Question 1

Question 1The following statements describe two types, or models, of HMOs:The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of the group practice, have an equity interest in the practice, and provide Choice A: a captive group a staff modelChoice B: a captive group a network modelChoice C: an independent group a network modelChoice D: an independent group a staff modelAnswer : BQuestion 2______________ HMOs can't medically underwrite any group incl small groups.Choice A: StateChoice B: Not-for-profitChoice C: For-profitChoice D: Federally qualifiedAnswer : BQuestion 3A common physician-only integrated model is a group practice without walls (GPWW). One characteristic of a typical GPWW is that theChoice A: GPWW combines multiple independent physician practices under one umbrella organizationChoice B: GPWW generally has a lesser degree of integration than does an IPAChoice C: member physicians cannot own the GPWWChoice D: GPWW's member physicians must perform their own business operationsAnswer : AQuestion 4A health plan may use one of several types of community rating methods to set premiums for a health plan. The following statements are about community rating. Select the answer choice containing the correct statement.Choice A: Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.Choice B: Under standard (pure) community rating, a health plan charges all employers or other group sponsors the same dollar amount for a given level of medical benefits or health plan, without adjusting for factors such as age, gender, or experience.Choice C: In using the adjusted community rating (ACR) method, a health plan must consider the actual experience of a group in developing premium rates for that group.Choice D: The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) meAnswer : BQuestion 5A health plan's ability to establish an effective provider network depends on the characteristics of the proposed service area and the needs of proposed plan members. It is generally correct to say thatChoice A: health plans have more contracting options if providers are affiliated with single entities than if providers are affiliated with multiple entitiesChoice B: urban areas offer more flexibility in provider contracting than do rural areasChoice C: consumers and purchasers in markets with little health plan activity are likely to be more receptive to HMOs than to loosely managed plans such as PPOsChoice D: large employers tend to adopt health plans more slowly than do small companiesAnswer : BQuestion 6A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For 2006, the annual deductible for self-only coverage mustChoice A: $525Choice B: $1,050Choice C: $2,100Choice D: $5,250Answer : BQuestion 7A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation mustChoice A: provide significant benefit to the communityChoice B: employ, rather than contract with, participating physiciansChoice C: achieve economies of scale through facility consolidation and practice managementChoice D: refrain from the corporate practice of medicineAnswer : AQuestion 8A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. This health plan requires preauthorization for certain medical services. With regard to the steps that the health plan's claims eChoice A: should assume that all services requiring preauthorization have been preauthorizedChoice B: should investigate any conflicts between diagnostic codes and treatment codes before approving the claim to ensure that the appropriate payment is made for the claimChoice C: need not verify that the provider is part of the health plan's network before approving the claim at the in-network level of benefitsChoice D: need not determine whether the member is covered by another health plan that allows for coordination of benefitsAnswer : BQuestion 9A physician-hospital organization (PHO) may be classified as an open PHO or a closed PHO. With respect to a closed PHO, it is correct to say thatA. the specialists in the PHO are typically compensated on a capitation basisChoice A: the specialists in the PHO are typically compensated on a capitation basisChoice B: it typically limits the number of specialists by type of specialtyChoice C: it is available to a hospital's entire eligible medical staffChoice D: physician membership in the PHO is limited to PCPsAnswer : BQuestion 10A public employer, such as a municipality or county government would be considered which of the following?Choice A: Employer-employee group.Choice B: Multiple-employer group.Choice C: Affinity group.Choice D: Debtor-creditor group.Answer : AQuestion 11According to the IRS, which of the following is not an allowable preventive care service:Choice A: Smoking cessation programs.Choice B: Periodic health examinations.Choice C: Health club memberships.Choice D: Immunizations for children and adults.Answer : CQuestion 12After a somewhat modest start in 2004, enrollment in HSA-related health plans more than tripled in 2005, making them todays fastest growing type of CDHP. As of January 2006, enrollment in HSAs had reached nearly:Choice A: 1.2 millionChoice B: 2.2 millionChoice C: 3.2 millionChoice D: 4.2 millionAnswer : BQuestion 13Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is thatChoice A: Mr. Marak has the right to appeal to the next level if the Level One appeal upholds the original decisionChoice B: it requires Frazier and Mr. Marak to submit to arbitration in order to resolve the disputeChoice C: it is considered to be an informal appealChoice D: it will be handled by an independent review organization (IRO)Answer : AQuestion 14All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.Choice A: TrueChoice B: FalseChoice C: Choice D: Answer : AQuestion 15Allgood Medical, Inc., a health plan, has contracted with Mercy Memorial Hospital to provide inpatient medical services to Allgood's plan members. The terms of the contract specify that Allgood will reimburse Mercy Memorial on the basis of a negotiated chChoice A: per diem agreementChoice B: fee-for-service agreementChoice C: withhold agreementChoice D: diagnostic related group (DRG) agreementAnswer : AQuestion 16Although the process is voluntary for health plans, external accreditation is becoming more and more important as states and purchasers require health plans undergo as many states and purchasers require health plans undergo some type of external review prChoice A: Is voluntary for health plans.Choice B: Requires all change accreditation organizations to use the same standards ofaccreditation.Choice C: Typically requires the accrediting organization to conduct a medical record review and a review of a health plan's credentialing processes, but not an evaluation of the health plans' member service systems processes.Choice D: Cannot assure that a health plan meets a specified level of quality.Answer : AQuestion 17Amendments to the HMO act 1973 do not permit federally qualified HMOs to useChoice A: Retrospective experience ratingChoice B: Adjusted community ratingChoice C: Community rating by classChoice D: Community ratingAnswer : AQuestion 18An exclusive provider organization (EPO) operates much like a PPO. However, one difference between an EPO and a PPO is that an EPOChoice A: is regulated under federal HMO legislationChoice B: generally provides no benefits for out-of-network careChoice C: has no provider network of physiciansChoice D: is not subject to state insurance lawsAnswer : BQuestion 19An HMO that combines characteristics of two or more HMO models is sometimes referred to as aChoice A: network model HMOChoice B: group model HMOChoice C: staff model HMOChoice D: mixed model HMOAnswer : DQuestion 20Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:Choice A: CodesChoice B: ListsChoice C: EditsChoice D: ChecksAnswer : CQuestion 21Arthur Moyer is covered under his employer's group health plan, which must comply with the Consolidated Omnibus Budget Reconciliation Act (COBRA). Mr. Moyer is terminating his employment. He has elected to continue his coverage under his employer's group Choice A: 18 months, but his coverage under COBRA will cease if he obtains group health coverage through another employer.Choice B: 18 months, even if he obtains group health coverage through another employer.Choice C: 36 months, but his coverage under COBRA will cease if he obtains group health coverage through another employer.Choice D: 36 months, even if he obtains group health coverage through another employer.Answer : AQuestion 22As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric imChoice A: Benchmarking.Choice B: Standard of care.Choice C: An adverse event.Choice D: Case-mix adjustment.Answer : AQuestion 23As part of its utilization management (UM) system, the Creole Health Plan uses a process known as case management. The following individuals are members of the Creole Health Plan: Jill Novacek, who has a chronic respiratory condition. Abraham Rashad, Choice A: Ms. Novacek, Mr. Rashad, and Mr. Devereaux.Choice B: Ms. Novacek and Mr. Rashad only.Choice C: Ms. Novacek and Mr. Devereaux only.Choice D: None of these members.Answer : AQuestion 24As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members: Brad Van Note, age 28, is taking many different, costly medications forChoice A: Mr. Van Note, Mr. Albrecht, and Ms. CromartieChoice B: Mr. Van Note and Ms. Cromartie onlyChoice C: Mr. Van Note and Mr. Albrecht onlyChoice D: Mr. Albrecht and Ms. Cromartie onlyAnswer : CQuestion 25Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a 30% coinsurance provision for all healthcare obtained outside the plans network of providers. In 1998, Ms. Martin became ill while she was on vacation, Choice A: $300Choice B: $510Choice C: $600Choice D: $810Answer : DQuestion 26Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of benefits provisiChoice A: 380Choice B: 130Choice