You are on page 1of 140

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, have an equity interest in the practice, and
provide

Choice A: a captive group a staff model

Choice B: a captive group a network mode

Choice C: an independent group a network model

Choice D: an independent group a staff model

Question 2

______________ HMOs can't medically underwrite any group –
incl small groups.

Choice A: State

Choice B: Not-for-profit

Choice C: For-profit

Choice D: Federally qualified

““:B

Question 3

A common physician-only integrated model is a group practice
without walls (GPWW). One characteristic of a typical GPWW is
that the

Choice A: GPWW combines multiple independent physician
practices under one umbrella organization

Choice B: GPWW generally has a lesser degree of integration
than does an IPA

Choice C: member physicians cannot own the GPWW

Choice D: GPWW's member physicians must perform their
own business operations

““:A

Question 4

A health plan may use one of several types of community
rating methods to set premiums for a health plan. The
following statements are about community rating. Select the “
“ choice containing the correct statement.

Choice A: Standard (pure) community rating is typically used
for large groups because it is the most competitive rating
method for large groups.

Choice B: Under standard (pure) community rating, a health
plan charges all employers or other group sponsors the same
dollar amount for a given level of medical benefits or health
plan, without adjusting for factors such as age, gender, or
experience.

Choice C: In using the adjusted community rating (ACR)
method, a health plan must consider the actual experience of
a group in developing premium rates for that group.

Choice D: The Centers for Medicare and Medicaid Services
(CMS) prohibits health plans that assume Medicare risk from
using the adjusted community rating (ACR) me

““:B

Question 5

A health plan's ability to establish an effective provider
network depends on the characteristics of the proposed
service area and the needs of proposed plan members. It is
generally correct to say that

Choice A: health plans have more contracting options if
providers are affiliated with single entities than if providers are
affiliated with multiple entities

Choice B: urban areas offer more flexibility in provider
contracting than do rural areas

Choice C: consumers and purchasers in markets with little
health plan activity are likely to be more receptive to HMOs
than to loosely managed plans such as PPOs

Choice D: large employers tend to adopt health plans more
slowly than do small companies

““:B

Question 6

A health savings account must be coupled with an HDHP that
meets federal requirements for minimum deductible and
maximum out-of-pocket expenses. Dollar amounts are indexed
annually for inflation. For 2006, the annual deductible for self-
only coverage must

Choice A: $525

Choice B: $1,050

Choice C: $2,100

Choice D: $5,250

““:B

Question 7

participating physicians Choice C: achieve economies of scale through facility consolidation and practice management Choice D: refrain from the corporate practice of medicine ““:A Question 8 A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. a medical foundation must Choice A: provide significant benefit to the community Choice B: employ. With respect to a closed PHO. rather than contract with. In order to retain its not-for- profit status. This health plan requires preauthorization for certain medical services. With regard to the steps that the health plan's claims e Choice A: should assume that all services requiring preauthorization have been preauthorized Choice B: should investigate any conflicts between diagnostic codes and treatment codes before approving the claim to ensure that the appropriate payment is made for the claim Choice C: need not verify that the provider is part of the health plan's network before approving the claim at the in-network level of benefits Choice D: need not determine whether the member is covered by another health plan that allows for coordination of benefits ““:B Question 9 A physician-hospital organization (PHO) may be classified as an open PHO or a closed PHO.A medical foundation is a not-for-profit entity that purchases and manages physician practices. it .

the specialists in the PHO are typically compensated on a capitation basis Choice A: the specialists in the PHO are typically compensated on a capitation basis Choice B: it typically limits the number of specialists by type of specialty Choice C: it is available to a hospital's entire eligible medical staff Choice D: physician membership in the PHO is limited to PCPs ““:B Question 10 A public employer. Choice D: Debtor-creditor group. Choice C: Affinity group.is correct to say that A. ““:A Question 11 According to the IRS. . Choice D: Immunizations for children and adults. which of the following is not an allowable preventive care service: Choice A: Smoking cessation programs. Choice C: Health club memberships. Choice B: Periodic health examinations. such as a municipality or county government would be considered which of the following? Choice A: Employer-employee group. Choice B: Multiple-employer group.

a member of the Frazier Health Plan.2 million ““:B Question 13 Al Marak. Marak's coverage. Marak to submit to arbitration in order to resolve the dispute Choice C: it is considered to be an informal appeal Choice D: it will be handled by an independent review organization (IRO) ““:A Question 14 All CDHP products provide federal tax advantages while .2 million Choice B: 2. enrollment in HSAs had reached nearly: Choice A: 1.2 million Choice D: 4. As of January 2006. enrollment in HSA- related health plans more than tripled in 2005. One true statement about this Level One appeal is that Choice A: Mr.2 million Choice C: 3. Marak has the right to appeal to the next level if the Level One appeal upholds the original decision Choice B: it requires Frazier and Mr.““:C Question 12 After a somewhat modest start in 2004. has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. making them today’s fastest growing type of CDHP.

The terms of the contract specify that Allgood will reimburse Mercy Memorial on the basis of a negotiated ch Choice A: per diem agreement Choice B: fee-for-service agreement Choice C: withhold agreement Choice D: diagnostic related group (DRG) agreement ““:A Question 16 Although the process is voluntary for health plans. Inc. external accreditation is becoming more and more important as states and purchasers require health plans undergo as many states and purchasers require health plans undergo some type of external review pr Choice A: Is voluntary for health plans. Choice A: True Choice B: False Choice C: Choice D: ““:A Question 15 Allgood Medical. a health plan. has contracted with Mercy Memorial Hospital to provide inpatient medical services to Allgood's plan members. .allowing consumers to save money for their healthcare.. Choice B: Requires all change accreditation organizations to use the same standards of accreditation.

Choice C: Typically requires the accrediting organization to conduct a medical record review and a review of a health plan's credentialing processes. Choice D: Cannot assure that a health plan meets a specified level of quality. one difference between an EPO and a PPO is that an EPO Choice A: is regulated under federal HMO legislation Choice B: generally provides no benefits for out-of-network care Choice C: has no provider network of physicians Choice D: is not subject to state insurance laws ““:B Question 19 . However. but not an evaluation of the health plans' member service systems processes. ““:A Question 17 Amendments to the HMO act 1973 do not permit federally qualified HMO’s to use Choice A: Retrospective experience rating Choice B: Adjusted community rating Choice C: Community rating by class Choice D: Community rating ““:A Question 18 An exclusive provider organization (EPO) operates much like a PPO.

He has elected to continue his coverage under his employer's group Choice A: 18 months. but his coverage under COBRA will cease if he obtains group health coverage through another . even if he obtains group health coverage through another employer. Choice C: 36 months. Moyer is terminating his employment. Mr.An HMO that combines characteristics of two or more HMO models is sometimes referred to as a Choice A: network model HMO Choice B: group model HMO Choice C: staff model HMO Choice D: mixed model HMO ““:D Question 20 Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called: Choice A: Codes Choice B: Lists Choice C: Edits Choice D: Checks ““:C Question 21 Arthur Moyer is covered under his employer's group health plan. which must comply with the Consolidated Omnibus Budget Reconciliation Act (COBRA). Choice B: 18 months. but his coverage under COBRA will cease if he obtains group health coverage through another employer.

who has a chronic respiratory condition. ““:A Question 23 As part of its utilization management (UM) system. Novacek and Mr. Choice D: Case-mix adjustment. ““:A Question 22 As part of its quality management program. The following individuals are members of the Creole Health Plan: • Jill Novacek. • Abraham Rashad. Devereaux only. the Creole Health Plan uses a process known as case management. Novacek and Mr. Rashad only. Choice B: Standard of care. Choice D: 36 months. and Mr. Devereaux. Choice C: An adverse event. Novacek. Choice B: Ms. Choice C: Ms. Choice A: Ms. When Lyric concludes that its competitor's practices or services are better than its own. ““:A . Mr. Lyric im Choice A: Benchmarking. Choice D: None of these members.employer. the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. even if he obtains group health coverage through another employer. Rashad.

Cromartie only ““:C Question 25 Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a 30% coinsurance provision for all healthcare obtained outside the plan’s network of providers. Martin became ill while she was on vacation. Albrecht and Ms. Van Note and Mr. and a managed care plan. Van Note. Albrecht only Choice D: Mr. and Ms. Both plans have a typical coordination of benefits (COB) . the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members: · Brad Van Note. age 28. Van Note and Ms. Cromartie only Choice C: Mr. costly medications for Choice A: Mr. is taking many different. Choice A: $300 Choice B: $510 Choice C: $600 Choice D: $810 ““:D Question 26 Bart Vereen is insured by both a traditional indemnity health insurance plan. Cromartie Choice B: Mr.Question 24 As part of its utilization management (UM) system. Ms. which is his primary plan. In 1998. Albrecht. Mr.

post-acute care for behavioral health di Choice A: Hospital observation units or psychiatric hospitals. the HMO first verifies the physician's credentials. but neither plan has a nonduplication of benefits provisi Choice A: 380 Choice B: 130 Choice C: 0 Choice D: 550 ““:A Question 27 Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision. Choice C: Subacute care facilities or skilled nursing facilities.provision. ““:C Question 28 Before an HMO contracts with a physician. Upon becoming part of the HMO's organized system of healthcare. Choice D: Psychiatric units in general hospitals or hospital observation units. Choice B: Psychiatric hospitals or rehabilitation hospitals. the physician is typically subject to Choice A: both recredentialing and peer review Choice B: recredentialing only Choice C: peer review only . For example. behavioral healthcare services can be delivered effectively in a variety of settings.

whereas the specialists have a positive incentive to help their plan members stay healthy. Choice B: Have no financial incentive to practice preventive care or to focus on improving the health of their plan members. whereas the specialists receive compensation based on a percentage discount from their normal fees. Choice C: Receive from the IPA the same monthly compensation for each Hill plan member under the PCP's care. it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the Choice A: Receive compensation based on the volume and variety of medical services they perform for Hill plan members.5 . Choice D: Receive compensation based on a fee schedule. whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services.Choice D: neither recredentialing nor peer review ““:C Question 29 Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X. whereas the specialists receive compensation based on per diem charges. ““:C Question 30 Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X. it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the Choice A: Hill had to have an initial net worth of at least $1.

whereas the specialists receive compensation based on per diem charges ““:C . whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services Choice B: have no financial incentive to practice preventive care or to focus on improving the health of their plan members. Choice C: Hill had to be organized as a partnership in order to obtain a COA Choice D: The COA in no way indicates that Hill has demonstrated that it is fiscally sound. whereas the specialists receive compensation based on a percentage discount from their normal fees Choice D: receive compensation based on a fee schedule. whereas the specialists have a positive incentive to help their plan members stay healthy Choice C: receive from the IPA the same monthly compensation for each Leo plan member under the PCP's care. Choice B: The COA most likely exempts Hill from any of State X's enabling statutes. it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the Choice A: receive compensation based on the volume and variety for medical services they perform for Leo plan members. ““:A Question 31 Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X.million in order to obtain a COA.

a non-formulary drug. BBB. brokers Choice A: are not required to be licensed by the states in which they market health plans . These factors included Choice A: increased stress on individuals and families Choice B: increased availability of behavioral healthcare services Choice C: greater awareness and acceptance of behavioral healthcare issues Choice D: all of the above ““:D Question 33 Bill Clinton is a member of Lewinsky's PBM plan which has a three-tier copayment structure. AAA. AAA. One true statement about brokers for health plan products is that. BBB. Bill fell ill and his doctor prescribed him AAA. several factors contributed to increased demand for behavioral healthcare services. AAA Choice C: BBB. a generic dr Choice A: CCC. a brand-name drug which was included in the Lewinsky's formulary. CCC. AAA ““:A Question 34 Brokers are one type of distribution channel that health plans use to market their health plans. and CCC. BBB Choice B: BBB. CCC Choice D: CCC. typically.Question 32 Beginning in the early 1980s.

a health plan's network refers to the Choice A: organizations and individuals involved in the consumption of healthcare provided by the plan Choice B: relative accessibility of the plan's providers to the plan's participants Choice C: group of physicians.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 Insurer ““:D Question 35 By definition. the marketing process of defining a certain place or market niche for a product relative to competitors and their products and then using the marketing mix to attract certain market segments is known as Choice A: branding Choice B: positioning Choice C: database marketing Choice D: personal selling ““:B . hospitals. and other medical care providers with whom the plan has contracted to deliver medical services to its members Choice D: integration of the plan's participants with the plan's providers ““:C Question 36 By definition.

is elegible to receive healthcare benefits under one of the three TRICARE health plan options. he will be Choice A: able to obtain full benefits for services obtained from network and non-network providers Choice B: subject to copayment.S. They . an HMO ensures that its members obtain quality. Martin Avery. Army. deductible. and appropriate medical care. and coinsurance requirements for any medical care he receives Choice C: required to formally enroll for coverage and pay an enrollment fee Choice D: assigned to a primary care manager who is responsible for coordinating all his care ““:D Question 39 Consumer-directed health plans are not a new concept.Question 37 By offering a comprehensive set of healthcare benefits to its members. on active duty in the U. cost-effective. Ways that an HMO provides comprehensive care include Choice A: coordinating care across a variety of benefits Choice B: emphasizing preventive care by covering many preventive services either in full or with a small copayment Choice C: offering its members access to wellness programs Choice D: All of the above ““:D Question 38 Col. If Col Avery elects to participate in TRICARE Prime.

