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Question 1 The 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, ha e an e!uity interest in the practice, and pro ide Choice A: a capti e group a staff model Choice B: a capti e group a networ" model Choice C: an independent group a networ" model Choice D: an independent group a staff model Answer : # Question $ %%%%%%%%%%%%%% HMOs can&t medically underwrite any group ' incl small groups. Choice A: (tate Choice B: )ot-for-profit Choice C: *or-profit Choice D: *ederally !ualified Answer : # Question + , common physician-only integrated model is a group practice without walls -./001. One characteristic of a typical ./00 is that the Choice A: ./00 combines multiple independent physician practices under one umbrella organi2ation Choice B: ./00 generally has a lesser degree of integration than does an 3/, Choice C: member physicians cannot own the ./00 Choice D: ./00&s member physicians must perform their own business operations Answer : , Question 4 , health plan may use one of se eral types of community rating methods to set premiums for a health plan. The following statements are about community rating. (elect the answer choice containing the correct statement. Choice A: (tandard -pure1 community rating is typically used for large groups because it is the most competiti e rating method for large groups.

Choice B: 5nder standard -pure1 community rating, a health plan charges all employers or other group sponsors the same dollar amount for a gi en le el of medical benefits or health plan, without ad6usting for factors such as age, gender, or e7perience. Choice C: 3n using the ad6usted community rating -,891 method, a health plan must consider the actual e7perience of a group in de eloping premium rates for that group. Choice D: The 8enters for Medicare and Medicaid (er ices -8M(1 prohibits health plans that assume Medicare ris" from using the ad6usted community rating -,891 me Answer : # Question : , health plan&s ability to establish an effecti e pro ider networ" depends on the characteristics of the proposed ser ice area and the needs of proposed plan members. 3t is generally correct to say that Choice A: health plans ha e more contracting options if pro iders are affiliated with single entities than if pro iders are affiliated with multiple entities Choice B: urban areas offer more fle7ibility in pro ider contracting than do rural areas Choice C: consumers and purchasers in mar"ets with little health plan acti ity are li"ely to be more recepti e to HMOs than to loosely managed plans such as //Os Choice D: large employers tend to adopt health plans more slowly than do small companies Answer : # Question ; , health sa ings account must be coupled with an H<H/ that meets federal re!uirements for minimum deductible and ma7imum out-of-poc"et e7penses. <ollar amounts are inde7ed annually for inflation. *or $==;, the annual deductible for self-only co erage must Choice A: >:$: Choice B: >1,=:= Choice C: >$,1== Choice D: >:,$:= Answer : #

Question ? , medical foundation is a not-for-profit entity that purchases and manages physician practices. 3n order to retain its not-for-profit status, a medical foundation must Choice A: pro ide significant benefit to the community Choice B: employ, rather than contract with, participating physicians Choice C: achie e economies of scale through facility consolidation and practice management Choice D: refrain from the corporate practice of medicine Answer : , Question @ , particular health plan offers a higher le el of benefits for ser ices pro ided in-networ" than for out-of-networ" ser ices. This health plan re!uires preauthori2ation for certain medical ser ices. 0ith regard to the steps that the health plan&s claims e Choice A: should assume that all ser ices re!uiring preauthori2ation ha e been preauthori2ed Choice B: should in estigate any conflicts between diagnostic codes and treatment codes before appro ing the claim to ensure that the appropriate payment is made for the claim Choice C: need not erify that the pro ider is part of the health plan&s networ" before appro ing the claim at the in-networ" le el of benefits Choice D: need not determine whether the member is co ered by another health plan that allows for coordination of benefits Answer : # Question A , physician-hospital organi2ation -/HO1 may be classified as an open /HO or a closed /HO. 0ith respect to a closed /HO, it is correct to say that ,. the specialists in the /HO are typically compensated on a capitation basis Choice A: the specialists in the /HO are typically compensated on a capitation basis Choice B: it typically limits the number of specialists by type of specialty Choice C: it is a ailable to a hospital&s entire eligible medical staff Choice D: physician membership in the /HO is limited to /8/s Answer : #

Question 1= , public employer, such as a municipality or county go ernment would be considered which of the followingB Choice A: Cmployer-employee group. Choice B: Multiple-employer group. Choice C: ,ffinity group. Choice D: <ebtor-creditor group. Answer : , Question 11 ,ccording to the 39(, which of the following is not an allowable pre enti e care ser ice: Choice A: (mo"ing cessation programs. Choice B: /eriodic health e7aminations. Choice C: Health club memberships. Choice D: 3mmuni2ations for children and adults. Answer : 8 Question 1$ ,fter a somewhat modest start in $==4, enrollment in H(,-related health plans more than tripled in $==:, ma"ing them todayDs fastest growing type of 8<H/. ,s of Eanuary $==;, enrollment in H(,s had reached nearly: Choice A: 1.$ million Choice B: $.$ million Choice C: +.$ million Choice D: 4.$ million Answer : # Question 1+ ,l Mara", a member of the *ra2ier Health /lan, has as"ed for a typical Fe el One appeal of a decision that *ra2ier made regarding Mr. Mara"&s co erage. One true statement about this Fe el One appeal is that Choice A: Mr. Mara" has the right to appeal to the ne7t le el if the Fe el One appeal upholds the original decision Choice B: it re!uires *ra2ier and Mr. Mara" to submit to arbitration in order to resol e the dispute Choice C: it is considered to be an informal appeal Choice D: it will be handled by an independent re iew organi2ation

-39O1 Answer : , Question 14 ,ll 8<H/ products pro ide federal ta7 ad antages while allowing consumers to sa e money for their healthcare. Choice A: True Choice B: *alse Choice C: Choice D: Answer : , Question 1: ,llgood Medical, 3nc., a health plan, has contracted with Mercy Memorial Hospital to pro ide inpatient medical ser ices to ,llgood&s plan members. The terms of the contract specify that ,llgood will reimburse Mercy Memorial on the basis of a negotiated ch Choice A: per diem agreement Choice B: fee-for-ser ice agreement Choice C: withhold agreement Choice D: diagnostic related group -<9.1 agreement Answer : , Question 1; ,lthough the process is oluntary for health plans, e7ternal accreditation is becoming more and more important as states and purchasers re!uire health plans undergo as many states and purchasers re!uire health plans undergo some type of e7ternal re iew pr Choice A: 3s oluntary for health plans. Choice B: 9e!uires all change accreditation organi2ations to use the same standards of accreditation. Choice C: Typically re!uires the accrediting organi2ation to conduct a medical record re iew and a re iew of a health plan&s credentialing processes, but not an e aluation of the health plans& member ser ice systems processes. Choice D: 8annot assure that a health plan meets a specified le el of !uality. Answer : ,

Question 1? ,mendments to the HMO act 1A?+ do not permit federally !ualified HMODs to use Choice A: 9etrospecti e e7perience rating Choice B: ,d6usted community rating Choice C: 8ommunity rating by class Choice D: 8ommunity rating Answer : , Question 1@ ,n e7clusi e pro ider organi2ation -C/O1 operates much li"e a //O. Howe er, one difference between an C/O and a //O is that an C/O Choice A: is regulated under federal HMO legislation Choice B: generally pro ides no benefits for out-of-networ" care Choice C: has no pro ider networ" of physicians Choice D: is not sub6ect to state insurance laws Answer : # Question 1A ,n HMO that combines characteristics of two or more HMO models is sometimes referred to as a Choice A: networ" model HMO Choice B: group model HMO Choice C: staff model HMO Choice D: mi7ed model HMO Answer : < Question $= ,ppropriateness of treatment pro ided is determined by de eloping criteria that if unmet will prompt further in estigation of a claim which are also called: Choice A: 8odes Choice B: Fists Choice C: Cdits Choice D: 8hec"s Answer : 8 Question $1

,rthur Moyer is co ered under his employer&s group health plan, which must comply with the 8onsolidated Omnibus #udget 9econciliation ,ct -8O#9,1. Mr. Moyer is terminating his employment. He has elected to continue his co erage under his employer&s group Choice A: 1@ months, but his co erage under 8O#9, will cease if he obtains group health co erage through another employer. Choice B: 1@ months, e en if he obtains group health co erage through another employer. Choice C: +; months, but his co erage under 8O#9, will cease if he obtains group health co erage through another employer. Choice D: +; months, e en if he obtains group health co erage through another employer. Answer : , Question $$ ,s part of its !uality management program, the Fyric Health /lan regularly compares its practices and ser ices with those of its most successful competitor. 0hen Fyric concludes that its competitor&s practices or ser ices are better than its own, Fyric im Choice A: #enchmar"ing. Choice B: (tandard of care. Choice C: ,n ad erse e ent. Choice D: 8ase-mi7 ad6ustment. Answer : , Question $+ ,s part of its utili2ation management -5M1 system, the 8reole Health /lan uses a process "nown as case management. The following indi iduals are members of the 8reole Health /lan: G Eill )o ace", who has a chronic respiratory condition. G ,braham 9ashad, Choice A: Ms. )o ace", Mr. 9ashad, and Mr. <e ereau7. Choice B: Ms. )o ace" and Mr. 9ashad only. Choice C: Ms. )o ace" and Mr. <e ereau7 only. Choice D: )one of these members. Answer : , Question $4 ,s part of its utili2ation management -5M1 system, the /oplar M8O uses

a process "nown as case management. The following statements describe indi iduals who are /oplar plan members: H #rad Ian )ote, age $@, is ta"ing many different, costly medications for Choice A: Mr. Ian )ote, Mr. ,lbrecht, and Ms. 8romartie Choice B: Mr. Ian )ote and Ms. 8romartie only Choice C: Mr. Ian )ote and Mr. ,lbrecht only Choice D: Mr. ,lbrecht and Ms. 8romartie only Answer : 8 Question $: ,shley Martin is co ered by a managed healthcare plan that specifies a >+== deductible and includes a +=J coinsurance pro ision for all healthcare obtained outside the planDs networ" of pro iders. 3n 1AA@, Ms. Martin became ill while she was on acation, Choice A: >+== Choice B: >:1= Choice C: >;== Choice D: >@1= Answer : < Question $; #art Iereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. #oth plans ha e a typical coordination of benefits -8O#1 pro ision, but neither plan has a nonduplication of benefits pro isi Choice A: +@= Choice B: 1+= Choice C: = Choice D: ::= Answer : , Question $? #ecause many patients with beha ioral health disorders do not re!uire round-the-cloc" nursing care and super ision, beha ioral healthcare ser ices can be deli ered effecti ely in a ariety of settings. *or e7ample, post-acute care for beha ioral health di Choice A: Hospital obser ation units or psychiatric hospitals. Choice B: /sychiatric hospitals or rehabilitation hospitals. Choice C: (ubacute care facilities or s"illed nursing facilities.

Choice D: /sychiatric units in general hospitals or hospital obser ation units. Answer : 8 Question $@ #efore an HMO contracts with a physician, the HMO first erifies the physician&s credentials. 5pon becoming part of the HMO&s organi2ed system of healthcare, the physician is typically sub6ect to Choice A: both recredentialing and peer re iew Choice B: recredentialing only Choice C: peer re iew only Choice D: neither recredentialing nor peer re iew Answer : 8 Question $A #efore the Hill Health Maintenance Organi2ation -HMO1 recei ed a certificate of authority -8O,1 to operate in (tate K, it had to meet the state&s licensing re!uirements and financial standards which were established by legislation that is identical to the Choice A: 9ecei e compensation based on the olume and ariety of medical ser ices they perform for Hill plan members, whereas the specialists recei e compensation based solely on the number of plan members who are co ered for specific ser ices. Choice B: Ha e no financial incenti e to practice pre enti e care or to focus on impro ing the health of their plan members, whereas the specialists ha e a positi e incenti e to help their plan members stay healthy. Choice C: 9ecei e from the 3/, the same monthly compensation for each Hill plan member under the /8/&s care, whereas the specialists recei e compensation based on a percentage discount from their normal fees. Choice D: 9ecei e compensation based on a fee schedule, whereas the specialists recei e compensation based on per diem charges. Answer : 8 Question += #efore the Hill Health Maintenance Organi2ation -HMO1 recei ed a certificate of authority -8O,1 to operate in (tate K, it had to meet the state&s licensing re!uirements and financial standards which were

established by legislation that is identical to the Choice A: Hill had to ha e an initial net worth of at least >1.: million in order to obtain a 8O,. Choice B: The 8O, most li"ely e7empts Hill from any of (tate K&s enabling statutes. Choice C: Hill had to be organi2ed as a partnership in order to obtain a 8O, Choice D: The 8O, in no way indicates that Hill has demonstrated that it is fiscally sound. Answer : , Question +1 #efore the Feo Health Maintenance Organi2ation -HMO1 recei ed a certificate of authority -8O,1 to operate in (tate K, it had to meet the state&s licensing re!uirements and financial standards which were established by legislation that is identical to the Choice A: recei e compensation based on the olume and ariety for medical ser ices they perform for Feo plan members, whereas the specialists recei e compensation based solely on the number of plan members who are co ered for specific ser ices Choice B: ha e no financial incenti e to practice pre enti e care or to focus on impro ing the health of their plan members, whereas the specialists ha e a positi e incenti e to help their plan members stay healthy Choice C: recei e from the 3/, the same monthly compensation for each Feo plan member under the /8/&s care, whereas the specialists recei e compensation based on a percentage discount from their normal fees Choice D: recei e compensation based on a fee schedule, whereas the specialists recei e compensation based on per diem charges Answer : 8 Question +$ #eginning in the early 1A@=s, se eral factors contributed to increased demand for beha ioral healthcare ser ices. These factors included Choice A: increased stress on indi iduals and families Choice B: increased a ailability of beha ioral healthcare ser ices Choice C: greater awareness and acceptance of beha ioral healthcare issues Choice D: all of the abo e

Answer : < Question ++ #ill 8linton is a member of Fewins"y&s /#M plan which has a three-tier copayment structure. #ill fell ill and his doctor prescribed him ,,,, a brand-name drug which was included in the Fewins"y&s formularyL ###, a non-formulary drugL and 888, a generic dr Choice A: 888, ,,,, ### Choice B: ###, 888, ,,, Choice C: ###, ,,,, 888 Choice D: 888, ###, ,,, Answer : , Question +4 #ro"ers are one type of distribution channel that health plans use to mar"et their health plans. One true statement about bro"ers for health plan products is that, typically, bro"ers Choice A: are not re!uired to be licensed by the states in which they mar"et health plans Choice B: are compensated on a salary basis Choice C: represent only one health plan or insurer Choice D: are considered to be an agent of the buyer rather than an agent of the health plan or 3nsurer Answer : < Question +: #y definition, a health plan&s networ" refers to the Choice A: organi2ations and indi iduals in ol ed in the consumption of healthcare pro ided by the plan Choice B: relati e accessibility of the plan&s pro iders to the plan&s participants Choice C: group of physicians, hospitals, and other medical care pro iders with whom the plan has contracted to deli er medical ser ices to its members Choice D: integration of the plan&s participants with the plan&s pro iders Answer : 8 Question +; #y definition, the mar"eting process of defining a certain place or mar"et

niche for a product relati e to competitors and their products and then using the mar"eting mi7 to attract certain mar"et segments is "nown as Choice A: branding Choice B: positioning Choice C: database mar"eting Choice D: personal selling Answer : # Question +? #y offering a comprehensi e set of healthcare benefits to its members, an HMO ensures that its members obtain !uality, cost-effecti e, and appropriate medical care. 0ays that an HMO pro ides comprehensi e care include Choice A: coordinating care across a ariety of benefits Choice B: emphasi2ing pre enti e care by co ering many pre enti e ser ices either in full or with a small copayment Choice C: offering its members access to wellness programs Choice D: ,ll of the abo e Answer : < Question +@ 8ol. Martin , ery, on acti e duty in the 5.(. ,rmy, is elegible to recei e healthcare benefits under one of the three T938,9C health plan options. 3f 8ol , ery elects to participate in T938,9C /rime, he will be Choice A: able to obtain full benefits for ser ices obtained from networ" and non-networ" pro iders Choice B: sub6ect to copayment, deductible, and coinsurance re!uirements for any medical care he recei es Choice C: re!uired to formally enroll for co erage and pay an enrollment fee Choice D: assigned to a primary care manager who is responsible for coordinating all his care Answer : < Question +A 8onsumer-directed health plans are not a new concept. They actually got their start in the late 1A?=s with the ad ent of: Choice A: Health sa ings accounts -H(,s1 Choice B: Health reimbursement arrangements -H9,s1