C: 0Choice D: 550Answer : AQuestion 27Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health diChoice A: Hospital observation units or psychiatric hospitals.Choice B: Psychiatric hospitals or rehabilitation hospitals.Choice C: Subacute care facilities or skilled nursing facilities.Choice D: Psychiatric units in general hospitals or hospital observation units.Answer : CQuestion 28Before an HMO contracts with a physician, the HMO first verifies the physician's credentials.Upon becoming part of the HMO's organized system of healthcare, the physician is typically subject toChoice A: both recredentialing and peer reviewChoice B: recredentialing onlyChoice C: peer review onlyChoice D: neither recredentialing nor peer reviewAnswer : CQuestion 29Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to theChoice A: Receive compensation based on the volume and variety of medical services they perform for Hill plan members, whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services.Choice B: Have no financial incentive to practice preventive care or to focus on improving the health of their plan members, whereas the specialists have a positive incentive to help their plan members stay healthy.Choice C: Receive from the IPA the same monthly compensation for each Hill plan member under the PCP's care, whereas the specialists receive compensation based on a percentage discount from their normal fees.Choice D: Receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem charges.Answer : CQuestion 30Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to theChoice A: Hill had to have an initial net worth of at least $1.5 million in order to obtain a COA.Choice B: The COA most likely exempts Hill from any of State X's enabling statutes.Choice C: Hill had to be organized as a partnership in order to obtain a COAChoice D: The COA in no way indicates that Hill has demonstrated that it is fiscally sound.Answer : AQuestion 31Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the Choice A: receive compensation based on the volume and variety for medical services they perform for Leo plan members, whereas the specialists receive compensation based solely on the number of plan members who are covered for specific servicesChoice B: have no financial incentive to practice preventive care or to focus on improving the health of their plan members, whereas the specialists have a positive incentive to help their plan members stay healthyChoice C: receive from the IPA the same monthly compensation for each Leo plan member under the PCP's care, whereas the specialists receive compensation based on a percentage discount from their normal feesChoice D: receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem chargesAnswer : CQuestion 32Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors includedChoice A: increased stress on individuals and familiesChoice B: increased availability of behavioral healthcare servicesChoice C: greater awareness and acceptance of behavioral healthcare issuesChoice D: all of the aboveAnswer : DQuestion 33Bill Clinton is a member of Lewinsky's PBM plan which has a three-tier copayment structure. Bill fell ill and his doctor prescribed him AAA, a brand-name drug which was included in the Lewinsky's formulary; BBB, a non-formulary drug; and CCC, a generic drChoice A: CCC, AAA, BBBChoice B: BBB, CCC, AAAChoice C: BBB, AAA, CCCChoice D: CCC, BBB, AAAAnswer : AQuestion 34Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokersChoice A: are not required to be licensed by the states in which they market health plansChoice B: are compensated on a salary basisChoice C: represent only one health plan or insurerChoice D: are considered to be an agent of the buyer rather than an agent of the health plan or InsurerAnswer : DQuestion 35By definition, a health plan's network refers to theChoice A: organizations and individuals involved in the consumption of healthcare provided by the planChoice B: relative accessibility of the plan's providers to the plan's participantsChoice C: group of physicians, hospitals, and other medical care providers with whom the plan has contracted to deliver medical services to its membersChoice D: integration of the plan's participants with the plan's providersAnswer : CQuestion 36By definition, the marketing process of defining a certain place or market niche for a product relative to competitors and their products and then using the marketing mix to attract certain market segments is known asChoice A: brandingChoice B: positioningChoice C: database marketingChoice D: personal sellingAnswer : BQuestion 37By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an HMO provides comprehensive care includeChoice A: coordinating care across a variety of benefitsChoice B: emphasizing preventive care by covering many preventive services either in full or with a small copaymentChoice C: offering its members access to wellness programsChoice D: All of the aboveAnswer : DQuestion 38Col. Martin Avery, on active duty in the U.S. Army, is elegible to receive healthcare benefits under one of the three TRICARE health plan options. If Col Avery elects to participate in TRICARE Prime, he will beChoice A: able to obtain full benefits for services obtained from network and non-network providersChoice B: subject to copayment, deductible, and coinsurance requirements for any medical care he receivesChoice C: required to formally enroll for coverage and pay an enrollment feeChoice D: assigned to a primary care manager who is responsible for coordinating all his careAnswer : DQuestion 39Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of:Choice A: Health savings accounts (HSAs)Choice B: Health reimbursement arrangements (HRAs)Choice C: Medical savings accounts (MSAs)Choice D: Flexible spending arrangements (FSAs)Answer : DQuestion 40Dr. Julia Phram is a cardiologist under contract to Holcomb HMO, Inc., a typical closed-panel plan. The following statements are about this situation. Select the answer choice containing the correct statement.Choice A: All members of Holcomb HMO must select Dr. Phram as their primary care physician (PCP).Choice B: Any physician who meets Holcomb's standards of care is eligible to contract with Holcomb HMO as a provider.Choice C: Dr. Phram is either an employee of Holcomb HMO or belongs to a group of physicians that has contracted with Holcomb HMOChoice D: Holcomb HMO plan members may self-refer to Dr. Phram at full benefits without first obtaining a referral from their PCPs.Answer : AQuestion 41Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Dr. Ware's provider contract with Riverside contains a typical no-balance billiChoice A: prevent Dr. Ware from requiring a Riverside member to pay any coinsurance, copayment, or deductibles that the member would normally pay under Riverside's planChoice B: require Dr. Ware to accept the amount that Riverside pays for medical services as payment in full and not to bill plan members for additional amountsChoice C: prevent Dr. Ware from seeking compensation from patients if Riverside fails to compensate him because of the MCO's insolvencyChoice D: prevent Dr. Ware from billing a Riverside member for medical services that are not included in Riverside's planAnswer : BQuestion 42Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:Choice A: State that Dr. Aldridge's provider contract with Badger will automaticallyterminate if he loses his medical license or hospital privileges.Choice B: Specify a time period during which the party that breaches the provider contract must remedy the problem in order to avoid termination of the contract.Choice C: Give Dr. Aldridge the right to appeal Badger's decision if he is terminated withcause from Badger's provider network.Choice D: Specify that Badger can terminate this provider contract without providing areason, but only if Badger gives Dr. Aldridge at least 90-days' notice of its intentto terminate the contract.Answer : CQuestion 43During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, foChoice A: the angina, the high blood pressure, and the broken ankleChoice B: the angina and the high blood pressure onlyChoice C: none of these conditionsChoice D: the broken ankle onlyAnswer : AQuestion 44During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a groups geographic location, the size and gender mix of the group, and the level of participation in the grouChoice A: Healthcare costs are typically higher in rural areas than in large urban areas.Choice B: The morbidity rate for males is higher than the morbidity rate for females.Choice C: The larger the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.Choice D: All of the aboveAnswer : CQuestion 45Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.Choice A: The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital.Choice B: UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days.Choice C: The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes, if necessary, to redirect care to a more appropriate care setting.Choice D: The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused, overused, or misused and designs strategies to prevent inappropriate utilization in the future.Answer : DQuestion 46Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Whenever Mr. Murray receives a health claim from a plan member, he reviews the claimChoice A: A, B, C, and DChoice B: A and C onlyChoice C: A, B, and D onlyChoice D: B, C, and D onlyAnswer : AQuestion 47Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transferred byChoice A: Confinement in the extended-care facility after his hospitalization.Choice B: Transportation by ambulance from the hospital to the extended-care facility.Choice C: Physicians' professional services while he was hospitalized.Choice D: physicians' professional services while he was at the extended-care