Medicare and Medicaid: Eligibility, Benefits, and Reimbursement

Question 1

In the Medicaid program, what is the primary function of managed care organizations (MCOs)?

Accepted Answer

Negotiating prices with healthcare providers for Medicaid beneficiaries

Answer

Administering Medicaid benefits as government agencies

Answer

Providing the full range of healthcare services to Medicaid beneficiaries

Question 2

Compare Medicare Part A and Part B in terms of eligibility, benefits, and funding.

Accepted Answer

Part A covers hospital insurance and is funded through general revenue, while Part B covers medical insurance and is funded through premiums.

Answer

Part A covers medical insurance and is funded through premiums, while Part B covers hospital insurance and is funded through general revenue.

Answer

Both Part A and Part B cover hospital insurance and are funded through premiums.

Answer

Both Part A and Part B cover medical insurance and are funded through general revenue.

Question 3

Regarding Medicare Part A, which of the following is true?

Accepted Answer

It covers inpatient hospital stays, skilled nursing facility stays, and hospice care.

Answer

It covers outpatient physician services, home health services, and durable medical equipment.

Answer

It is an optional program that individuals can choose to enroll in.

Answer

It is primarily funded through beneficiary premiums.

Question 4

Which of the following is one of the primary goals of Medicare?

Accepted Answer

To provide health insurance to individuals age 65 and older, as well as those with certain disabilities.

Answer

To reduce the cost of healthcare for all Americans.

Answer

To improve the quality of healthcare for all Americans.

Answer

To eliminate all out-of-pocket expenses for healthcare.

Question 5

What is the primary responsibility of the Centers for Medicare & Medicaid Services (CMS)?

Accepted Answer

To administer the Medicare and Medicaid programs.

Answer

To set reimbursement rates for healthcare providers.

Answer

To regulate the healthcare industry.

Answer

To provide health insurance to low-income individuals.

Question 6

What is the primary purpose of the Health Insurance Portability and Accountability Act (HIPAA)?

Accepted Answer

To protect the privacy and security of patient health information.

Answer

To regulate the use of electronic health records.

Answer

To ensure the accuracy and completeness of medical records.

Answer

To improve the efficiency of healthcare delivery.

Question 7

Which type of reimbursement method rewards healthcare providers for providing high-quality and efficient care?

Accepted Answer

Value-based purchasing.

Answer

Fee-for-service.

Answer

Capitation.

Answer

Prospective payment system.

Question 8

What is the primary aim of the Medicare Access and CHIP Reauthorization Act (MACRA)?

Accepted Answer

To enhance the quality and value of healthcare services provided to Medicare beneficiaries.

Answer

To increase access to affordable health insurance coverage.

Answer

To reduce the overall cost of healthcare.

Answer

To improve the efficiency of Medicare administration.

Question 9

Which of the following is NOT a characteristic of Medicare Advantage plans?

Accepted Answer

They are only available to individuals who qualify for both Medicare Part A and Part B.

Answer

They are offered by private insurance companies.

Answer

They often cover additional benefits beyond traditional Medicare.

Answer

They may have premiums and cost-sharing requirements.

Question 10

Medicaid's Primary Purpose
The primary purpose of Medicaid is to:

Accepted Answer

Provide health insurance to low-income individuals and families

Answer

Regulate the healthcare industry

Answer

Fund research into new medical treatments

Answer

Provide subsidies to health insurance companies

Question 11

Medically Necessary Care in Medicare
Under Medicare, "medically necessary" care refers to:

Accepted Answer

Care that is appropriate for the patient's condition and is performed in the most cost-effective manner

Answer

Care that is recommended by a licensed physician

Answer

Care that is provided in a hospital setting

Answer

Care that is covered by Medicare

Question 12

Health Care Financing Administration (HCFA): Role in Medicare and Medicaid
The HCFA is responsible for:

Accepted Answer

Overseeing the administration of both Medicare and Medicaid

Answer

Setting reimbursement rates for Medicare providers

Answer

Determining eligibility for Medicaid

Answer

Enforcing Medicare fraud and abuse regulations

Question 13

Purpose of Medicare Part D
The Medicare Part D prescription drug benefit aims to:

Accepted Answer

Provide subsidized prescription drug coverage to Medicare beneficiaries

Answer

Negotiate lower prices for prescription drugs

Answer

Regulate the pharmaceutical industry

Answer

Provide financial assistance to low-income seniors

Question 14

Which of the following is NOT a purpose of the Medicare program?

Accepted Answer

Providing health insurance to active military personnel

Answer

Providing health insurance to individuals aged 65 and older

Answer

Providing health insurance to individuals with disabilities

Answer

Providing health insurance to low-income individuals

Question 15

Which of the following types of providers is NOT eligible for Medicare reimbursement?

Accepted Answer

Chiropractors

Answer

Hospitals

Answer

Physicians

Answer

Nursing homes

Question 16

What is the name of the federal agency responsible for administering the Medicare program?

