1 in 5 Americans
b) 3 in 5 Americans
c) All Americans
a) 1 in 5 Americans
With Medicaid, is prescription drug coverage a required or optional benefit?
a) Required
b) Optional
c) Prescription drug coverage may be either required or optional, depending on the state.
b) Optional
True or False? Most patients enrolled in Medicaid get care through private managed care organizations, such as HMOs or PPOs.
a) True
b) False
a) True
Fill in the blank with the term that BEST completes the sentence. "In general, the reimbursement payment for Medicaid to providers is_____compared to other health plan reimbursements."
a) higher
b) lower
c) about the same as
b) lower
For a Medicaid patient, which of the following may be a typical co-pay for a prescription drug?
a) $2.00
b) $20.00
c) $50.00
a) $2.00
What is the main goal of the Patient Protection and Affordable Care Act of 2010?
a) To provide affordable drugs to U.S. citizens, who otherwise would not be able to afford them
b) To provide health insurance to U.S. citizens, who otherwise would not be able to afford it
c) To increase the number of patients who need to enroll in Medicare
b) To provide health insurance to U.S. citizens, who otherwise would not be able to afford it
One aspect of the Affordable Care Act is to meet the needs of the uninsured. Which of the following explains a way that this will take place?
a) Implement a government-run insurance plan similar to the system in Canada
b) Expanding Medicaid coverage
c) Expanding Medicare coverage
b) Expanding Medicaid coverage
True or False? A major criticism of the Affordable Care Act is that it addresses the health insurance needs of lower income individuals, but has no provision to help the middle class.
a) True
b) False
b) False
What is the CHIP program?
a) Elderly receive free or low-cost health insurance.
b) Low-income individuals can receive a voucheror "chip" to help with high drug costs.
c) Children receive free or low-cost health insurance.
c) Children receive free or low-cost health insurance.
With the Affordable Care Act, when shopping for health insurance at an Exchange, how many levels do consumers have to choose from?
a) Three
b) Four
c) Five
b) Four
With the Affordable Care Act, when shopping for health insurance at an Exchange, consumers have different levels to choose from, such as "platinum," "gold," "silver," and "bronze." Plans offering the most coverage, such as Platinum and Gold, will have _____ premiums. (Fill in the blank with the term that BEST completes the sentence.)
a) higher
b) lower
c) no
a) higher
According to proponents (those in favor) of the Health Care Reform law, or Affordable Care Act, why are the mandates necessary?
a) Prevent insurance companies from denying coverage
b) Increase Medicaid enrollment
c) Spread the "risk" pool
c) Spread the "risk" pool
Regarding Health Care Reform and the Affordable Care Act, which of the following BEST describes Essential Health Benefits (EHB)?
a) "requires nearly everyone to have health insurance that meets minimum standards"
b) "an online portal where consumers can shop for health insurance"
c) "a set of health care service categories that must be covered by certain insurance plans"
c) "a set of health care service categories that must be covered by certain insurance plans"
True or False? The Affordable Care Act mandates that new qualified health plans provide prescription drug coverage as an Essential Health Benefit.
a) True
b) False
a) True
The largest group of uninsured individuals is comprised of young adults in their 20s. Under the Affordable Care Act, young adults can remain on their parent's health insurance until the age of:
a) 21
b) 26
c) 28
b) 26
According to the documentary "Sick Around the World," the author visited Great Britain in the United Kingdom.
In Great Britain, the National Health Service (NHS) provides healthcare for citizens. With the NHS, how much does the average citizen pay for a typical doctor's visit?
a) $0.00 for low and middle-income citizens, and the wealthy pay according to their income level.
b) The average citizen likely will pay $0.00.
c) Unlike the United States, all fees are set on a "sliding scale" which means citizens pay an amount according to their level of income.
d) Only a $5.00 co-pay for all citizens, regardless of income level.
b) The average citizen likely will pay $0.00.
According to the documentary "Sick Around the World," in several countries, to receive health care, a patient must see a "gatekeeper."
According to the video, which of the following is a gatekeeper?
a) Counselor
b) Social Worker
c) Nurse Practioner
d) General Practioner
e) This topic was not discussed in the video.
d) General Practioner
According to the documentary "Sick Around the World," the author describes the following health care system:
"The citizens pay for health care out of tax revenue, so the government owns the hospitals, like the Whittington Hospital... The doctors who work here are salaried government employees." Which country is the author talking about?
a) Canada
b) Germany
c) Switzerland
d) Japan
e) Great Britain
e) Great Britain
Which country is described? In this country a healthcare system exists known as "social insurance."
Everyone must sign up for a health insurance policy or through a community-based insurer. In this system, doctors can only change what the official price book dictates.
Which country is the author talking about?
a) United States
b) Japan
c) Canada
d) Switzerland
e) This topic was not discussed in the video.
b) Japan
According to the documentary "Sick Around the World," the following conversation takes place between the author and a doctor.
"So you know how much it costs to spend the night in a hospital here, according to this price book? If you stay in a room with four people, $10 a night. If you have a private room, $90 to spend the night in a hospital in a private room here. That's because the government sets the price."
Which country is the author talking about?
a) Switzerland
b) Brazil
c) Canada
d) Japan
e) This topic was not discussed in the video.
d) Japan
According to the documentary "Sick Around the World," the individual who invented the concept of health care systems - the "notion that the government has to provide mechanisms so that all its people can get medical care when they need it" originated in which country?
a) Canada
b) Germany
c) Switzerland
d) Japan
e) Great Britain
b) Germany
Gross Domestic Product (GDP) is a measure of a country's overall economic output.
According to the documentary "Sick Around the World," which country has the highest percentage of GDP spent on Health Care?
a) Germany
b) Great Britain
c) Puerto Rico
d) Japan
e) United States
e) United States
According to the documentary "Sick Around the World," the author describes the following health care system:
"As in Japan, the delivery of health care is largely a market affair, carried out by private hospitals... To finance health care, these citizens pay premiums based on income to one of 240 private insurers. They call them "sickness funds." A worker earning $60,000 would split a $750 monthly family premium with her employer. It's more expensive than Japan and the U.K., but still a bargain by U.S. standards, about two thirds of ours."
Which country is the author talking about?
a) Canada
b) Great Britain
c) Puerto Rico
d) Switzerland
e) Germany
e) Germany
According to the documentary "Sick Around the World," the author describes the following health care system:
"They wanted a system that gave everybody equal access to health care, free choice of doctors, with no waiting time, and a system that encouraged lots of competition among medical providers. To finance the scheme, they chose a national insurance system that forced everybody to join in and pay. The solution: To have one government insurer collecting the money and no chance to opt out.
The result: A system that works a bit like the U.S. Medicare system for the elderly, and in fact, a lot like Canada's."
Which country is the author talking about?
a) Germany
b) Great Britain
c) Taiwan
d) Switzerland
e) New Zealand
c) Taiwan
This country designed its new health system using state-of-the-art information technology. Everybody has to have a smart card like this to go to the doctor.
The doc puts it in a reader, and the patient's history, medications, et cetera, all show up on the screen. And then the bill goes directly to the government insurance office and is paid.
Which country is the author talking about?
a) Canada
b) Japan
c) Taiwan
d) Switzerland
e) Germany
c) Taiwan
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