facility.Answer : AQuestion 48Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:Choice A: Provides Ms. Giambi with healthcare coverage for any illness or injury, but only if the cause of the illness or injury is work-related.Choice B: Combines the group health plan and disability plan offered by Ms. Giambi's employer with workers' compensation coverage.Choice C: Requires Ms. Giambi and her employer to each pay half of the cost of this coverage.Choice D: Requires Ms. Giambi to pay specified deductibles and copayments before receiving benefits under this program for any illness or injury.Answer : BQuestion 49Emily Brown works for Integral Health Plan and represents the company as a board member for the board of directors. Which best describes Emily's position?Choice A: Community RepresentativeChoice B: Inside DirectorChoice C: Outside DirectorChoice D: None of theseAnswer : BQuestion 50Employer-sponsored benefit plans that provide healthcare benefits must comply with the Employee Retirement Income Security Act (ERISA). One of the most significant features of ERISA is that itChoice A: contains a provision stating that the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plansChoice B: standardizes the conversion of group healthcare benefits to individual healthcare benefitsChoice C: mandates that self-funded healthcare plans must pay state premium taxesChoice D: requires that all active employees, regardless of age, must be eligible for coverage under employer-sponsored benefit plansAnswer : AQuestion 51Federal Employee Health Benefits Program (FEHBP) requires health plans offering services to federal employees and their dependents to provideA. Immediate access to emergency servicesB. Urgent Appointments within 24 hoursC. Routine appointments once a mChoice A: DChoice B: AChoice C: B & CChoice D: All of the listed optionsAnswer : FQuestion 52Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.This federal legislation is theChoice A: Clayton ActChoice B: Federal Trade Commission ActChoice C: McCarran-Ferguson ActChoice D: Sherman ActAnswer : CQuestion 53Following a report by the Institute of Medicine on the incidence and consequences of medical errors, a national task force recommended implementation of a nationwide mandatory system of collecting, analyzing, and reporting standardized information about mChoice A: random changeChoice B: structural changeChoice C: haphazard changeChoice D: reactive changeAnswer : DQuestion 54For providers, integration occurs when two or more previously separate providers combine under common ownership or control, or when two or more providers combine business operations that they previously carried out separately and independently. Such proviChoice A: higher costs for health plans, healthcare purchasers, and healthcare consumersChoice B: improved provider contracting position with health plansChoice C: an increase in providers' autonomy and control over their own work environmentChoice D: all of the aboveAnswer : BQuestion 55For this question, select the answer choice containing the terms that correctly complete the blanks labeled A and B in the paragraph below.NCQA offers Quality Compass, a national database of performance and accreditation information submitted by managed Choice A: Health Plan Employer Data and Information Set (HEDIS) mandatoryChoice B: Health Plan Employer Data and Information Set (HEDIS) voluntaryChoice C: ORYX mandatoryChoice D: ORYX voluntaryAnswer : BQuestion 56From the answer choices below, select the response that correctly identifies the rating method that Mr. Sybex used and the premium rate PMPM that Mr. Sybex calculated for the Koster group.Choice A: Rating Method book rating Premium Rate PMPM $132Choice B: Rating Method book rating Premium Rate PMPM $138Choice C: Rating Method blended rating Premium Rate PMPM $132Choice D: Rating Method blended rating Premium Rate PMPM $138Answer : CQuestion 57From the following answer choices, choose the description of the ethical principle that best corresponds to the term AutonomyChoice A: Health plans and their providers are obligated not to harm their membersChoice B: Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a groupChoice C: Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the membersChoice D: Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their livesAnswer : DQuestion 58From the following answer choices, choose the description of the ethical principle that best corresponds to the term AutonomyChoice A: Health plans and their providers are obligated not to harm their membersChoice B: Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a groupChoice C: Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the membersChoice D: Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their livesAnswer : DQuestion 59From the following answer choices, choose the description of the ethical principle that best corresponds to the term BeneficenceChoice A: Health plans and their providers are obligated not to harm their membersChoice B: Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a groupChoice C: Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the membersChoice D: Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their livesAnswer : BQuestion 60From the following answer choices, choose the description of the ethical principle that best corresponds to the term BeneficenceChoice A: Health plans and their providers are obligated not to harm their membersChoice B: Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a groupChoice C: Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the membersChoice D: Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their livesAnswer : BQuestion 61From the following choices, choose the definition that best matches the term health risk assessment (HRA)Choice A: A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselvesChoice B: A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problemChoice C: A technique in which information about a plan member's health status, personal and family health history, and health-related behaviors is used to predict the member's likelihood of experiencing specific illnesses or injuriesChoice D: A technique used to evaluate the medical necessity, appropriateness, and cost-effectiveness of healthcare services for a given patientAnswer : CQuestion 62From the following choices, choose the definition that best matches the term ScreeningChoice A: A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselvesChoice B: A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problemChoice C: A technique in which information about a plan member's health status, personal and family health history, and health-related behaviors is used to predict the member's likelihood of experiencing specific illnesses or injuriesChoice D: A technique used to evaluate the medical necessity, appropriateness, and cost-effectiveness of healthcare services for a given patientAnswer : BQuestion 63General HMO is building a provider network and is considering Universal Hospital as an addition to its network. Minimum requirements that General should consider in determining whether Universal is qualified to participate in General's network includeA. Choice A: Both A and BChoice B: A onlyChoice C: B onlyChoice D: Neither A nor BAnswer : AQuestion 64Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in GreenChoice A: Greentree is prevented by law from offering a contract to Dr. Cortelyou until the credentialing process is completeChoice B: any contract signed by Dr. Cortelyou should include a clause requiring the successful completion of the credentialing process within a defined time frame in order for the contract to be effectiveChoice C: Greentree must offer a standard contract to Dr. Cortelyou, without regard to the outcome of the credentialing processChoice D: Greentree will abandon the credentialing process now that Dr. Cortelyou has agreed to participate in Greentree's networkAnswer : BQuestion 65Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organizations typicallyChoice A: are exempt from review by the Internal Revenue Service (IRS)Choice B: are organized as stock companies for greater flexibility in raising capitalChoice C: rely on income from operations for the large cash outlays needed to fund long-term projects and expansionChoice D: engage in lobbying or political activities in order to maintain their tax-exempt statusAnswer : CQuestion 66Health plans may use different capitation arrangements for different levels of service. One typical capitation arrangement provides a capitation payment that may include primary care only, or both primary and secondary care, but not ancillary services. ThChoice A: global capitation arrangementChoice B: gatekeeper arrangementChoice C: carve-out arrangementChoice D: partial capitation arrangementAnswer : DQuestion 67Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for examplChoice A: Encounter reportsChoice B: Diagnostic codesChoice C: Durational ratingsChoice D: EditsAnswer : DQuestion 68Health plans require utilization review for all services administered by its participating physicians.Choice A: TrueChoice B: FalseChoice C: Choice D: Answer : BQuestion 69Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health plChoice A: Low or stable costs.Choice B: Appropriate, rather than inappropriate, utilization rates.Choice C: A benefit that cannot be easily defined.Choice D: Defined patient population.Answer : DQuestion 70Health plans' use of the Internet to provide plan members with health-related information has grown rapidly in recent years. One advantage the Internet has over other forms of communication is thatChoice A: users can access the Internet using a number of different types of computer systemsChoice B: access to the Internet is available only to members of the health plan's