. The following statements are about this situation. is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Phram 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 Dr. Ware's provider contract with Riverside contains a typical no-balance billi Choice A: prevent Dr.actually got their start in the late 1970s with the advent of: Choice A: Health savings accounts (HSAs) Choice B: Health reimbursement arrangements (HRAs) Choice C: Medical savings accounts (MSAs) Choice D: Flexible spending arrangements (FSAs) ““:D Question 40 Dr. ““:A Question 41 Dr. Dr. Choice B: Any physician who meets Holcomb's standards of care is eligible to contract with Holcomb HMO as a provider. Phram as their primary care physician (PCP). Choice C: Dr. Ware from requiring a Riverside . a physician in the Riverside MCO's network of providers. Select the “ “ choice containing the correct statement. Phram at full benefits without first obtaining a referral from their PCPs. Choice A: All members of Holcomb HMO must select Dr. Inc. Milton Ware. a typical closed-panel plan. Julia Phram is a cardiologist under contract to Holcomb HMO.

or deductibles that the member would normally pay under Riverside's plan Choice B: require Dr. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network. Choice C: Give Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. Aldridge at least 90-days' notice of its intent to terminate the contract.member to pay any coinsurance. Ware from billing a Riverside member for medical services that are not included in Riverside's plan ““:B Question 42 Dr. ““:C . but only if Badger gives Dr. The primary purpose of this clause is to: Choice A: State that Dr. copayment. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges. Ware from seeking compensation from patients if Riverside fails to compensate him because of the MCO's insolvency Choice D: prevent Dr. Ware to accept the amount that Riverside pays for medical services as payment in full and not to bill plan members for additional amounts Choice C: prevent Dr. Choice B: Specify a time period during which the party that breaches the provider contract must remedy the problem in order to avoid termination of the contract. Choice D: Specify that Badger can terminate this provider contract without providing a reason.

group underwriters consider such characteristics as a group’s geographic location. fo Choice A: the angina. and the level of participation in the grou Choice A: Healthcare costs are typically higher in rural areas than in large urban areas. the high blood pressure. At the time of her enrollment. the more likely it is that the group will experience losses similar to the average rate of loss that was predicted. the size and gender mix of the group. Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan. Hadek had three pre-existing medical conditions: angina. Choice C: The larger the group.Question 43 During an open enrollment period in 1997. Choice D: All of the above ““:C Question 45 . Choice B: The morbidity rate for males is higher than the morbidity rate for females. Ms. and the broken ankle Choice B: the angina and the high blood pressure only Choice C: none of these conditions Choice D: the broken ankle only ““:A Question 44 During the risk assessment process for a traditional indemnity group insurance health plan. a federally qualified HMO.

Choice D: The Axis Medical Group examines provider practice patterns to identify areas in which services are being underused. Choice A: The Serenity Healthcare Organization requires a plan member or the provider in charge of the member's care to obtain authorization for inpatient care before the member is admitted to the hospital. and D only Choice D: B. and D Choice B: A and C only Choice C: A. Choice B: UR nurses employed by the Friendship Health Plan monitor length of stay to identify factors that might contribute to unnecessary hospital days. B. if necessary. Select the “ “ choice that describes a health plan's use of retrospective review to decrease utilization of hospital services. Whenever Mr.Each of the following statements describes a health plan that is using a method of managing institutional utilization. Choice C: The Optimum Health Group evaluates the medical necessity and appropriateness of proposed services and intervenes. C. to redirect care to a more appropriate care setting. C. Murray receives a health claim from a plan member. overused. he reviews the claim Choice A: A. or misused and designs strategies to prevent inappropriate utilization in the future. ““:D Question 46 Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in- network than for services received out-of-network. and D only ““:A . B.

Giambi with healthcare coverage for any illness or injury. but only if the cause of the illness or injury is work-related. Giambi to pay specified deductibles and copayments before receiving benefits under this program for any illness or injury. One characteristic of this program is that it: Choice A: Provides Ms. Choice C: Requires Ms. Choice D: physicians' professional services while he was at the extended-care facility. Choice B: Combines the group health plan and disability plan offered by Ms. Giambi's employer with workers' compensation coverage. Choice C: Physicians' professional services while he was hospitalized. Giambi and her employer to each pay half of the cost of this coverage. ““:B . Choice B: Transportation by ambulance from the hospital to the extended-care facility. Mr. ““:A Question 48 Eleanor Giambi is covered by a typical 24-hour managed care program. Later. he was transferred by Choice A: Confinement in the extended-care facility after his hospitalization. Choice D: Requires Ms.Question 47 Ed O'Brien has both Medicare Part A and Part B coverage. O'Brien was hospitalized for an aneurysm. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently.

Which best describes Emily's position? Choice A: Community Representative Choice B: Inside Director Choice C: Outside Director Choice D: None of these ““:B Question 50 Employer-sponsored benefit plans that provide healthcare benefits must comply with the Employee Retirement Income Security Act (ERISA). One of the most significant features of ERISA is that it Choice A: contains a provision stating that the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans Choice B: standardizes the conversion of group healthcare benefits to individual healthcare benefits Choice C: mandates that self-funded healthcare plans must pay state premium taxes Choice D: requires that all active employees. regardless of age.Question 49 Emily Brown works for Integral Health Plan and represents the company as a board member for the board of directors. must be eligible for coverage under employer-sponsored benefit plans ““:A Question 51 Federal Employee Health Benefits Program (FEHBP) requires health plans offering services to federal employees and their .

Immediate access to emergency services B. and reporting standardized information about m Choice A: random change . analyzing.dependents to provide A. Routine appointments once a m Choice A: D Choice B: A Choice C: B & C Choice D: All of the listed options ““:F Question 52 Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level. Urgent Appointments within 24 hours C. a national task force recommended implementation of a nationwide mandatory system of collecting. This federal legislation is the Choice A: Clayton Act Choice B: Federal Trade Commission Act Choice C: McCarran-Ferguson Act Choice D: Sherman Act ““:C Question 53 Following a report by the Institute of Medicine on the incidence and consequences of medical errors.

and healthcare consumers Choice B: improved provider contracting position with health plans Choice C: an increase in providers' autonomy and control over their own work environment Choice D: all of the above ““:B Question 55 For this question. a national database of performance and accreditation information submitted by managed Choice A: Health Plan Employer Data and Information Set (HEDIS) mandatory Choice B: Health Plan Employer Data and Information Set (HEDIS) voluntary .Choice B: structural change Choice C: haphazard change Choice D: reactive change ““:D Question 54 For providers. select the “ “ choice containing the terms that correctly complete the blanks labeled A and B in the paragraph below. healthcare purchasers. or when two or more providers combine business operations that they previously carried out separately and independently. integration occurs when two or more previously separate providers combine under common ownership or control. NCQA offers Quality Compass. Such provi Choice A: higher costs for health plans.

choose the description of the ethical principle that best corresponds to the term Autonomy Choice A: Health plans and their providers are obligated not to harm their members Choice B: Health plans and their providers should treat each member in a manner that respects the member's goals and values.Choice C: ORYX mandatory Choice D: ORYX voluntary ““:B Question 56 From the “ “ choices below. Sybex used and the premium rate PMPM that Mr. Choice A: Rating Method book rating Premium Rate PMPM $132 Choice B: Rating Method book rating Premium Rate PMPM $138 Choice C: Rating Method blended rating Premium Rate PMPM $132 Choice D: Rating Method blended rating Premium Rate PMPM $138 ““:C Question 57 From the following “ “ choices. select the response that correctly identifies the rating method that Mr. Sybex calculated for the Koster group. and they also have a duty to promote the good of the members as a group Choice C: Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members .

choose the description of the ethical principle that best corresponds to the term Beneficence Choice A: Health plans and their providers are obligated not to harm their members Choice B: Health plans and their providers should treat each member in a manner that respects the member's goals and values.Choice D: Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives ““:D Question 58 From the following “ “ choices. and they also have a duty to promote the good of the members as a group Choice C: Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens . and they also have a duty to promote the good of the members as a group Choice C: Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members Choice D: Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives ““:D Question 59 From the following “ “ choices. choose the description of the ethical principle that best corresponds to the term Autonomy Choice A: Health plans and their providers are obligated not to harm their members Choice B: Health plans and their providers should treat each member in a manner that respects the member's goals and values.

choose the description of the ethical principle that best corresponds to the term Beneficence Choice A: Health plans and their providers are obligated not to harm their members Choice B: Health plans and their providers should treat each member in a manner that respects the member's goals and values.among the members Choice D: Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives ““:B Question 60 From the following “ “ choices. and they also have a duty to promote the good of the members as a group Choice C: Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members Choice D: Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives ““:B Question 61 From the following choices. choose the definition that best matches the term health risk assessment (HRA) Choice A: A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselves Choice B: A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problem .

and health-related behaviors is used to predict the member's likelihood of experiencing specific illnesses or injuries Choice D: A technique used to evaluate the medical necessity.Choice C: A technique in which information about a plan member's health status. and health-related behaviors is used to predict the member's likelihood of experiencing specific illnesses or injuries Choice D: A technique used to evaluate the medical necessity. and cost-effectiveness of healthcare services for a given patient ““:B Question 63 General HMO is building a provider network and is considering Universal Hospital as an addition to its network. Minimum requirements that General should consider in determining whether Universal is qualified to participate in General's network include . and cost-effectiveness of healthcare services for a given patient ““:C Question 62 From the following choices. personal and family health history. appropriateness. personal and family health history. choose the definition that best matches the term Screening Choice A: A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselves Choice B: A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problem Choice C: A technique in which information about a plan member's health status. appropriateness.

. without regard to the outcome of the credentialing process Choice D: Greentree will abandon the credentialing process now that Dr. a health plan. Cortelyou. Choice A: Both A and B Choice B: A only Choice C: B only Choice D: Neither A nor B ““:A Question 64 Greentree Medical. has been meeting with Melissa Cortelyou. is currently recruiting PCPs in preparation for its expansion into a new service area. Cortelyou should include a clause requiring the successful completion of the credentialing process within a defined time frame in order for the contract to be effective Choice C: Greentree must offer a standard contract to Dr. Cortelyou has agreed to participate in Greentree's network ““:B Question 65 Health plans can organize under a not-for-profit form or a for- profit form.D. One true statement regarding not-for-profit health .A. in an effort to recruit her as a PCP in Green Choice A: Greentree is prevented by law from offering a contract to Dr. Cortelyou until the credentialing process is complete Choice B: any contract signed by Dr. a recruiter for Greentree. M. Abigail Davis.

these criteria may signal the need for further review when.plans is that these organizations typically Choice A: are exempt from review by the Internal Revenue Service (IRS) Choice B: are organized as stock companies for greater flexibility in raising capital Choice C: rely on income from operations for the large cash outlays needed to fund long-term projects and expansion Choice D: engage in lobbying or political activities in order to maintain their tax-exempt status ““:C Question 66 Health plans may use different capitation arrangements for different levels of service. Th Choice A: global capitation arrangement Choice B: gatekeeper arrangement Choice C: carve-out arrangement Choice D: partial capitation arrangement ““:D Question 67 Health plans often program into their claims processing systems certain criteria that. or both primary and secondary care. One typical capitation arrangement provides a capitation payment that may include primary care only. if unmet. but not ancillary services. In an automated claims processing system. for exampl Choice A: Encounter reports . will prompt further investigation of a claim.

““:D Question 70 . Choice D: Defined patient population. Choice B: Appropriate. utilization rates.Choice B: Diagnostic codes Choice C: Durational ratings Choice D: Edits ““:D Question 68 Health plans require utilization review for all services administered by its participating physicians. Choice A: True Choice B: False Choice C: Choice D: ““:B Question 69 Health plans sometimes contract with independent organizations to provide specialty services. Specialty services that have certain characteristics are generally good candidates for health pl Choice A: Low or stable costs. rather than inappropriate. such as vision care or rehabilitation services. Choice C: A benefit that cannot be easily defined. to plan members.

Health plans' use of the Internet to provide plan members with health-related information has grown rapidly in recent years. One advantage the Internet has over other forms of communication is that Choice A: users can access the Internet using a number of different types of computer systems Choice B: access to the Internet is available only to members of the health plan's network Choice C: the Internet is immune to internal security breaches by employees or trading partners within the network Choice D: users can contact a single controlling organization to rectify disruptions in Internet service ““:A Question 71 Health plans use the following to determine the number of providers to add to a network: Choice A: Staffing ratios Choice B: Drive time Choice C: Geographic availability Choice D: All of the above ““:D Question 72 Health savings accounts were created by which of the following laws: Choice A: COBRA Choice B: HIPAA Choice C: Medicare Modernization Act .

Mr. Vladmir is a member of a health plan that will allow him to select the physician of his choice. One technique that an HMO uses to manage member utilization is Choice A: the use of physician practice guidelines Choice B: the requirement of copayments for office visits Choice C: capitation Choice D: risk pools ““:B Question 75 Ian Vladmir wants to have a routine physical examination to ascertain that he is in good health.Choice D: None of the Above ““:C Question 73 Historically most HMOs have been Choice A: Closed-access HMO Choice B: Closed-panel HMO Choice C: Open-access HMO Choice D: Open-panel HMO ““:B Question 74 HMOs typically employ several techniques to manage provider utilization and member utilization of medical services. either from within his plan's network or from outside of h Choice A: a traditional HMO plan .

Choice C: Sell the HMO's assets in order to satisfy the HMO's obligations. Choice B: Allow the state commissioner. then the purpose of this action most likely is to: Choice A: Transfer all of the HMO's business to other carriers. the more likely it is that the group will experience losses similar to the average rate of loss that was predicted. to take control of and administer the HMO's assets and liabilities.Choice B: a managed indemnity plan Choice C: a point of service (POS) option Choice D: an exclusive provider organization (EPO) ““:C Question 76 Identify the CORRECT statement(s): (A) Smaller the group. . (B) Gender of the group's participants has no effect on the likelihood of loss. acting for a state court. ( Choice A: All of the listed options Choice B: B & C Choice C: None of the listed options Choice D: A & C ““:C Question 77 If a state commissioner of insurance places an HMO under administrative supervision.

““:D Question 78 If left unresolved. and the reviewer's decision is final and binding ““:A Question 79 If most of the physicians. then a health plan building a network in the service area ________________________. or many of the physicians in a particular specialty. and the reviewer's decision is final and binding Choice C: an independent external appeal.Choice D: Place the HMO's operations under the direction and control of the state commissioner or a person appointed by the commissioner. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info Choice A: a Level One appeal. and the member has the right to a further appeal Choice D: arbitration. are affiliated with a single entity. member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. Choice B: Should not contract with that entity Choice C: Most likely needs to contract with that entity Choice D: Should attempt to disband the existing affiliations ““:C . and the member has the right to a further appeal Choice B: a Level Two appeal. Choice A: Has many contracting options available.