Accepted Answer

Centers for Medicare & Medicaid Services

Answer

Social Security Administration

Answer

Health Resources and Services Administration

Answer

Food and Drug Administration

Question 17

What is the role of the Health Insurance Portability and Accountability Act (HIPAA) in healthcare law?

Accepted Answer

It protects the privacy of patient information.

Answer

It prohibits discrimination against individuals with disabilities in health insurance coverage.

Answer

It regulates the use of electronic health records.

Answer

It provides funding for low-income individuals to obtain health insurance.

Question 18

What is the primary goal of the Medicaid program?

Accepted Answer

To provide health insurance to low-income individuals

Answer

To provide long-term care for elderly individuals

Answer

To provide mental health services to individuals with disabilities

Answer

To provide prescription drug coverage to all Americans

Question 19

What is the primary method of reimbursement under Medicare?

Accepted Answer

Fee-for-service reimbursement

Answer

Cost-plus reimbursement

Answer

Capitation

Answer

Pay-for-performance

Question 20

Which agency is responsible for administering the Medicare program?

Accepted Answer

Centers for Medicare & Medicaid Services (CMS)

Answer

Social Security Administration

Answer

Department of Veterans Affairs

Answer

Department of Health and Human Services

Question 21

Medicare and Medicaid rely on distinct funding mechanisms. Identify the primary difference between their financing structures.

Accepted Answer

Medicare: payroll taxes and general revenues; Medicaid: general revenues only

Answer

Medicaid: payroll taxes and general revenues; Medicare: general revenues only

Answer

Both Medicare and Medicaid: payroll taxes only

Answer

Both Medicare and Medicaid: general revenues only

Question 22

Which of the following is NOT a requirement for Medicare Part A eligibility?

Accepted Answer

Being under the age of 65

Answer

Having a qualifying disability

Answer

Being a U.S. citizen or permanent resident

Answer

Paying Medicare taxes for a certain number of quarters

Question 23

Which of the following services is covered by Medicare Part B?

Accepted Answer

Outpatient surgery

Answer

Nursing home care

Answer

Long-term hospital stays

Question 24

What was the primary objective of the Medicaid expansion under the Affordable Care Act?

Accepted Answer

To extend Medicaid coverage to low-income adults who were previously ineligible.

Answer

To create a public health insurance option.

Answer

To reduce overall Medicaid expenditures for states.

Question 25

Identify a potential criticism of the Medicare Advantage program.

Accepted Answer

May result in higher overall costs for beneficiaries with complex medical conditions.

Answer

Generally improves the quality of care for beneficiaries.

Answer

Offers increased choice and flexibility to beneficiaries.

Question 26

What is the primary responsibility of the Centers for Medicare & Medicaid Services (CMS)?

Accepted Answer

To administer the Medicare and Medicaid programs.

Answer

To deliver healthcare services to low-income populations.

Answer

To provide training for healthcare practitioners.

Answer

To regulate private health insurance plans.

Question 27

What is the primary goal of the Prospective Payment System (PPS) in Medicare?

Accepted Answer

To control healthcare costs

Answer

To reduce fraud and abuse

Answer

To improve the quality of care

Answer

To increase access to care

Question 28

What is the statutory basis for the Medicare program?

Accepted Answer

The Social Security Act

Answer

The Medicaid Act

Answer

The Affordable Care Act

Question 29

What is the primary role of the Centers for Medicare & Medicaid Services (CMS) in the Medicare program?

Accepted Answer

To administer the program and establish policy

Answer

To investigate and prosecute fraud and abuse

Answer

To provide direct medical care to Medicare beneficiaries

Question 30

Which of the following is a key provision of the Medicare Modernization Act (MMA) of 2003?

Accepted Answer

Creation of the Medicare Part D prescription drug benefit

Answer

Expansion of Medicaid eligibility

Answer

Implementation of the Prospective Payment System

Question 31

What is the main purpose of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015?

Accepted Answer

To reform the Medicare physician payment system

Answer

To expand Medicaid eligibility

Answer

To increase Medicare funding

Answer

To create a new Medicare Part E benefit

Question 32

Which of the following is NOT a Medicare Part A benefit?

Accepted Answer

Prescription drug coverage

Answer

Home health care

Answer

Skilled nursing facility care

Answer

Hospitalization

Question 33

What is the primary purpose of the Medicare Advantage program?

Accepted Answer

To provide an alternative to traditional Medicare

Answer

To expand access to Medicare

Answer

To eliminate the need for private health insurance

Answer

To reduce the cost of Medicare

Question 34

What is the key difference between Medicare Part B and Medicare Part D?

Accepted Answer

Part B covers medical expenses, while Part D covers prescription drug coverage

Answer

Part B is mandatory, while Part D is optional

Answer

Part B is for seniors over the age of 65, while Part D is for individuals with disabilities

Question 35

Which of the following is a goal of the Affordable Care Act (ACA) as it relates to Medicaid?

