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3 Months Free Update
3 Months Free Update
Wellborne HMO provides health-related information to its plan members through an Internet Web site. Laura Knight, a Wellborne plan member, visited Wellborne's Web site to gather uptodate information about the risks and benefits of various treatment option
The following statements apply to enrollment statistics for HSAs. Select the answer choice that contains the CORRECT statement.
Utilization management techniques that most HMOs use for hospital providers include:
The agreement by two or more independent competitors on the prices or fees that they will charge for services is known as:
The process of calculating the appropriate premium to charge purchasers, given the degree of risk represented by the individual or group, the expected costs to deliver medical services, and the expected marketability and competitiveness of the health plan
The following statements describe corporate transactions:
Transaction A – An MCO acquired another MCO.
Transaction B – A group of providers formed an organization to carry out billings, collections, and contracting with MCOs for the entire group of provide
To determine fee reimbursements to be paid to physicians, the Triangle Health Plan assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier. Triangle and the providers negotiate the value of the
The following statements are about concepts related to the underwriting function within a health plan. Select the answer choice containing the correct statement.
When determining the premium rates it will charge a particular group, the Blue Jay Health Plan used a rating method known as community rating by class (CRC). Under this rating method, Blue Jay
Which of the following people would be considered part of the individual market segment?
The Venus Hospital provides medical care to paying patients, as well as to people who either have no healthcare coverage and cannot pay for the care by themselves or who receive services at reduced rates because they are covered under government sponsored
Which of the following is(are) CORRECT?
(A) Staff model HMOs can achieve maximum economies of scale but are heavily capital intensive.
(B) Staff model HMOs are closed panel.
(C) Staff model HMOs operate out of ambulatory care facilities.
Which of the following is NOT a factor that is used by MCOs to determine which services will undergo utilization review?
Combined system of preventive, diagnostic and therapeutic measures that focuses on management of specific chronic illness or medical conditions are:
Which of the following is NOT a preventive care initiative often used by health plans?
The following types of CDHPs allow federal tax advantages including the ability to roll funds from one year to the next:
The National Committee for Quality Assurance (NCQA) is a nonprofit organization that accredits health plans and other healthcare organizations. Under the current NCQA accreditation program, a health plan's accreditation score is determined, in part, by pe
The following statement(s) can correctly be made about electronic data interchange (EDI):
In 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?
The following statements are about preferred provider organizations (PPOs). Select the answer choice that contains the correct statement.
The main purpose of the Health Plan Employer Data and Information Set (HEDIS) is to provide
The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential
The NAIC adopted the HMO Model Act in order to provide a system of ongoing regulatory monitoring of HMOs. All of the following statements are correct about the HMO Model Act EXCEPT that it:
System classifies hundreds of hospital services based on a number of criteria, such as primary and secondary diagnosis, surgical procedures, age, gender, and the presence of complications.
The act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage is:
The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the correct response.
Arrange the following provider organizations in the order ranging from least integrated.
I. Physician Practice Management (PPM) company
II. Integrated Delivery System (IDS)
III. Group Practice Without Walls (GPWW)
IV. Independent Practice Association (IPA)
Health 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. The
From the following choices, choose the definition that best matches the term Screening
Arthur 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
Before 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
A 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 that
By 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 as
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
Before 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 to
Col. Martin Avery, on active duty in the U.S. Army, is eligible to receive healthcare benefits under one of the three TRICARE health plan options. If Col Avery elects to participate in TRICARE Prime, he will be
In most cases, medical errors are caused by breakdowns in the healthcare system rather than by provider mistakes.
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
In large health plans, management functions such as provider recruiting, credentialing, contracting, provider service, and performance management for providers are typically the responsibility of the
A public employer, such as a municipality or county government would be considered which of the following?
In 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?
The provision of mental health and chemical dependency services is collectively known as behavioral healthcare. The following statements are about behavioral healthcare. Three of these statements are true and one statement is false. Select the answer choice
Which of the choices below contains the four tools used by marketers that make up the 'promotion mix'?
One true statement regarding ethics and laws is that the values of a community are reflected in
Primary care case managers (PCCMs) provide managed healthcare services to eligible Medicaid recipients. With regard to PCCMs, it is correct to say that
Phoebe 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 by
The contract between the Honolulu MCO and Beverley Hills Hospital contains a 90 day cure provision. The Beverley Hills Hospital breached one of the contract requirements on July 31, 2004. The hospital remedied the problem by October 31, 2004. Which of the
The Conquest Corporation contracts with the Apex health plan to provide basic medical and surgical services to Conquest employees. Conquest entered into a separate contract with the Bright Dental Group to provide and manage a dental care program for employee
Primary care case managers (PCCMs) provide case management services to eligible Medicaid recipients. With regard to PCCMs it is correct to say that:
Pharmacy 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 involves
In 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
The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive Committee serves as a long-term advisory body on issues
The 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 prohibit
The Employee Retirement Income Security Act (ERISA) requires health plan members who receive healthcare benefits through employee benefit plans to file legal challenges involving coverage decisions or plan administration at the federal level. Under the te
The 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 be
The Courtland PPO maintains computerized records that include clinical, demographic, and administrative data about individual plan members. The data in these records is available to plan providers, ancillary service departments, pharmacies, and others inv
One ethical principle in health plans is the principle of non-malfeasance, which holds that health plans and their providers:
Lansdale 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 copayment
One true statement regarding ethics and laws is that the values of a community are reflected in
Many 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 a
Specialty services that have certain characteristics generally are good candidates for managed care approaches. These characteristics generally include that the specialty service should have
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. In early efforts to manage healthcare costs, traditional indemnity health insurers included in their health pla
Member 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 from
Janet Riva is covered by a traditional 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.
Patrick 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 special
Members 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 for
John 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 on
Medicare Part C can be delivered by the following Medicare Advantage plans:
Medicaid 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 that
The Advantage Health Plan recently added the following features to its member services program:
1. IVR
2. Active member outreach program
3. Advantage's member services staffing needs are likely to increase as a result of
The following statement can be correctly made about Medicare Advantage eligibility:
Katrina 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 —
Parable 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-gr
The criteria used to identify and measure healthcare quality are generally divided into three categories: structure, process, and outcomes measures. Structure measures, which relate to the nature and quality of the resources that a health plan has available
One typical characteristic of an integrated delivery system (IDS) is that an IDS.
Janet 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 incurred
Katrina 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 -
The 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 be
The Acme HMO recruits and contracts directly with a wide range of physicians—both PCPs and specialists—in its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The
All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.
During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a group’s geographic location, the size and gender mix of the group, and the level of participation in the grou
In 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 several
As 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:
Before 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 the
Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included
Federal 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 the
After a somewhat modest start in 2004, enrollment in HSA-related health plans more than tripled in 2005, making them today’s fastest growing type of CDHP. As of January 2006, enrollment in HSAs had reached nearly:
Each 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.
From the following choices, choose the definition that best matches the term health risk assessment (HRA)
As 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 im
Health 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 pl
Identify 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.
As 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:
In 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 of
Ian 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 h
A 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 that
During 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, fo
Employer-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 it
Although 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 pr
A 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 must
TESTED 12 Sep 2025