Hospital emergency departments B. C Choice B: A. B Choice C: B. Choice D: Agree not to disclose personally identifiable financial information or personally identifiable health information. C. the United States Congress passed the Financial Services Modernization Act. their privacy policies regarding the sharing of nonpublic personal financial information. Choice B: Prohibit customers from having the opportunity to 'opt-out' of sharing non-public personal financial information. Physician's offices C. but not to third parties.Question 80 Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings: A. . Choice C: Disclose to affiliates. B ““:B Question 81 In 1999. referred to as the Gramm-Leach- Bliley (GLB) Act. Urgent care centers If these settings are ranked in order of the cost of providing c Choice A: A. The primary provisions included under the GLB Act require financial institutions. A. B. C. to take several Choice A: Notify customers of any sharing of non-public personal financial information with nonaffiliated third parties. including health plans. A Choice D: C.

the health plan must also perform recredentialing of the same providers on an ongoing basis. and receivables—are generally known as the company's Choice A: revenue Choice B: net income Choice C: surplus Choice D: assets ““:D Question 84 In addition to the credentialing activities that an health plan performs when initially accepting a provider into its network. The following statement(s) can correctly be made about this act: A. which is referred to as the Gramm- Leach-Bliley (GLB) Act. The GLB Act allows convergence among the tra Choice A: A only Choice B: Both A and B Choice C: B only Choice D: Neither A nor B ““:B Question 83 In accounting terminology. the United States Congress passed the Financial Services Modernization Act.““:A Question 82 In 1999. cash equivalents. Many of the same activities are . the items of value that a company owns—such as cash.

a health underwriter considers the factor of antiselection. if necessary. a health plan can use the results of utilization review to intervene. to alter the course of a plan member's medical care.per Choice A: verification of a network provider's medical education and residency Choice B: performance of site inspections in a provider's facilities Choice C: review of information from a provider's quality improvement activities Choice D: verification of a provider's licensure and certification ““:A Question 85 In assessing the potential degree of risk represented by a proposed insured. Such intervention can be . Antiselection can correctly be defined as the Choice A: inability of a proposed insured to share with the insurer the financial risks of healthcare coverage Choice B: possibility that a proposed insured will profit from an illness by receiving benefits that exceed the total amount of his or her eligible medical expenses Choice C: inability of a proposed insured to provide sufficient evidence that proves he or she is an insurable risk Choice D: tendency of people who have a greater-than- average likelihood of loss to apply for or continue insurance protection to a greater extent than people who have an average or less than average likelihood of the same loss ““:D Question 86 In certain situations.

Concurrent review C. a claims investigation is correctly defined as the process of . B.based on the results of A. Concurrent review C. Such intervention can be based on the results of A. Prospective review B. if necessary. and C Choice B: A and B only Choice C: A and C only Choice D: B only ““:D Question 87 In certain situations. Choice A: A. Choice A: A. a health plan can use the results of utilization review to intervene. and C Choice B: A and B only Choice C: A and C only Choice D: B only ““:B Question 88 In claims administration terminology. to alter the course of a plan member's medical care. B. Prospective review B.

member self-care. wellness.Choice A: reporting management information about services provided each time a patient visits a provider for purposes of analyzing utilization and provider practice patterns Choice B: obtaining all the information necessary to determine the appropriate amount to pay on a given claim Choice C: routinely reviewing 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 ““:B Question 89 In health plan terminology. and coordinating and monitoring the care ““:B Question 90 In large health plans. and/or appropriateness of healthcare services and treatment plans for a given patient Choice B: a series of strategies designed to reduce plan members' needs to utilize healthcare services by encouraging preventive care. demand management. and appropriate use of healthcare services Choice C: a technique that prevents a provider who is being reimbursed under a fee schedule arrangement from billing a plan member for any fees that exceed the maximum fee reimbursed by the plan Choice D: a system of identifying plan members with special healthcare needs. developing a healthcare strategy to meet those needs. management functions such as provider . can best be described as Choice A: an evaluation of the medical necessity. efficiency. as used by health plans.

many healthcare providers spread these unreimbursed costs to paying patients or third-party payors.recruiting. This practice is known Choice A: dual choice Choice B: cost shifting Choice C: accreditation Choice D: defensive medicine . contracting. Choice A: True Choice B: False Choice C: Choice D: ““:A Question 92 In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients. provider service. credentialing. medical errors are caused by breakdowns in the healthcare system rather than by provider mistakes. and performance management for providers are typically the responsibility of the Choice A: chief executive officer (CEO) Choice B: network management director Choice C: board of directors Choice D: director of operations ““:B Question 91 In most cases.

and Choice A: segmentation Choice B: publicity Choice C: promotion Choice D: plan design ““:C Question 95 . ““:A Question 94 In order to generate exchanges with consumers. Which of the following statements about Medicare supplements is correct? Choice A: The initial ten (A-J) Medigap policies offer a basic benefit package that includes coverage for Medicare Part A and Medicare Part B coinsurance. Choice D: Medigap benefits vary by plan type (A through L). beneficiaries often rely on Medicare supplements. and are not uniform nationally. price. Choice C: Medicare SELECT is a Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part A coverage. place (distribution). Choice B: Each insurance company selling Medigap must sell all the different Medigap policies.““:B Question 93 In order to cover some of the gap between FFS Medicare coverage and the actual cost of services. healthcare plan marketers use the four elements of the marketing mix: product.

Buhner complies with all of the provisions of the Ethics in Patient Referrals Act . uses the standard formula to calculate hospital bed days per 1. a cardiologist who practices in Regal's new service area. Holt used the following information to calculate the bed days per Choice A: 278 Choice B: 397 Choice C: 403 Choice D: 920 ““:B Question 97 In preparation for its expansion into a new service area. Sahalee used the following inf Choice A: 67 Choice B: 274 Choice C: 365 Choice D: 1. On October 23. the Sahalee Medical Group.000 plan members for the month to date (MTD). On April 20.000 ““:B Question 96 In order to measure the expenses of institutional utilization. Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1. the Regal MCO is meeting with Dr. Nancy Buhner. in order to convince her to become one of the plan's participating providers. a health plan.In order to help review its institutional utilization rates.000 plan members per year. As part of th Choice A: ensure that Dr.

Buhner is a licensed medical practitioner Choice C: confirm Dr. and quality of the resources that a health plan has available for member service and patient care. regulators. and others can use to compare health Choice A: quality standards Choice B: accreditation decisions Choice C: standards of care Choice D: performance measures ““:D Question 99 In the following sections. Choice B: The methods and procedures a health plan and its . Buhner's membership in the National Committee for Quality Assurance (NCQA) Choice D: learn whether Dr. accrediting organizations and other government and commercial groups have developed quantitative measures of quality that consumers. Buhner has had a medical malpractice claim filed or other disciplinary actions taken against her ““:D Question 98 In response to the demand for a method of assessing outcomes. Which of the following is the best description of what a 'Process measure' evaluates? Choice A: The nature.Choice B: learn whether Dr. we will describe some of the measures health plans use to evaluate the quality of the services and healthcare they offer their members. quantity. purchasers.

Then select the “ “ choice containing the two terms that you have chosen. Choice C: The extent to which services succeed in improving or maintaining satisfaction and patient health. Choice D: None of the above ““:B Question 100 In the paragraph below. Then select the “ “ choice containing the two words that you have chosen. Determine which word in each pair correctly completes the sentence. Many pharmacy benefit Choice A: Therapeutic / always Choice B: Generic / always Choice C: Generic / never Choice D: Therapeutic / never ““:A Question 101 In the paragraph below. (operational / Choice A: operational / an acquisition Choice B: operational / a consolidation Choice C: structural / an acquisition Choice D: structural / a consolidation ““:D .providers use to furnish service and care. two statements each contain a pair of terms enclosed in parentheses. a sentence contains two pairs of words enclosed in parentheses.For providers. Determine which term correctly completes each statement.

One true statement about TRICARE is that Choice A: hospitals participating in TRICARE program are exempt from JCAHO accrediation and Medicare certification Choice B: TRICARE enrollees are not entitiled to appeal authorization coverage decisions Choice C: active duty personnel are automatically considered enrolled in TRICARE Prime Choice D: TRICARE covers inpatient and outpatient services. One true statement about TRICARE is that: Choice A: Active duty military personnel are automatically considered enrolled in TRICARE Prime Choice B: TRICARE covers inpatient and outpatient services. ““:A . and medical supplies. and medical supplies. the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. but not mental health services ““:C Question 103 In the United States. but not mental health services. Choice C: TRICARE enrollees are not entitled to appeal authorization or coverage decisions Choice D: Hospitals participating in the TRICARE program are exempt from JCAHO accreditation and Medicare certification. physician and hospital charges. the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. physician and hospital charges.Question 102 In the United States.

she incurred $2. Riva was hospitalized.250 ““:B Question 106 Janet Riva is covered by a traditional idemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized. Choice A: Qualified disability insurance Choice B: COBRA continuation coverage. When Ms. Choice D: All of the above. she incurred $2.000 Choice D: $2. ““:B Question 105 Janet Riva is covered by a indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision.750 . She incurre Choice A: $1. Choice A: $1. Choice C: Medigap coverage (for those over 65).500 in medical expenses that were covered by her health plan.750 Choice B: $1.800 Choice C: $2.500 in medical expenses that were covered by her health plan.Question 104 Individuals can use HSAs to pay for the following types of health coverage:.

800 Choice C: $2. and D only Choice D: A and C only ““:A .Choice B: $1.250 ““:B Question 107 John Kerry's employer has contracted to receive healthcare for its employees from the Democratic Healthcare System. who sends him to have some blood tests. B. and D only Choice C: B. and D Choice B: A. Kerry visits his PCP. The PCP then refers Mr.000 Choice D: $2. B. Mr. Kerry to a specialist who hospitalizes him for on Choice A: a physician practice organisation Choice B: a physician-hospital organisation Choice C: a management services organisation Choice D: an integrated delivery sysem ““:D Question 108 Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in- network than for services received out-of-network. Ms. C. C. Lopez reviewed a health claim for “ “s to the following questions: Question A - Choice A: A.

Dental services Choice A: dental preferred provider organization (PPO) Choice B: traditional fee-for-service (FFS) dental plan Choice C: plan with a dental point of service (POS) option Choice D: dental health maintenance organization (DHMO) ““:D Question 111 Lansdale Healthcare. offers comprehensive healthcare coverage to its members through a network of physicians. hospitals. and D Choice B: A.Question 109 Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in- network than for services received out-of-network. B. and D only Choice D: A and C only ““:A Question 110 Khalyn Drury's employer includes managed dental care in its employee benefits package. C. and other service providers. During open enrollment. Plan members who use in-network services pay a copayment for . Ms. Lopez reviewed a health claim for “ “s to the following questions: Question A — Choice A: A. C. a health plan. which provides dental services to its members in exchange for a prepayment (the premium). Drury enrolled in the dental plan. B. and D only Choice C: B. Ms.

Choice B: The level of care needed to treat behavioral disorders is the same for all patients and all disorders. Choice A: MBHOs generally provide benefits for mental health services but not for chemical dependency services. more effective treatment. and more efficient use of resources than do centralized referral systems. ““:C . The following statements are about these strategies. MBHOs have decreased the use of costly inpatient therapies. Choice D: PCP gatekeeper systems for behavioral healthcare generally result in more accurate diagnoses. Select the “ “ choice that contains the correct statement. The copayment Choice A: specified dollar amount charge that a plan member must pay out-of-pocket for a specified medical service at the time the service is rendered Choice B: percentage of the fees for medical services that a plan member must pay after Magellan has paid its share of the costs of those services Choice C: flat amount that a plan member must pay each year before Magellan will make any benefit payments on behalf of the plan member Choice D: specified payment for services that was negotiated between the provider and Magellan ““:A Question 112 Managed behavioral health organizations (MBHOs) use several strategies to manage the delivery of behavioral healthcare services. Choice C: By using outpatient treatment more extensively.these services.

a plan member typically pays a Choice A: fixed amount in advance for each medical service the member receives Choice B: a small fee such as $10 or $15 that a member pays at the time of an office visit to a network provider Choice C: a fixed. That . Under a prepaid care arrangement. monthly premium paid in advance of the delivery of medical care that covers most healthcare services that a member might need.Question 113 Many HMOs are compensated for the delivery of healthcare to members under a prepaid care arrangement. no matter how often the member uses medical services Choice D: specified amount of the member's medical expenses before any benefits are paid by the HMO ““:C Question 114 Many of the credentialing standards and criteria used by health plans are often taken from already existing standards established by Choice A: the National Practitioner Data Bank (NPDB) Choice B: the National Association of Insurance Commissioners (NAIC) Choice C: the Centers for Medicare and Medicaid Services (CMS) Choice D: independent accrediting organizations ““:D Question 115 Marlee Whitcomb was covered as a dependent under the group health plan provided by her father's employer.

copayments. but has the right to convert the group coverage to an individual health plan Choice D: can continue her group coverage indefinitely ““:B Question 116 Medicaid is a jointly funded federal and state program that provides hospital and medical expense coverage to low- income individuals and certain aged and disabled individuals.health plan complied with the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. she c Choice A: can continue her group coverage for a period not to exceed 48 months Choice B: can continue her group coverage for a period not to exceed 36 months Choice C: cannot continue her group coverage. When Ms. medical savings accounts . Whitcomb married. One characteristic of Medicaid is that Choice A: providers who care for Medicaid recipients must accept Medicaid payment as payment in full for services rendered Choice B: Medicaid requires recipients to pay deductibles. and coinsurance amounts for all services Choice C: Medicaid is always the primary payor of benefits Choice D: benefits offered by Medicaid programs are federally mandated and do not vary by state ““:A Question 117 Medicare Advantage product options include: Choice A: Coordinated care plans.

PFFS or MSA. Medicare is available for: Choice A: Persons age 63 or older. Choice C: HMO. medical and other covered benefits to elderly and disabled persons. health care prepayment plans and medical savings accounts Choice C: Coordinated care plans. PPO (local or regional). Choice B: CCPs . POS. Choice B: Private Fee for Service plans. or MSA. Choice B: Persons with qualifying disabilities (over the age of 63) Choice C: Persons with end-stage renal disease (ESRD) Choice D: Low income individuals ““:C Question 119 Medicare Part C can be delivered by the following Medicare Advantage plans: Choice A: HCCP. Choice D: HMO. PFFS or MSA. PFFS or MSA. HMO. coordinated care programs and medical savings accounts. PPO (local or regional). ““:B . HSA. ““:C Question 118 Medicare is the federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital. PPO (local or regional). regional PPOs and private fee for service plans Choice D: Cost contracts.and national PPOs.