Accepted Answer

To expand access to Medicaid

Answer

To eliminate Medicaid

Answer

To reduce the cost of Medicaid

Question 36

What is the primary role of the Centers for Medicare & Medicaid Services (CMS) in administering Medicare and Medicaid?

Accepted Answer

To oversee the programs and ensure compliance

Answer

To provide direct care to beneficiaries

Answer

To set reimbursement rates for providers

Answer

To determine eligibility for benefits

Question 37

Which of the following is NOT a requirement for Medicare Part A eligibility?

Accepted Answer

Payment of monthly premiums

Answer

Attainment of age 65

Answer

U.S. citizenship or permanent residency

Answer

Disability for at least two years

Question 38

Which of the following is a mandatory benefit under Medicaid?

Accepted Answer

Nursing home care

Answer

Dental care

Answer

Vision care

Answer

Transportation

Question 39

What is the main funding source for Medicare?

Accepted Answer

Payroll taxes

Answer

General revenue

Answer

State appropriations

Answer

Patient premiums

Question 40

What is the primary goal of the Medicare Prospective Payment System (PPS)?

Accepted Answer

To control hospital costs by paying a fixed amount per patient based on their diagnosis and treatment.

Answer

To encourage hospitals to provide more outpatient services.

Answer

To ensure hospitals are reimbursed for all documented costs.

Answer

To incentivize hospitals to use the most expensive treatments.

Question 41

Which of the following best describes the role of the Centers for Medicare & Medicaid Services (CMS)?

Accepted Answer

Administers and oversees both the Medicare and Medicaid programs.

Answer

Regulates private health insurance plans, including those offered through the Affordable Care Act (ACA).

Answer

Conducts research and sets national healthcare policy guidelines.

Answer

Provides direct healthcare services to low-income individuals.

Question 42

What is the central aim of the Affordable Care Act (ACA) in relation to Medicare and Medicaid?

Accepted Answer

To expand healthcare access to more Americans by increasing eligibility for both programs.

Answer

To eliminate all instances of fraud and abuse within the healthcare system.

Answer

To ensure that all Americans receive the highest quality healthcare possible.

Answer

To significantly reduce the overall cost of healthcare services for all individuals.

Question 43

Which of the following is NOT a mandatory requirement for Medicare Part A eligibility?

Accepted Answer

Having worked for at least 10 years in a covered profession.

Answer

Having paid Medicare taxes for a sufficient period.

Answer

Having reached the age of 65.

Answer

Being a U.S. citizen or lawful permanent resident.

Question 44

What is the primary function of the Medicare Advantage program?

Accepted Answer

To provide private health insurance options as an alternative to traditional Medicare.

Answer

To offer a more affordable option for individuals with low incomes.

Answer

To streamline Medicare enrollment and benefit administration.

Answer

To expand Medicare coverage to include dental and vision care for all beneficiaries.

Question 45

What was the primary impact of the Balanced Budget Act of 1997 on Medicare?

Accepted Answer

It introduced managed care options and cost-containment measures to control Medicare spending.

Answer

It established the Medicare Part D prescription drug program, which was later implemented in 2003.

Answer

It expanded Medicare coverage to include a comprehensive prescription drug benefit.

Question 46

Which of the following healthcare providers is most likely to be subject to the Medicaid 'clawback' provision?

Accepted Answer

A nursing home that receives Medicaid payments for resident care.

Answer

A hospital providing emergency services to an uninsured patient.

Answer

A pharmaceutical company that develops a new drug for cancer treatment.

Question 47

What is the main purpose of the 'dual eligibles' category within the Medicaid program?

Accepted Answer

To provide comprehensive healthcare coverage for individuals who qualify for both Medicare and Medicaid.

Answer

To offer subsidized health insurance to low-income individuals who are ineligible for Medicare.

Answer

To expand Medicaid coverage to include prescription drugs for all beneficiaries, regardless of Medicare eligibility.

Question 48

How did the Affordable Care Act (ACA) directly influence the Medicaid program?

Accepted Answer

It expanded Medicaid eligibility to cover more low-income individuals, including adults without dependent children.

Answer

It established a national health insurance exchange for individuals to purchase health insurance.

Answer

It created a new Medicare Part D program to cover prescription drugs, which was not directly related to Medicaid.

Question 49

A physician submits a Medicare claim for a patient's treatment, but the claim is denied because the patient's diagnosis does not meet Medicare's criteria for medical necessity. What does this scenario primarily illustrate?

Accepted Answer

The importance of medical necessity criteria in Medicare reimbursement decisions, as they determine whether services are covered.

Answer

The challenges of obtaining prior authorization for certain medical procedures, which is a separate process from medical necessity.

Answer

The limitations of Medicare coverage for preventive services, which is a distinct aspect of Medicare coverage.

Question 50

Which of the following is a major legal and regulatory framework governing both Medicare and Medicaid?

Accepted Answer

The Social Security Act

Answer

The Patient Protection and Affordable Care Act (ACA)

Answer

The Health Insurance Portability and Accountability Act (HIPAA)

Answer

The Emergency Medical Treatment and Active Labor Act (EMTALA)