networkChoice C: the Internet is immune to internal security breaches by employees or trading partners within the networkChoice D: users can contact a single controlling organization to rectify disruptions in Internet serviceAnswer : AQuestion 71Health plans use the following to determine the number of providers to add to a network:Choice A: Staffing ratiosChoice B: Drive timeChoice C: Geographic availabilityChoice D: All of the aboveAnswer : DQuestion 72Health savings accounts were created by which of the following laws:Choice A: COBRAChoice B: HIPAAChoice C: Medicare Modernization ActChoice D: None of the AboveAnswer : CQuestion 73Historically most HMOs have beenChoice A: Closed-access HMOChoice B: Closed-panel HMOChoice C: Open-access HMOChoice D: Open-panel HMOAnswer : BQuestion 74HMOs typically employ several techniques to manage provider utilization and member utilization of medical services. One technique that an HMO uses to manage member utilization isChoice A: the use of physician practice guidelinesChoice B: the requirement of copayments for office visitsChoice C: capitationChoice D: risk poolsAnswer : BQuestion 75Ian Vladmir wants to have a routine physical examination to ascertain that he is in good health. Mr. Vladmir is a member of a health plan that will allow him to select the physician of his choice, either from within his plan's network or from outside of hChoice A: a traditional HMO planChoice B: a managed indemnity planChoice C: a point of service (POS) optionChoice D: an exclusive provider organization (EPO)Answer : CQuestion 76Identify the CORRECT statement(s):(A) Smaller the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.(B) Gender of the group's participants has no effect on the likelihood of loss.(Choice A: All of the listed optionsChoice B: B & CChoice C: None of the listed optionsChoice D: A & CAnswer : CQuestion 77If a state commissioner of insurance places an HMO under administrative supervision, then the purpose of this action most likely is to:Choice A: Transfer all of the HMO's business to other carriers.Choice B: Allow the state commissioner, acting for a state court, to take control of and administer the HMO's assets and liabilities.Choice C: Sell the HMO's assets in order to satisfy the HMO's obligations.Choice D: Place the HMO's operations under the direction and control of the state commissioner or a person appointed by the commissioner.Answer : DQuestion 78If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting infoChoice A: a Level One appeal, and the member has the right to a further appealChoice B: a Level Two appeal, and the reviewer's decision is final and bindingChoice C: an independent external appeal, and the member has the right to a further appealChoice D: arbitration, and the reviewer's decision is final and bindingAnswer : AQuestion 79If most of the physicians, or many of the physicians in a particular specialty, are affiliated with a single entity, then a health plan building a network in the service area ________________________.Choice A: Has many contracting options available.Choice B: Should not contract with that entityChoice C: Most likely needs to contract with that entityChoice D: Should attempt to disband the existing affiliationsAnswer : CQuestion 80Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:A. Hospital emergency departmentsB. Physician's officesC. Urgent care centersIf these settings are ranked in order of the cost of providing cChoice A: A, B, CChoice B: A, C, BChoice C: B, C, AChoice D: C, A, BAnswer : BQuestion 81In 1999, the United States Congress passed the Financial Services Modernization Act, referred to as the Gramm-Leach-Bliley (GLB) Act. The primary provisions included under the GLB Act require financial institutions, including health plans, to take severalChoice A: Notify customers of any sharing of non-public personal financial information with nonaffiliated third parties.Choice B: Prohibit customers from having the opportunity to 'opt-out' of sharing non-public personal financial information.Choice C: Disclose to affiliates, but not to third parties, their privacy policies regarding the sharing of nonpublic personal financial information.Choice D: Agree not to disclose personally identifiable financial information or personally identifiable health information.Answer : AQuestion 82In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:A. The GLB Act allows convergence among the traChoice A: A onlyChoice B: Both A and BChoice C: B onlyChoice D: Neither A nor BAnswer : BQuestion 83In accounting terminology, the items of value that a company ownssuch as cash, cash equivalents, and receivablesare generally known as the company'sChoice A: revenueChoice B: net incomeChoice C: surplusChoice D: assetsAnswer : DQuestion 84In addition to the credentialing activities that an health plan performs when initially accepting a provider into its network, the health plan must also perform recredentialing of the same providers on an ongoing basis. Many of the same activities are perChoice A: verification of a network provider's medical education and residencyChoice B: performance of site inspections in a provider's facilitiesChoice C: review of information from a provider's quality improvement activitiesChoice D: verification of a provider's licensure and certificationAnswer : AQuestion 85In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of antiselection. Antiselection can correctly be defined as theChoice A: inability of a proposed insured to share with the insurer the financial risks of healthcare coverageChoice B: possibility that a proposed insured will profit from an illness by receiving benefits that exceed the total amount of his or her eligible medical expensesChoice C: inability of a proposed insured to provide sufficient evidence that proves he or she is an insurable riskChoice D: tendency of people who have a greater-than-average likelihood of loss to apply for or continue insurance protection to a greater extent than people who have an average or less than average likelihood of the same lossAnswer : DQuestion 86In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results ofA. Prospective reviewB. Concurrent reviewC. Choice A: A, B, and CChoice B: A and B onlyChoice C: A and C onlyChoice D: B onlyAnswer : DQuestion 87In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results ofA. Prospective reviewB. Concurrent reviewC. Choice A: A, B, and CChoice B: A and B onlyChoice C: A and C onlyChoice D: B onlyAnswer : BQuestion 88In claims administration terminology, a claims investigation is correctly defined as the process ofChoice A: reporting management information about services provided each time a patient visits a provider for purposes of analyzing utilization and provider practice patternsChoice B: obtaining all the information necessary to determine the appropriate amount to pay on a given claimChoice C: routinely reviewing and processing a claim for either payment or denialChoice D: assigning to each diagnosis or treatment reported on a claim special codes that briefly and specifically describe each diagnosis and treatmentAnswer : BQuestion 89In health plan terminology, demand management, as used by health plans, can best be described asChoice A: an evaluation of the medical necessity, efficiency, and/or appropriateness of healthcare services and treatment plans for a given patientChoice B: a series of strategies designed to reduce plan members' needs to utilize healthcare services by encouraging preventive care, wellness, member self-care, and appropriate use of healthcare servicesChoice C: a technique that prevents a provider who is being reimbursed under a fee schedule arrangement from billing a plan member for any fees that exceed the maximum fee reimbursed by the planChoice D: a system of identifying plan members with special healthcare needs, developing a healthcare strategy to meet those needs, and coordinating and monitoring the careAnswer : BQuestion 90In large health plans, management functions such as provider recruiting, credentialing, contracting, provider service, and performance management for providers are typically the responsibility of theChoice A: chief executive officer (CEO)Choice B: network management directorChoice C: board of directorsChoice D: director of operationsAnswer : BQuestion 91In most cases, medical errors are caused by breakdowns in the healthcare system rather than by provider mistakes.Choice A: TrueChoice B: FalseChoice C: Choice D: Answer : AQuestion 92In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known Choice A: dual choiceChoice B: cost shiftingChoice C: accreditationChoice D: defensive medicineAnswer : BQuestion 93In order to cover some of the gap between FFS Medicare coverage and the actual cost of services, beneficiaries often rely on Medicare supplements. Which of the following statements about Medicare supplements is correct?Choice A: The initial ten (A-J) Medigap policies offer a basic benefit package that includes coverage for Medicare Part A and Medicare Part B coinsurance.Choice B: Each insurance company selling Medigap must sell all the different Medigap policies.Choice C: Medicare SELECT is a Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part A coverage.Choice D: Medigap benefits vary by plan type (A through L), and are not uniform nationally.Answer : AQuestion 94In order to generate exchanges with consumers, healthcare plan marketers use the four elements of the marketing mix: product, price, place (distribution), andChoice A: segmentationChoice B: publicityChoice C: promotionChoice D: plan designAnswer : CQuestion 95In order to help review its institutional utilization rates, the Sahalee Medical Group, a health plan, uses the standard formula to calculate hospital bed days per 1,000 plan members for the month to date (MTD). On April 20, Sahalee