During the course of the member's treatment. Appro Choice A: Both A and B Choice B: A only Choice C: B only Choice D: Neither A nor B ““:B Question 122 .Question 120 Member satisfaction is a critical element of a health plan's quality management program. A health plan can obtain information about member satisfaction with various aspects of the health plan from Choice A: surveys completed by members following a visit to a provider Choice B: surveys sent to plan members who have not received healthcare services during a specified time period Choice C: periodic reports of complaints received by member services personnel Choice D: all of the above ““:D Question 121 Members who qualify to participate in a health plan's case management program are typically assigned a case manager. the case manager is responsible for A. Coordinating and monitoring the member's care B.

the diagnostic tests. Such a provision is kn . Spencer recently was hospitalized for chest pains. and the physician's professional services Choice C: cost of hospitalization Choice D: cost of hospitalization and the physician's professional services ““:D Question 123 More procedures or services may be fully covered within the PPO network than those out-of network. Ms. Choice A: True Choice B: False Choice C: Choice D: ““:A Question 124 Most contracts between health plans and providers contain a provision which forbids providers from seeking compensation from patients if the health plan fails to compensate the provider because of insolvency or for any other reason.Merle Spencer has coverage under both Medicare Part A and Medicare Part B. and she incurred charges for: · The cost of hospitalization for two days · Diagnostic tests performed in the hospital · Trans Choice A: ambulance and the diagnostic tests Choice B: ambulance.

Lee Choice B: Ultra's system allows its members open access to all of Ultra's participating providers. Choice C: Within Ultra's system. David Craig.Choice A: due process provision Choice B: cure provision Choice C: hold-harmless provision Choice D: risk-sharing provision ““:C Question 125 Mr. Ms. Chan received primary care from both Dr. This indicates that Choice A: he can receive coverage for parmaceuticals only if they are on the PBM plan's preferred list of drugs Choice B: he must receive all of his pharmaceuticals from a mail-order pharmacy program Choice C: he can receive coverage for pharmaceuticals that are on the PBM plan's preferred list of drugs. George Bush is covered by a PBM plan that uses a closed formulary. Ms. Chan cannot self-refer to a specialist. she sees Dr. a health plan. as well as for pharmacueticals that are not on the preferred list Choice D: the PBM plan cannot recive a rebate on any pharmacueticals it obtains from the pharmaceuticalfacturer ““:A Question 126 Natalie Chan is a member of the Ultra Health Plan. Whenever she needs nonemergency medical care. Craig serves as a . Craig when she experienced headaches. Craig and Dr. Cr Choice A: Within Ultra's system. Dr. Dr. so she saw Dr. an internist.

Choice D: Ultra's network of providers includes Dr. an internist. Craig and Dr. Chan received primary care from both Dr. Whenever she needs non-emergency medical care. Lee but not Arrow Hospital ““:C Question 127 Natalie Chan is a member of the Ultra Health Plan. Craig and Dr. Chan receives. Craig and Dr. Craig referred h Choice A: Within Ultra's system. Chan receives. ““:C Question 128 One characteristic of disease management programs is that they typically Choice A: focus on individual episodes of medical care rather than on the comprehensive care of the patient over time Choice B: are used to coordinate the care of members with any type of disease. so she saw Dr. either chronic or nonchronic Choice C: focus on managing populations of patients who have a specific chronic illness or medical condition. Dr. Dr. Choice D: Ultra's network of providers includes Dr. Choice B: Ultra's system allows its members open access to all of Ultra's participating providers. Lee but not Arrow Hospital.coordinator of care or gatekeeper for the medical services that Ms. Choice C: Within Ultra's system. Ms. but do not focus . Chan cannot self-refer to a specialist. Craig when she experienced headaches. Craig serves as a coordinator of care or gatekeeper for the medical services that Ms. Ms. David Craig. Lee. she sees Dr.

on patient populations who are at risk of developing such an illness or condition Choice D: use clinical practice processes to standardize the implementation of best practices among providers ““:D Question 129 One characteristic of the accreditation process for MCOs is that Choice A: an accrediting agency typically conducts an on-site review of an MCO's operations. but it does not review an MCO's medical records or assess its member service systems Choice B: each accrediting organization has its own standards of accreditation Choice C: the accrediting process is mandatory for all MCOs Choice D: government agencies conduct all accreditation activities for MCOs ““:B Question 130 One component of information systems used by health plans incorporates membership data and information about provider reimbursement arrangements and analyzes transactions according to contract rules. This information system component is known as Choice A: a contract management system Choice B: a credentialing system Choice C: a legacy system Choice D: an interoperable communication system ““:A .

Question 131 One device that PBM plans use to manage both the cost and use of pharmaceuticals is a formulary. participating physicians are Back 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 (PCPs) ““:A Question 133 One distinguishing characteristic of a health maintenance . in a staff model HMO. A formulary is defined as Choice A: a listing of drugs classified by therapeutic category or disease class that are considered preferred therapy for a given managed population and that are to be used by a health plan's providers in prescribing medications Choice B: a reduction in the price of a particular pharmaceutical obtained by the PBM from the pharmaceutical manufacturer Choice C: drugs ordered and delivered through the mail to the PBM's plan members at a reduced cost Choice D: an identification card issued by the PBM to its plan members ““:A Question 132 One distinction that can be made between a staff model HMO and a group model HMO is that.

organization (HMO) is that, typically, an HMO

Choice A: arranges for the delivery of medical care and
provides, or shares in providing, the financing of that care

Choice B: must be organized on a not-for-profit basis

Choice C: may be organized as a corporation, a partnership, or
any other legal entity

Choice D: must be federally qualified in order to conduct
business in any state

““:A

Question 134

One ethical principle in health plans is the principle of non-
maleficence, which holds that health plans and their providers:

Choice A: Should allocate resources in a way that fairly
distributes benefits and burdens among the members.

Choice B: Have a duty to present information honestly and are
obligated to honor commitments.

Choice C: Are obligated not to harm their members.

Choice D: Should treat each plan member in a manner that
respects his or her goals and values.

““:C

Question 135

One ethical principle in managed care is the principle of
justice/equity, which specifically holds that MCOs and their
providers have a duty to

Choice A: treat each member in a manner that respects his or
her own goals and values

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: make sure they do not harm their members

““:B

Question 136

One factor the Sandpiper Health Plan uses to assess its quality
is a clinician's bedside manner, i.e., how friendly and
understanding the clinician is, whether the patient feels that
the clinician listens to the patient's concerns, how well the
clinicia

Choice A: a provider service quality issue

Choice B: an administrative service quality issuea healthcare
process quality issue

Choice C: a healthcare outcomes quality issue

Choice D: a healthcare process quality issue

““:A

Question 137

One feature of the Employee Retirement Income Security Act
(ERISA) is that it:

Choice A: Requires self-funded employee benefit plans to pay
premium taxes at the state level.

Choice B: Contains a pre-emption provision, which typically
makes the terms of ERISA take precedence over any state
laws that regulate employee welfare benefit plans.

Choice C: Contains strict reporting and disclosure
requirements for all employee benefit plans except health
plans.

Choice D: Requires that state insurance laws apply to all
employee benefit plans except insured plans.

““:B

Question 138

One HMO model can be described as an extension of a group
model HMO because it contracts with multiple group practices,
rather than with a single group practice. This HMO model is
known as the

Choice A: staff model HMO

Choice B: IPA model HMO

Choice C: direct contract model HMO

Choice D: network model HMO

““:D

Question 139

One non-group market segment to which health plans market
health plan products is the senior market, which is comprised
mostly of persons over age 65 who are eligible for Medicare
benefits. One factor that affects a health plan's efforts to
market to the

Choice A: The Centers for Medicare and Medicaid Services
(CMS) must approve all marketing materials used by health
plans to market health plan products to the Medicare
population

Choice B: managed Medicare plans typically require Medicare
beneficiaries to purchase Medigap insurance to supplement
gaps in coverage

Choice C: managed Medicare plans can refuse to cover
persons with certain health problems

Choice D: the CMS prohibits health plans from using
telemarketing to market health plan products to the Medicare
population

not local markets. 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 qualification ““:D Question 142 . Choice A: True Choice B: False Choice C: Choice D: ““:B Question 141 One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. Choice B: required all employers that offered healthcare coverage to their employees to offer only one type of federally qualified HMO.““:B Question 140 One of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national. One of the provisions of the Act was that it Choice A: exempted HMOs from all state licensure requirements.

Choice B: A health plan usually uses community rating to set premiums for large groups.One of the most influential pieces of legislation in the advancement of managed care within the United States was the HMO Act of 1973. a rating method commonly used by health plans. is that: Choice A: It requires a health plan to set premiums for financing medical care according to the health plan's expected cost of providing medical benefits to a sub-group within the community. Choice C: It tends to lead to greater fluctuations in premium rates than do other rating methods. ““:D Question 144 One true statement regarding ethics and laws is that the . One provision of the HMO Act of 1973 was that it Choice A: emphasized compensating physicians based solely on the volume of medical services they provide Choice B: exempted HMOs from all state licensure requirements Choice C: established a process under which HMOs could elect to be federally qualified Choice D: required federally qualified HMOs to relate premium levels to the health status of the individual enrollee or employer group ““:C Question 143 One true statement about community rating. Choice D: A health plan seldom uses community rating to set premiums for large groups.

and both ethics and laws are enforceable in the court system Choice B: both ethics and laws. but both ethics and laws are enforceable in the court system ““:B Question 145 One true statement regarding ethics and laws is that the values of a community are reflected in Choice A: both ethics and laws. but only laws are enforceable in the court system Choice D: laws only. 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 . 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.values of a community are reflected in Choice A: 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 ““:B Question 146 One type of physician-only integration model is a consolidated medical group.

Choice B: Require plan members to obtain a referral before getting medical services from specialists. or other healthcare purchasers. hospital services. although at a higher cost. and ancillary services. including physician services. plan sponsors.many independent offices Choice C: achieves economies of scale in the group's integrated operations Choice D: all of the above ““:D Question 147 One typical characteristic of an integrated delivery system (IDS) is that an IDS. such as negotiating with health plans on behalf of all of the member providers. Choice C: Use a capitation arrangement. instead of a fee schedule. for . Choice A: Is more highly integrated structurally than it is operationally. to reimburse physicians. Choice B: Provides a full range of healthcare services. Choice D: Performs a single business function. Choice C: Cannot negotiate directly with health plans. Choice D: Offer some coverage. ““:B Question 148 One typical characteristic of preferred provider organization (PPO) benefit plans is that PPOs: Choice A: Assume full financial risk for arranging medical services for their members.

such as using an ethics task force or bioethics .plan members who choose to use the services of non-network providers. ““:D Question 149 One way in which a health plan can support an ethical environment is by Choice A: requiring organizations with which it contracts to adopt the plan's formal ethical policy Choice B: developing and maintaining a culture where ethical considerations are integrated into decision making at the top organizational level only Choice C: establishing a formal method of managing ethical conflicts. such as using an ethics task force or bioethics consultant Choice D: maintaining control of policy development by removing providers and members from the process of developing and implementing policies and procedures that provide guidance to providers and members confronted with ethical issues ““:C Question 150 One way in which a health plan can support an ethical environment is by Choice A: requiring organizations with which it contracts to adopt the plan's formal ethical policy Choice B: developing and maintaining a culture where ethical considerations are integrated into decision making at the top organizational level only Choice C: establishing a formal method of managing ethical conflicts.

At the end of the plan year. customary. and reasonable (UCR) fees .consultant Choice D: maintaining control of policy development by removing providers and members from the process of developing and implementing policies and procedures that provide guidance to providers and members confronted with ethical issues ““:C Question 151 One way in which health plans differ from traditional indemnity plans is that health plans Typically Choice A: provide less extensive benefits than those provided under traditional indemnity plans Choice B: place a greater emphasis on preventive care than do traditional indemnity plans Choice C: require members to pay a percentage of the cost of medical services rendered after a claim is filed. rather than a fixed copayment at the time of service as required by indemnity plans Choice D: contain cost-sharing requirements that result in more out-of-pocket spending by members than do the cost- sharing requirements in traditional indemnity plans ““:B Question 152 One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers' payment during a plan year. the MCO may use the amount retained to offset or pay for any cost overruns for referral or hospital Choice A: withholds Choice B: usual.

which Choice A: can exclude coverage for treatment of Ms. Gupta's diabetes as a pre- existing condition. she has been undergoing treatment for diabetes. Ms. Gupta's diabetes for one year. because she did not have at least two years of creditable coverage under her previous health plan Choice B: cannot exclude Ms. Parable began the process by dividing the healthcare market into two broad categories: non-group and group. because the one-year pre-existing condition provision is offset by at least one year of continuous coverage under her previous health plan Choice C: can exclude coverage for treatment of Ms. Parable further segmented the non-gr Choice A: channel segmentation Choice B: geographic segmentation Choice C: demographic segmentation Choice D: product segmentation ““:C Question 154 Parul Gupta has been covered by a group health plan for eighteen months. a health plan. because HIPAA does not impact a group . Next. For the past four months. recently segmented the market for a new healthcare service.Choice C: risk pools Choice D: per diems ““:A Question 153 Parable Healthcare Providers. Gupta began a new job and immediately enrolled in her new company's group health plan. Last week. Gupta's diabetes for one year.

Flaherty to a spe Choice A: an integrated delivery system (IDS) Choice B: a Management Services Organization (MSO) Choice C: a Physician Practice Management (PPM) company Choice D: a physician-hospital organization (PHO) ““:A Question 156 Paul Gilbert has been covered by a group health plan for two years. Gilbert began a new job and immediately enrolled in his new company's group health plan. . Mr. Flaherty visits his primary care physician (PCP). Gilbert's angina for one year. The PCP then refers Mr. because HIPAA does not impact a group health plan's pre-existing condition provision. who sends him to have some blood tests. He has been undergoing treatment for angina for the past three months.health plan's pre-existing condition provision Choice D: can exclude coverage for treatment of Ms. which has a Choice A: Can exclude coverage for treatment of Mr. Gupta's diabetes for four months. because Mr. Choice B: Can exclude coverage for treatment of Mr. because that is the length of time she received treatment for this medical condition prior to her enrollment in the new health plan ““:B Question 155 Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Last week. Gilbert did not have at least 36 months of creditable coverage under his previous health plan. Mr. Gilbert's angina for one year.