Choice C: Medical sa ings accounts -M(,s1 Choice D: *le7ible spending arrangements -*(,s1 Answer : < Question 4= <r. Eulia /hram is a cardiologist under contract to Holcomb HMO, 3nc., a typical closed-panel plan. The following statements are about this situation. (elect the answer choice containing the correct statement. Choice A: ,ll members of Holcomb HMO must select <r. /hram as their primary care physician -/8/1. Choice B: ,ny physician who meets Holcomb&s standards of care is eligible to contract with Holcomb HMO as a pro ider. Choice C: <r. /hram is either an employee of Holcomb HMO or belongs to a group of physicians that has contracted with Holcomb HMO Choice D: Holcomb HMO plan members may self-refer to <r. /hram at full benefits without first obtaining a referral from their /8/s. Answer : , Question 41 <r. Milton 0are, a physician in the 9i erside M8O&s networ" of pro iders, is reimbursed under a fee schedule arrangement for medical ser ices he pro ides to 9i erside members. <r. 0are&s pro ider contract with 9i erside contains a typical no-balance billi Choice A: pre ent <r. 0are from re!uiring a 9i erside member to pay any coinsurance, copayment, or deductibles that the member would normally pay under 9i erside&s plan Choice B: re!uire <r. 0are to accept the amount that 9i erside pays for medical ser ices as payment in full and not to bill plan members for additional amounts Choice C: pre ent <r. 0are from see"ing compensation from patients if 9i erside fails to compensate him because of the M8O&s insol ency Choice D: pre ent <r. 0are from billing a 9i erside member for medical ser ices that are not included in 9i erside&s plan Answer : # Question 4$ <r. (amuel ,ldridge&s pro ider contract with the #adger Health /lan includes a typical due process clause. The primary purpose of this clause is to:

Choice A: (tate that <r. ,ldridge&s pro ider contract with #adger will automatically terminate if he loses his medical license or hospital pri ileges. Choice B: (pecify a time period during which the party that breaches the pro ider contract must remedy the problem in order to a oid termination of the contract. Choice C: .i e <r. ,ldridge the right to appeal #adger&s decision if he is terminated with cause from #adger&s pro ider networ". Choice D: (pecify that #adger can terminate this pro ider contract without pro iding a reason, but only if #adger gi es <r. ,ldridge at least A=-days& notice of its intent to terminate the contract. Answer : 8 Question 4+ <uring an open enrollment period in 1AA?, ,my Hade" enrolled through her employer for group health co erage with the Owl Health /lan, a federally !ualified HMO. ,t the time of her enrollment, Ms. Hade" had three pre-e7isting medical conditions: angina, fo Choice A: the angina, the high blood pressure, and the bro"en an"le Choice B: the angina and the high blood pressure only Choice C: none of these conditions Choice D: the bro"en an"le only Answer : , Question 44 <uring the ris" assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a groupDs geographic location, the si2e and gender mi7 of the group, and the le el of participation in the grou Choice 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 li"ely it is that the group will e7perience losses similar to the a erage rate of loss that was predicted. Choice D: ,ll of the abo e

Answer : 8 Question 4: Cach of the following statements describes a health plan that is using a method of managing institutional utili2ation. (elect the answer choice that describes a health plan&s use of retrospecti e re iew to decrease utili2ation of hospital ser ices. Choice A: The (erenity Healthcare Organi2ation re!uires a plan member or the pro ider in charge of the member&s care to obtain authori2ation for inpatient care before the member is admitted to the hospital. Choice B: 59 nurses employed by the *riendship Health /lan monitor length of stay to identify factors that might contribute to unnecessary hospital days. Choice C: The Optimum Health .roup e aluates the medical necessity and appropriateness of proposed ser ices and inter enes, if necessary, to redirect care to a more appropriate care setting. Choice D: The ,7is Medical .roup e7amines pro ider practice patterns to identify areas in which ser ices are being underused, o erused, or misused and designs strategies to pre ent inappropriate utili2ation in the future. Answer : < Question 4; Cd Murray is a claims analyst for a managed care plan that pro ides a higher le el of benefits for ser ices recei ed in-networ" than for ser ices recei ed out-of-networ". 0hene er Mr. Murray recei es a health claim from a plan member, he re iews the claim Choice A: ,, #, 8, and < Choice B: , and 8 only Choice C: ,, #, and < only Choice D: #, 8, and < only Answer : , Question 4? Cd O&#rien has both Medicare /art , and /art # co erage. He also has co erage under a /#M plan that uses a closed formulary to manage the cost and use of pharmaceuticals. 9ecently, Mr. O&#rien was hospitali2ed for an aneurysm. Fater, he was transferred by Choice A: 8onfinement in the e7tended-care facility after his hospitali2ation.

Choice B: Transportation by ambulance from the hospital to the e7tendedcare facility. Choice C: /hysicians& professional ser ices while he was hospitali2ed. Choice D: physicians& professional ser ices while he was at the e7tendedcare facility. Answer : , Question 4@ Cleanor .iambi is co ered by a typical $4-hour managed care program. One characteristic of this program is that it: Choice A: /ro ides Ms. .iambi with healthcare co erage for any illness or in6ury, but only if the cause of the illness or in6ury is wor"-related. Choice B: 8ombines the group health plan and disability plan offered by Ms. .iambi&s employer with wor"ers& compensation co erage. Choice C: 9e!uires Ms. .iambi and her employer to each pay half of the cost of this co erage. Choice D: 9e!uires Ms. .iambi to pay specified deductibles and copayments before recei ing benefits under this program for any illness or in6ury. Answer : # Question 4A Cmily #rown wor"s for 3ntegral Health /lan and represents the company as a board member for the board of directors. 0hich best describes Cmily&s positionB Choice A: 8ommunity 9epresentati e Choice B: 3nside <irector Choice C: Outside <irector Choice D: )one of these Answer : # Question := Cmployer-sponsored benefit plans that pro ide healthcare benefits must comply with the Cmployee 9etirement 3ncome (ecurity ,ct -C93(,1. One of the most significant features of C93(, is that it Choice A: contains a pro ision stating that the terms of C93(, generally ta"e precedence o er any state laws that regulate employee welfare benefit plans Choice B: standardi2es the con ersion of group healthcare benefits to

indi idual healthcare benefits Choice C: mandates that self-funded healthcare plans must pay state premium ta7es Choice D: re!uires that all acti e employees, regardless of age, must be eligible for co erage under employer-sponsored benefit plans Answer : , Question :1 *ederal Cmployee Health #enefits /rogram -*CH#/1 re!uires health plans offering ser ices to federal employees and their dependents to pro ide ,. 3mmediate access to emergency ser ices #. 5rgent ,ppointments within $4 hours 8. 9outine appointments once a m Choice A: < Choice B: , Choice C: # M 8 Choice D: ,ll of the listed options Answer : * Question :$ *ederal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that ser ice pri ate sector -commercial1 plan members at the state le el. This federal legislation is the Choice A: 8layton ,ct Choice B: *ederal Trade 8ommission ,ct Choice C: Mc8arran-*erguson ,ct Choice D: (herman ,ct Answer : 8 Question :+ *ollowing a report by the 3nstitute of Medicine on the incidence and conse!uences of medical errors, a national tas" force recommended implementation of a nationwide mandatory system of collecting, analy2ing, and reporting standardi2ed information about m Choice A: random change Choice B: structural change Choice C: hapha2ard change Choice D: reacti e change

Answer : < Question :4 *or pro iders, integration occurs when two or more pre iously separate pro iders combine under common ownership or control, or when two or more pro iders combine business operations that they pre iously carried out separately and independently. (uch pro i Choice A: higher costs for health plans, healthcare purchasers, and healthcare consumers Choice B: impro ed pro ider contracting position with health plans Choice C: an increase in pro iders& autonomy and control o er their own wor" en ironment Choice D: all of the abo e Answer : # Question :: *or this !uestion, select the answer choice containing the terms that correctly complete the blan"s labeled , and # in the paragraph below. )8Q, offers Quality 8ompass, a national database of performance and accreditation information submitted by managed Choice A: Health /lan Cmployer <ata and 3nformation (et -HC<3(1 mandatory Choice B: Health /lan Cmployer <ata and 3nformation (et -HC<3(1 oluntary Choice C: O9NK mandatory Choice D: O9NK oluntary Answer : # Question :; *rom the answer choices below, select the response that correctly identifies the rating method that Mr. (ybe7 used and the premium rate /M/M that Mr. (ybe7 calculated for the Ooster group. Choice A: 9ating Method boo" rating /remium 9ate /M/M >1+$ Choice B: 9ating Method boo" rating /remium 9ate /M/M >1+@ Choice C: 9ating Method blended rating /remium 9ate /M/M >1+$ Choice D: 9ating Method blended rating /remium 9ate /M/M >1+@ Answer : 8 Question :?

*rom the following answer choices, choose the description of the ethical principle that best corresponds to the term ,utonomy Choice A: Health plans and their pro iders are obligated not to harm their members Choice B: Health plans and their pro iders should treat each member in a manner that respects the member&s goals and alues, and they also ha e a duty to promote the good of the members as a group Choice C: Health plans and their pro iders should allocate resources in a way that fairly distributes benefits and burdens among the members Choice D: Health plans and their pro iders ha e a duty to respect the right of their members to ma"e decisions about the course of their li es Answer : < Question :@ *rom the following answer choices, choose the description of the ethical principle that best corresponds to the term ,utonomy Choice A: Health plans and their pro iders are obligated not to harm their members Choice B: Health plans and their pro iders should treat each member in a manner that respects the member&s goals and alues, and they also ha e a duty to promote the good of the members as a group Choice C: Health plans and their pro iders should allocate resources in a way that fairly distributes benefits and burdens among the members Choice D: Health plans and their pro iders ha e a duty to respect the right of their members to ma"e decisions about the course of their li es Answer : < Question :A *rom the following answer choices, choose the description of the ethical principle that best corresponds to the term #eneficence Choice A: Health plans and their pro iders are obligated not to harm their members Choice B: Health plans and their pro iders should treat each member in a manner that respects the member&s goals and alues, and they also ha e a duty to promote the good of the members as a group Choice C: Health plans and their pro iders should allocate resources in a way that fairly distributes benefits and burdens among the members Choice D: Health plans and their pro iders ha e a duty to respect the right of their members to ma"e decisions about the course of their li es

Answer : # Question ;= *rom the following answer choices, choose the description of the ethical principle that best corresponds to the term #eneficence Choice A: Health plans and their pro iders are obligated not to harm their members Choice B: Health plans and their pro iders should treat each member in a manner that respects the member&s goals and alues, and they also ha e a duty to promote the good of the members as a group Choice C: Health plans and their pro iders should allocate resources in a way that fairly distributes benefits and burdens among the members Choice D: Health plans and their pro iders ha e a duty to respect the right of their members to ma"e decisions about the course of their li es Answer : # Question ;1 *rom the following choices, choose the definition that best matches the term health ris" assessment -H9,1 Choice A: , techni!ue used to educate plan members on how to distinguish between minor problems and serious conditions and effecti ely treat minor problems themsel es Choice B: , techni!ue used to determine if a health condition is present e en if a member has not e7perienced symptoms of the problem Choice C: , techni!ue in which information about a plan member&s health status, personal and family health history, and health-related beha iors is used to predict the member&s li"elihood of e7periencing specific illnesses or in6uries Choice D: , techni!ue used to e aluate the medical necessity, appropriateness, and cost-effecti eness of healthcare ser ices for a gi en patient Answer : 8 Question ;$ *rom the following choices, choose the definition that best matches the term (creening Choice A: , techni!ue used to educate plan members on how to distinguish between minor problems and serious conditions and effecti ely treat minor problems themsel es

Choice B: , techni!ue used to determine if a health condition is present e en if a member has not e7perienced symptoms of the problem Choice C: , techni!ue in which information about a plan member&s health status, personal and family health history, and health-related beha iors is used to predict the member&s li"elihood of e7periencing specific illnesses or in6uries Choice D: , techni!ue used to e aluate the medical necessity, appropriateness, and cost-effecti eness of healthcare ser ices for a gi en patient Answer : # Question ;+ .eneral HMO is building a pro ider networ" and is considering 5ni ersal Hospital as an addition to its networ". Minimum re!uirements that .eneral should consider in determining whether 5ni ersal is !ualified to participate in .eneral&s networ" include ,. Choice A: #oth , and # Choice B: , only Choice C: # only Choice D: )either , nor # Answer : , Question ;4 .reentree Medical, a health plan, is currently recruiting /8/s in preparation for its e7pansion into a new ser ice area. ,bigail <a is, a recruiter for .reentree, has been meeting with Melissa 8ortelyou, M.<., in an effort to recruit her as a /8/ in .reen Choice A: .reentree is pre ented by law from offering a contract to <r. 8ortelyou until the credentialing process is complete Choice B: any contract signed by <r. 8ortelyou should include a clause re!uiring the successful completion of the credentialing process within a defined time frame in order for the contract to be effecti e Choice C: .reentree must offer a standard contract to <r. 8ortelyou, without regard to the outcome of the credentialing process Choice D: .reentree will abandon the credentialing process now that <r. 8ortelyou has agreed to participate in .reentree&s networ" Answer : #

Question ;: Health plans can organi2e under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organi2ations typically Choice A: are e7empt from re iew by the 3nternal 9e enue (er ice -39(1 Choice B: are organi2ed as stoc" companies for greater fle7ibility in raising capital Choice C: rely on income from operations for the large cash outlays needed to fund long-term pro6ects and e7pansion Choice D: engage in lobbying or political acti ities in order to maintain their ta7-e7empt status Answer : 8 Question ;; Health plans may use different capitation arrangements for different le els of ser ice. One typical capitation arrangement pro ides a capitation payment that may include primary care only, or both primary and secondary care, but not ancillary ser ices. Th Choice A: global capitation arrangement Choice B: gate"eeper arrangement Choice C: car e-out arrangement Choice D: partial capitation arrangement Answer : < Question ;? Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further in estigation of a claim. 3n an automated claims processing system, these criteria may signal the need for further re iew when, for e7ampl Choice A: Cncounter reports Choice B: <iagnostic codes Choice C: <urational ratings Choice D: Cdits Answer : < Question ;@ Health plans re!uire utili2ation re iew for all ser ices administered by its participating physicians. Choice A: True

Choice B: *alse Choice C: Choice D: Answer : # Question ;A Health plans sometimes contract with independent organi2ations to pro ide specialty ser ices, such as ision care or rehabilitation ser ices, to plan members. (pecialty ser ices that ha e certain characteristics are generally good candidates for health pl Choice A: Fow or stable costs. Choice B: ,ppropriate, rather than inappropriate, utili2ation rates. Choice C: , benefit that cannot be easily defined. Choice D: <efined patient population. Answer : < Question ?= Health plans& use of the 3nternet to pro ide plan members with healthrelated information has grown rapidly in recent years. One ad antage the 3nternet has o er other forms of communication is that Choice A: users can access the 3nternet using a number of different types of computer systems Choice B: access to the 3nternet is a ailable only to members of the health plan&s networ" Choice C: the 3nternet is immune to internal security breaches by employees or trading partners within the networ" Choice D: users can contact a single controlling organi2ation to rectify disruptions in 3nternet ser ice Answer : , Question ?1 Health plans use the following to determine the number of pro iders to add to a networ": Choice A: (taffing ratios Choice B: <ri e time Choice C: .eographic a ailability Choice D: ,ll of the abo e Answer : <

Question ?$ Health sa ings accounts were created by which of the following laws: Choice A: 8O#9, Choice B: H3/,, Choice C: Medicare Moderni2ation ,ct Choice D: )one of the ,bo e Answer : 8 Question ?+ Historically most HMOs ha e been Choice A: 8losed-access HMO Choice B: 8losed-panel HMO Choice C: Open-access HMO Choice D: Open-panel HMO Answer : # Question ?4 HMOs typically employ se eral techni!ues to manage pro ider utili2ation and member utili2ation of medical ser ices. One techni!ue that an HMO uses to manage member utili2ation is Choice A: the use of physician practice guidelines Choice B: the re!uirement of copayments for office isits Choice C: capitation Choice D: ris" pools Answer : # Question ?: 3an Iladmir wants to ha e a routine physical e7amination to ascertain that he is in good health. Mr. Iladmir is a member of a health plan that will allow him to select the physician of his choice, either from within his plan&s networ" or from outside of h Choice A: a traditional HMO plan Choice B: a managed indemnity plan Choice C: a point of ser ice -/O(1 option Choice D: an e7clusi e pro ider organi2ation -C/O1 Answer : 8 Question ?; 3dentify the 8O99C8T statement-s1:

-,1 (maller the group, the more li"ely it is that the group will e7perience losses similar to the a erage rate of loss that was predicted. -#1 .ender of the group&s participants has no effect on the li"elihood of loss. Choice A: ,ll of the listed options Choice B: # M 8 Choice C: )one of the listed options Choice D: , M 8 Answer : 8 Question ?? 3f a state commissioner of insurance places an HMO under administrati e super ision, then the purpose of this action most li"ely is to: Choice A: Transfer all of the HMO&s business to other carriers. Choice B: ,llow the state commissioner, acting for a state court, to ta"e control of and administer the HMO&s assets and liabilities. Choice C: (ell the HMO&s assets in order to satisfy the HMO&s obligations. Choice D: /lace the HMO&s operations under the direction and control of the state commissioner or a person appointed by the commissioner. Answer : < Question ?@ 3f left unresol ed, member complaints about the actions or decisions made by a health plan or its pro iders can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info Choice A: a Fe el One appeal, and the member has the right to a further appeal Choice B: a Fe el Two appeal, and the re iewer&s decision is final and binding Choice C: an independent e7ternal appeal, and the member has the right to a further appeal Choice D: arbitration, and the re iewer&s decision is final and binding Answer : , Question ?A 3f 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

networ" in the ser ice area %%%%%%%%%%%%%%%%%%%%%%%%. Choice A: Has many contracting options a ailable. Choice B: (hould not contract with that entity Choice C: Most li"ely needs to contract with that entity Choice D: (hould attempt to disband the e7isting affiliations Answer : 8 Question @= 3mmediate e aluation and treatment of illness or in6ury can be pro ided in any of the following care settings: ,. Hospital emergency departments #. /hysician&s offices 8. 5rgent care centers 3f these settings are ran"ed in order of the cost of pro iding c Choice A: ,, #, 8 Choice B: ,, 8, # Choice C: #, 8, , Choice D: 8, ,, # Answer : # Question @1 3n 1AAA, the 5nited (tates 8ongress passed the *inancial (er ices Moderni2ation ,ct, referred to as the .ramm-Feach-#liley -.F#1 ,ct. The primary pro isions included under the .F# ,ct re!uire financial institutions, including health plans, to ta"e se eral Choice A: )otify customers of any sharing of non-public personal financial information with nonaffiliated third parties. Choice B: /rohibit customers from ha ing the opportunity to &opt-out& of sharing non-public personal financial information. Choice C: <isclose to affiliates, but not to third parties, their pri acy policies regarding the sharing of nonpublic personal financial information. Choice D: ,gree not to disclose personally identifiable financial information or personally identifiable health information. Answer : , Question @$ 3n 1AAA, the 5nited (tates 8ongress passed the *inancial (er ices Moderni2ation ,ct, which is referred to as the .ramm-Feach-#liley -.F#1 ,ct. The following statement-s1 can correctly be made about this

act: ,. The .F# ,ct allows con ergence among the tra Choice A: , only Choice B: #oth , and # Choice C: # only Choice D: )either , nor # Answer : # Question @+ 3n accounting terminology, the items of alue that a company ownsPsuch as cash, cash e!ui alents, and recei ablesPare generally "nown as the company&s Choice A: re enue Choice B: net income Choice C: surplus Choice D: assets Answer : < Question @4 3n addition to the credentialing acti ities that an health plan performs when initially accepting a pro ider into its networ", the health plan must also perform recredentialing of the same pro iders on an ongoing basis. Many of the same acti ities are per Choice A: erification of a networ" pro ider&s medical education and residency Choice B: performance of site inspections in a pro ider&s facilities Choice C: re iew of information from a pro ider&s !uality impro ement acti ities Choice D: erification of a pro ider&s licensure and certification Answer : , Question @: 3n assessing the potential degree of ris" represented by a proposed insured, a health underwriter considers the factor of antiselection. ,ntiselection can correctly be defined as the Choice A: inability of a proposed insured to share with the insurer the financial ris"s of healthcare co erage Choice B: possibility that a proposed insured will profit from an illness by recei ing benefits that e7ceed the total amount of his or her eligible

medical e7penses Choice C: inability of a proposed insured to pro ide sufficient e idence that pro es he or she is an insurable ris" Choice D: tendency of people who ha e a greater-than-a erage li"elihood of loss to apply for or continue insurance protection to a greater e7tent than people who ha e an a erage or less than a erage li"elihood of the same loss Answer : < Question @; 3n certain situations, a health plan can use the results of utili2ation re iew to inter ene, if necessary, to alter the course of a plan member&s medical care. (uch inter ention can be based on the results of ,. /rospecti e re iew #. 8oncurrent re iew 8. Choice A: ,, #, and 8 Choice B: , and # only Choice C: , and 8 only Choice D: # only Answer : < Question @? 3n certain situations, a health plan can use the results of utili2ation re iew to inter ene, if necessary, to alter the course of a plan member&s medical care. (uch inter ention can be based on the results of ,. /rospecti e re iew #. 8oncurrent re iew 8. Choice A: ,, #, and 8 Choice B: , and # only Choice C: , and 8 only Choice D: # only Answer : # Question @@ 3n claims administration terminology, a claims in estigation is correctly defined as the process of Choice A: reporting management information about ser ices pro ided

each time a patient isits a pro ider for purposes of analy2ing utili2ation and pro ider practice patterns Choice B: obtaining all the information necessary to determine the appropriate amount to pay on a gi en claim Choice C: routinely re iewing and processing a claim for either payment or denial Choice D: assigning to each diagnosis or treatment reported on a claim special codes that briefly and specifically describe each diagnosis and treatment Answer : # Question @A 3n health plan terminology, demand management, as used by health plans, can best be described as Choice A: an e aluation of the medical necessity, efficiency, andQor appropriateness of healthcare ser ices and treatment plans for a gi en patient Choice B: a series of strategies designed to reduce plan members& needs to utili2e healthcare ser ices by encouraging pre enti e care, wellness, member self-care, and appropriate use of healthcare ser ices Choice C: a techni!ue that pre ents a pro ider who is being reimbursed under a fee schedule arrangement from billing a plan member for any fees that e7ceed the ma7imum fee reimbursed by the plan Choice D: a system of identifying plan members with special healthcare needs, de eloping a healthcare strategy to meet those needs, and coordinating and monitoring the care Answer : # Question A= 3n large health plans, management functions such as pro ider recruiting, credentialing, contracting, pro ider ser ice, and performance management for pro iders are typically the responsibility of the Choice A: chief e7ecuti e officer -8CO1 Choice B: networ" management director Choice C: board of directors Choice D: director of operations Answer : # Question A1

3n most cases, medical errors are caused by brea"downs in the healthcare system rather than by pro ider mista"es. Choice A: True Choice B: *alse Choice C: Choice D: Answer : , Question A$ 3n order to compensate for lost re enue resulting from ser ices pro ided free or at a significantly reduced cost to other patients, many healthcare pro iders spread these unreimbursed costs to paying patients or third-party payors. This practice is "nown Choice A: dual choice Choice B: cost shifting Choice C: accreditation Choice D: defensi e medicine Answer : # Question A+ 3n order to co er some of the gap between **( Medicare co erage and the actual cost of ser ices, beneficiaries often rely on Medicare supplements. 0hich of the following statements about Medicare supplements is correctB Choice A: The initial ten -,-E1 Medigap policies offer a basic benefit pac"age that includes co erage for Medicare /art , and Medicare /art # coinsurance. Choice B: Cach insurance company selling Medigap must sell all the different Medigap policies. Choice C: Medicare (CFC8T is a Medicare supplement that uses a preferred pro ider organi2ation -//O1 to supplement Medicare /art , co erage. Choice D: Medigap benefits ary by plan type -, through F1, and are not uniform nationally. Answer : , Question A4 3n order to generate e7changes with consumers, healthcare plan mar"eters use the four elements of the mar"eting mi7: product, price, place -distribution1, and

Choice A: segmentation Choice B: publicity Choice C: promotion Choice D: plan design Answer : 8 Question A: 3n order to help re iew its institutional utili2ation rates, the (ahalee Medical .roup, a health plan, uses the standard formula to calculate hospital bed days per 1,=== plan members for the month to date -MT<1. On ,pril $=, (ahalee used the following inf Choice A: ;? Choice B: $?4 Choice C: +;: Choice D: 1,=== Answer : # Question A; 3n order to measure the e7penses of institutional utili2ation, Holt Healthcare .roup uses the standard formula to calculate hospital bed days per 1,=== plan members per year. On October $+, Holt used the following information to calculate the bed days per Choice A: $?@ Choice B: +A? Choice C: 4=+ Choice D: A$= Answer : # Question A? 3n preparation for its e7pansion into a new ser ice area, the 9egal M8O is meeting with <r. )ancy #uhner, a cardiologist who practices in 9egal&s new ser ice area, in order to con ince her to become one of the plan&s participating pro iders. ,s part of th Choice A: ensure that <r. #uhner complies with all of the pro isions of the Cthics in /atient 9eferrals ,ct Choice B: learn whether <r. #uhner is a licensed medical practitioner Choice C: confirm <r. #uhner&s membership in the )ational 8ommittee for Quality ,ssurance -)8Q,1 Choice D: learn whether <r. #uhner has had a medical malpractice claim

filed or other disciplinary actions ta"en against her Answer : < Question A@ 3n response to the demand for a method of assessing outcomes, accrediting organi2ations and other go ernment and commercial groups ha e de eloped !uantitati e measures of !uality that consumers, purchasers, regulators, and others can use to compare health Choice A: !uality standards Choice B: accreditation decisions Choice C: standards of care Choice D: performance measures Answer : < Question AA 3n the following sections, we will describe some of the measures health plans use to e aluate the !uality of the ser ices and healthcare they offer their members. 0hich of the following is the best description of what a &/rocess measure& e aluatesB Choice A: The nature, !uantity, and !uality of the resources that a health plan has a ailable for member ser ice and patient care. Choice B: The methods and procedures a health plan and its pro iders use to furnish ser ice and care. Choice C: The e7tent to which ser ices succeed in impro ing or maintaining satisfaction and patient health. Choice D: )one of the abo e Answer : # Question 1== 3n the paragraph below, a sentence contains two pairs of words enclosed in parentheses. <etermine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you ha e chosen. Many pharmacy benefit Choice A: Therapeutic Q always Choice B: .eneric Q always Choice C: .eneric Q ne er Choice D: Therapeutic Q ne er Answer : ,

Question 1=1 3n the paragraph below, two statements each contain a pair of terms enclosed in parentheses. <etermine which term correctly completes each statement. Then select the answer choice containing the two terms that you ha e chosen.*or pro iders, -operational Q Choice A: operational Q an ac!uisition Choice B: operational Q a consolidation Choice C: structural Q an ac!uisition Choice D: structural Q a consolidation Answer : < Question 1=$ 3n the 5nited (tates, the <epartment of <efense offers ongoing healthcare co erage to military personnel and their families through the T938,9C health plan. One true statement about T938,9C is that Choice A: hospitals participating in T938,9C program are e7empt from E8,HO accrediation and Medicare certification Choice B: T938,9C enrollees are not entitiled to appeal authori2ation co erage decisions Choice C: acti e duty personnel are automatically considered enrolled in T938,9C /rime Choice D: T938,9C co ers inpatient and outpatient ser ices, physician and hospital charges, and medical supplies, but not mental health ser ices Answer : 8 Question 1=+ 3n the 5nited (tates, the <epartment of <efense offers ongoing healthcare co erage to military personnel and their families through the T938,9C health plan. One true statement about T938,9C is that: Choice A: ,cti e duty military personnel are automatically considered enrolled in T938,9C /rime Choice B: T938,9C co ers inpatient and outpatient ser ices, physician and hospital charges, and medical supplies, but not mental health ser ices. Choice C: T938,9C enrollees are not entitled to appeal authori2ation or co erage decisions Choice D: Hospitals participating in the T938,9C program are e7empt from E8,HO accreditation and Medicare certification. Answer : ,

Question 1=4 3ndi iduals can use H(,s to pay for the following types of health co erage:. Choice A: Qualified disability insurance Choice B: 8O#9, continuation co erage. Choice C: Medigap co erage -for those o er ;:1. Choice D: ,ll of the abo e. Answer : # Question 1=: Eanet 9i a is co ered by a indemnity health insurance plan that specifies a >$:= deductible and includes a $=J coinsurance pro ision. 0hen Ms. 9i a was hospitali2ed, she incurred >$,:== in medical e7penses that were co ered by her health plan. (he incurre Choice A: >1,?:= Choice B: >1,@== Choice C: >$,=== Choice D: >$,$:= Answer : # Question 1=; Eanet 9i a is co ered by a traditional idemnity health insurance plan that specifies a >$:= deductible and includes a $=J coinsurance pro ision. 0hen Ms. 9i a was hospitali2ed, she incurred >$,:== in medical e7penses that were co ered by her health plan. Choice A: >1,?:= Choice B: >1,@== Choice C: >$,=== Choice D: >$,$:= Answer : # Question 1=? Eohn Oerry&s employer has contracted to recei e healthcare for its employees from the <emocratic Healthcare (ystem. Mr. Oerry isits his /8/, who sends him to ha e some blood tests. The /8/ then refers Mr. Oerry to a specialist who hospitali2es him for on Choice A: a physician practice organisation Choice B: a physician-hospital organisation

Choice C: a management ser ices organisation Choice D: an integrated deli ery sysem Answer : < Question 1=@ Oatrina Fope2 is a claims analyst for a health plan that pro ides a higher le el of benefits for ser ices recei ed in-networ" than for ser ices recei ed out-of-networ". Ms. Fope2 re iewed a health claim for answers to the following !uestions: Question , Choice A: ,, #, 8, and < Choice B: ,, #, and < only Choice C: #, 8, and < only Choice D: , and 8 only Answer : , Question 1=A Oatrina Fope2 is a claims analyst for a health plan that pro ides a higher le el of benefits for ser ices recei ed in-networ" than for ser ices recei ed out-of-networ". Ms. Fope2 re iewed a health claim for answers to the following !uestions: Question , P Choice A: ,, #, 8, and < Choice B: ,, #, and < only Choice C: #, 8, and < only Choice D: , and 8 only Answer : , Question 11= Ohalyn <rury&s employer includes managed dental care in its employee benefits pac"age. <uring open enrollment, Ms. <rury enrolled in the dental plan, which pro ides dental ser ices to its members in e7change for a prepayment -the premium1. <ental ser ices Choice A: dental preferred pro ider organi2ation -//O1 Choice B: traditional fee-for-ser ice -**(1 dental plan Choice C: plan with a dental point of ser ice -/O(1 option Choice D: dental health maintenance organi2ation -<HMO1 Answer : <

Question 111 Fansdale Healthcare, a health plan, offers comprehensi e healthcare co erage to its members through a networ" of physicians, hospitals, and other ser ice pro iders. /lan members who use in-networ" ser ices pay a copayment for these ser ices. The copayment Choice A: specified dollar amount charge that a plan member must pay out-of-poc"et for a specified medical ser ice at the time the ser ice is rendered Choice B: percentage of the fees for medical ser ices that a plan member must pay after Magellan has paid its share of the costs of those ser ices Choice C: flat amount that a plan member must pay each year before Magellan will ma"e any benefit payments on behalf of the plan member Choice D: specified payment for ser ices that was negotiated between the pro ider and Magellan Answer : , Question 11$ Managed beha ioral health organi2ations -M#HOs1 use se eral strategies to manage the deli ery of beha ioral healthcare ser ices. The following statements are about these strategies. (elect the answer choice that contains the correct statement. Choice A: M#HOs generally pro ide benefits for mental health ser ices but not for chemical dependency ser ices. Choice B: The le el of care needed to treat beha ioral disorders is the same for all patients and all disorders. Choice C: #y using outpatient treatment more e7tensi ely, M#HOs ha e decreased the use of costly inpatient therapies. Choice D: /8/ gate"eeper systems for beha ioral healthcare generally result in more accurate diagnoses, more effecti e treatment, and more efficient use of resources than do centrali2ed referral systems. Answer : 8 Question 11+ Many HMOs are compensated for the deli ery of healthcare to members under a prepaid care arrangement. 5nder a prepaid care arrangement, a plan member typically pays a Choice A: fi7ed amount in ad ance for each medical ser ice the member recei es Choice B: a small fee such as >1= or >1: that a member pays at the time

of an office isit to a networ" pro ider Choice C: a fi7ed, monthly premium paid in ad ance of the deli ery of medical care that co ers most healthcare ser ices that a member might need, no matter how often the member uses medical ser ices Choice D: specified amount of the member&s medical e7penses before any benefits are paid by the HMO Answer : 8 Question 114 Many of the credentialing standards and criteria used by health plans are often ta"en from already e7isting standards established by Choice A: the )ational /ractitioner <ata #an" -)/<#1 Choice B: the )ational ,ssociation of 3nsurance 8ommissioners -),381 Choice C: the 8enters for Medicare and Medicaid (er ices -8M(1 Choice D: independent accrediting organi2ations Answer : < Question 11: Marlee 0hitcomb was co ered as a dependent under the group health plan pro ided by her father&s employer. That health plan complied with the pro isions of the 8onsolidated Omnibus #udget 9econciliation ,ct -8O#9,1 of 1A@;. 0hen Ms. 0hitcomb married, she c Choice A: can continue her group co erage for a period not to e7ceed 4@ months Choice B: can continue her group co erage for a period not to e7ceed +; months Choice C: cannot continue her group co erage, but has the right to con ert the group co erage to an indi idual health plan Choice D: can continue her group co erage indefinitely Answer : # Question 11; Medicaid is a 6ointly funded federal and state program that pro ides hospital and medical e7pense co erage to low-income indi iduals and certain aged and disabled indi iduals. One characteristic of Medicaid is that Choice A: pro iders who care for Medicaid recipients must accept Medicaid payment as payment in full for ser ices rendered Choice B: Medicaid re!uires recipients to pay deductibles, copayments,

and coinsurance amounts for all ser ices Choice C: Medicaid is always the primary payor of benefits Choice D: benefits offered by Medicaid programs are federally mandated and do not ary by state Answer : , Question 11? Medicare ,d antage product options include: Choice A: 8oordinated care plans, medical sa ings accounts and national //Os. Choice B: /ri ate *ee for (er ice plans, health care prepayment plans and medical sa ings accounts Choice C: 8oordinated care plans, regional //Os and pri ate fee for ser ice plans Choice D: 8ost contracts, coordinated care programs and medical sa ings accounts. Answer : 8 Question 11@ Medicare is the federal go ernment program established under Title KI333 of the (ocial (ecurity ,ct of 1A;: to pro ide hospital, medical and other co ered benefits to elderly and disabled persons. Medicare is a ailable for: Choice A: /ersons age ;+ or older. Choice B: /ersons with !ualifying disabilities -o er the age of ;+1 Choice C: /ersons with end-stage renal disease -C(9<1 Choice D: Fow income indi iduals Answer : 8 Question 11A Medicare /art 8 can be deli ered by the following Medicare ,d antage plans: Choice A: H88/, HMO, //O -local or regional1, /**( or M(,. Choice B: 88/s , /**( or M(,. Choice C: HMO, H(,, //O -local or regional1, /**( or M(,. Choice D: HMO, //O -local or regional1, /O(, or M(,. Answer : # Question 1$= Member satisfaction is a critical element of a health plan&s !uality

management program. , health plan can obtain information about member satisfaction with arious aspects of the health plan from Choice A: sur eys completed by members following a isit to a pro ider Choice B: sur eys sent to plan members who ha e not recei ed healthcare ser ices during a specified time period Choice C: periodic reports of complaints recei ed by member ser ices personnel Choice D: all of the abo e Answer : < Question 1$1 Members who !ualify to participate in a health plan&s case management program are typically assigned a case manager. <uring the course of the member&s treatment, the case manager is responsible for ,. 8oordinating and monitoring the member&s care #. ,ppro Choice A: #oth , and # Choice B: , only Choice C: # only Choice D: )either , nor # Answer : # Question 1$$ Merle (pencer has co erage under both Medicare /art , and Medicare /art #. Ms. (pencer recently was hospitali2ed for chest pains, and she incurred charges for: H The cost of hospitali2ation for two days H <iagnostic tests performed in the hospital H Trans Choice A: ambulance and the diagnostic tests Choice B: ambulance, the diagnostic tests, and the physician&s professional ser ices Choice C: cost of hospitali2ation Choice D: cost of hospitali2ation and the physician&s professional ser ices Answer : < Question 1$+ More procedures or ser ices may be fully co ered within the //O networ" than those out-of networ".