used the following infChoice A: 67Choice B: 274Choice C: 365Choice D: 1,000Answer : BQuestion 96In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On October 23, Holt used the following information to calculate the bed days perChoice A: 278Choice B: 397Choice C: 403Choice D: 920Answer : BQuestion 97In preparation for its expansion into a new service area, the Regal MCO is meeting with Dr. Nancy Buhner, a cardiologist who practices in Regal's new service area, in order to convince her to become one of the plan's participating providers. As part of thChoice A: ensure that Dr. Buhner complies with all of the provisions of the Ethics in Patient Referrals ActChoice B: learn whether Dr. Buhner is a licensed medical practitionerChoice C: confirm Dr. Buhner's membership in the National Committee for Quality Assurance (NCQA)Choice D: learn whether Dr. Buhner has had a medical malpractice claim filed or other disciplinary actions taken against herAnswer : DQuestion 98In response to the demand for a method of assessing outcomes, accrediting organizations and other government and commercial groups have developed quantitative measures of quality that consumers, purchasers, regulators, and others can use to compare healthChoice A: quality standardsChoice B: accreditation decisionsChoice C: standards of careChoice D: performance measuresAnswer : DQuestion 99In the following sections, we will describe some of the measures health plans use to evaluate the quality of the services and healthcare they offer their members.Which of the following is the best description of what a 'Process measure' evaluates?Choice A: The nature, quantity, and quality of the resources that a health plan has available for member service and patient care.Choice B: The methods and procedures a health plan and its providers use to furnish service and care.Choice C: The extent to which services succeed in improving or maintaining satisfaction and patient health.Choice D: None of the aboveAnswer : BQuestion 100In the paragraph below, a sentence contains two pairs of words enclosed in parentheses. Determine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you have chosen. Many pharmacy benefit Choice A: Therapeutic / alwaysChoice B: Generic / alwaysChoice C: Generic / neverChoice D: Therapeutic / neverAnswer : AQuestion 101In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice containing the two terms that you have chosen.For providers, (operational /Choice A: operational / an acquisitionChoice B: operational / a consolidationChoice C: structural / an acquisitionChoice D: structural / a consolidationAnswer : DQuestion 102In the United States, the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. One true statement about TRICARE is thatChoice A: hospitals participating in TRICARE program are exempt from JCAHO accrediation and Medicare certificationChoice B: TRICARE enrollees are not entitiled to appeal authorization coverage decisionsChoice C: active duty personnel are automatically considered enrolled in TRICARE PrimeChoice D: TRICARE covers inpatient and outpatient services, physician and hospital charges, and medical supplies, but not mental health servicesAnswer : CQuestion 103In the United States, the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. One true statement about TRICARE is that:Choice A: Active duty military personnel are automatically considered enrolled in TRICARE PrimeChoice B: TRICARE covers inpatient and outpatient services, physician and hospital charges, and medical supplies, but not mental health services.Choice C: TRICARE enrollees are not entitled to appeal authorization or coverage decisionsChoice D: Hospitals participating in the TRICARE program are exempt from JCAHO accreditation and Medicare certification.Answer : AQuestion 104Individuals can use HSAs to pay for the following types of health coverage:.Choice A: Qualified disability insuranceChoice B: COBRA continuation coverage.Choice C: Medigap coverage (for those over 65).Choice D: All of the above.Answer : BQuestion 105Janet Riva is covered by a indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan. She incurreChoice A: $1,750Choice B: $1,800Choice C: $2,000Choice D: $2,250Answer : BQuestion 106Janet Riva is covered by a traditional idemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan. Choice A: $1,750Choice B: $1,800Choice C: $2,000Choice D: $2,250Answer : BQuestion 107John Kerry's employer has contracted to receive healthcare for its employees from the Democratic Healthcare System. Mr. Kerry visits his PCP, who sends him to have some blood tests. The PCP then refers Mr. Kerry to a specialist who hospitalizes him for onChoice A: a physician practice organisationChoice B: a physician-hospital organisationChoice C: a management services organisationChoice D: an integrated delivery sysemAnswer : DQuestion 108Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Ms. Lopez reviewed a health claim for answers to the following questions:Question A -Choice A: A, B, C, and DChoice B: A, B, and D onlyChoice C: B, C, and D onlyChoice D: A and C onlyAnswer : AQuestion 109Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Ms. Lopez reviewed a health claim for answers to the following questions:Question A Choice A: A, B, C, and DChoice B: A, B, and D onlyChoice C: B, C, and D onlyChoice D: A and C onlyAnswer : AQuestion 110Khalyn Drury's employer includes managed dental care in its employee benefits package. During open enrollment, Ms. Drury enrolled in the dental plan, which provides dental services to its members in exchange for a prepayment (the premium). Dental servicesChoice A: dental preferred provider organization (PPO)Choice B: traditional fee-for-service (FFS) dental planChoice C: plan with a dental point of service (POS) optionChoice D: dental health maintenance organization (DHMO)Answer : DQuestion 111Lansdale Healthcare, a health plan, offers comprehensive healthcare coverage to its members through a network of physicians, hospitals, and other service providers. Plan members who use in-network services pay a copayment for these services. The copaymentChoice A: specified dollar amount charge that a plan member must pay out-of-pocket for a specified medical service at the time the service is renderedChoice B: percentage of the fees for medical services that a plan member must pay after Magellan has paid its share of the costs of those servicesChoice C: flat amount that a plan member must pay each year before Magellan will make any benefit payments on behalf of the plan memberChoice D: specified payment for services that was negotiated between the provider and MagellanAnswer : AQuestion 112Managed behavioral health organizations (MBHOs) use several strategies to manage the delivery of behavioral healthcare services. The following statements are about these strategies. Select the answer choice that contains the correct statement.Choice A: MBHOs generally provide benefits for mental health services but not for chemical dependency services.Choice B: The level of care needed to treat behavioral disorders is the same for all patients and all disorders.Choice C: By using outpatient treatment more extensively, MBHOs have decreased the use of costly inpatient therapies.Choice D: PCP gatekeeper systems for behavioral healthcare generally result in more accurate diagnoses, more effective treatment, and more efficient use of resources than do centralized referral systems.Answer : CQuestion 113Many HMOs are compensated for the delivery of healthcare to members under a prepaid care arrangement. Under a prepaid care arrangement, a plan member typically pays aChoice A: fixed amount in advance for each medical service the member receivesChoice B: a small fee such as $10 or $15 that a member pays at the time of an office visit to a network providerChoice C: a fixed, monthly premium paid in advance of the delivery of medical care that covers most healthcare services that a member might need, no matter how often the member uses medical servicesChoice D: specified amount of the member's medical expenses before any benefits are paid by the HMOAnswer : CQuestion 114Many of the credentialing standards and criteria used by health plans are often taken from already existing standards established byChoice A: the National Practitioner Data Bank (NPDB)Choice B: the National Association of Insurance Commissioners (NAIC)Choice C: the Centers for Medicare and Medicaid Services (CMS)Choice D: independent accrediting organizationsAnswer : DQuestion 115Marlee Whitcomb was covered as a dependent under the group health plan provided by her father's employer. That health plan complied with the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. When Ms. Whitcomb married, she cChoice A: can continue her group coverage for a period not to exceed 48 monthsChoice B: can continue her group coverage for a period not to exceed 36 monthsChoice C: cannot continue her group coverage, but has the right to convert the group coverage to an individual health planChoice D: can continue her group coverage indefinitelyAnswer : BQuestion 116Medicaid is a jointly funded federal and state program that provides hospital and medical expense coverage to low-income individuals and certain aged and disabled individuals. One characteristic of Medicaid is thatChoice A: providers who care for Medicaid recipients must accept Medicaid payment as payment in full for services renderedChoice B: Medicaid requires recipients to pay deductibles, copayments, and coinsurance amounts for all servicesChoice C: Medicaid is always the primary payor of benefitsChoice D: benefits offered by Medicaid programs are federally mandated and do not vary by stateAnswer : AQuestion 117Medicare Advantage product options include:Choice A: Coordinated care plans, medical savings accounts and national PPOs.Choice B: Private Fee for Service plans, health care prepayment plans and medical savings accountsChoice C: Coordinated care plans, regional PPOs and private fee for service plansChoice D: Cost contracts, coordinated care programs and medical savings accounts.Answer : CQuestion 118Medicare is the federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital, medical and other covered benefits to elderly and disabled persons. Medicare is available for:Choice A: Persons age 63 or older.Choice B: Persons with qualifying disabilities (over the age of 63)Choice C: Persons with end-stage renal disease (ESRD)Choice D: Low income individualsAnswer : CQuestion 119Medicare Part C can be delivered by the following Medicare Advantage plans:Choice A: HCCP, HMO, PPO (local or regional), PFFS or MSA.Choice B: CCPs , PFFS or MSA.Choice C: HMO, HSA, PPO (local or regional), PFFS or MSA.Choice D: HMO, PPO (local or regional), POS, or MSA.Answer : BQuestion 120Member satisfaction is a critical element of a health plan's quality management program. A health plan can obtain information about member satisfaction with various aspects of the health plan fromChoice A: surveys completed by members following a visit to a providerChoice B: surveys sent to plan members who have not received healthcare services during a specified time periodChoice C: periodic reports of complaints received by member services personnelChoice D: all of the aboveAnswer : DQuestion 121Members who qualify to participate in a health plan's case management program are typically assigned a case manager. During the course of the member's treatment, the case manager is responsible forA. Coordinating and monitoring the member's careB. ApproChoice A: Both A and BChoice B: A onlyChoice C: B onlyChoice D: Neither A nor BAnswer : BQuestion 122Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for: The cost of hospitalization for two days Diagnostic tests performed in the hospital TransChoice A: ambulance and the diagnostic testsChoice B: ambulance, the diagnostic tests, and the physician's professional servicesChoice C: cost of hospitalizationChoice D: cost of hospitalization and the physician's professional servicesAnswer : DQuestion 123More procedures or services may be fully covered within the PPO network than those out-of network.Choice A: TrueChoice B: FalseChoice C: Choice D: Answer : AQuestion 124Most contracts between health plans and providers contain a provision which forbids providers from seeking compensation from patients if the health plan fails to compensate the provider because of insolvency or for any other reason. Such a provision is knChoice A: due process provisionChoice B: cure provisionChoice C: hold-harmless provisionChoice D: risk-sharing provisionAnswer : CQuestion 125Mr. George Bush is covered by a PBM plan that uses a closed formulary. This indicates thatChoice A: he can receive coverage for parmaceuticals only if they are on the PBM plan's preferred list of drugsChoice B: he must receive all of his pharmaceuticals from a mail-order pharmacy programChoice C: he can receive coverage for pharmaceuticals that are on the PBM plan's preferred list of drugs, as well as for pharmacueticals that are not on the preferred listChoice D: the PBM plan cannot recive a rebate on any pharmacueticals it obtains from the pharmaceuticalfacturerAnswer : AQuestion 126Natalie Chan is a member of the Ultra Health Plan, a health plan. Whenever she needs nonemergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. CrChoice A: Within Ultra's system, Ms. Chan received primary care from both Dr. Craig and Dr. LeeChoice B: Ultra's system allows its members open access to all of Ultra's participating providers.Choice C: Within Ultra's system, Dr. Craig serves as a coordinator of care or gatekeeper for the medical services that Ms. Chan receives.Choice D: Ultra's network of providers includes Dr. Craig and Dr. Lee but not Arrow HospitalAnswer : CQuestion 127Natalie Chan is a member of the Ultra Health Plan. Whenever she needs non-emergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Craig referred hChoice A: Within Ultra's system, Ms. Chan received primary care from both Dr. Craig and Dr. Lee.Choice B: Ultra's system allows its members open access to all of Ultra's participating providers.Choice C: Within Ultra's system, Dr. Craig serves as a coordinator of care or gatekeeper for the medical services that Ms. Chan receives.Choice D: Ultra's network of providers includes Dr. Craig and Dr. Lee but not Arrow Hospital.Answer : CQuestion 128One characteristic of disease management programs is that they typicallyChoice A: focus on individual episodes of medical care rather than on the comprehensive care of the patient over timeChoice B: are used to coordinate the care of members with any type of disease, either chronic or nonchronicChoice C: focus on managing populations of patients who have a specific chronic illness or medical condition, but do not focus on patient populations who are at risk of developing such an illness or conditionChoice D: use clinical practice processes to standardize the implementation of best practices among providersAnswer : DQuestion 129One characteristic of the accreditation process for MCOs is thatChoice A: an accrediting agency typically conducts an on-site review of an MCO's operations, but it does not review an MCO's medical records or assess its member service systemsChoice B: each accrediting organization has its own standards of accreditationChoice C: the accrediting process is mandatory for all MCOsChoice D: government agencies conduct all accreditation activities for MCOsAnswer : BQuestion 130One component of information systems used by health plans incorporates membership data and information about provider reimbursement arrangements and analyzes transactions according to contract rules. This information system component is known asChoice A: a contract management systemChoice B: a credentialing systemChoice C: a legacy systemChoice D: an interoperable communication systemAnswer : AQuestion 131One device that PBM plans use to manage both the cost and use of pharmaceuticals is a formulary. A formulary is defined asChoice A: a listing of drugs classified by therapeutic category or disease class that are considered preferred therapy for a given managed population and that are to be used by a health plan's providers in prescribing medicationsChoice B: a reduction in the price of a particular pharmaceutical obtained by the PBM from the pharmaceutical manufacturerChoice C: drugs ordered and delivered through the mail to the PBM's plan members at a reduced costChoice D: an identification card issued by the PBM to its plan membersAnswer : AQuestion 132One distinction that can be made between a staff model HMO and a group model HMO is that, in a staff model HMO, participating physicians are Back to TopChoice A: employees of the HMOChoice B: employees of a group practice that has contracted with the HMOChoice C: compensated primarily through capitationChoice D: limited to primary care physicians (PCPs)Answer : AQuestion 133One distinguishing characteristic of a health maintenance organization (HMO) is that, typically, an HMOChoice A: arranges for the delivery of medical care and provides, or shares in providing, the financing of that careChoice B: must be organized on a not-for-profit basisChoice C: may be organized as a corporation, a partnership, or any other legal entityChoice D: must be federally qualified in order to conduct business in any stateAnswer : AQuestion 134One ethical principle in health plans is the principle of non-maleficence, which holds that health plans and their providers:Choice A: Should allocate resources in a way that fairly distributes benefits and burdens among the members.Choice B: Have a duty to present information honestly and are obligated to honor commitments.Choice C: Are obligated not to harm their members.Choice D: Should treat each plan member in a manner that respects his or her goals and values.Answer : CQuestion 135One ethical principle in managed care is the principle of justice/equity, which specifically holds that MCOs and their providers have a duty toChoice A: treat each member in a manner that respects his or her own goals and valuesChoice B: allocate resources in a way that fairly distributes benefits and burdens among the membersChoice C: present information honestly to their members and to honor commitments to their membersChoice D: make sure they do not harm their membersAnswer : BQuestion 136One factor the Sandpiper Health Plan uses to assess its quality is a clinician's bedside manner, i.e., how friendly and understanding the clinician is, whether the patient feels that the clinician listens to the patient's concerns, how well the cliniciaChoice A: a provider service quality issueChoice B: an administrative service quality issuea healthcare process quality issueChoice C: a healthcare outcomes quality issueChoice D: a healthcare process quality issueAnswer : AQuestion 137One feature of the Employee Retirement Income Security Act (ERISA) is that it:Choice A: Requires self-funded employee benefit plans to pay premium taxes at the state level.Choice B: Contains a pre-emption provision, which typically makes the terms of ERISA take precedence over any state laws that regulate employee welfare benefit plans.Choice C: Contains strict reporting and disclosure requirements for all employee benefit plans except health plans.Choice D: Requires that state insurance laws apply to all employee benefit plans except insured plans.Answer : BQuestion 138One HMO model can be described as an extension of a group model HMO because it contracts with multiple group practices, rather than with a single group practice. This HMO model is known as theChoice A: staff model HMOChoice B: IPA model HMOChoice C: direct contract