Choice D: Cannot exclude his angina as a pre-existing condition. ““:D Question 157 PBM plans operate under several types of contractual arrangements. If the actual cost per employee per month is greater than the target cost. the PBM plan and the employer agree on a target cost per employee per month. Under one contractual arrangement. Gilbert's angina for three months.Choice C: Can exclude coverage for treatment of Mr. because that is the length of time he received treatment for this medical condition prior to his enrollment in the new health plan. t Choice A: fee-for-service arrangement Choice B: risk sharing contract Choice C: capitation contract Choice D: rebate contract ““:B Question 158 Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves Choice A: ascertaining that physicians in the plan have the necessary and appropriate credentials to prescribe medications Choice B: compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to . because the one-year pre-existing condition provision is offset by at least one year of continuous coverage under his previous health plan.

which is his primary plan. Both plans have typical coordination of benefits (COB) provisions. Both plans have typical coordination of benefits (COB) provisions. which is his primary plan. which is his secondary plan. but neither has a nonduplication of Choice A: $0 Choice B: $300 Choice C: $400 Choice D: $900 . which is his secondary plan. and a health plan. and a health plan. but neither has a nonduplication of benefits p Choice A: $0 Choice B: $300 Choice C: $400 Choice D: $900 ““:C Question 160 Phillip Tsai is insured by both a traditional idemnity health insurance plan.expected patterns within select drug categories Choice C: monitoring patient-specific drug problems through concurrent and retrospective review Choice D: establishing protocols that require physicians to obtain certification of medical necessity prior to drug dispensing ““:B Question 159 Phillip Tsai is insured by both a indemnity health insurance plan.

Urich was hospitalized.““:C Question 161 Phoebe Urich is covered by a traditional indemnity health insurance plan that specifies a $500 calendar-year deductible and includes a 20% coinsurance provision. Choice B: All Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs. When Ms. ““:C Question 163 . she incurred $3.000 in medical expenses that were covered by Choice A: 1900 Choice B: 2000 Choice C: 2400 Choice D: 2500 ““:B Question 162 Primary care case managers (PCCMs) provide case management services to eligible Medicaid recipients. Choice D: PCCMs contract directly with the federal government to provide case management services to Medicaid recipients. for the services they provide to Medicaid recipients. Choice C: PCCMs receive a case management fee in addition to reimbursement for medical services on a FFS basis. With regard to PCCMs it is correct to say that: Choice A: PCCMs typically receive a case management fee. rather than reimbursement for medical services on a FFS basis.

collections. and contracting with health plans for the entire group of providers. ““:C . Choice C: Formation of an organization by a group of providers to carry out billing. Choice B: Joint venture entered into by the Eclipse Health Plan and a local hospital system to create a new health plan in which Eclipse and the hospital system share ownership. Choice D: Consolidation of the Carver Health Plan and the Limestone Health Plan. it is correct to say that Choice A: PCCMs contract directly with the federal government to provide case management services to Medicaid recipients Choice B: all Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs Choice C: Medicaid PCCM programs are exempt from the Health Care Financing Administration's (HCFA's) Quality Improvement System for Managed Care (QISMC) standards Choice D: PCCMs typically receive a case management fee. An example of operational integration in health plans is the: Choice A: Acquisition of the Leopard Health Plan by the Hickory Health Plan. for the services they provide to Medicaid recipients ““:C Question 164 Provider integration has two components: operational integration and structural integration. With regard to PCCMs. rather than reimbursement for medical services on a FFS basis.Primary care case managers (PCCMs) provide managed healthcare services to eligible Medicaid recipients.

When Mr. accounting for 43% of the increase. Choice B: Omega's network of providers includes Dr. ““:A . Miller. Choice C: Omega's system allows its members open access to all of Omega's participating providers. ““:A Question 166 Several marketplace factors helped fuel the movement toward consumer choice. Choice D: Employer payers began seeking ways to control spiraling utilization rates and provide lowercost health coverage options. but not Dr.Question 165 Ronald Canton is a member of the Omega MCO. Choice D: Omega used a financing arrangement known as a relative value scale (RVS) to compensate Dr. an internist. he first had to obtain a referral from Dr. Choice C: Increased utilization was the largest factor contributing to the rise in premiums. High. He receives his nonemergency medical care from Dr. annual growth in private health spending per capita began to increase rapidly in 2002. Miller. High to see Choice A: Dr. Kristen High. Canton needed to visit a cardiologist about his irregular heartbeat. Choice B: During the height of the recent cost upswing. High serves as the coordinator of care for the medical services that Mr. insurance premiums were increasing by more than 13% annually. Canton receives. Which one of the following statements is NOT accurate with regard to these factors? Choice A: After a period of relative stability.

The following statement(s) can correctly be made about EMRs: A. health plans typically use captive agents who give sales presentations to potential customers. or advertising. demographic.Question 167 Some providers use electronic medical records (EMRs) to document their patients' care in an electronic form. Choice C: To promote a health plan product to the individual market. and administra Choice A: B only Choice B: Both A and B Choice C: Neither A nor B Choice D: A only ““:D Question 168 Some states mandate that an independent enrollment broker or benefits counselor contractor selected by the state must manage enrollment of the eligible Medicaid population into managed care. In other states a health plan can engage independent brokers and Choice A: Many states have regulations that prohibit health plans from using door-to-door and/or telephone solicitation to market health plan products to the Medicaid population. Choice B: Health plans are never allowed to medically underwrite individual market customers who are under age 65. telemarketing. EMRs are computerized records of a patient's clinical. Choice D: Health plans typically are allowed to medically underwrite all individual market customers who are covered by Medicare and can refuse to . rather than using promotion tools such as direct mail.

utilization Choice B: a defined patient population Choice C: low. These characteristics generally include that the specialty service should have Choice A: appropriate. rather than inappropriate. One characteristic used to identify a specialty service that may be a good candidate for a health plan approach is that the service should have Choice A: a defined patient population Choice B: a complex benefit structure Choice C: low. ““:A Question 169 Specialty services that have certain characteristics generally are good candidates for managed care approaches.cover such customers. stable costs Choice D: appropriate utilization rates ““:A Question 171 The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive . stable costs Choice D: a benefit that cannot be easily defined ““:B Question 170 Specialty services with certain characteristics tend to make good candidates for health plan approaches.

stabilize all patients who come to their emergency departments. Choice A: True Choice B: False Choice C: Choice D: ““:B Question 172 The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and. The Choice A: an independent practice association (IPA) model HMO Choice B: a staff model HMO . Choice A: True Choice B: False Choice C: Choice D: ““:B Question 173 The Acme HMO recruits and contracts directly with a wide range of physicians—both PCPs and specialists—in its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. if necessary.Medicare or Medicaid reimbursement to screen and. stabilize all patients who come to their emergency departments. if necessary.

healthcare providers. In general. payment. payment. these privacy standards prohibit Choice A: all health plans. and healthcare clearinghouses from using any protected health information for purposes of treatment.Choice C: a direct contract model HMO Choice D: a group model HMO ““:C Question 174 The administrative simplification standards described under Title II of HIPAA include privacy standards to control the use and disclosure of health information. or healthcare operations without an individual's written consent Choice B: patients from requesting that restrictions be placed on the accessibility and use of protected health information Choice C: transmission of individually identifiable health information for purposes other than treatment. or healthcare operations without the individual's written authorization Choice D: patients from accessing their medical records and requesting the amendment of incorrect or incomplete information ““:D Question 175 The Advantage Health Plan recently added the following features to its member services program: IVR Active member outreach program Advantage's member services staffing needs are likely to increase as a result of .

in order to convince her to be Choice A: Credentialing Choice B: Accreditation . Nan Shea. One key difference is tha Choice A: limits coverage to eligible employees and excludes part-time employees Choice B: specifies an annual lifetime benefit maximum on dollar coverage for medical costs Choice C: provides benefits regardless of the cause of an injury or illness Choice D: provides benefits for both healthcare costs and lost wages ““:D Question 177 The Ark Health Plan. is currently recruiting providers in preparation for its expansion into a new service area.Choice A: 1 Choice B: 2 Choice C: 1 & 2 Choice D: Neither 1 nor 2 ““:B Question 176 The application of health plan principles to workers' compensation insurance programs has presented some unique challenges because of the differences between health plan for traditional group healthcare and workers' compensation. a pediatrician who practices in Ark's new service area. A recruiter for Ark has been meeting with Dr.

Choice B: A sister corporation of the Fordham Group. The Fordham Group's sole business is the ownership of controlling interests in the shares of other companies. is currently recruiting providers in preparation for its expansion into a new service area. a pediatrician who practices in Ark's new service area. A recruiter for Ark has been meeting with Dr. ““:D Question 179 The Azure Group is a for-profit health plan that operates in the United States.Choice C: A sentinel event Choice D: A screening program ““:A Question 178 The Ark Health Plan. in order to convince her to be Choice A: Has ever participated in any quality improvement activities. Choice D: All of the above. The Fordham Group owns all of Azure's stock. Choice B: Is a participating provider in a health plan that will compete with Ark in its new service area. Choice C: Meets the requirements of the Ethics in Patient Referrals Act. This information ind Choice A: A holding company of the Fordham Group. Choice D: Has had a medical malpractice claim filed or other disciplinary actions taken against her. Choice C: A subsidiary of the Fordham Group. Nan Shea. .

Blaine can then determine areas in which it can emulate the best practices in order to equal or surpass the best Choice A: provider profiling Choice B: benchmarking Choice C: peer review Choice D: quality assessment ““:B Question 181 The Citywide Health Group is a large provider-based health plan that includes physician groups. and other facilities. Citywide has established an enterprise scheduling system. and malpractice history Choice B: detect instances of overutilization.““:C Question 180 The Blaine Healthcare Corporation seeks to manage its quality by first identifying the best practices and best outcomes for a given procedure. hospitals. Th Choice A: provide information to Citywide's management regarding provider licensure. certification. underutilization. or inappropriate utilization of medical resources Choice C: allow Citywide's different components to function as a single organization in arranging access to facilities and resources Choice D: facilitate the processing of requests for authorization of payment of benefits ““:C . In order to oversee and manage the operation of the organization.

Question 182

The Cleopatra Group, a third-party administrator (TPA), has
entered into a TPA agreement with the Alexander MCO with
regard to the administration of a particular health plan. This
agreement complies with all of the provisions of the NAIC TPA
Model Law. On

Choice A: hold all funds it receives on behalf of Alexander 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 government a certificate of
authority designating the Cleopatra Group as a TPA

““:A

Question 183

The Clover Group is a for-profit MCO that operates in the
United States. The Valentine Group owns all of Clover's stock.
The Valentine Group's sole business is the ownership of
controlling interests in the shares of other companies. This
information indic

Choice A: holding company of the Valentine Group

Choice B: sister corporation of the Valentine Group

Choice C: parent company of the Valentine Group

Choice D: subsidiary of the Valentine Group

““:D

Question 184

The Conquest Corporation contracts with the Apex health plan

to provide basic medical and surgical services to Conquest
employees. Conquest entered into a separate contract with
the Bright Dental Group to provide and manage a dental care
program for emplo

Choice A: a negotiated rebate agreement

Choice B: a carve-out arrangement

Choice C: an indemnity plan

Choice D: PBM

““:B

Question 185

The contract between the Honolulu MCO and Beverley Hills
Hospital contains a 90 day cure provision. The Beverley Hills
Hospital breached one of the contract reqirements on July 31,
2004. The hospital remedied the problem by October 31,
2004. Which of the

Choice A: The contract would not be terminated as Beverley
Hills hospital rectified the problem within 90 days.

Choice B: The contract would be terminated as Beverley Hills
hospital was required to notify Honolulu MCO about the
problem at least 90 days in advance.

Choice C: The contract would be terminated as Beverley Hills
hospital was required to rectify the problem within 90 days.

Choice D: The contract would not be terminated as Beverley
Hills hospital may escape adherence to the cure provision.

““:C

Question 186

The Courtland PPO maintains computerized records that
include clinical, demographic, and administrative data about
individual plan members. The data in these records is
available to plan providers, ancillary service departments,

pharmacies, and others inv

Choice A: a data warehouse

Choice B: a decision support system

Choice C: an outsourcing system

Choice D: an electronic medical record (EMR) system

““:D

Question 187

The criteria used to identify and measure healthcare quality
are generally divided into three categories: structure, process,
and outcomes measures. Structure measures, which relate to
the nature and quality of the resources that a health plan has
availab

Choice A: length of time patients have to wait at the office to
be seen by a provider

Choice B: percentage of plan physicians who are board-
certified

Choice C: percentage of children receiving immunizations

Choice D: number of patients contracting an infection in the
hospital

““:B

Question 188

The data evaluation stage of utilization review (UR) includes
both administrative reviews and medical reviews. One true
statement about these types of reviews is that:

Choice A: An administrative review must be conducted by a
health plan staff member who is a medical professional.

Choice B: The primary purpose of an administrative review is
to evaluate the appropriateness of a proposed medical

which compensate the injured party for his or her injuries Choice C: punitive damages. a health plan that is subject to the requirements of HIPAA. Choice C: UR staff members typically conduct a medical review of a proposed medical service before they conduct an administrative review for that same service. which cover the cost of denied treatment Choice B: compensatory damages. Under the te Choice A: contract damages. The Executive Committee serves as a long-term advisory body on issues Choice A: Both 1 and 2 Choice B: 1 only . which are designed to punish or make an example of the wrongdoer Choice D: all of the above ““:A Question 190 The existing committees at the Majestic Health Plan. ““:D Question 189 The Employee Retirement Income Security Act (ERISA) requires health plan members who receive healthcare benefits through employee benefit plans to file legal challenges involving coverage decisions or plan administration at the federal level. include the Executive Committee and the Corporate Compliance Committee.service. Choice D: One purpose of a medical review is to evaluate the medical necessity of a proposed medical service.

National Committee for Qualty Assurance (NCQA) B. American Accreditation HealthCare Commission/URAC Of these organizations.Choice C: 2 only Choice D: Neither 1 nor 2 ““:B Question 191 The Fairway Health Group contracted with the Empire Corporation to provide behavioral healthcare services to Empire employees. As a condition of providing behavioral healthcare services. performance data is included i Choice A: A only Choice B: B only Choice C: A and B Choice D: none of the above ““:A . Fairway required Empire to contract with Fairway for basic medical s Choice A: horizontal group boycott Choice B: price-fixing agreement Choice C: horizontal division of markets Choice D: tying arrangement ““:D Question 192 The following organizations are the primary sources of accreditation of healthcare organizations: A.

Question 193 The following paragraph contains an incomplete statement. Select the “ “ choice containing the term that correctly completes the statement. Select the “ “ choice containing the term that correctly completes the statement.Advances in computer technology have revolutionized the processing of medical and drug claims. traditional indemnity health insurers included in their health pla Choice A: cost shifting Choice B: deductibles Choice C: underwriting Choice D: copay ““:B Question 194 The following paragraph contains an incomplete statement.Claims processing i Choice A: Lower Choice B: Higher Choice C: Same Choice D: No change ““:B Question 195 The following programs are part of the Alcove Health Plan's utilization management (UM) program: • Preventive care initiatives . In early efforts to manage healthcare costs.