Choice A: True Choice B: *alse Choice C: Choice D: Answer : , Question 1$4 Most contracts between health plans and pro iders contain a pro ision which forbids pro iders from see"ing compensation from patients if the health plan fails to compensate the pro ider because of insol ency or for any other reason. (uch a pro ision is "n Choice A: due process pro ision Choice B: cure pro ision Choice C: hold-harmless pro ision Choice D: ris"-sharing pro ision Answer : 8 Question 1$: Mr. .eorge #ush is co ered by a /#M plan that uses a closed formulary. This indicates that Choice A: he can recei e co erage for parmaceuticals only if they are on the /#M plan&s preferred list of drugs Choice B: he must recei e all of his pharmaceuticals from a mail-order pharmacy program Choice C: he can recei e co erage for pharmaceuticals that are on the /#M plan&s preferred list of drugs, as well as for pharmacueticals that are not on the preferred list Choice D: the /#M plan cannot reci e a rebate on any pharmacueticals it obtains from the pharmaceuticalfacturer Answer : , Question 1$; )atalie 8han is a member of the 5ltra Health /lan, a health plan. 0hene er she needs nonemergency medical care, she sees <r. <a id 8raig, an internist. Ms. 8han cannot self-refer to a specialist, so she saw <r. 8raig when she e7perienced headaches. <r. 8r Choice A: 0ithin 5ltra&s system, Ms. 8han recei ed primary care from both <r. 8raig and <r. Fee Choice B: 5ltra&s system allows its members open access to all of 5ltra&s

participating pro iders. Choice C: 0ithin 5ltra&s system, <r. 8raig ser es as a coordinator of care or gate"eeper for the medical ser ices that Ms. 8han recei es. Choice D: 5ltra&s networ" of pro iders includes <r. 8raig and <r. Fee but not ,rrow Hospital Answer : 8 Question 1$? )atalie 8han is a member of the 5ltra Health /lan. 0hene er she needs non-emergency medical care, she sees <r. <a id 8raig, an internist. Ms. 8han cannot self-refer to a specialist, so she saw <r. 8raig when she e7perienced headaches. <r. 8raig referred h Choice A: 0ithin 5ltra&s system, Ms. 8han recei ed primary care from both <r. 8raig and <r. Fee. Choice B: 5ltra&s system allows its members open access to all of 5ltra&s participating pro iders. Choice C: 0ithin 5ltra&s system, <r. 8raig ser es as a coordinator of care or gate"eeper for the medical ser ices that Ms. 8han recei es. Choice D: 5ltra&s networ" of pro iders includes <r. 8raig and <r. Fee but not ,rrow Hospital. Answer : 8 Question 1$@ One characteristic of disease management programs is that they typically Choice A: focus on indi idual episodes of medical care rather than on the comprehensi e care of the patient o er time Choice B: are used to coordinate the care of members with any type of disease, either chronic or nonchronic Choice C: focus on managing populations of patients who ha e a specific chronic illness or medical condition, but do not focus on patient populations who are at ris" of de eloping such an illness or condition Choice D: use clinical practice processes to standardi2e the implementation of best practices among pro iders Answer : < Question 1$A One characteristic of the accreditation process for M8Os is that Choice A: an accrediting agency typically conducts an on-site re iew of an M8O&s operations, but it does not re iew an M8O&s medical records or

assess its member ser ice systems Choice B: each accrediting organi2ation has its own standards of accreditation Choice C: the accrediting process is mandatory for all M8Os Choice D: go ernment agencies conduct all accreditation acti ities for M8Os Answer : # Question 1+= One component of information systems used by health plans incorporates membership data and information about pro ider reimbursement arrangements and analy2es transactions according to contract rules. This information system component is "nown as Choice A: a contract management system Choice B: a credentialing system Choice C: a legacy system Choice D: an interoperable communication system Answer : , Question 1+1 One de ice that /#M plans use to manage both the cost and use of pharmaceuticals is a formulary. , formulary is defined as Choice A: a listing of drugs classified by therapeutic category or disease class that are considered preferred therapy for a gi en managed population and that are to be used by a health plan&s pro iders in prescribing medications Choice B: a reduction in the price of a particular pharmaceutical obtained by the /#M from the pharmaceutical manufacturer Choice C: drugs ordered and deli ered through the mail to the /#M&s plan members at a reduced cost Choice D: an identification card issued by the /#M to its plan members Answer : , Question 1+$ One 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 #ac" to Top Choice A: employees of the HMO Choice B: employees of a group practice that has contracted with the

HMO Choice C: compensated primarily through capitation Choice D: limited to primary care physicians -/8/s1 Answer : , Question 1++ One distinguishing characteristic of a health maintenance organi2ation -HMO1 is that, typically, an HMO Choice A: arranges for the deli ery of medical care and pro ides, or shares in pro iding, the financing of that care Choice B: must be organi2ed on a not-for-profit basis Choice C: may be organi2ed as a corporation, a partnership, or any other legal entity Choice D: must be federally !ualified in order to conduct business in any state Answer : , Question 1+4 One ethical principle in health plans is the principle of non-maleficence, which holds that health plans and their pro iders: Choice A: (hould allocate resources in a way that fairly distributes benefits and burdens among the members. Choice B: Ha e a duty to present information honestly and are obligated to honor commitments. Choice C: ,re obligated not to harm their members. Choice D: (hould treat each plan member in a manner that respects his or her goals and alues. Answer : 8 Question 1+: One ethical principle in managed care is the principle of 6usticeQe!uity, which specifically holds that M8Os and their pro iders ha e a duty to Choice A: treat each member in a manner that respects his or her own goals and alues Choice B: allocate resources in a way that fairly distributes benefits and burdens among the members Choice C: present information honestly to their members and to honor commitments to their members Choice D: ma"e sure they do not harm their members

Answer : # Question 1+; One factor the (andpiper Health /lan uses to assess its !uality 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 clinicia Choice A: a pro ider ser ice !uality issue Choice B: an administrati e ser ice !uality issuea healthcare process !uality issue Choice C: a healthcare outcomes !uality issue Choice D: a healthcare process !uality issue Answer : , Question 1+? One feature of the Cmployee 9etirement 3ncome (ecurity ,ct -C93(,1 is that it: Choice A: 9e!uires self-funded employee benefit plans to pay premium ta7es at the state le el. Choice B: 8ontains a pre-emption pro ision, which typically ma"es the terms of C93(, ta"e precedence o er any state laws that regulate employee welfare benefit plans. Choice C: 8ontains strict reporting and disclosure re!uirements for all employee benefit plans e7cept health plans. Choice D: 9e!uires that state insurance laws apply to all employee benefit plans e7cept insured plans. Answer : # Question 1+@ One HMO model can be described as an e7tension of a group model HMO because it contracts with multiple group practices, rather than with a single group practice. This HMO model is "nown as the Choice A: staff model HMO Choice B: 3/, model HMO Choice C: direct contract model HMO Choice D: networ" model HMO Answer : < Question 1+A

One non-group mar"et segment to which health plans mar"et health plan products is the senior mar"et, which is comprised mostly of persons o er age ;: who are eligible for Medicare benefits. One factor that affects a health plan&s efforts to mar"et to the Choice A: The 8enters for Medicare and Medicaid (er ices -8M(1 must appro e all mar"eting materials used by health plans to mar"et health plan products to the Medicare population Choice B: managed Medicare plans typically re!uire Medicare beneficiaries to purchase Medigap insurance to supplement gaps in co erage Choice C: managed Medicare plans can refuse to co er persons with certain health problems Choice D: the 8M( prohibits health plans from using telemar"eting to mar"et health plan products to the Medicare population Answer : # Question 14= One of the distinguishing characteristics of healthcare mar"eting is that many of the mar"ets for health plans are national, not local mar"ets. Choice A: True Choice B: *alse Choice C: Choice D: Answer : # Question 141 One of the most influential pieces of legislation in the ad ancement of health plans within the 5nited (tates was the Health Maintenance Organi2ation -HMO1 ,ct of 1A?+. One of the pro isions of the ,ct was that it Choice A: e7empted HMOs from all state licensure re!uirements. Choice B: re!uired all employers that offered healthcare co erage to their employees to offer only one type of federally !ualified 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 !ualification Answer : <

Question 14$ One of the most influential pieces of legislation in the ad ancement of managed care within the 5nited (tates was the HMO ,ct of 1A?+. One pro ision of the HMO ,ct of 1A?+ was that it Choice A: emphasi2ed compensating physicians based solely on the olume of medical ser ices they pro ide Choice B: e7empted HMOs from all state licensure re!uirements Choice C: established a process under which HMOs could elect to be federally !ualified Choice D: re!uired federally !ualified HMOs to relate premium le els to the health status of the indi idual enrollee or employer group Answer : 8 Question 14+ One true statement about community rating, a rating method commonly used by health plans, is that: Choice A: 3t re!uires a health plan to set premiums for financing medical care according to the health plan&s e7pected cost of pro iding medical benefits to a sub-group within the community. Choice B: , health plan usually uses community rating to set premiums for large groups. Choice C: 3t tends to lead to greater fluctuations in premium rates than do other rating methods. Choice D: , health plan seldom uses community rating to set premiums for large groups. Answer : < Question 144 One true statement regarding ethics and laws is that the alues of a community are reflected in Choice A: both ethics and laws, and both ethics and laws are enforceable in the court system Choice B: both ethics and laws, but only laws are enforceable in the court system Choice C: ethics only, but only laws are enforceable in the court system Choice D: laws only, but both ethics and laws are enforceable in the court system Answer : #

Question 14: One true statement regarding ethics and laws is that the alues of a community are reflected in Choice A: both ethics and laws, and both ethics and laws are enforceable in the court system Choice B: both ethics and laws, but only laws are enforceable in the court system Choice C: ethics only, but only laws are enforceable in the court system Choice D: laws only, but both ethics and laws are enforceable in the court system Answer : # Question 14; One type of physician-only integration model is a consolidated medical group. Typical characteristics of a consolidated medical group include Choice A: that it may be a single-specialty or multi-specialty practice Choice B: operates in one or a few facilities rather than in many independent offices Choice C: achie es economies of scale in the group&s integrated operations Choice D: all of the abo e Answer : < Question 14? One typical characteristic of an integrated deli ery system -3<(1 is that an 3<(. Choice A: 3s more highly integrated structurally than it is operationally. Choice B: /ro ides a full range of healthcare ser ices, including physician ser ices, hospital ser ices, and ancillary ser ices. Choice C: 8annot negotiate directly with health plans, plan sponsors, or other healthcare purchasers. Choice D: /erforms a single business function, such as negotiating with health plans on behalf of all of the member pro iders. Answer : # Question 14@ One typical characteristic of preferred pro ider organi2ation -//O1 benefit plans is that //Os: Choice A: ,ssume full financial ris" for arranging medical ser ices for

their members. Choice B: 9e!uire plan members to obtain a referral before getting medical ser ices from specialists. Choice C: 5se a capitation arrangement, instead of a fee schedule, to reimburse physicians. Choice D: Offer some co erage, although at a higher cost, for plan members who choose to use the ser ices of non-networ" pro iders. Answer : < Question 14A One way in which a health plan can support an ethical en ironment is by Choice A: re!uiring organi2ations with which it contracts to adopt the plan&s formal ethical policy Choice B: de eloping and maintaining a culture where ethical considerations are integrated into decision ma"ing at the top organi2ational le el only Choice C: establishing a formal method of managing ethical conflicts, such as using an ethics tas" force or bioethics consultant Choice D: maintaining control of policy de elopment by remo ing pro iders and members from the process of de eloping and implementing policies and procedures that pro ide guidance to pro iders and members confronted with ethical issues Answer : 8 Question 1:= One way in which a health plan can support an ethical en ironment is by Choice A: re!uiring organi2ations with which it contracts to adopt the plan&s formal ethical policy Choice B: de eloping and maintaining a culture where ethical considerations are integrated into decision ma"ing at the top organi2ational le el only Choice C: establishing a formal method of managing ethical conflicts, such as using an ethics tas" force or bioethics consultant Choice D: maintaining control of policy de elopment by remo ing pro iders and members from the process of de eloping and implementing policies and procedures that pro ide guidance to pro iders and members confronted with ethical issues Answer : 8

Question 1:1 One way in which health plans differ from traditional indemnity plans is that health plans Typically Choice A: pro ide less e7tensi e benefits than those pro ided under traditional indemnity plans Choice B: place a greater emphasis on pre enti e care than do traditional indemnity plans Choice C: re!uire members to pay a percentage of the cost of medical ser ices rendered after a claim is filed, rather than a fi7ed copayment at the time of ser ice as re!uired by indemnity plans Choice D: contain cost-sharing re!uirements that result in more out-ofpoc"et spending by members than do the cost-sharing re!uirements in traditional indemnity plans Answer : # Question 1:$ One way that M8Os in ol e pro iders in ris" sharing is by retaining a percentage of the pro iders& payment during a plan year. ,t the end of the plan year, the M8O may use the amount retained to offset or pay for any cost o erruns for referral or hospital Choice A: withholds Choice B: usual, customary, and reasonable -5891 fees Choice C: ris" pools Choice D: per diems Answer : , Question 1:+ /arable Healthcare /ro iders, a health plan, recently segmented the mar"et for a new healthcare ser ice. /arable began the process by di iding the healthcare mar"et into two broad categories: non-group and group. )e7t, /arable further segmented the non-gr Choice A: channel segmentation Choice B: geographic segmentation Choice C: demographic segmentation Choice D: product segmentation Answer : 8 Question 1:4 /arul .upta has been co ered by a group health plan for eighteen months.

*or the past four months, she has been undergoing treatment for diabetes. Fast wee", Ms. .upta began a new 6ob and immediately enrolled in her new company&s group health plan, which Choice A: can e7clude co erage for treatment of Ms. .upta&s diabetes for one year, because she did not ha e at least two years of creditable co erage under her pre ious health plan Choice B: cannot e7clude Ms. .upta&s diabetes as a pre-e7isting condition, because the one-year pre-e7isting condition pro ision is offset by at least one year of continuous co erage under her pre ious health plan Choice C: can e7clude co erage for treatment of Ms. .upta&s diabetes for one year, because H3/,, does not impact a group health plan&s pree7isting condition pro ision Choice D: can e7clude co erage for treatment of Ms. .upta&s diabetes for four months, because that is the length of time she recei ed treatment for this medical condition prior to her enrollment in the new health plan Answer : # Question 1:: /atric" *laherty&s employer has contracted to recei e healthcare for its employees from the ,bundant Healthcare (ystem. Mr. *laherty isits his primary care physician -/8/1, who sends him to ha e some blood tests. The /8/ then refers Mr. *laherty to a spe Choice A: an integrated deli ery system -3<(1 Choice B: a Management (er ices Organi2ation -M(O1 Choice C: a /hysician /ractice Management -//M1 company Choice D: a physician-hospital organi2ation -/HO1 Answer : , Question 1:; /aul .ilbert has been co ered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Fast wee", Mr. .ilbert began a new 6ob and immediately enrolled in his new company&s group health plan, which has a Choice A: 8an e7clude co erage for treatment of Mr. .ilbert&s angina for one year, because H3/,, does not impact a group health plan&s pree7isting condition pro ision. Choice B: 8an e7clude co erage for treatment of Mr. .ilbert&s angina for one year, because Mr. .ilbert did not ha e at least +; months of creditable co erage under his pre ious health plan.