model HMOChoice D: network model HMOAnswer : DQuestion 139One non-group market segment to which health plans market health plan products is the senior market, which is comprised mostly of persons over age 65 who are eligible for Medicare benefits. One factor that affects a health plan's efforts to market to the Choice A: The Centers for Medicare and Medicaid Services (CMS) must approve all marketing materials used by health plans to market health plan products to the Medicare populationChoice B: managed Medicare plans typically require Medicare beneficiaries to purchase Medigap insurance to supplement gaps in coverageChoice C: managed Medicare plans can refuse to cover persons with certain health problemsChoice D: the CMS prohibits health plans from using telemarketing to market health plan products to the Medicare populationAnswer : BQuestion 140One of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national, not local markets.Choice A: TrueChoice B: FalseChoice C: Choice D: Answer : BQuestion 141One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. One of the provisions of the Act was that itChoice A: exempted HMOs from all state licensure requirements.Choice B: required all employers that offered healthcare coverage to their employees to offeronly one type of federally qualified HMO.Choice C: eliminated funding that supported the planning and start-up phases of new HMOs.Choice D: established a process by which HMOs could obtain federal qualificationAnswer : DQuestion 142One of the most influential pieces of legislation in the advancement of managed care within the United States was the HMO Act of 1973. One provision of the HMO Act of 1973 was that itChoice A: emphasized compensating physicians based solely on the volume of medical services they provideChoice B: exempted HMOs from all state licensure requirementsChoice C: established a process under which HMOs could elect to be federally qualifiedChoice D: required federally qualified HMOs to relate premium levels to the health status of the individual enrollee or employer groupAnswer : CQuestion 143One true statement about community rating, a rating method commonly used by health plans, is that:Choice A: It requires a health plan to set premiums for financing medical care according to the health plan's expected cost of providing medical benefits to a sub-group within the community.Choice B: A health plan usually uses community rating to set premiums for large groups.Choice C: It tends to lead to greater fluctuations in premium rates than do other rating methods.Choice D: A health plan seldom uses community rating to set premiums for large groups.Answer : DQuestion 144One true statement regarding ethics and laws is that the values of a community are reflected inChoice A: both ethics and laws, and both ethics and laws are enforceable in the court systemChoice B: both ethics and laws, but only laws are enforceable in the court systemChoice C: ethics only, but only laws are enforceable in the court systemChoice D: laws only, but both ethics and laws are enforceable in the court systemAnswer : BQuestion 145One true statement regarding ethics and laws is that the values of a community are reflected inChoice A: both ethics and laws, and both ethics and laws are enforceable in the court systemChoice B: both ethics and laws, but only laws are enforceable in the court systemChoice C: ethics only, but only laws are enforceable in the court systemChoice D: laws only, but both ethics and laws are enforceable in the court systemAnswer : BQuestion 146One type of physician-only integration model is a consolidated medical group. Typical characteristics of a consolidated medical group includeChoice A: that it may be a single-specialty or multi-specialty practiceChoice B: operates in one or a few facilities rather than in many independent officesChoice C: achieves economies of scale in the group's integrated operationsChoice D: all of the aboveAnswer : DQuestion 147One typical characteristic of an integrated delivery system (IDS) is that an IDS.Choice A: Is more highly integrated structurally than it is operationally.Choice B: Provides a full range of healthcare services, including physician services, hospital services, and ancillary services.Choice C: Cannot negotiate directly with health plans, plan sponsors, or other healthcare purchasers.Choice D: Performs a single business function, such as negotiating with health plans on behalf of all of the member providers.Answer : BQuestion 148One typical characteristic of preferred provider organization (PPO) benefit plans is that PPOs:Choice A: Assume full financial risk for arranging medical services for their members.Choice B: Require plan members to obtain a referral before getting medical services from specialists.Choice C: Use a capitation arrangement, instead of a fee schedule, to reimburse physicians.Choice D: Offer some coverage, although at a higher cost, for plan members who choose to use the services of non-network providers.Answer : DQuestion 149One way in which a health plan can support an ethical environment is byChoice A: requiring organizations with which it contracts to adopt the plan's formal ethical policyChoice B: developing and maintaining a culture where ethical considerations are integrated into decision making at the top organizational level onlyChoice C: establishing a formal method of managing ethical conflicts, such as using an ethics task force or bioethics consultantChoice D: maintaining control of policy development by removing providers and members from the process of developing and implementing policies and procedures that provide guidance to providers and members confronted with ethical issuesAnswer : CQuestion 150One way in which a health plan can support an ethical environment is byChoice A: requiring organizations with which it contracts to adopt the plan's formal ethical policyChoice B: developing and maintaining a culture where ethical considerations are integrated into decision making at the top organizational level onlyChoice C: establishing a formal method of managing ethical conflicts, such as using an ethics task force or bioethics consultantChoice D: maintaining control of policy development by removing providers and members from the process of developing and implementing policies and procedures that provide guidance to providers and members confronted with ethical issuesAnswer : CQuestion 151One way in which health plans differ from traditional indemnity plans is that health plans TypicallyChoice A: provide less extensive benefits than those provided under traditional indemnity plansChoice B: place a greater emphasis on preventive care than do traditional indemnity plansChoice C: require members to pay a percentage of the cost of medical services rendered after a claim is filed, rather than a fixed copayment at the time of service as required by indemnity plansChoice D: contain cost-sharing requirements that result in more out-of-pocket spending by members than do the cost-sharing requirements in traditional indemnity plansAnswer : BQuestion 152One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers' payment during a plan year. At the end of the plan year, the MCO may use the amount retained to offset or pay for any cost overruns for referral or hospitalChoice A: withholdsChoice B: usual, customary, and reasonable (UCR) feesChoice C: risk poolsChoice D: per diemsAnswer : AQuestion 153Parable Healthcare Providers, a health plan, recently segmented the market for a new healthcare service. Parable began the process by dividing the healthcare market into two broad categories: non-group and group. Next, Parable further segmented the non-grChoice A: channel segmentationChoice B: geographic segmentationChoice C: demographic segmentationChoice D: product segmentationAnswer : CQuestion 154Parul Gupta has been covered by a group health plan for eighteen months. For the past four months, she has been undergoing treatment for diabetes. Last week, Ms. Gupta began a new job and immediately enrolled in her new company's group health plan, which Choice A: can exclude coverage for treatment of Ms. Gupta's diabetes for one year, because she did not have at least two years of creditable coverage under her previous health planChoice B: cannot exclude Ms. Gupta's diabetes as a pre-existing condition, because the one-year pre-existing condition provision is offset by at least one year of continuous coverage under her previous health planChoice C: can exclude coverage for treatment of Ms. Gupta's diabetes for one year, because HIPAA does not impact a group health plan's pre-existing condition provisionChoice D: can exclude coverage for treatment of Ms. Gupta's diabetes for four months, because that is the length of time she received treatment for this medical condition prior to her enrollment in the new health planAnswer : BQuestion 155Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a speChoice A: an integrated delivery system (IDS)Choice B: a Management Services Organization (MSO)Choice C: a Physician Practice Management (PPM) companyChoice D: a physician-hospital organization (PHO)Answer : AQuestion 156Paul Gilbert has been covered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began a new job and immediately enrolled in his new company's group health plan, which has a Choice A: Can exclude coverage for treatment of Mr. Gilbert's angina for one year, because HIPAA does not impact a group health plan's pre-existing condition provision.Choice B: Can exclude coverage for treatment of Mr. Gilbert's angina for one year, because Mr. Gilbert did not have at least 36 months of creditable coverage under his previous health plan.Choice C: Can exclude coverage for treatment of Mr. Gilbert's angina for three months, because that is the length of time he received treatment for this