Choice B: Telephone triage program is staffed by physicians only. it is most Choice A: Preventive care initiatives include immunization programs but not health promotion programs. ““:D Question 196 The following programs are part of the Alcove MCO's utilization management (UM) program: · A telephone triage program· Preventive care initiatives· A shared decision-making program· A self-care program With regard to the UM programs.• A telephone triage program • A shared decision-making program • A self-care program With regard to the UM programs. rather than to supercede or eliminate these services Choice B: telephone triage program is staffed by physicians only Choice C: shared decision-making program is appropriate for virtually any medical condition Choice D: preventive care initiatives include immunization programs but not health promotion programs ““:A . Choice C: Shared decision-making program is appropriate for virtually any medical condition. Choice D: Self-care program is intended to complement physicians' services. rather than to supersede or eliminate these services. it is most likely cor Choice A: self-care program is intended to complement physicians' services.

Utilization management B. Select the “ “ choice that contains the words that correctly fill in the missing blanks. Select the “ “ choice that contains the . Case management Choice A: A and B only Choice B: A and C only Choice C: All of the listed options Choice D: B and C only ““:C Question 198 The following sentence contains an incomplete statement with two missing words. At its core. Self-care C.Question 197 The following programs are typically included in TRICARE medical management efforts: A. consumer choice involves empowering healthcare consumers to play a __ Choice A: greater/lesser Choice B: greater/greater Choice C: lesser/greater Choice D: lesser/lesser ““:B Question 199 The following sentence contains an incomplete statement with two missing words.

““:C Question 201 The following statement(s) can correctly be made about electronic data interchange (EDI): A. Choice D: Individuals can enroll in MA plan in multiple regions. whereas eCommerce is the transfer of d . The philosophy of consumer choice involves having consumers play a(n) ______ Choice A: Decreased … Increased Choice B: Increased … Decreased Choice C: Increased … Increased Choice D: Decreased … Decreased ““:C Question 200 The following statement can be correctly made about Medicare Advantage eligibility: Choice A: Individuals enrolled in a MA plan must enroll in a stand-alone Part D prescription drug plan. respectively. Choice B: Individuals enrolled in a MA plan do not have to be eligible for Medicare Part A Choice C: Individuals enrolled in an MSA plan or a PFFS plan without Medicare drug coverage can enroll in Medicare Part D.words that correctly fill the two blanks. EDI differs from eCommerce in that EDI involves back-and- forth exchanges of information concerning individual transactions.

Info Choice A: Both A and B Choice B: A only Choice C: B only . A state may mandate health plan enrollment if it offers enrollees in non-rural areas a choice of at least two health plans and offers rural enrollees a choice of at lea Choice A: Both A and B Choice B: A only Choice C: B only Choice D: Neither A nor B ““:A Question 203 The following statement(s) can correctly be made about the characteristics of reports that should be provided to managers for use in managing a healthcare delivery system: A.Choice A: Both A and B Choice B: A only Choice C: B only Choice D: Neither A nor B ““:C Question 202 The following statement(s) can correctly be made about Medicaid managed care plans: A. Users typically need access to all the raw data used to generate reports B.

Choice A: MSAs were established as a demonstration project under the Medicare Modernization Act. JCAHO's accreditation process for MCOs and healthcare networks consists of complete on-site surveys conducted every three Choice A: A only Choice B: Neither A nor B Choice C: Both A and B Choice D: B only ““:A Question 205 The following statements apply to Archer medical savings accounts.Choice D: Neither A nor B ““:D Question 204 The following statement(s) can correctly be made about the Joint Commission on Accreditation of Healthcare Organizations (JCAHO): A. Choice D: MSAs are one of the fastest growing Types of Consumer-Directed Health Plans. ““:B . Choice C: The popularity of MSAs has been limited because funds may not be rolled over from year to year. Choice B: MSAs were seen as an improvement over FSAs because they are portable. allowing employees to take the funds with them when they change jobs. Select the “ “ choice that contains the correct statement.

Choice C: Most people receiving coverage through HSA health plans are individuals rather than families. ““:A Question 207 The following statements apply to flexible spending arrangements.Question 206 The following statements apply to enrollment statistics for HSAs. Select the “ “ choice that contains the correct . Select the “ “ choice that contains the CORRECT statement. Select the “ “ choice that contains the correct statement. ““:C Question 208 The following statements apply to health reimbursement arrangements. Choice A: HSAs have helped expand health care coverage to consumers who were previously uninsured. Choice D: A popular feature of FSAs is their portability. Choice A: FSAs were designed to help increase health insurance coverage among self-employed individuals. Choice C: The popularity of FSAs has been limited because funds may not be rolled over from year to year. Choice B: The vast majority of enrollees in HSA health plans are wealthy. which allows employees to take the funds with them when they change jobs. Choice D: HSAs appeal primarily to young consumers. Choice B: Only employers may contribute funds to FSAs.

Choice D: The guaranteed portability feature of HRAs has contributed to their popularity. ““:D Question 210 The following statements are about concepts related to the underwriting function within a health plan. Choice C: HRAs must be offered in conjunction with a high- deductible health plan.S.statement. Choice C: Results of accreditation evaluations are provided only to state regulatory agencies and are not made available to the general public. Choice B: The popularity of HRAs waned following a 2002 ruling by U. Choice A: Accreditation is typically performed by a panel of physicians and administrators employed by the health plan under evaluation. Select the “ “ choice that contains the correct statement. Choice B: All accrediting organizations use the same standards of accreditation. Choice D: Accreditation demonstrates to an health plan's external customers that the plan meets established standards for quality care. Treasury Department regarding their treatment in the tax code. Choice A: Only employers are permitted to establish and fund HRAs. Select the “ “ . ““:A Question 209 The following statements are about accreditation in health plans.

Choice A: The Women's Health and Cancer Rights Act (WHCRA) of 1998 requires health plans to offer mastectomy benefits. Select the “ “ choice containing the correct response. Choice D: When evaluating the risk for a group policy. Choice C: The Newborns' and Mothers' Health Protection Act (NMHPA) of 1996 mandates that coverage for hospital stays for childbirth must generally be a minimum of 24 hours for normal deliveries and 48 hours for cesarean births. even if these entities adhere to due process standards that are outlined in HCQIA. Choice B: The Health Care Quality Improvement Act (HCQIA) requires hospitals. it imposes requirements on those plans that do offer mental health benefits. the stability of the group. underwriters typically focus on such factors as the size of the group.choice containing the correct statement. and the activities of the group. Choice D: Although the Mental Health Parity Act (MHPA) does not require health plans to offer mental health coverage. ““:D Question 211 The following statements are about federal laws that affect healthcare organizations. a health plan guarantees the premium rate for a group health contract for a period of five years. and HMOs to comply with all standard antitrust legislation. Choice A: Antiselection refers to the fact that individuals who believe that they have a less-than-average likelihood of loss tend to seek healthcare coverage to a greater extent than do individuals who believe that they have an average or greater- than-average like Choice B: Federally qualified HMOs are required to medically underwrite all groups applying for coverage. group practices. . Choice C: Typically.

Select the “ “ choice containing the FALSE statement: Choice A: Health plans find EDI useful for transmitting data among different health plan locations. Choice B: EDI is different from eCommerce in the EDI is the transfer of data. while ecommerce is a back-and-forth exchange of information concerning individual transactions. Choice C: A health plan can use a secured extranet design or a distributed database approach for its HIN. Choice D: HINs have the potential to increase the quality of medical care because they make a patient's medical history readily available to each provider at the point of service. Three of the statements are true and one statement is false. Choice B: While a HIN is for the exclusive use of one organization. Three of the statements are true and one statement is false. Choice C: The majority of health plan eCommerce occurs via .““:D Question 212 The following statements are about health information networks (HINs). typically in batches. ““:A Question 213 The following statements are about information management in health plans. Choice A: Most HINs are built on proprietary computer networks rather than being Internetbased. a community health information network (CHIN) is shared by several organizations. Select the “ “ choice containing the FALSE statement.

price is typically the most critical consideration for small businesses in selecting a healthcare plan. Choice B: PPOs generally pay a larger portion of a member's medical expenses when that member uses in-network providers than when the member uses out-of-network . Choice A: In the large group market. Select the “ “ choice that contains the correct statement. ““:C Question 214 The following statements are about issues associated with marketing healthcare plans to small groups and large groups. Choice A: PPOs generally assume full financial risk for arranging medical services for their members. Choice C: health plans typically treat an employer purchasing coalition as a small group for marketing purposes. Select the “ “ choice that contains the correct statement. ““:B Question 215 The following statements are about preferred provider organizations (PPOs). Choice D: Large groups rarely use self-funding to finance their healthcare plans.proprietary computer networks. Choice B: Because providing healthcare coverage for employees is often a burden for small businesses. large group accounts that have employees in more than one geographic area who are covered through a single national contract for healthcare coverage are known as large local groups. Choice D: Benefits that health plans can receive from using electronic data interchange.

providers. the most common method used to reimburse physicians is capitation. Choice D: In a PPO. ““:B Question 216 The following statements are about standards set forth in the Quality Improvement System for Managed Care (QISMC). Choice D: QISMC standards and guidelines are required for Medicare MCOs. but generally do not include specialists. now known as the Centers for Medicare and Medicaid Services). established by the Health Care Financing Administration (HCFA. Select the answ Choice A: As a result of the Balanced Budget Refinement Act (BBRA). Choice C: Medicaid primary care case manager (PCCM) programs are subject to the same QISMC quality standards and performance measures as are all other Medicare and Medicaid programs. PPOs are required to meet all QISMC quality requirements. Select the “ “ choice that contains the correct statement. Choice A: A person’s employment status as a full-time . ““:D Question 217 The following statements are about the accessibility of healthcare coverage and medical care in the United States. Choice C: PPO networks may include primary care physicians and hospitals. but they are applicable to Medicaid MCOs at the discretion of the individual states. Choice B: QISMC standards typically do not apply to such Medicare services as mental health or substance abuse services.

Choice C: The percentage of the population without healthcare coverage is evenly distributed throughout the United States. Choice B: Most people who have healthcare coverage are covered under an individual insurance policy rather than a group insurance plan. ““:D Question 219 The following statements are about the non-group market for managed care products in the United States. Select the “ “ .employee guarantees that person access to healthcare coverage. Select the “ “ choice that contains the correct statement. Choice D: Hospital closings have occurred disproportionately in rural areas and inner cities and have reduced access to healthcare in these areas. ““:D Question 218 The following statements are about the make-up and function of an HMO's board of directors. Choice C: An HMO's board of directors is not responsible for supervising the performance of its officers and outside advisors. Choice B: The board of directors of a not-for-profit HMO is exempt from liability for its actions. Choice D: A primary function of the board of directors is to approve and evaluate the organization's operational policies and procedures. Choice A: The make-up of an HMO's board of directors is prescribed by state regulations and does not vary according to whether the plan is a for-profit or not-for-profit plan.

Choice B: Managed Medicare plans typically are allowed to reject a Medicare applicant on the basis of the results of medical underwriting of the applicant. Choice D: In order to determine the actual premium to charge a group.choice containing the correct statement. and advertising. Choice D: Managed care plans are not allowed to health screen individual market customers who are under age 65. Choice B: Compared to a health plan with relaxed underwriting requirements. Choice C: Typically. Choice A: The underwriting function in a health plan is primarily concerned with ensuring that the group being underwritten does not include any individuals who are likely to have higher than averageutilization of medical services. Choice A: In order to promote a product to the individual market. a similar health plan with very strict underwriting requirements can expect to experience increased healthcare costs and to have significantly higher plan enrollment. ““:C Question 220 The following statements are about the underwriting function within a health plan. telemarketing. MCOs typically rely on personal selling by captive agents rather than on promotional tools such as direct mail. a health plan guarantees the premium rate for a group health contract for a period of no more than six months. a group underwriter typically considers such factors . Select the “ “ choice containing the correct statement. Choice C: HCFA (now known as the Centers for Medicare and Medicaid Services) must approve all membership and enrollment materials used by MCOs to market managed care products to the Medicare population. even if the health screen could help prevent antiselection.

physician practice management (PPM) Casa- physician hospital organization (PHO) company. not just 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 services company Choice D: physician hospital organisation medical foundation ““:B Question 222 The following statements describe common types of physician/hospital integrated models: The Iota Company.as level of participation.physician hospital organization (PHO)Casa- physician practice management (PPM) company. Choice C: Iota.management . which is owned by a group of investors. is a for-profit legal entity that buys entire physician practices. Choice B: Iota.medical foundation Casa. ““:D Question 221 The following statements describe common types of physician/hospital integrated models: (A) The Alpha Company. and the age and gender distribution of group members. Choice D: Iota. benefits. is a for-profit legal entity that buys entire physician practices. which is owned by a group of investors. not just the tangible assets of the practi Choice A: Iota.physician hospital organization (PHO)Casa- medical foundation.

Choice C: Corinne Maxwell underwent physical therapy after being hospitalized for hip replacement surgery. Choice A: Adele Farnsworth visited a dermatologist to have a mole removed from her arm. Choice D: Jose Redriguez. collections. received a flu shot as part of his annual physical examination. a 70-year-old Medicare patient. Choice B: Jonathan Lang underwent an electrocardiogram (EKG) during an office visit with his cardiologist. ““:C Question 223 The following statements describe corporate transactions: Transaction A – An MCO acquired another MCO. Transaction B – A group of providers formed an organization to carry out billings. and C Choice C: B and C only Choice D: A and B only ““:A Question 224 The following statements describe healthcare services delivered to health plan members by plan providers. Select the statement that describes a service that would most likely require utilization review and authorization. B. ““:C .services organization (MSO). and contracting with MCOs for the entire group of provi Choice A: A and C only Choice B: A.