Choice C: 8an e7clude co erage for treatment of Mr. .ilbert&s angina for three months, because that is the length of time he recei ed treatment for this medical condition prior to his enrollment in the new health plan. Choice D: 8annot e7clude his angina as a pre-e7isting condition, because the one-year pre-e7isting condition pro ision is offset by at least one year of continuous co erage under his pre ious health plan. Answer : < Question 1:? /#M plans operate under se eral types of contractual arrangements. 5nder one contractual arrangement, the /#M plan and the employer agree on a target cost per employee per month. 3f the actual cost per employee per month is greater than the target cost, t Choice A: fee-for-ser ice arrangement Choice B: ris" sharing contract Choice C: capitation contract Choice D: rebate contract Answer : # Question 1:@ /harmacy benefit management -/#M1 companies typically interact with physicians and pharmacists by performing such clinical ser ices as physician profiling. /hysician profiling from a /#M&s point of iew in ol es Choice A: ascertaining that physicians in the plan ha e the necessary and appropriate credentials to prescribe medications Choice B: compiling data on physician prescribing patterns and comparing physicians& actual prescribing patterns to e7pected patterns within select drug categories Choice C: monitoring patient-specific drug problems through concurrent and retrospecti e re iew Choice D: establishing protocols that re!uire physicians to obtain certification of medical necessity prior to drug dispensing Answer : # Question 1:A /hillip Tsai is insured by both a indemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. #oth plans ha e typical coordination of benefits -8O#1 pro isions, but neither

has a nonduplication of benefits p Choice A: >= Choice B: >+== Choice C: >4== Choice D: >A== Answer : 8 Question 1;= /hillip 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. #oth plans ha e typical coordination of benefits -8O#1 pro isions, but neither has a nonduplication of Choice A: >= Choice B: >+== Choice C: >4== Choice D: >A== Answer : 8 Question 1;1 /hoebe 5rich is co ered by a traditional indemnity health insurance plan that specifies a >:== calendar-year deductible and includes a $=J coinsurance pro ision. 0hen Ms. 5rich was hospitali2ed, she incurred >+,=== in medical e7penses that were co ered by Choice A: 1A== Choice B: $=== Choice C: $4== Choice D: $:== Answer : # Question 1;$ /rimary care case managers -/88Ms1 pro ide case management ser ices to eligible Medicaid recipients. 0ith regard to /88Ms it is correct to say that: Choice A: /88Ms typically recei e a case management fee, rather than reimbursement for medical ser ices on a **( basis, for the ser ices they pro ide to Medicaid recipients. Choice B: ,ll Medicaid recipients who li e in rural areas must be gi en a choice of at least four /88Ms. Choice C: /88Ms recei e a case management fee in addition to

reimbursement for medical ser ices on a **( basis. Choice D: /88Ms contract directly with the federal go ernment to pro ide case management ser ices to Medicaid recipients. Answer : 8 Question 1;+ /rimary care case managers -/88Ms1 pro ide managed healthcare ser ices to eligible Medicaid recipients. 0ith regard to /88Ms, it is correct to say that Choice A: /88Ms contract directly with the federal go ernment to pro ide case management ser ices to Medicaid recipients Choice B: all Medicaid recipients who li e in rural areas must be gi en a choice of at least four /88Ms Choice C: Medicaid /88M programs are e7empt from the Health 8are *inancing ,dministration&s -H8*,&s1 Quality 3mpro ement (ystem for Managed 8are -Q3(M81 standards Choice D: /88Ms typically recei e a case management fee, rather than reimbursement for medical ser ices on a **( basis, for the ser ices they pro ide to Medicaid recipients Answer : 8 Question 1;4 /ro ider integration has two components: operational integration and structural integration. ,n e7ample of operational integration in health plans is the: Choice A: ,c!uisition of the Feopard Health /lan by the Hic"ory Health /lan. Choice B: Eoint enture entered into by the Cclipse Health /lan and a local hospital system to create a new health plan in which Cclipse and the hospital system share ownership. Choice C: *ormation of an organi2ation by a group of pro iders to carry out billing, collections, and contracting with health plans for the entire group of pro iders. Choice D: 8onsolidation of the 8ar er Health /lan and the Fimestone Health /lan. Answer : 8 Question 1;: 9onald 8anton is a member of the Omega M8O. He recei es his

nonemergency medical care from <r. Oristen High, an internist. 0hen Mr. 8anton needed to isit a cardiologist about his irregular heartbeat, he first had to obtain a referral from <r. High to see Choice A: <r. High ser es as the coordinator of care for the medical ser ices that Mr. 8anton recei es. Choice B: Omega&s networ" of pro iders includes <r. High, but not <r. Miller. Choice C: Omega&s system allows its members open access to all of Omega&s participating pro iders. Choice D: Omega used a financing arrangement "nown as a relati e alue scale -9I(1 to compensate <r. Miller. Answer : , Question 1;; (e eral mar"etplace factors helped fuel the mo ement toward consumer choice. 0hich one of the following statements is )OT accurate with regard to these factorsB Choice A: ,fter a period of relati e stability, annual growth in pri ate health spending per capita began to increase rapidly in $==$. Choice B: <uring the height of the recent cost upswing, insurance premiums were increasing by more than 1+J annually. Choice C: 3ncreased utili2ation was the largest factor contributing to the rise in premiums, accounting for 4+J of the increase. Choice D: Cmployer payers began see"ing ways to control spiraling utili2ation rates and pro ide lowercost health co erage options. Answer : , Question 1;? (ome pro iders use electronic medical records -CM9s1 to document their patients& care in an electronic form. The following statement-s1 can correctly be made about CM9s: ,. CM9s are computeri2ed records of a patient&s clinical, demographic, and administra Choice A: # only Choice B: #oth , and # Choice C: )either , nor # Choice D: , only Answer : <

Question 1;@ (ome states mandate that an independent enrollment bro"er or benefits counselor contractor selected by the state must manage enrollment of the eligible Medicaid population into managed care. 3n other states a health plan can engage independent bro"ers and Choice A: Many states ha e regulations that prohibit health plans from using door-to-door andQor telephone solicitation to mar"et health plan products to the Medicaid population. Choice B: Health plans are ne er allowed to medically underwrite indi idual mar"et customers who are under age ;:. Choice C: To promote a health plan product to the indi idual mar"et, health plans typically use capti e agents who gi e sales presentations to potential customers, rather than using promotion tools such as direct mail, telemar"eting, or ad ertising. Choice D: Health plans typically are allowed to medically underwrite all indi idual mar"et customers who are co ered by Medicare and can refuse to co er such customers. Answer : , Question 1;A (pecialty ser ices that ha e certain characteristics generally are good candidates for managed care approaches. These characteristics generally include that the specialty ser ice should ha e Choice A: appropriate, rather than inappropriate, utili2ation Choice B: a defined patient population Choice C: low, stable costs Choice D: a benefit that cannot be easily defined Answer : # Question 1?= (pecialty ser ices with certain characteristics tend to ma"e good candidates for health plan approaches. One characteristic used to identify a specialty ser ice that may be a good candidate for a health plan approach is that the ser ice should ha e Choice A: a defined patient population Choice B: a comple7 benefit structure Choice C: low, stable costs Choice D: appropriate utili2ation rates

Answer : , Question 1?1 The prudent layperson standard described in the #alanced #udget ,ct -##,1 of 1AA? re!uires all hospitals that recei e Medicare or Medicaid reimbursement to screen and, if necessary, stabili2e all patients who come to their emergency departments. Choice A: True Choice B: *alse Choice C: Choice D: Answer : # Question 1?$ The prudent layperson standard described in the #alanced #udget ,ct -##,1 of 1AA? re!uires all hospitals that recei e Medicare or Medicaid reimbursement to screen and, if necessary, stabili2e all patients who come to their emergency departments. Choice A: True Choice B: *alse Choice C: Choice D: Answer : # Question 1?+ The ,cme HMO recruits and contracts directly with a wide range of physiciansPboth /8/s and specialistsPin its geographic area on a none7clusi e basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The Choice A: an independent practice association -3/,1 model HMO Choice B: a staff model HMO Choice C: a direct contract model HMO Choice D: a group model HMO Answer : 8 Question 1?4 The administrati e simplification standards described under Title 33 of H3/,, include pri acy standards to control the use and disclosure of health information. 3n general, these pri acy standards prohibit

Choice A: all health plans, healthcare pro iders, and healthcare clearinghouses from using any protected health information for purposes of treatment, payment, or healthcare operations without an indi idual&s written consent Choice B: patients from re!uesting that restrictions be placed on the accessibility and use of protected health information Choice C: transmission of indi idually identifiable health information for purposes other than treatment, payment, or healthcare operations without the indi idual&s written authori2ation Choice D: patients from accessing their medical records and re!uesting the amendment of incorrect or incomplete information Answer : < Question 1?: The ,d antage Health /lan recently added the following features to its member ser ices program: 3I9 ,cti e member outreach program ,d antage&s member ser ices staffing needs are li"ely to increase as a result of Choice A: 1 Choice B: $ Choice C: 1 M $ Choice D: )either 1 nor $ Answer : # Question 1?; The application of health plan principles to wor"ers& compensation insurance programs has presented some uni!ue challenges because of the differences between health plan for traditional group healthcare and wor"ers& compensation. One "ey difference is tha Choice A: limits co erage to eligible employees and e7cludes part-time employees Choice B: specifies an annual lifetime benefit ma7imum on dollar co erage for medical costs Choice C: pro ides benefits regardless of the cause of an in6ury or illness Choice D: pro ides benefits for both healthcare costs and lost wages Answer : <

Question 1?? The ,r" Health /lan, is currently recruiting pro iders in preparation for its e7pansion into a new ser ice area. , recruiter for ,r" has been meeting with <r. )an (hea, a pediatrician who practices in ,r"&s new ser ice area, in order to con ince her to be Choice A: 8redentialing Choice B: ,ccreditation Choice C: , sentinel e ent Choice D: , screening program Answer : , Question 1?@ The ,r" Health /lan, is currently recruiting pro iders in preparation for its e7pansion into a new ser ice area. , recruiter for ,r" has been meeting with <r. )an (hea, a pediatrician who practices in ,r"&s new ser ice area, in order to con ince her to be Choice A: Has e er participated in any !uality impro ement acti ities. Choice B: 3s a participating pro ider in a health plan that will compete with ,r" in its new ser ice area. Choice C: Meets the re!uirements of the Cthics in /atient 9eferrals ,ct. Choice D: Has had a medical malpractice claim filed or other disciplinary actions ta"en against her. Answer : < Question 1?A The ,2ure .roup is a for-profit health plan that operates in the 5nited (tates. The *ordham .roup owns all of ,2ure&s stoc". The *ordham .roup&s sole business is the ownership of controlling interests in the shares of other companies. This information ind Choice A: , holding company of the *ordham .roup. Choice B: , sister corporation of the *ordham .roup. Choice C: , subsidiary of the *ordham .roup. Choice D: ,ll of the abo e. Answer : 8 Question 1@= The #laine Healthcare 8orporation see"s to manage its !uality by first identifying the best practices and best outcomes for a gi en procedure. #laine can then determine areas in which it can emulate the best practices

in order to e!ual or surpass the best Choice A: pro ider profiling Choice B: benchmar"ing Choice C: peer re iew Choice D: !uality assessment Answer : # Question 1@1 The 8itywide Health .roup is a large pro ider-based health plan that includes physician groups, hospitals, and other facilities. 3n order to o ersee and manage the operation of the organi2ation, 8itywide has established an enterprise scheduling system. Th Choice A: pro ide information to 8itywide&s management regarding pro ider licensure, certification, and malpractice history Choice B: detect instances of o erutili2ation, underutili2ation, or inappropriate utili2ation of medical resources Choice C: allow 8itywide&s different components to function as a single organi2ation in arranging access to facilities and resources Choice D: facilitate the processing of re!uests for authori2ation of payment of benefits Answer : 8 Question 1@$ The 8leopatra .roup, a third-party administrator -T/,1, has entered into a T/, agreement with the ,le7ander M8O with regard to the administration of a particular health plan. This agreement complies with all of the pro isions of the ),38 T/, Model Faw. On Choice A: hold all funds it recei es on behalf of ,le7ander in trust Choice B: assume full responsibility for determining the claim payment procedures for the plan Choice C: assume full responsibility for ensuring that the health plan is administered properly Choice D: obtain from the federal go ernment a certificate of authority designating the 8leopatra .roup as a T/, Answer : , Question 1@+ The 8lo er .roup is a for-profit M8O that operates in the 5nited (tates. The Ialentine .roup owns all of 8lo er&s stoc". The Ialentine .roup&s

sole business is the ownership of controlling interests in the shares of other companies. This information indic Choice A: holding company of the Ialentine .roup Choice B: sister corporation of the Ialentine .roup Choice C: parent company of the Ialentine .roup Choice D: subsidiary of the Ialentine .roup Answer : < Question 1@4 The 8on!uest 8orporation contracts with the ,pe7 health plan to pro ide basic medical and surgical ser ices to 8on!uest employees. 8on!uest entered into a separate contract with the #right <ental .roup to pro ide and manage a dental care program for emplo Choice A: a negotiated rebate agreement Choice B: a car e-out arrangement Choice C: an indemnity plan Choice D: /#M Answer : # Question 1@: The contract between the Honolulu M8O and #e erley Hills Hospital contains a A= day cure pro ision. The #e erley Hills Hospital breached one of the contract re!irements on Euly +1, $==4. The hospital remedied the problem by October +1, $==4. 0hich of the Choice A: The contract would not be terminated as #e erley Hills hospital rectified the problem within A= days. Choice B: The contract would be terminated as #e erley Hills hospital was re!uired to notify Honolulu M8O about the problem at least A= days in ad ance. Choice C: The contract would be terminated as #e erley Hills hospital was re!uired to rectify the problem within A= days. Choice D: The contract would not be terminated as #e erley Hills hospital may escape adherence to the cure pro ision. Answer : 8 Question 1@; The 8ourtland //O maintains computeri2ed records that include clinical, demographic, and administrati e data about indi idual plan members. The data in these records is a ailable to plan pro iders, ancillary ser ice

departments, pharmacies, and others in Choice A: a data warehouse Choice B: a decision support system Choice C: an outsourcing system Choice D: an electronic medical record -CM91 system Answer : < Question 1@? The criteria used to identify and measure healthcare !uality are generally di ided into three categories: structure, process, and outcomes measures. (tructure measures, which relate to the nature and !uality of the resources that a health plan has a ailab Choice A: length of time patients ha e to wait at the office to be seen by a pro ider Choice B: percentage of plan physicians who are board-certified Choice C: percentage of children recei ing immuni2ations Choice D: number of patients contracting an infection in the hospital Answer : # Question 1@@ The data e aluation stage of utili2ation re iew -591 includes both administrati e re iews and medical re iews. One true statement about these types of re iews is that: Choice A: ,n administrati e re iew must be conducted by a health plan staff member who is a medical professional. Choice B: The primary purpose of an administrati e re iew is to e aluate the appropriateness of a proposed medical ser ice. Choice C: 59 staff members typically conduct a medical re iew of a proposed medical ser ice before they conduct an administrati e re iew for that same ser ice. Choice D: One purpose of a medical re iew is to e aluate the medical necessity of a proposed medical ser ice. Answer : < Question 1@A The Cmployee 9etirement 3ncome (ecurity ,ct -C93(,1 re!uires health plan members who recei e healthcare benefits through employee benefit plans to file legal challenges in ol ing co erage decisions or plan administration at the federal le el. 5nder the te