medical condition prior to his enrollment in the new health plan.Choice D: Cannot exclude his angina as a pre-existing condition, because the one-year pre-existing condition provision is offset by at least one year of continuous coverage under his previous health plan.Answer : DQuestion 157PBM plans operate under several types of contractual arrangements. Under one contractual arrangement, the PBM plan and the employer agree on a target cost per employee per month. If the actual cost per employee per month is greater than the target cost, tChoice A: fee-for-service arrangementChoice B: risk sharing contractChoice C: capitation contractChoice D: rebate contractAnswer : BQuestion 158Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involvesChoice A: ascertaining that physicians in the plan have the necessary and appropriate credentials to prescribe medicationsChoice B: compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to expected patterns within select drug categoriesChoice C: monitoring patient-specific drug problems through concurrent and retrospective reviewChoice D: establishing protocols that require physicians to obtain certification of medical necessity prior to drug dispensingAnswer : BQuestion 159Phillip Tsai is insured by both a indemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication of benefits pChoice A: $0Choice B: $300Choice C: $400Choice D: $900Answer : CQuestion 160Phillip Tsai is insured by both a traditional idemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication ofChoice A: $0Choice B: $300Choice C: $400Choice D: $900Answer : CQuestion 161Phoebe Urich is covered by a traditional indemnity health insurance plan that specifies a $500 calendar-year deductible and includes a 20% coinsurance provision. When Ms. Urich was hospitalized, she incurred $3,000 in medical expenses that were covered byChoice A: 1900Choice B: 2000Choice C: 2400Choice D: 2500Answer : BQuestion 162Primary care case managers (PCCMs) provide case management services to eligible Medicaid recipients. With regard to PCCMs it is correct to say that:Choice A: PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipients.Choice B: All Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs.Choice C: PCCMs receive a case management fee in addition to reimbursement for medical services on a FFS basis.Choice D: PCCMs contract directly with the federal government to provide case management services to Medicaid recipients.Answer : CQuestion 163Primary care case managers (PCCMs) provide managed healthcare services to eligible Medicaid recipients. With regard to PCCMs, it is correct to say thatChoice A: PCCMs contract directly with the federal government to provide case management services to Medicaid recipientsChoice B: all Medicaid recipients who live in rural areas must be given a choice of at least four PCCMsChoice C: Medicaid PCCM programs are exempt from the Health Care Financing Administration's (HCFA's) Quality Improvement System for Managed Care (QISMC) standardsChoice D: PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipientsAnswer : CQuestion 164Provider integration has two components: operational integration and structural integration. An example of operational integration in health plans is the:Choice A: Acquisition of the Leopard Health Plan by the Hickory Health Plan.Choice B: Joint venture entered into by the Eclipse Health Plan and a local hospital system to create a new health plan in which Eclipse and the hospital system share ownership.Choice C: Formation of an organization by a group of providers to carry out billing, collections, and contracting with health plans for the entire group of providers.Choice D: Consolidation of the Carver Health Plan and the Limestone Health Plan.Answer : CQuestion 165Ronald Canton is a member of the Omega MCO. He receives his nonemergency medical care from Dr. Kristen High, an internist. When Mr. Canton needed to visit a cardiologist about his irregular heartbeat, he first had to obtain a referral from Dr. High to seeChoice A: Dr. High serves as the coordinator of care for the medical services that Mr. Canton receives.Choice B: Omega's network of providers includes Dr. High, but not Dr. Miller.Choice C: Omega's system allows its members open access to all of Omega's participating providers.Choice D: Omega used a financing arrangement known as a relative value scale (RVS) to compensate Dr. Miller.Answer : AQuestion 166Several marketplace factors helped fuel the movement toward consumer choice. Which one of the following statements is NOT accurate with regard to these factors?Choice A: After a period of relative stability, annual growth in private health spending per capita began to increase rapidly in 2002.Choice B: During the height of the recent cost upswing, insurance premiums were increasing by more than 13% annually.Choice C: Increased utilization was the largest factor contributing to the rise in premiums, accounting for 43% of the increase.Choice D: Employer payers began seeking ways to control spiraling utilization rates and provide lowercost health coverage options.Answer : AQuestion 167Some providers use electronic medical records (EMRs) to document their patients' care in an electronic form. The following statement(s) can correctly be made about EMRs:A. EMRs are computerized records of a patient's clinical, demographic, and administraChoice A: B onlyChoice B: Both A and BChoice C: Neither A nor BChoice D: A onlyAnswer : DQuestion 168Some states mandate that an independent enrollment broker or benefits counselor contractor selected by the state must manage enrollment of the eligible Medicaid population into managed care. In other states a health plan can engage independent brokers andChoice A: Many states have regulations that prohibit health plans from using door-to-door and/or telephone solicitation to market health plan products to the Medicaid population.Choice B: Health plans are never allowed to medically underwrite individual market customers who are under age 65.Choice C: To promote a health plan product to the individual market, health plans typically use captive agents who give sales presentations to potential customers, rather than using promotion tools such as direct mail, telemarketing, or advertising.Choice D: Health plans typically are allowed to medically underwrite all individual marketcustomers who are covered by Medicare and can refuse to cover such customers.Answer : AQuestion 169Specialty services that have certain characteristics generally are good candidates for managed care approaches. These characteristics generally include that the specialty service should haveChoice A: appropriate, rather than inappropriate, utilizationChoice B: a defined patient populationChoice C: low, stable costsChoice D: a benefit that cannot be easily definedAnswer : BQuestion 170Specialty services with certain characteristics tend to make good candidates for health plan approaches. One characteristic used to identify a specialty service that may be a good candidate for a health plan approach is that the service should haveChoice A: a defined patient populationChoice B: a complex benefit structureChoice C: low, stable costsChoice D: appropriate utilization ratesAnswer : AQuestion 171The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.Choice A: TrueChoice B: FalseChoice C: Choice D: Answer : BQuestion 172The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.Choice A: TrueChoice B: FalseChoice C: Choice D: Answer : BQuestion 173The Acme HMO recruits and contracts directly with a wide range of physiciansboth PCPs and specialistsin its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The Choice A: an independent practice association (IPA) model HMOChoice B: a staff model HMOChoice C: a direct contract model HMOChoice D: a group model HMOAnswer : CQuestion 174The administrative simplification standards described under Title II of HIPAA include privacy standards to control the use and disclosure of health information. In general, these privacy standards prohibitChoice A: all health plans, healthcare providers, and healthcare clearinghouses from using any protected health information for purposes of treatment, payment, or healthcare operations without an individual's written consentChoice B: patients from requesting that restrictions be placed on the accessibility and use of protected health informationChoice C: transmission of individually identifiable health information for purposes other than treatment, payment, or healthcare operations without the individual's written authorizationChoice D: patients from accessing their medical records and requesting the amendment of incorrect or incomplete informationAnswer : DQuestion 175The Advantage Health Plan recently added the following features to its member services program:IVRActive member outreach programAdvantage's member services staffing needs are likely to increase as a result ofChoice A: 1Choice B: 2Choice C: 1 & 2Choice D: Neither 1 nor 2Answer : BQuestion 176The application of health plan principles to workers' compensation insurance programs has presented some unique challenges because of the differences between health plan for traditional group healthcare and workers' compensation. One key difference is thaChoice A: limits coverage to eligible employees and excludes part-time employeesChoice B: specifies an annual lifetime benefit maximum on dollar coverage for medical costsChoice C: provides benefits regardless of the cause of an injury or illnessChoice D: provides benefits for both healthcare costs and lost wagesAnswer : DQuestion 177The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to beChoice A: CredentialingChoice B: AccreditationChoice C: A sentinel eventChoice D: A screening programAnswer : AQuestion 178The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to beCh