Beeker ““:A Question 226 The following statements describe violations of antitrust legislation: • Situation A . . Beeker Choice B: Mr. Beeker only Choice D: neither Mr.horizontal group boycott Situation B .tying arrangement. Choice B: Situation A . Choice C: Situation A .horizontal group boycott Situation B .horizontal division of markets Situation B .Two health plans in a single service area divided purchasers into two groups andagreed to each market their products to only one purchaser group. Wilbur Lee lost his health insurance coverage due to a reduction in work hours and has exhausted his coverage under COBRA.horizontal division of markets Situation B . Choice D: Situation A .Question 225 The following statements describe individuals who are applying for individual health insurance coverage: Six months ago. • Situation B . Lee nor Mr. Mr.price fixing.A spec Choice A: Situation A .price fixing.tying arrangement. Lee only Choice C: Mr. Lee has Choice A: both Mr. Lee and Mr.

HSAs Choice D: FSAs. MRAs. HSAs Choice B: FSAs. HRAs Choice C: FSAs. HRAs. This practice. MRAs HSAs ““:A Question 228 The Gable MCO sometimes experience-rates small groups by underwriting a number of small groups as if they constituted one large group and then evaluating the experience of the entire large group.““:A Question 227 The following types of CDHPs allow federal tax advantages including the ability to roll funds from one year to the next: Choice A: MSAs. which allows small groups to take advantage Choice A: prospective experience rating Choice B: pooling Choice C: retrospective experience rating Choice D: positioning ““:B Question 229 The Granite Health Plan is a coodinated care plan (CCP) that partcipates in the Medicare+Choice program. HRAs. This information indicates that Granite Choice A: must comply with all state-mandated benefits and provider requirements .

Choice B: A decision as to how to establish the network of participating providers for this product Choice C: A determination of the level at which this product . and household composition. gender. The Amberly MCO segmented the non-group market 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 ““:C Question 231 The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. and it developed advertising designed to inform potenti Choice A: A decision as to which exclusions or limitations would apply for this product.Choice B: must offer each of its enrollees a Medicare supplement Choice C: places primary care t the cener of the delivery system and focuses on manaing patient care at all levels Choice D: most likely must cover Medicare Part A. benefits ““:C Question 230 The Helm MCO segmented the non-group market for its new healthcare product by using factors such as education level. Hill then established a pricing structure that allowed its product to compete in the small group market. but not Medicare Part B.

would cover out-of-network services.

Choice D: All of the above.

““:D

Question 232

The Hill Health Plan designed a set of benefits that it packaged
in the form of a PPO product. Hill then established a pricing
structure that allowed its product to compete in the small
group market, and it developed advertising designed to inform
potenti

Choice A: $140

Choice B: $170

Choice C: $180

Choice D: $210

““:B

Question 233

The Hill Health Plan designed a set of benefits that it packaged
in the form of a PPO product. Hill then established a pricing
structure that allowed its product to compete in the small
group market, and it developed advertising designed to inform
potenti

Choice A: An indemnity wraparound plan

Choice B: A self-funded plan

Choice C: An aggregate stop-loss plan

Choice D: A fully funded plan

““:D

Question 234

The Hill Health Plan designed a set of benefits that it packaged
in the form of a PPO product. Hill then established a pricing
structure that allowed its product to compete in the small
group market,and it developed advertising designed to inform
potentia

Choice A: The number of specialists in Hill's network of
providers.

Choice B: The price for the PPO product.

Choice C: Hill's ability to report utilization data.

Choice D: Hill's use of brokers to market its PPO product.

““:B

Question 235

The HMO Act of 1973 was significant in that the Act

Choice A: mandated certain requirements that all HMOs had to
meet in order to conduct business

Choice B: required that all HMOs be licensed as insurance
companies

Choice C: offered HMOs federal financial assistance through
grants and loans, and provided access to the employer-based
insurance market

Choice D: encouraged the use of pre-existing condition
exclusion provisions in all HMO contracts

““:C

Question 236

The Houston Company, a United States company, offers its
eligible employees health insurance coverage through a group
health plan. Houston hired the Dallas Company to handle the
plan's claim administration and membership services, but
Houston is financial

Choice A: Houston is required to purchase stop-loss insurance
to cover its losses under this group health plan

Choice B: Houston's plan is a self-funded plan

Choice C: Dallas is the plan's sponsor

Choice D: Houston's plan is not exempt from any state
insurance regulations under ERISA

““:B

Question 237

The Internal Revenue Service has ruled that an HDHP coupled
with an HSA may cover certain types of preventive care
without a deductible or with a lower amount than the annual
deductible applicable to all other services. According to IRS
guidance, which on

Choice A: Immunizations for children and adults

Choice B: Tests and diagnostic procedures ordered with routine
examinations

Choice C: Smoking cessation programs

Choice D: Gastric bypass surgery for obesity

““:D

Question 238

The Koster Company plans to purchase a health plan for its
employees from Intuitive HMO. Intuitive will administer the
plan and will bear the responsibility of guaranteeing claim
payments by paying all incurred covered benefits. Koster will
pay for the he

Choice A: fully funded plan

Choice B: stop-loss plan

Choice C: self-pay plan

The contract between Links Choice A: a manual rating contract Choice B: a funding vehicle contract Choice C: an administrative services only (ASO) contract Choice D: a pooling contract ““:C Question 240 The Mabry County Hospital negotiated a contract with Wellfolk HMO.Choice D: self-funded plan ““:A Question 239 The Links Company. a national MCO. The TPA handles the group's membership services and claims administration. signed a contract with a third party administrator (TPA) to administer the plan. and a local hospital . Mabry negotiated the inclusion of a provision in the contract whereby Mabry agreed to capitated compensation from Wellfolk up to a specified total cost of providing medical services for an Choice A: quality assurance provision Choice B: performance-based financial provision Choice C: dual-choice provision Choice D: stop-loss provision ““:D Question 241 The Madison Health Plan. which offers its employees a self-funded health plan.

system that operates its own managed healthcare network recently created a new and separate managed healthcare organization. Madison and the hospital system share own Choice A: a consolidation Choice B: a joint venture Choice C: a merger Choice D: an acquisition ““:B Question 242 The main advantage of using outcomes measures to evaluate healthcare quality is that they Typically Choice A: are easy to identify and report Choice B: demonstrate improved clinical and functional status over time Choice C: are insensitive to changes in structures or processes Choice D: provide meaningful feedback on care delivery even when the delay between treatment and outcome stretches over several years ““:B Question 243 The main purpose of the Health Plan Employer Data and Information Set (HEDIS) is to provide Choice A: expert consultation to end-users for solving specialized and complex healthcare problems through the use of a knowledge-based computer system Choice B: a comprehensive accrediation for PPOs Choice C: measurements of plan performance and . the Pineapple Health Plan.

structure and outcomes. In situations w Choice A: a group practice without walls (GPWW) Choice B: a messenger model Choice C: an individual practice association (IPA) Choice D: a Physician Practice Management (PPM) company ““:C Question 245 The measures used to evaluate healthcare quality are generally divided into three categories: process. and then Meadowcreek contracts separately with its physician members. Meadowcreek enters into contracts with health plans.effectiveness that potential healthcare purchasers can use to compare quality offered by different healthcare plans Choice D: a mathemetical model that can predict future claim payments and premiums ““:C Question 244 The Meadowcreek Group is an organization comprised of individual physicians and physicians in small group practices. An example of a process measure that can be used to evaluate an MCO's performance is the Choice A: percentage of baord certified physicians within the MCO's network 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 receive regular medical checkups .

““:D Question 246 The measures used to evaluate healthcare quality are generally divided into three categories: process. Choice C: Percentage of board certified physicians within the health plan's network. and outcomes. structure. ““:A Question 247 The Military Health System of the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the Choice A: Health Care Quality Improvement Program (HCQIP) Choice B: Health Plan Management System (HPMS) Choice C: TRICARE healthcare system Choice D: Health Care Prepayment Plan (HCPP) ““:C Question 248 The Mirror Health Plan uses a form of computer/telephony integration (CTI) to manage telephone calls coming into its . Choice D: Number of hospital admissions for plan members with certain medical conditions. Choice B: Number of plan members contracting an infection in the hospital. An example of a process measure that can be used to evaluate a health plan's performance is the: Choice A: Percentage of adult plan members who receive regular medical checkups.

All of the following statements are correct about the HMO Model Act EXCEPT that it: Choice A: Regulates HMO operations in two critical areas: financial responsibility and healthcare delivery. Choice D: Is organized by the type of treatment or by provider. Choice B: Is designed to supply information at the site of care. a device “ “s the call with a recorded message and Choice A: a member outreach program Choice B: a complaint resolution procedure (CRP) Choice C: an automatic call distributor (ACD) Choice D: an interactive voice response (IVR) system ““:C Question 249 The Mosaic health plan uses a typical electronic medical record (EMR) to document the medical care its members receive.member services department. Choice C: Contains a Mosaic member's clinical data only. Choice C: Focuses on three key aspects of healthcare delivery: . Choice B: Requires each HMO to send state regulators an annual report describing the HMO's finances and operations. One characteristic of Mosaic's EMR is that it: Choice A: Does not provide any clinical decision support for Mosaic's providers. ““:B Question 250 The NAIC adopted the HMO Model Act in order to provide a system of ongoing regulatory monitoring of HMOs. When a member calls the plan's central telephone number.

the model law limits the rate spread.network adequacy. group health benefits. quality assurance. Specifically. yet affordable. quality assurance programs. group health benefits. The model law limits the rate spread. According to this model law. which is the difference between the hi Choice A: $60 Choice B: $80 Choice C: $120 Choice D: $160 ““:B . yet affordable. and provider networks. Choice D: Requires state insurance departments to conduct annual examinations of an HMO's operations. if the lowest rate that an HMO charges a small g Choice A: $80 Choice B: $120 Choice C: $160 Choice D: $240 ““:C Question 252 The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible. ““:D Question 251 The NAIC designed a small group model law to enable small groups to obtain accessible. and grievance procedures.

Choice C: is updated annually and measures are changed or new measures added. in part. a health plan's accreditation score is determined. Choice B: divides performance measures into 8 domains. by pe Choice A: is a performance-measurement tool designed to help healthcare purchasers and consumers compare quality offered by different plans.Question 253 The National Association of Insurance Commissioners' (NAIC's) Unfair Claims Settlement Practices Act specifies standards for the investigation and handling of claims. Under the current NCQA accreditation program. Choice D: all of the above ““:D Question 255 The nature of the claims function within health plans varies by . The Act defines unfair claims practices and notes that such practices are improper if th Choice A: Both A and B Choice B: A only Choice C: B only Choice D: Neither A nor B ““:A Question 254 The National Committee for Quality Assurance (NCQA) is a nonprofit organization that accredits health plans and other healthcare organizations. and organizes reporting measures under these domains.

whenever an Oriole member is hospitalized at Isle. Preferred provider organization (PPO).type of plan and by the compensation arrangement that the plan has made with its providers. th Choice A: Both A and B Choice B: A only Choice C: B only Choice D: Neither A nor B ““:A Question 256 The Neptune Hospital provides medical care to paying patients. in a A. as well as to people who either have no healthcare coverage and cannot afford to pay for the care by themselves or who receive services at reduced rates because they are covered under governme Choice A: cost shifting Choice B: Antiselection Choice C: receivership Choice D: Underwriting ““:A Question 257 The Oriole MCO uses a typical diagnosis-related groups (DRGs) payment method to reimburse the Isle Hospital for its treatment of Oriole members. Oriole pays Isle Choice A: an amount based on the weighted value of each medical procedure or service that Isle provides. Under the DRG payment method. and the weighted value is determined by the appropriate current . For example. it is generally correct to say that.

Then select the “ “ choice containing the two terms you have selected. The Harbor Health Plan convened a litig Choice A: a standing / ongoing Choice B: a standing / specific Choice C: an ad hoc / ongoing Choice D: an ad hoc / specific . Determine which term in each pair correctly completes the paragraph.procedural terminology (CPT) code for the procedure or service Choice B: a fixed rate based on average expected use of hospital resources in a given geographical area for that DRG Choice C: a retrospective reimbursement based on the actual costs of the Oriole member's hospitalization Choice D: a specific negotiated amount for each day the Oriole member is hospitalized ““:B Question 258 The owners of an MCO typically delegate authority for governing the operation of the MCO by electing the MCO's Choice A: quality management committee Choice B: medical director Choice C: board of directors Choice D: chief executive officer ““:C Question 259 The paragraph below contains two pairs of terms enclosed in parentheses.

a health plan and subsidiary of Polestar. Kayak can correctly be characterized 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 ““:B Question 261 The parties to the contractual relationship that provides Castle's group health coverage to Knoll employees are Choice A: Castle and Knoll only Choice B: Knoll and all covered Knoll employees only Choice C: Castle. the rest are Choice A: Polestar's relationship to Polaris: partnership . Some members of Polestar's board of directors hold positions with Polestar in addition to their positions on the board.““:D Question 260 The participating physicians remain independent practitioners who operate out of their own offices and can treat other patients in addition to Kayak plan members. and all covered Knoll employees Choice D: Castle and all covered Knoll employees only ““:A Question 262 The Polestar Company's sole business is the ownership of Polaris Medical Group. Knoll.

the expected costs to deliver medical services. and the expected marketability and competitiveness of the health plan Choice A: financing Choice B: rating Choice C: underwriting Choice D: budgeting ““:B Question 264 The process that Mr. given the degree of risk represented by the individual or group. Sybex used to identify and classify the risk represented by the Koster Group so that Intuitive can charge premiums that are adequate to cover its expected costs is known as Choice A: coinsurance Choice B: plan funding .Type of board member: operations director Choice B: Polestar's relationship to Polaris: partnership Type of board member:outside director Choice C: Polestar's relationship to Polaris: holding company Type of board member: operations director Choice D: Polestar's relationship to Polaris: holding company Type of board member:outside director ““:D Question 263 The process of calculating the appropriate premium to charge purchasers.