Choice A: contract damages, which co er the cost of denied treatment Choice B: compensatory damages, which compensate the in6ured party for his or her in6uries Choice C: puniti e damages, which are designed to punish or ma"e an e7ample of the wrongdoer Choice D: all of the abo e Answer : , Question 1A= The e7isting committees at the Ma6estic Health /lan, a health plan that is sub6ect to the re!uirements of H3/,,, include the C7ecuti e 8ommittee and the 8orporate 8ompliance 8ommittee. The C7ecuti e 8ommittee ser es as a long-term ad isory body on issues Choice A: #oth 1 and $ Choice B: 1 only Choice C: $ only Choice D: )either 1 nor $ Answer : # Question 1A1 The *airway Health .roup contracted with the Cmpire 8orporation to pro ide beha ioral healthcare ser ices to Cmpire employees. ,s a condition of pro iding beha ioral healthcare ser ices, *airway re!uired Cmpire to contract with *airway for basic medical s Choice A: hori2ontal group boycott Choice B: price-fi7ing agreement Choice C: hori2ontal di ision of mar"ets Choice D: tying arrangement Answer : < Question 1A$ The following organi2ations are the primary sources of accreditation of healthcare organi2ations: ,. )ational 8ommittee for Qualty ,ssurance -)8Q,1 #. ,merican ,ccreditation Health8are 8ommissionQ59,8 Of these organi2ations, performance data is included i Choice A: , only Choice B: # only Choice C: , and #

Choice D: none of the abo e Answer : , Question 1A+ The following paragraph contains an incomplete statement. (elect the answer choice containing the term that correctly completes the statement. 3n early efforts to manage healthcare costs, traditional indemnity health insurers included in their health pla Choice A: cost shifting Choice B: deductibles Choice C: underwriting Choice D: copay Answer : # Question 1A4 The following paragraph contains an incomplete statement. (elect the answer choice containing the term that correctly completes the statement.,d ances in computer technology ha e re olutioni2ed the processing of medical and drug claims.8laims processing i Choice A: Fower Choice B: Higher Choice C: (ame Choice D: )o change Answer : # Question 1A: The following programs are part of the ,lco e Health /lan&s utili2ation management -5M1 program: G /re enti e care initiati es G , telephone triage program G , shared decision-ma"ing program G , self-care program 0ith regard to the 5M programs, it is most Choice A: /re enti e care initiati es include immuni2ation programs but not health promotion programs. Choice B: Telephone triage program is staffed by physicians only. Choice C: (hared decision-ma"ing program is appropriate for irtually any medical condition. Choice D: (elf-care program is intended to complement physicians&

ser ices, rather than to supersede or eliminate these ser ices. Answer : < Question 1A; The following programs are part of the ,lco e M8O&s utili2ation management -5M1 program: H , telephone triage programH /re enti e care initiati esH , shared decision-ma"ing programH , self-care program 0ith regard to the 5M programs, it is most li"ely cor Choice A: self-care program is intended to complement physicians& ser ices, rather than to supercede or eliminate these ser ices Choice B: telephone triage program is staffed by physicians only Choice C: shared decision-ma"ing program is appropriate for irtually any medical condition Choice D: pre enti e care initiati es include immuni2ation programs but not health promotion programs Answer : , Question 1A? The following programs are typically included in T938,9C medical management efforts: ,. 5tili2ation management #. (elf-care 8. 8ase management Choice A: , and # only Choice B: , and 8 only Choice C: ,ll of the listed options Choice D: # and 8 only Answer : 8 Question 1A@ The following sentence contains an incomplete statement with two missing words. (elect the answer choice that contains the words that correctly fill in the missing blan"s. ,t its core, consumer choice in ol es empowering healthcare consumers to play a %% Choice A: greaterQlesser Choice B: greaterQgreater Choice C: lesserQgreater Choice D: lesserQlesser

Answer : # Question 1AA The following sentence contains an incomplete statement with two missing words. (elect the answer choice that contains the words that correctly fill the two blan"s, respecti ely. The philosophy of consumer choice in ol es ha ing consumers play a-n1 %%%%%% Choice A: <ecreased R 3ncreased Choice B: 3ncreased R <ecreased Choice C: 3ncreased R 3ncreased Choice D: <ecreased R <ecreased Answer : 8 Question $== The following statement can be correctly made about Medicare ,d antage eligibility: Choice A: 3ndi iduals enrolled in a M, plan must enroll in a stand-alone /art < prescription drug plan. Choice B: 3ndi iduals enrolled in a M, plan do not ha e to be eligible for Medicare /art , Choice C: 3ndi iduals enrolled in an M(, plan or a /**( plan without Medicare drug co erage can enroll in Medicare /art <. Choice D: 3ndi iduals can enroll in M, plan in multiple regions. Answer : 8 Question $=1 The following statement-s1 can correctly be made about electronic data interchange -C<31: ,. C<3 differs from e8ommerce in that C<3 in ol es bac"-and-forth e7changes of information concerning indi idual transactions, whereas e8ommerce is the transfer of d Choice A: #oth , and # Choice B: , only Choice C: # only Choice D: )either , nor # Answer : 8

Question $=$ The following statement-s1 can correctly be made about Medicaid managed care plans: ,. , state may mandate health plan enrollment if it offers enrollees in nonrural areas a choice of at least two health plans and offers rural enrollees a choice of at lea Choice A: #oth , and # Choice B: , only Choice C: # only Choice D: )either , nor # Answer : , Question $=+ The following statement-s1 can correctly be made about the characteristics of reports that should be pro ided to managers for use in managing a healthcare deli ery system: ,. 5sers typically need access to all the raw data used to generate reports #. 3nfo Choice A: #oth , and # Choice B: , only Choice C: # only Choice D: )either , nor # Answer : < Question $=4 The following statement-s1 can correctly be made about the Eoint 8ommission on ,ccreditation of Healthcare Organi2ations -E8,HO1: ,. E8,HO&s accreditation process for M8Os and healthcare networ"s consists of complete on-site sur eys conducted e ery three Choice A: , only Choice B: )either , nor # Choice C: #oth , and # Choice D: # only Answer : , Question $=: The following statements apply to ,rcher medical sa ings accounts. (elect the answer choice that contains the correct statement. Choice A: M(,s were established as a demonstration pro6ect under the

Medicare Moderni2ation ,ct. Choice B: M(,s were seen as an impro ement o er *(,s because they are portable, allowing employees to ta"e the funds with them when they change 6obs. Choice C: The popularity of M(,s has been limited because funds may not be rolled o er from year to year. Choice D: M(,s are one of the fastest growing Types of 8onsumer<irected Health /lans. Answer : # Question $=; The following statements apply to enrollment statistics for H(,s. (elect the answer choice that contains the 8O99C8T statement. Choice A: H(,s ha e helped e7pand health care co erage to consumers who were pre iously uninsured. Choice B: The ast ma6ority of enrollees in H(, health plans are wealthy. Choice C: Most people recei ing co erage through H(, health plans are indi iduals rather than families. Choice D: H(,s appeal primarily to young consumers. Answer : , Question $=? The following statements apply to fle7ible spending arrangements. (elect the answer choice that contains the correct statement. Choice A: *(,s were designed to help increase health insurance co erage among self-employed indi iduals. Choice B: Only employers may contribute funds to *(,s. Choice C: The popularity of *(,s has been limited because funds may not be rolled o er from year to year. Choice D: , popular feature of *(,s is their portability, which allows employees to ta"e the funds with them when they change 6obs. Answer : 8 Question $=@ The following statements apply to health reimbursement arrangements. (elect the answer choice that contains the correct statement. Choice A: Only employers are permitted to establish and fund H9,s. Choice B: The popularity of H9,s waned following a $==$ ruling by 5.(. Treasury <epartment regarding their treatment in the ta7 code.

Choice C: H9,s must be offered in con6unction with a high-deductible health plan. Choice D: The guaranteed portability feature of H9,s has contributed to their popularity. Answer : , Question $=A The following statements are about accreditation in health plans. (elect the answer choice that contains the correct statement. Choice A: ,ccreditation is typically performed by a panel of physicians and administrators employed by the health plan under e aluation. Choice B: ,ll accrediting organi2ations use the same standards of accreditation. Choice C: 9esults of accreditation e aluations are pro ided only to state regulatory agencies and are not made a ailable to the general public. Choice D: ,ccreditation demonstrates to an health plan&s e7ternal customers that the plan meets established standards for !uality care. Answer : < Question $1= The following statements are about concepts related to the underwriting function within a health plan. (elect the answer choice containing the correct statement. Choice A: ,ntiselection refers to the fact that indi iduals who belie e that they ha e a less-than-a erage li"elihood of loss tend to see" healthcare co erage to a greater e7tent than do indi iduals who belie e that they ha e an a erage or greater-than-a erage li"e Choice B: *ederally !ualified HMOs are re!uired to medically underwrite all groups applying for co erage. Choice C: Typically, a health plan guarantees the premium rate for a group health contract for a period of fi e years. Choice D: 0hen e aluating the ris" for a group policy, underwriters typically focus on such factors as the si2e of the group, the stability of the group, and the acti ities of the group. Answer : < Question $11 The following statements are about federal laws that affect healthcare organi2ations. (elect the answer choice containing the correct response.

Choice A: The 0omen&s Health and 8ancer 9ights ,ct -0H89,1 of 1AA@ re!uires health plans to offer mastectomy benefits. Choice B: The Health 8are Quality 3mpro ement ,ct -H8Q3,1 re!uires hospitals, group practices, and HMOs to comply with all standard antitrust legislation, e en if these entities adhere to due process standards that are outlined in H8Q3,. Choice C: The )ewborns& and Mothers& Health /rotection ,ct -)MH/,1 of 1AA; mandates that co erage for hospital stays for childbirth must generally be a minimum of $4 hours for normal deli eries and 4@ hours for cesarean births. Choice D: ,lthough the Mental Health /arity ,ct -MH/,1 does not re!uire health plans to offer mental health co erage, it imposes re!uirements on those plans that do offer mental health benefits. Answer : < Question $1$ The following statements are about health information networ"s -H3)s1. Three of the statements are true and one statement is false. (elect the answer choice containing the *,F(C statement. Choice A: Most H3)s are built on proprietary computer networ"s rather than being 3nternetbased. Choice B: 0hile a H3) is for the e7clusi e use of one organi2ation, a community health information networ" -8H3)1 is shared by se eral organi2ations. Choice C: , health plan can use a secured e7tranet design or a distributed database approach for its H3). Choice D: H3)s ha e the potential to increase the !uality of medical care because they ma"e a patient&s medical history readily a ailable to each pro ider at the point of ser ice. Answer : , Question $1+ The following statements are about information management in health plans. Three of the statements are true and one statement is false. (elect the answer choice containing the *,F(C statement: Choice A: Health plans find C<3 useful for transmitting data among different health plan locations. Choice B: C<3 is different from e8ommerce in the C<3 is the transfer of

data, typically in batches, while ecommerce is a bac"-and-forth e7change of information concerning indi idual transactions. Choice C: The ma6ority of health plan e8ommerce occurs ia proprietary computer networ"s. Choice D: #enefits that health plans can recei e from using electronic data interchange. Answer : 8 Question $14 The following statements are about issues associated with mar"eting healthcare plans to small groups and large groups. (elect the answer choice that contains the correct statement. Choice A: 3n the large group mar"et, large group accounts that ha e employees in more than one geographic area who are co ered through a single national contract for healthcare co erage are "nown as large local groups. Choice B: #ecause pro iding healthcare co erage for employees is often a burden for small businesses, price is typically the most critical consideration for small businesses in selecting a healthcare plan. Choice C: health plans typically treat an employer purchasing coalition as a small group for mar"eting purposes. Choice D: Farge groups rarely use self-funding to finance their healthcare plans. Answer : # Question $1: The following statements are about preferred pro ider organi2ations -//Os1. (elect the answer choice that contains the correct statement. Choice A: //Os generally assume full financial ris" for arranging medical ser ices for their members. Choice B: //Os generally pay a larger portion of a member&s medical e7penses when that member uses in-networ" pro iders than when the member uses out-of-networ" pro iders. Choice C: //O networ"s may include primary care physicians and hospitals, but generally do not include specialists. Choice D: 3n a //O, the most common method used to reimburse physicians is capitation. Answer : #

Question $1; The following statements are about standards set forth in the Quality 3mpro ement (ystem for Managed 8are -Q3(M81, established by the Health 8are *inancing ,dministration -H8*,, now "nown as the 8enters for Medicare and Medicaid (er ices1. (elect the answ Choice A: ,s a result of the #alanced #udget 9efinement ,ct -##9,1, //Os are re!uired to meet all Q3(M8 !uality re!uirements. Choice B: Q3(M8 standards typically do not apply to such Medicare ser ices as mental health or substance abuse ser ices. Choice C: Medicaid primary care case manager -/88M1 programs are sub6ect to the same Q3(M8 !uality standards and performance measures as are all other Medicare and Medicaid programs. Choice D: Q3(M8 standards and guidelines are re!uired for Medicare M8Os, but they are applicable to Medicaid M8Os at the discretion of the indi idual states. Answer : < Question $1? The following statements are about the accessibility of healthcare co erage and medical care in the 5nited (tates. (elect the answer choice that contains the correct statement. Choice A: , personDs employment status as a full-time employee guarantees that person access to healthcare co erage. Choice B: Most people who ha e healthcare co erage are co ered under an indi idual insurance policy rather than a group insurance plan. Choice C: The percentage of the population without healthcare co erage is e enly distributed throughout the 5nited (tates. Choice D: Hospital closings ha e occurred disproportionately in rural areas and inner cities and ha e reduced access to healthcare in these areas. Answer : < Question $1@ The following statements are about the ma"e-up and function of an HMO&s board of directors. (elect the answer choice that contains the correct statement. Choice A: The ma"e-up of an HMO&s board of directors is prescribed by state regulations and does not ary according to whether the plan is a forprofit or not-for-profit plan. Choice B: The board of directors of a not-for-profit HMO is e7empt from

liability for its actions. Choice C: ,n HMO&s board of directors is not responsible for super ising the performance of its officers and outside ad isors. Choice D: , primary function of the board of directors is to appro e and e aluate the organi2ation&s operational policies and procedures. Answer : < Question $1A The following statements are about the non-group mar"et for managed care products in the 5nited (tates. (elect the answer choice containing the correct statement. Choice A: 3n order to promote a product to the indi idual mar"et, M8Os typically rely on personal selling by capti e agents rather than on promotional tools such as direct mail, telemar"eting, and ad ertising. Choice B: Managed Medicare plans typically are allowed to re6ect a Medicare applicant on the basis of the results of medical underwriting of the applicant. Choice C: H8*, -now "nown as the 8enters for Medicare and Medicaid (er ices1 must appro e all membership and enrollment materials used by M8Os to mar"et managed care products to the Medicare population. Choice D: Managed care plans are not allowed to health screen indi idual mar"et customers who are under age ;:, e en if the health screen could help pre ent antiselection. Answer : 8 Question $$= The following statements are about the underwriting function within a health plan. (elect the answer choice containing the correct statement. Choice A: The underwriting function in a health plan is primarily concerned with ensuring that the group being underwritten does not include any indi iduals who are li"ely to ha e higher than a erageutili2ation of medical ser ices. Choice B: 8ompared to a health plan with rela7ed underwriting re!uirements, a similar health plan with ery strict underwriting re!uirements can e7pect to e7perience increased healthcare costs and to ha e significantly higher plan enrollment. Choice C: Typically, a health plan guarantees the premium rate for a group health contract for a period of no more than si7 months. Choice D: 3n order to determine the actual premium to charge a group, a

group underwriter typically considers such factors as le el of participation, benefits, and the age and gender distribution of group members. Answer : < Question $$1 The following statements describe common types of physicianQhospital integrated models: -,1 The ,lpha 8ompany, which is owned by a group of in estors, is a for-profit legal entity that buys entire physician practices, not 6ust the tangible assets of the p Choice A: physician hospital orgnanisation physician practice management company Choice B: physician practice management company physician hospital organisation Choice C: medical foundation management ser ices company Choice D: physician hospital organisation medical foundation Answer : # Question $$$ The following statements describe common types of physicianQhospital integrated models: The 3ota 8ompany, which is owned by a group of in estors, is a for-profit legal entity that buys entire physician practices, not 6ust the tangible assets of the practi Choice A: 3ota- physician hospital organi2ation -/HO18asa- physician practice management -//M1 company. Choice B: 3ota- physician hospital organi2ation -/HO18asa- medical foundation. Choice C: 3ota- physician practice management -//M1 8asa- physician hospital organi2ation -/HO1 company. Choice D: 3ota- medical foundation 8asa- management ser ices organi2ation -M(O1. Answer : 8 Question $$+ The following statements describe corporate transactions: Transaction , ' ,n M8O ac!uired another M8O. Transaction # ' , group of pro iders formed an organi2ation to carry out billings, collections, and contracting with M8Os for the entire group of pro i

Choice A: , and 8 only Choice B: ,, #, and 8 Choice C: # and 8 only Choice D: , and # only Answer : , Question $$4 The following statements describe healthcare ser ices deli ered to health plan members by plan pro iders. (elect the statement that describes a ser ice that would most li"ely re!uire utili2ation re iew and authori2ation. Choice A: ,dele *arnsworth isited a dermatologist to ha e a mole remo ed from her arm. Choice B: Eonathan Fang underwent an electrocardiogram -CO.1 during an office isit with his cardiologist. Choice C: 8orinne Ma7well underwent physical therapy after being hospitali2ed for hip replacement surgery. Choice D: Eose 9edrigue2, a ?=-year-old Medicare patient, recei ed a flu shot as part of his annual physical e7amination. Answer : 8 Question $$: The following statements describe indi iduals who are applying for indi idual health insurance co erage: (i7 months ago, 0ilbur Fee lost his health insurance co erage due to a reduction in wor" hours and has e7hausted his co erage under 8O#9,. Mr. Fee has Choice A: both Mr. Fee and Mr. #ee"er Choice B: Mr. Fee only Choice C: Mr. #ee"er only Choice D: neither Mr. Fee nor Mr. #ee"er Answer : , Question $$; The following statements describe iolations of antitrust legislation: G (ituation , - Two health plans in a single ser ice area di ided purchasers into two groups andagreed to each mar"et their products to only one purchaser group. G (ituation # - , spec Choice A: (ituation , - hori2ontal di ision of mar"ets