Choice A: In most preferred provider organizations (PPOs) and open access plans. and counseling. Select the “ “ choice containing the correct statement. Three of these statements are true and one statement is false. Choice C: Managed behavioral health organizations (MBHOs) typically are prohibited from negotiating with network providers for reduced fees in exchange for increased patient volume. managed behavioral health organizations (MBHOs) typically use alternative treatment levels and alternative treatment methods rather than crisis intervention or alternative treatment settings. Select the “ “ choi . The following statements are about behavioral healthcare. Choice D: The treatment approaches for behavioral healthcare most often include drug therapy.Choice C: underwriting Choice D: pooling ““:C Question 265 The provision of mental health and chemical dependency services is collectively known as behavioral healthcare. The following statements are about behavioral healthcare. Choice B: To manage the delivery of behavioral healthcare services. ““:B Question 266 The provision of mental health and chemical dependency services is collectively known as behavioral healthcare. psychotherapy. plan members must receive a referral before accessing behavioral healthcare services from a specialist.

and increased reliance on case management have shifted the emphasis of managed behavioral healthcare from meeting the service needs of ““:B Question 267 The Robust Health Plan sometimes uses prospective experience rating to calculate the premiums for a group. Under prospective experience rating. Choice D: The development of alternative treatment options. psychotherapy.Choice A: Factors that have increased the demand for behavioral healthcare services include increased stress on individuals and families and the increasing availability of behavioral healthcare services. Choice B: To manage the delivery of behavioral healthcare services. Choice C: The treatment approaches for behavioral healthcare most often include drug therapy. if the group's experience during the period is better than expected. refund part of the group's premium in the form of an experience rati Choice B: Use Robust's average experience with all groups to calculate this particular group's premium. incorporation of community-based resources into the healthcare system. the financial gains and losses experienced by the group during that rating period and. managed behavioral health organizations (MBHOs) use only two basic strategies: alternative treatment levels and crisis intervention. Choice D: All of the above ““:C . and counseling. Robust most likely will: Choice A: At the end of a rating period. Choice C: Use the group's past experience to estimate the group's expected experience for the next period.

““:B Question 269 The statements below describe technology used by two MCOs to respond to incoming telephone calls: · The Morton MCO uses an automated system that “ “s telephone calls with recorded or synthesized speech and prompts the caller to respond to a menu of opt Choice A: Autumn's device is best described as an interactive voice response (IVR) system. Choice B: Both Morton's system and Autumn's device are applications of computer/telephony integration (CTI). Choice C: Morton's system is best described as an automatic call distributor (ACD). Choice D: Morton's system can be correctly characterized as an expert system. Choice B: Both Manor's system and Squire's device are applications of computer/telephone integration (CTI). Choice C: Squire's device is best described as an interactive voice response (IVR) system.Question 268 The statements below describe technology used by two health plans to respond to incoming telephone calls: • The Manor Health Plan uses an automated system that “ “s telephone calls with recorded or synthesized speech and prompts the caller to respond t Choice A: Manor's system is best described as an automated call distributor (ACD). Choice D: All of these statements are correct. ““:B .

This agreement complies with all of the provisions of the NAIC TPA Model Law. One of the TPA's Choice A: Hold all funds it receives on behalf of Titanium in trust. Choice D: Assume full responsibility for determining the claim . Measure A: Incidence of foot ulcers among long-term diabetes patients Measure B: Ability of long-term diabetes patients to m Choice A: Measure A clinical status Measure B patient perception Choice B: Measure A clinical status Measure B functional status Choice C: Measure A functional status Measure B patient perception Choice D: Measure A functional status Measure B clinical status ““:B Question 271 The Titanium Health Plan and a third-party administrator (TPA) have entered into a TPA agreement with regard to the administration of a particular health plan. Choice B: Assume full responsibility for ensuring that the health plan is administered properly Choice C: Obtain from the federal government a certificate of authority designating the organization as a TPA.Question 270 The Stateside Health Plan uses the following outcomes measures to evaluate the quality of its diabetes disease management program.

as well as to people who either have no healthcare coverage and cannot pay for the care by themselves or who receive services at reduced rates because they are covered under government sponsored Choice A: antiselection Choice B: cost shifting Choice C: receivership Choice D: underwriting ““:B Question 273 To achieve widespread use of electronic data interchange (EDI) in the healthcare industry.payment procedures for the plan ““:A Question 272 The Venus Hospital provides medical care to paying patients. Several organizations are making cont Choice A: Computer-based Patient Records Institute (CPRI) Choice B: American National Standards Institute (ANSI) Choice C: American Health Information Management Association (AHIMA) Choice D: American Medical Association (AMA) ““:B Question 274 . all entities within the industry need to agree on industry standards regarding the information format and software to be used.

““:D Question 275 To determine fee reimbursements to be paid to physicians.To address the problems associated with multiple data management systems. the Triangle Health Plan assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier. the Triangle Health Plan assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier. Triangle and the providers negotiate the value of the . Triangle and the providers negotiate the value of the Choice A: Diagnosis-related group (DRG) system Choice B: Relative value scale (RVS) Choice C: Partial capitation arrangement Choice D: Capped fee system ““:B Question 276 To determine fee reimbursements to be paid to physicians. Choice D: The data in the warehouse are linked by a common subject. Choice C: It stores historical data rather than current data. Choice B: It contains data from internal sources only. the Kayak Health Plan has begun to use a data warehouse. One likely characteristic of Kayak's data warehouse is that: Choice A: It requires Kayak's individual databases to store large amounts of data that are not needed for daily operations.

With regard to the ways these parts differ from each other. ““:D Question 278 Traditional Medicare includes two parts: Medicare Part A and Medicare Part B. an individual must: Choice A: Be covered by a high-deductible health plan that meets federal requirements. Choice C: Not be enrolled in Medicare. whereas Medicare Part B provides basic hospitalization insurance Choice B: is financed through premiums paid by covered persons and from the federal government's general tax revenues. whereas Medicare Part B includes annual deductible and coinsurance provisions Choice D: is provided automatically to most eligible persons. it is correct to say that Medicare Part A Choice A: provides benefits for physicians' professional services.Choice A: diagnosis-related group (DRG) system Choice B: relative value scale (RVS) Choice C: partial capitation arrangement Choice D: capped fee system ““:B Question 277 To set up and contribute to an HSA. . whereas Medicare Part B is funded primarily through a payroll tax imposed on employers and workers Choice C: provides 100% coverage for eligible medical expenses. Choice D: All of the above. Choice B: Not have other health insurance.

the cost of facilities. compared to the cost of: Choice A: Facilities. and stepdown units. equipment. the cost of care delivered in urgent care centers is generally lower. equipment. . and staffing in hospital emergency departments (EDs). One difference between the costs associated with alternative care centers is that. Choice D: Primary care in a physician's office. observation care units. and staffing in observation care units is generally lower Choice B: Care delivered in urgent care centers. the cost of acute inpatient care is generally lower. the cost of care delivered in hospital emergency departments (EDs) is generally lower.whereas Medicare Part B is a voluntary program ““:D Question 279 Two MCOs in a single service area divided purchasers into two groups and agreed to each market their products to only one purchaser group. This information indicates that these two MCOs violated antitrust requirements because they engaged in an activity k Choice A: horizontal group boycott Choice B: horizontal division of markets Choice C: a tying arrangement Choice D: price fixing ““:B Question 280 Types of alternative care centers include urgent care centers. Choice C: Care in step-down units.

Compared to other methods of data transmittal. or electronically. a Wellborne plan member. Laura Knight. manual transmittal is generally Choice A: less cumbersome and labor intensive Choice B: faster and more accurate Choice C: more acceptable to physicians Choice D: subject to greater scrutiny by regulatory bodies ““:C Question 283 Wellborne HMO provides health-related information to its plan members through an Internet Web site.““:A Question 281 Using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in igher reimbursement to the provider is called ______________. visited Wellborne's Web site to gather uptodate information about the risks and benefits of various treatment option . Choice A: Coding error Choice B: Overcharging Choice C: Upcoding Choice D: Unbundling ““:C Question 282 Utilization data can be transmitted to the health plan manually. by telephone.

Under this rating method. Blue Jay Choice A: was allowed to use no more than four rating classes when determining how much to charge the group for health coverage Choice B: was required to make the average premium in each class no more than 105% of the average premium for any other class Choice C: divided its members into rating classes based on . the Blossom Managed Healthcare Group assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier.Choice A: shared decision making Choice B: self-care Choice C: preventive care Choice D: triage ““:A Question 284 When determining physicians' fee reimbursements. as shown below: Weighted value for service × Money Choice A: discounted fee-for-service system Choice B: global capitation arrangement Choice C: withhold arrangement Choice D: relative value scale (RVS) ““:D Question 285 When determining the premium rates it will charge a particular group. the Blue Jay Health Plan used a rating method known as community rating by class (CRC).

Choice C: Pure community rating. or experience ““:C Question 286 When determining the rates it will charge a small group. Eagle then charges all members of a Choice A: Retrospective experienced rating. experience. Choice B: Adjusted community rating (ACR). industry.demographic factors. family composition. Choice D: Standard community rating. Because Knoll had been covered under a previo Choice A: Castle is responsible for paying for all incurred covered benefits Choice B: Knoll is solely responsible for guaranteeing claim payments Choice C: Knoll makes no premium payments to Castle . and age. gender. a federally qualified HMO. ““:B Question 287 When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO). without adjustments for age. divides its members into classes or groups based on demographic factors such as geography. the agreement between the two parties specified that the plan would be a typical fully funded plan. 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 given level of medical benefits. or industry characteristics. the Eagle HMO.

Because Knoll had been covered under a previo Choice A: 230 Choice B: 270 Choice C: 220 Choice D: 180 ““:C Question 289 Which is an advantage of a for-profit health plan? Choice A: Flexibility in raising capital Choice B: Double taxation Choice C: Exemption from paying federal income taxes. and .Choice D: Castle has no responsibilities for administering the health plan ““:A Question 288 When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO). personal selling. ““:A Question 290 Which of the choices below contains the four tools used by marketers that make up the 'promotion mix?' Choice A: Advertising. Choice D: None of the above. sales promotion. the agreement between the two parties specified that the plan would be a typical fully funded plan.

Choice C: Admissions. Choice C: Medical review is conducted before administrative review. Choice B: Advertising. personal selling. concurent review and retrospective review are types of utilization review . Choice D: Advertising. and privacy. Choice D: Consolidated Medical Group. sales promotion.publicity. sales promotion. Choice B: Group Practice Without Walls (GPWW) Choice C: Management Services Organization (MSO). and publicity. ““:C Question 292 Which of the following is CORRECT? Choice A: Electronic transmittal of authorization is subject to the same regulatory requirements as other methods of transmittal Choice B: Telephone transmittal increases data entry errors. and publicity. Choice D: Prospective review. personal selling. ““:A Question 291 Which of the following best describes an organization that is owned by a hospital or group of investors and provides management and administrative support services to individual physicians or small group practices? Choice A: Independent Practice Association (IPA). price. sales promotion.

““:D Question 293 Which of the following is NOT a factor that is used by MCOs to determine which services will undergo utilization review. Choice A: Cost per procedure Choice B: Concurrent review Choice C: Cost of review Choice D: Access requirements ““:D Question 294 Which of the following is NOT a preventive care initiative often used by health plans? Choice A: Screening for high blood pressure Choice B: Maternity management programs Choice C: Vaccines Choice D: Physical therapy ““:D Question 295 Which of the following is NOT a reason for conducting utilization reviews? Choice A: Improve the quality and cost effectiveness of patient care Choice B: Reduce unnecessry practice variations Choice C: Make appropriate authorization decisions .

Choice D: Accommodate special equirements of inpatient care Question 296 Which of the following is WRONG? Choice A: Computer Based Patient Records Institute (CPRI) deveoped the standards for digital imaging of xrays. (B) Staff model HMOs are closed panel. Choice B: HL7 developers focuses on interchange of Clinical Health Data Choice C: ANSI. Choice A: A & B Choice B: None of the listed options Choice C: B & C Choice D: All of the listed options Question 298 . a voluntary national standards organization. Choice D: American Health Information Management Association focuses on EDI standards for exchange of clinical data Question 297 Which of the following is(are) CORRECT? (A) Staff model HMOs can achieve maximum economies of scale but are heavily capital intensive. creates a consensus based process by which fair and equitable standards can be developed and serves as a legitmizer of standards. (C ) Staff model HMOs operate out of ambulatory care facilities.

Choice C: Out-of-network visit is not allowed in EPO model. Choice C: Determine urgency of the condition. administer drugs. write prescriptions. schedule appointments. Question 299 Which of the following people would be considered part of the individual market segment? Choice A: John is eligible for Medicare. . Choice D: None of the above. Choice D: In-network visit is allowed only on PCP's referral in EPO model. schedule appointments. authorize referrals. Choice B: Julie has coverage through an employer group. Choice B: Greet patients at the door. collect payments. Choice D: Jenny is eligible for Medicaid. Choice C: James works for an employer that does not offer health coverage. notify emergency department.Which of the following job descriptions best match the job of a telephone triage staff member? Choice A: Check patient vitals. provide self-care information. Choice B: Out-of-network visit is not allowed in HMO model. Question 300 Which of the following statements about EPO & HMO models is FALSE? Choice A: In-network visit is allowed only on PCP's referral in HMO model. collect insurance information.

Choice D: Protects all employees Question 303 Which of the following statements is FALSE? Choice A: The license that HMOs get in each state is called ‘Certificate of Authority’ .Question 301 Which of the following statements about Family and Medical Leave Act (FMLA) is WRONG? Choice A: Employers need to maintain the coverage of group health insurance during this period Choice B: Employees can take upto 12 weeks of unpaid leave in a 36 month perio Choice C: Protects people faced with birth/adoption or seriously ill family members Choice D: Employers that have > 50 employees need to comply Question 302 Which of the following statements about the Title VII of the Civil Rights Act is WRONG? Choice A: Employers with more than 15 employees engaged in interstate commerce need to comply Choice B: Pregnancy Discrimination Act (an amendment to this act) requires health plans to provide coverage during childbirth and related medical conditions on the same basis as they provide coverage for other medical conditions Choice C: Allows HMOs to set different policies for people from different races. religions. sex or national origin to safeguard their interests.

Question 305 Which of the following statements is true? Choice A: A declining economy can lead to lower healthcare costs as a result of an older population with greater healthcare needs. Choice C: In accordance with the standards of good medical practice. Choice C: All medicare/mediclaim beneficiaries should comply with utilization management requirements set forth by HCFA Choice D: HMO’s usually impose high coinsurance or deductible requirements Question 304 Which of the following statements is NOT a requirement for a service to be deemed a 'medically necessary service?' Choice A: Furnished in the least intensive type of medical care setting required by the member's condition. Choice B: Solely for the convenience of the member. Choice C: Provider networks are not affected by the federal and state laws that apply to health plans Choice D: Network management standards established by independent accrediting organizations have no influence on . Choice D: Consisitent with the symptoms of the member's condition.Choice B: The HMO contracts directly with the individual physicians who provide the medical services to the HMO members in a variation of the IPA model called direct contract model HMO. Choice B: A larger patient population increases pressure on the health plan to offer larger panels.

.health plan network design.