(ituation # - tying arrangement. Choice B: (ituation , - hori2ontal di ision of mar"ets (ituation # - price fi7ing. Choice C: (ituation , - hori2ontal group boycott (ituation # - tying arrangement. Choice D: (ituation , - hori2ontal group boycott (ituation # - price fi7ing. Answer : , Question $$? The following types of 8<H/s allow federal ta7 ad antages including the ability to roll funds from one year to the ne7t: Choice A: M(,s, H9,s, H(,s Choice B: *(,s, M9,s, H9,s Choice C: *(,s, H9,s, H(,s Choice D: *(,s, M9,s H(,s Answer : , Question $$@ The .able M8O sometimes e7perience-rates small groups by underwriting a number of small groups as if they constituted one large group and then e aluating the e7perience of the entire large group. This practice, which allows small groups to ta"e ad antage Choice A: prospecti e e7perience rating Choice B: pooling Choice C: retrospecti e e7perience rating Choice D: positioning Answer : # Question $$A The .ranite Health /lan is a coodinated care plan -88/1 that partcipates in the MedicareSChoice program. This information indicates that .ranite Choice A: must comply with all state-mandated benefits and pro ider re!uirements Choice B: must offer each of its enrollees a Medicare supplement Choice C: places primary care t the cener of the deli ery system and focuses on manaing patient care at all le els Choice D: most li"ely must co er Medicare /art ,, but not Medicare /art #, benefits

Answer : 8 Question $+= The Helm M8O segmented the non-group mar"et for its new healthcare product by using factors such as education le el, gender, and household composition. The ,mberly M8O segmented the non-group mar"et for its products based on the approaches by which it sol Choice A: demographic product or benefit Choice B: geographic distribution channel Choice C: demographic distribution channel Choice D: geographic product or benefit Answer : 8 Question $+1 The Hill Health /lan designed a set of benefits that it pac"aged in the form of a //O product. Hill then established a pricing structure that allowed its product to compete in the small group mar"et, and it de eloped ad ertising designed to inform potenti Choice A: , decision as to which e7clusions or limitations would apply for this product. Choice B: , decision as to how to establish the networ" of participating pro iders for this product Choice C: , determination of the le el at which this product would co er out-of-networ" ser ices. Choice D: ,ll of the abo e. Answer : < Question $+$ The Hill Health /lan designed a set of benefits that it pac"aged in the form of a //O product. Hill then established a pricing structure that allowed its product to compete in the small group mar"et, and it de eloped ad ertising designed to inform potenti Choice A: >14= Choice B: >1?= Choice C: >1@= Choice D: >$1= Answer : # Question $++

The Hill Health /lan designed a set of benefits that it pac"aged in the form of a //O product. Hill then established a pricing structure that allowed its product to compete in the small group mar"et, and it de eloped ad ertising designed to inform potenti Choice A: ,n indemnity wraparound plan Choice B: , self-funded plan Choice C: ,n aggregate stop-loss plan Choice D: , fully funded plan Answer : < Question $+4 The Hill Health /lan designed a set of benefits that it pac"aged in the form of a //O product. Hill then established a pricing structure that allowed its product to compete in the small group mar"et,and it de eloped ad ertising designed to inform potentia Choice A: The number of specialists in Hill&s networ" of pro iders. Choice B: The price for the //O product. Choice C: Hill&s ability to report utili2ation data. Choice D: Hill&s use of bro"ers to mar"et its //O product. Answer : # Question $+: The HMO ,ct of 1A?+ was significant in that the ,ct Choice A: mandated certain re!uirements that all HMOs had to meet in order to conduct business Choice B: re!uired that all HMOs be licensed as insurance companies Choice C: offered HMOs federal financial assistance through grants and loans, and pro ided access to the employer-based insurance mar"et Choice D: encouraged the use of pre-e7isting condition e7clusion pro isions in all HMO contracts Answer : 8 Question $+; The Houston 8ompany, a 5nited (tates company, offers its eligible employees health insurance co erage through a group health plan. Houston hired the <allas 8ompany to handle the plan&s claim administration and membership ser ices, but Houston is financial Choice A: Houston is re!uired to purchase stop-loss insurance to co er its losses under this group health plan

Choice B: Houston&s plan is a self-funded plan Choice C: <allas is the plan&s sponsor Choice D: Houston&s plan is not e7empt from any state insurance regulations under C93(, Answer : # Question $+? The 3nternal 9e enue (er ice has ruled that an H<H/ coupled with an H(, may co er certain types of pre enti e care without a deductible or with a lower amount than the annual deductible applicable to all other ser ices. ,ccording to 39( guidance, which on Choice A: 3mmuni2ations for children and adults Choice B: Tests and diagnostic procedures ordered with routine e7aminations Choice C: (mo"ing cessation programs Choice D: .astric bypass surgery for obesity Answer : < Question $+@ The Ooster 8ompany plans to purchase a health plan for its employees from 3ntuiti e HMO. 3ntuiti e will administer the plan and will bear the responsibility of guaranteeing claim payments by paying all incurred co ered benefits. Ooster will pay for the he Choice A: fully funded plan Choice B: stop-loss plan Choice C: self-pay plan Choice D: self-funded plan Answer : , Question $+A The Fin"s 8ompany, which offers its employees a self-funded health plan, signed a contract with a third party administrator -T/,1 to administer the plan. The T/, handles the group&s membership ser ices and claims administration. The contract between Fin"s Choice A: a manual rating contract Choice B: a funding ehicle contract Choice C: an administrati e ser ices only -,(O1 contract Choice D: a pooling contract Answer : 8

Question $4= The Mabry 8ounty Hospital negotiated a contract with 0ellfol" HMO. Mabry negotiated the inclusion of a pro ision in the contract whereby Mabry agreed to capitated compensation from 0ellfol" up to a specified total cost of pro iding medical ser ices for an Choice A: !uality assurance pro ision Choice B: performance-based financial pro ision Choice C: dual-choice pro ision Choice D: stop-loss pro ision Answer : < Question $41 The Madison Health /lan, a national M8O, and a local hospital system that operates its own managed healthcare networ" recently created a new and separate managed healthcare organi2ation, the /ineapple Health /lan. Madison and the hospital system share own Choice A: a consolidation Choice B: a 6oint enture Choice C: a merger Choice D: an ac!uisition Answer : # Question $4$ The main ad antage of using outcomes measures to e aluate healthcare !uality is that they Typically Choice A: are easy to identify and report Choice B: demonstrate impro ed clinical and functional status o er time Choice C: are insensiti e to changes in structures or processes Choice D: pro ide meaningful feedbac" on care deli ery e en when the delay between treatment and outcome stretches o er se eral years Answer : # Question $4+ The main purpose of the Health /lan Cmployer <ata and 3nformation (et -HC<3(1 is to pro ide Choice A: e7pert consultation to end-users for sol ing speciali2ed and comple7 healthcare problems through the use of a "nowledge-based computer system

Choice B: a comprehensi e accrediation for //Os Choice C: measurements of plan performance and effecti eness that potential healthcare purchasers can use to compare !uality offered by different healthcare plans Choice D: a mathemetical model that can predict future claim payments and premiums Answer : 8 Question $44 The Meadowcree" .roup is an organi2ation comprised of indi idual physicians and physicians in small group practices. Meadowcree" enters into contracts with health plans, and then Meadowcree" contracts separately with its physician members. 3n situations w Choice A: a group practice without walls -./001 Choice B: a messenger model Choice C: an indi idual practice association -3/,1 Choice D: a /hysician /ractice Management -//M1 company Answer : 8 Question $4: The measures used to e aluate healthcare !uality are generally di ided into three categories: process, structure and outcomes. ,n e7ample of a process measure that can be used to e aluate an M8O&s performance is the Choice A: percentage of baord certified physicians within the M8O&s networ" Choice B: number of hospital admissions for plan members with certain medical conditions Choice C: number of plan members contracting an infection in the ospital Choice D: percentage of adult plan members who recei e regular medical chec"ups Answer : < Question $4; The measures used to e aluate healthcare !uality are generally di ided into three categories: process, structure, and outcomes. ,n e7ample of a process measure that can be used to e aluate a health plan&s performance is the: Choice A: /ercentage of adult plan members who recei e regular medical chec"ups.

Choice B: )umber of plan members contracting an infection in the hospital. Choice C: /ercentage of board certified physicians within the health plan&s networ". Choice D: )umber of hospital admissions for plan members with certain medical conditions. Answer : , Question $4? The Military Health (ystem of the <epartment of <efense offers ongoing healthcare co erage to military personnel and their families through the Choice A: Health 8are Quality 3mpro ement /rogram -H8Q3/1 Choice B: Health /lan Management (ystem -H/M(1 Choice C: T938,9C healthcare system Choice D: Health 8are /repayment /lan -H8//1 Answer : 8 Question $4@ The Mirror Health /lan uses a form of computerQtelephony integration -8T31 to manage telephone calls coming into its member ser ices department. 0hen a member calls the plan&s central telephone number, a de ice answers the call with a recorded message and Choice A: a member outreach program Choice B: a complaint resolution procedure -89/1 Choice C: an automatic call distributor -,8<1 Choice D: an interacti e oice response -3I91 system Answer : 8 Question $4A The Mosaic health plan uses a typical electronic medical record -CM91 to document the medical care its members recei e. One characteristic of Mosaic&s CM9 is that it: Choice A: <oes not pro ide any clinical decision support for Mosaic&s pro iders. Choice B: 3s designed to supply information at the site of care. Choice C: 8ontains a Mosaic member&s clinical data only. Choice D: 3s organi2ed by the type of treatment or by pro ider. Answer : #

Question $:= The ),38 adopted the HMO Model ,ct in order to pro ide a system of ongoing regulatory monitoring of HMOs. ,ll of the following statements are correct about the HMO Model ,ct CK8C/T that it: Choice A: 9egulates HMO operations in two critical areas: financial responsibility and healthcare deli ery. Choice B: 9e!uires each HMO to send state regulators an annual report describing the HMO&s finances and operations. Choice C: *ocuses on three "ey aspects of healthcare deli ery: networ" ade!uacy, !uality assurance, and grie ance procedures. Choice D: 9e!uires state insurance departments to conduct annual e7aminations of an HMO&s operations, !uality assurance programs, and pro ider networ"s. Answer : < Question $:1 The ),38 designed a small group model law to enable small groups to obtain accessible, yet affordable, group health benefits. (pecifically, the model law limits the rate spread. ,ccording to this model law, if the lowest rate that an HMO charges a small g Choice A: >@= Choice B: >1$= Choice C: >1;= Choice D: >$4= Answer : 8 Question $:$ The )ational ,ssociation of 3nsurance 8ommissioners -),381 de eloped the (mall .roup Model ,ct to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the hi Choice A: >;= Choice B: >@= Choice C: >1$= Choice D: >1;= Answer : # Question $:+ The )ational ,ssociation of 3nsurance 8ommissioners& -),38&s1 5nfair

8laims (ettlement /ractices ,ct specifies standards for the in estigation and handling of claims. The ,ct defines unfair claims practices and notes that such practices are improper if th Choice A: #oth , and # Choice B: , only Choice C: # only Choice D: )either , nor # Answer : , Question $:4 The )ational 8ommittee for Quality ,ssurance -)8Q,1 is a nonprofit organi2ation that accredits health plans and other healthcare organi2ations. 5nder the current )8Q, accreditation program, a health plan&s accreditation score is determined, in part, by pe Choice A: is a performance-measurement tool designed to help healthcare purchasers and consumers compare !uality offered by different plans. Choice B: di ides performance measures into @ domains, and organi2es reporting measures under these domains. Choice C: is updated annually and measures are changed or new measures added. Choice D: all of the abo e Answer : < Question $:: The nature of the claims function within health plans aries by type of plan and by the compensation arrangement that the plan has made with its pro iders. *or e7ample, it is generally correct to say that, in a ,. /referred pro ider organi2ation -//O1, th Choice A: #oth , and # Choice B: , only Choice C: # only Choice D: )either , nor # Answer : , Question $:; The )eptune Hospital pro ides medical care to paying patients, as well as to people who either ha e no healthcare co erage and cannot afford to pay for the care by themsel es or who recei e ser ices at reduced rates because they are co ered under go ernme

Choice A: cost shifting Choice B: ,ntiselection Choice C: recei ership Choice D: 5nderwriting Answer : , Question $:? The Oriole M8O uses a typical diagnosis-related groups -<9.s1 payment method to reimburse the 3sle Hospital for its treatment of Oriole members. 5nder the <9. payment method, whene er an Oriole member is hospitali2ed at 3sle, Oriole pays 3sle Choice A: an amount based on the weighted alue of each medical procedure or ser ice that 3sle pro ides, and the weighted alue is determined by the appropriate current procedural terminology -8/T1 code for the procedure or ser ice Choice B: a fi7ed rate based on a erage e7pected use of hospital resources in a gi en geographical area for that <9. Choice C: a retrospecti e reimbursement based on the actual costs of the Oriole member&s hospitali2ation Choice D: a specific negotiated amount for each day the Oriole member is hospitali2ed Answer : # Question $:@ The owners of an M8O typically delegate authority for go erning the operation of the M8O by electing the M8O&s Choice A: !uality management committee Choice B: medical director Choice C: board of directors Choice D: chief e7ecuti e officer Answer : 8 Question $:A The paragraph below contains two pairs of terms enclosed in parentheses. <etermine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms you ha e selected. The Harbor Health /lan con ened a litig Choice A: a standing Q ongoing Choice B: a standing Q specific

Choice C: an ad hoc Q ongoing Choice D: an ad hoc Q specific Answer : < Question $;= The participating physicians remain independent practitioners who operate out of their own offices and can treat other patients in addition to Oaya" plan members. Oaya" can correctly be characteri2ed as Choice A: a closed-panel HMO Choice B: an open-panel HMO Choice C: a direct contract model HMO Choice D: a dual choice HMO Answer : # Question $;1 The parties to the contractual relationship that pro ides 8astle&s group health co erage to Onoll employees are Choice A: 8astle and Onoll only Choice B: Onoll and all co ered Onoll employees only Choice C: 8astle, Onoll, and all co ered Onoll employees Choice D: 8astle and all co ered Onoll employees only Answer : , Question $;$ The /olestar 8ompany&s sole business is the ownership of /olaris Medical .roup, a health plan and subsidiary of /olestar. (ome members of /olestar&s board of directors hold positions with /olestar in addition to their positions on the boardL the rest are Choice A: /olestar&s relationship to /olaris: partnership Type of board member: operations director Choice B: /olestar&s relationship to /olaris: partnership Type of board member:outside director Choice C: /olestar&s relationship to /olaris: holding company Type of board member: operations director Choice D: /olestar&s relationship to /olaris: holding company Type of board member:outside director Answer : < Question $;+

The process of calculating the appropriate premium to charge purchasers, gi en the degree of ris" represented by the indi idual or group, the e7pected costs to deli er medical ser ices, and the e7pected mar"etability and competiti eness of the health plan Choice A: financing Choice B: rating Choice C: underwriting Choice D: budgeting Answer : # Question $;4 The process that Mr. (ybe7 used to identify and classify the ris" represented by the Ooster .roup so that 3ntuiti e can charge premiums that are ade!uate to co er its e7pected costs is "nown as Choice A: coinsurance Choice B: plan funding Choice C: underwriting Choice D: pooling Answer : 8 Question $;: The pro ision of mental health and chemical dependency ser ices is collecti ely "nown as beha ioral healthcare. The following statements are about beha ioral healthcare. (elect the answer choice containing the correct statement. Choice A: 3n most preferred pro ider organi2ations -//Os1 and open access plans, plan members must recei e a referral before accessing beha ioral healthcare ser ices from a specialist. Choice B: To manage the deli ery of beha ioral healthcare ser ices, managed beha ioral health organi2ations -M#HOs1 typically use alternati e treatment le els and alternati e treatment methods rather than crisis inter ention or alternati e treatment settings. Choice C: Managed beha ioral health organi2ations -M#HOs1 typically are prohibited from negotiating with networ" pro iders for reduced fees in e7change for increased patient olume. Choice D: The treatment approaches for beha ioral healthcare most often include drug therapy, psychotherapy, and counseling. Answer : #

Question $;; The pro ision of mental health and chemical dependency ser ices is collecti ely "nown as beha ioral healthcare. The following statements are about beha ioral healthcare. Three of these statements are true and one statement is false. (elect the answer choi Choice A: *actors that ha e increased the demand for beha ioral healthcare ser ices include increased stress on indi iduals and families and the increasing a ailability of beha ioral healthcare ser ices. Choice B: To manage the deli ery of beha ioral healthcare ser ices, managed beha ioral health organi2ations -M#HOs1 use only two basic strategies: alternati e treatment le els and crisis inter ention. Choice C: The treatment approaches for beha ioral healthcare most often include drug therapy, psychotherapy, and counseling. Choice D: The de elopment of alternati e treatment options, incorporation of community-based resources into the healthcare system, and increased reliance on case management ha e shifted the emphasis of managed beha ioral healthcare from meeting the ser ice needs of Answer : # Question $;? The 9obust Health /lan sometimes uses prospecti e e7perience rating to calculate the premiums for a group. 5nder prospecti e e7perience rating, 9obust most li"ely will: Choice A: ,t the end of a rating period, the financial gains and losses e7perienced by the group during that rating period and, if the group&s e7perience during the period is better than e7pected, refund part of the group&s premium in the form of an e7perience rati Choice B: 5se 9obust&s a erage e7perience with all groups to calculate this particular group&s premium. Choice C: 5se the group&s past e7perience to estimate the group&s e7pected e7perience for the ne7t period. Choice D: ,ll of the abo e Answer : 8 Question $;@ The statements below describe technology used by two health plans to respond to incoming telephone calls: G The Manor Health /lan uses an automated system that answers telephone calls with recorded or synthesi2ed speech and prompts the caller to

respond t Choice A: Manor&s system is best described as an automated call distributor -,8<1. Choice B: #oth Manor&s system and (!uire&s de ice are applications of computerQtelephone integration -8T31. Choice C: (!uire&s de ice is best described as an interacti e oice response -3I91 system. Choice D: ,ll of these statements are correct. Answer : # Question $;A The statements below describe technology used by two M8Os to respond to incoming telephone calls: H The Morton M8O uses an automated system that answers telephone calls with recorded or synthesi2ed speech and prompts the caller to respond to a menu of opt Choice A: ,utumn&s de ice is best described as an interacti e oice response -3I91 system. Choice B: #oth Morton&s system and ,utumn&s de ice are applications of computerQtelephony integration -8T31. Choice C: Morton&s system is best described as an automatic call distributor -,8<1. Choice D: Morton&s system can be correctly characteri2ed as an e7pert system. Answer : # Question $?= The (tateside Health /lan uses the following outcomes measures to e aluate the !uality of its diabetes disease management program. Measure A: 3ncidence of foot ulcers among long-term diabetes patients Measure B: ,bility of long-term diabetes patients to m Choice A: Measure , clinical status Measure # patient perception Choice B: Measure , clinical status Measure # functional status Choice C: Measure , functional status Measure # patient perception Choice D: Measure , functional status Measure # clinical status Answer : # Question $?1 The Titanium Health /lan and a third-party administrator -T/,1 ha e

entered into a T/, agreement with regard to the administration of a particular health plan. This agreement complies with all of the pro isions of the ),38 T/, Model Faw. One of the T/,&s Choice A: Hold all funds it recei es on behalf of Titanium in trust. Choice B: ,ssume full responsibility for ensuring that the health plan is administered properly Choice C: Obtain from the federal go ernment a certificate of authority designating the organi2ation as a T/,. Choice D: ,ssume full responsibility for determining the claim payment procedures for the plan Answer : , Question $?$ The Ienus Hospital pro ides medical care to paying patients, as well as to people who either ha e no healthcare co erage and cannot pay for the care by themsel es or who recei e ser ices at reduced rates because they are co ered under go ernment sponsored Choice A: antiselection Choice B: cost shifting Choice C: recei ership Choice D: underwriting Answer : # Question $?+ To achie e widespread use of electronic data interchange -C<31 in the healthcare industry, all entities within the industry need to agree on industry standards regarding the information format and software to be used. (e eral organi2ations are ma"ing cont Choice A: 8omputer-based /atient 9ecords 3nstitute -8/931 Choice B: ,merican )ational (tandards 3nstitute -,)(31 Choice C: ,merican Health 3nformation Management ,ssociation -,H3M,1 Choice D: ,merican Medical ,ssociation -,M,1 Answer : # Question $?4 To address the problems associated with multiple data management systems, the Oaya" Health /lan has begun to use a data warehouse. One li"ely characteristic of Oaya"&s data warehouse is that:

Choice A: 3t re!uires Oaya"&s indi idual databases to store large amounts of data that are not needed for daily operations. Choice B: 3t contains data from internal sources only. Choice C: 3t stores historical data rather than current data. Choice D: The data in the warehouse are lin"ed by a common sub6ect. Answer : < Question $?: To determine fee reimbursements to be paid to physicians, the Triangle Health /lan assigns a weighted alue to each medical procedure or ser ice and multiplies the weighted alue by a money multiplier. Triangle and the pro iders negotiate the alue of the Choice A: <iagnosis-related group -<9.1 system Choice B: 9elati e alue scale -9I(1 Choice C: /artial capitation arrangement Choice D: 8apped fee system Answer : # Question $?; To determine fee reimbursements to be paid to physicians, the Triangle Health /lan assigns a weighted alue to each medical procedure or ser ice and multiplies the weighted alue by a money multiplier. Triangle and the pro iders negotiate the alue of the Choice A: diagnosis-related group -<9.1 system Choice B: relati e alue scale -9I(1 Choice C: partial capitation arrangement Choice D: capped fee system Answer : # Question $?? To set up and contribute to an H(,, an indi idual must: Choice A: #e co ered by a high-deductible health plan that meets federal re!uirements. Choice B: )ot ha e other health insurance. Choice C: )ot be enrolled in Medicare. Choice D: ,ll of the abo e. Answer : < Question $?@

Traditional Medicare includes two parts: Medicare /art , and Medicare /art #. 0ith regard to the ways these parts differ from each other, it is correct to say that Medicare /art , Choice A: pro ides benefits for physicians& professional ser ices, whereas Medicare /art # pro ides basic hospitali2ation insurance Choice B: is financed through premiums paid by co ered persons and from the federal go ernment&s general ta7 re enues, whereas Medicare /art # is funded primarily through a payroll ta7 imposed on employers and wor"ers Choice C: pro ides 1==J co erage for eligible medical e7penses, whereas Medicare /art # includes annual deductible and coinsurance pro isions Choice D: is pro ided automatically to most eligible persons, whereas Medicare /art # is a oluntary program Answer : < Question $?A Two M8Os in a single ser ice area di ided purchasers into two groups and agreed to each mar"et their products to only one purchaser group. This information indicates that these two M8Os iolated antitrust re!uirements because they engaged in an acti ity " Choice A: hori2ontal group boycott Choice B: hori2ontal di ision of mar"ets Choice C: a tying arrangement Choice D: price fi7ing Answer : # Question $@= Types of alternati e care centers include urgent care centers, obser ation care units, and stepdown units. One difference between the costs associated with alternati e care centers is that, compared to the cost of: Choice A: *acilities, e!uipment, and staffing in hospital emergency departments -C<s1, the cost of facilities, e!uipment, and staffing in obser ation care units is generally lower Choice B: 8are deli ered in urgent care centers, the cost of care deli ered in hospital emergency departments -C<s1 is generally lower. Choice C: 8are in step-down units, the cost of acute inpatient care is generally lower. Choice D: /rimary care in a physician&s office, the cost of care deli ered in urgent care centers is generally lower.

Answer : , Question $@1 5sing a code for a procedure or diagnosis that is more comple7 than the actual procedure or diagnosis and that results in igher reimbursement to the pro ider is called %%%%%%%%%%%%%%. Choice A: 8oding error Choice B: O ercharging Choice C: 5pcoding Choice D: 5nbundling Answer : 8 Question $@$ 5tili2ation data can be transmitted to the health plan manually, by telephone, or electronically. 8ompared to other methods of data transmittal, manual transmittal is generally Choice A: less cumbersome and labor intensi e Choice B: faster and more accurate Choice C: more acceptable to physicians Choice D: sub6ect to greater scrutiny by regulatory bodies Answer : 8 Question $@+ 0ellborne HMO pro ides health-related information to its plan members through an 3nternet 0eb site. Faura Onight, a 0ellborne plan member, isited 0ellborne&s 0eb site to gather uptodate information about the ris"s and benefits of arious treatment option Choice A: shared decision ma"ing Choice B: self-care Choice C: pre enti e care Choice D: triage Answer : , Question $@4 0hen determining physicians& fee reimbursements, the #lossom Managed Healthcare .roup assigns a weighted alue to each medical procedure or ser ice and multiplies the weighted alue by a money multiplier, as shown below: 0eighted alue for ser ice T Money

Choice A: discounted fee-for-ser ice system Choice B: global capitation arrangement Choice C: withhold arrangement Choice D: relati e alue scale -9I(1 Answer : < Question $@: 0hen determining the premium rates it will charge a particular group, the #lue Eay Health /lan used a rating method "nown as community rating by class -8981. 5nder this rating method, #lue Eay Choice A: was allowed to use no more than four rating classes when determining how much to charge the group for health co erage Choice B: was re!uired to ma"e the a erage premium in each class no more than 1=:J of the a erage premium for any other class Choice C: di ided its members into rating classes based on demographic factors, e7perience, or industry characteristics, and then charged each member in a rating class the same premium Choice D: charged all employers or other group sponsors the same dollar amount for a gi en le el of medical benefits, without ad6ustments for age, gender, industry, or e7perience Answer : 8 Question $@; 0hen determining the rates it will charge a small group, the Cagle HMO, a federally !ualified HMO, di ides its members into classes or groups based on demographic factors such as geography, family composition, and age. Cagle then charges all members of a Choice A: 9etrospecti e e7perienced rating. Choice B: ,d6usted community rating -,891. Choice C: /ure community rating. Choice D: (tandard community rating. Answer : # Question $@? 0hen the Onoll 8ompany purchased group health co erage from the 8astle Health Maintenance Organi2ation -HMO1, the agreement between the two parties specified that the plan would be a typical fully funded plan. #ecause Onoll had been co ered under a pre io Choice A: 8astle is responsible for paying for all incurred co ered

benefits Choice B: Onoll is solely responsible for guaranteeing claim payments Choice C: Onoll ma"es no premium payments to 8astle Choice D: 8astle has no responsibilities for administering the health plan Answer : , Question $@@ 0hen the Onoll 8ompany purchased group health co erage from the 8astle Health Maintenance Organi2ation -HMO1, the agreement between the two parties specified that the plan would be a typical fully funded plan. #ecause Onoll had been co ered under a pre io Choice A: $+= Choice B: $?= Choice C: $$= Choice D: 1@= Answer : 8 Question $@A 0hich is an ad antage of a for-profit health planB Choice A: *le7ibility in raising capital Choice B: <ouble ta7ation Choice C: C7emption from paying federal income ta7es. Choice D: )one of the abo e. Answer : , Question $A= 0hich of the choices below contains the four tools used by mar"eters that ma"e up the &promotion mi7B& Choice A: ,d ertising, personal selling, sales promotion, and publicity. Choice B: ,d ertising, price, sales promotion, and publicity. Choice C: ,dmissions, personal selling, sales promotion, and publicity. Choice D: ,d ertising, personal selling, sales promotion, and pri acy. Answer : , Question $A1 0hich of the following best describes an organi2ation that is owned by a hospital or group of in estors and pro ides management and administrati e support ser ices to indi idual physicians or small group practicesB

Choice A: 3ndependent /ractice ,ssociation -3/,1. Choice B: .roup /ractice 0ithout 0alls -./001 Choice C: Management (er ices Organi2ation -M(O1. Choice D: 8onsolidated Medical .roup. Answer : 8 Question $A$ 0hich of the following is 8O99C8TB Choice A: Clectronic transmittal of authori2ation is sub6ect to the same regulatory re!uirements as other methods of transmittal Choice B: Telephone transmittal increases data entry errors. Choice C: Medical re iew is conducted before administrati e re iew. Choice D: /rospecti e re iew, concurent re iew and retrospecti e re iew are types of utili2ation re iew Answer : < Question $A+ 0hich of the following is )OT a factor that is used by M8Os to determine which ser ices will undergo utili2ation re iew. Choice A: 8ost per procedure Choice B: 8oncurrent re iew Choice C: 8ost of re iew Choice D: ,ccess re!uirements Answer : < Question $A4 0hich of the following is )OT a pre enti e care initiati e often used by health plansB Choice A: (creening for high blood pressure Choice B: Maternity management programs Choice C: Iaccines Choice D: /hysical therapy Answer : < Question $A: 0hich of the following is )OT a reason for conducting utili2ation re iewsB Choice A: 3mpro e the !uality and cost effecti eness of patient care Choice B: 9educe unnecessry practice ariations

Choice C: Ma"e appropriate authori2ation decisions Choice D: ,ccommodate special e!uirements of inpatient care Answer : < Question $A; 0hich of the following is 09O).B Choice A: 8omputer #ased /atient 9ecords 3nstitute -8/931 de eoped the standards for digital imaging of 7rays. Choice B: HF? de elopers focuses on interchange of 8linical Health <ata Choice C: ,)(3, a oluntary national standards organi2ation, creates a consensus based process by which fair and e!uitable standards can be de eloped and ser es as a legitmi2er of standards. Choice D: ,merican Health 3nformation Management ,ssociation focuses on C<3 standards for e7change of clinical data Answer : , Question $A? 0hich of the following is-are1 8O99C8TB -,1 (taff model HMOs can achie e ma7imum economies of scale but are hea ily capital intensi e. -#1 (taff model HMOs are closed panel. -8 1 (taff model HMOs operate out of ambulatory care facilities. Choice A: , M # Choice B: )one of the listed options Choice C: # M 8 Choice D: ,ll of the listed options Answer : < Question $A@ 0hich of the following 6ob descriptions best match the 6ob of a telephone triage staff memberB Choice A: 8hec" patient itals, write prescriptions, administer drugs. Choice B: .reet patients at the door, collect insurance information, schedule appointments, collect payments. Choice C: <etermine urgency of the condition, notify emergency department, schedule appointments, authori2e referrals, pro ide self-care information. Choice D: )one of the abo e. Answer : 8

Question $AA 0hich of the following people would be considered part of the indi idual mar"et segmentB Choice A: Eohn is eligible for Medicare. Choice B: Eulie has co erage through an employer group. Choice C: Eames wor"s for an employer that does not offer health co erage. Choice D: Eenny is eligible for Medicaid. Answer : 8 Question +== 0hich of the following statements about C/O M HMO models is *,F(CB Choice A: 3n-networ" isit is allowed only on /8/&s referral in HMO model. Choice B: Out-of-networ" isit is not allowed in HMO model. Choice C: Out-of-networ" isit is not allowed in C/O model. Choice D: 3n-networ" isit is allowed only on /8/&s referral in C/O model. Answer : , Question +=1 0hich of the following statements about *amily and Medical Fea e ,ct -*MF,1 is 09O).B Choice A: Cmployers need to maintain the co erage of group health insurance during this period Choice B: Cmployees can ta"e upto 1$ wee"s of unpaid lea e in a +; month perio Choice C: /rotects people faced with birthQadoption or seriously ill family members Choice D: Cmployers that ha e U := employees need to comply Answer : # Question +=$ 0hich of the following statements about the Title I33 of the 8i il 9ights ,ct is 09O).B Choice A: Cmployers with more than 1: employees engaged in interstate commerce need to comply Choice B: /regnancy <iscrimination ,ct -an amendment to this act1

re!uires health plans to pro ide co erage during childbirth and related medical conditions on the same basis as they pro ide co erage for other medical conditions Choice C: ,llows HMOs to set different policies for people from different races, religions, se7 or national origin to safeguard their interests. Choice D: /rotects all employees Answer : 8 Question +=+ 0hich of the following statements is *,F(CB Choice A: The license that HMOs get in each state is called V8ertificate of ,uthorityD Choice B: The HMO contracts directly with the indi idual physicians who pro ide the medical ser ices to the HMO members in a ariation of the 3/, model called direct contract model HMO. Choice C: ,ll medicareQmediclaim beneficiaries should comply with utili2ation management re!uirements set forth by H8*, Choice D: HMODs usually impose high coinsurance or deductible re!uirements Answer : < Question +=4 0hich of the following statements is )OT a re!uirement for a ser ice to be deemed a &medically necessary ser iceB& Choice A: *urnished in the least intensi e type of medical care setting re!uired by the member&s condition. Choice B: (olely for the con enience of the member. Choice C: 3n accordance with the standards of good medical practice. Choice D: 8onsisitent with the symptoms of the member&s condition. Answer : # Question +=: 0hich of the following statements is trueB Choice A: , declining economy can lead to lower healthcare costs as a result of an older population with greater healthcare needs. Choice B: , larger patient population increases pressure on the health plan to offer larger panels. Choice C: /ro ider networ"s are not affected by the federal and state laws that apply to health plans

Choice D: )etwor" management standards established by independent accrediting organi2ations ha e no influence on health plan networ" design. Answer : #