1

1) ABC company provides insurance. If the total claims cross $10 million then Insurance
Company pays. This is called.
a)Aggregate Stop-loss
b)Individual stop-loss
c)None of these
d)Group Stop-loss
myAnswer:- (a)

2) Which are factors in Anti-Selection

a)Age,occupation
b) Age,Occupation,location
c)Age,Sex,location
d)Occupation,age,location,sex
myAnswer: d

3)Which of the following is the market research technique?

Ans: Focus Groups

4)Balance Sheet consists of

a)Assets,Liabilities,Capital
b)Expenses and Revenues
c)Surplus and revenues
Ans:- (a)Assets,Liabilities,Capital

5)Variance is
a)subtracting actual results for expected results
b)Liabilites and capital subtracted from assets
etc..

6)HealthPlan market research is

a)little regional
b)little different
c)all the listed options
d)state laws
myAnswer:- (c)

7)A Health Plan offers same premium to all the members of the organization
(a)CRC
(b)none of the listed
(c)ACRadjusted community rating
(d)SCR
myAnswer :- (c)

8)what is the difference between the publicity and Advertising

a)Both are same
b)Publicity is not paid but Advertising is paid
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c)Publicity is through personal contact and Advertising is through mass media

d)None of the above

9).The health plans are getting more costly because of – Increasing customer needs and
increase in the technology

10).The main difference between traditional indemnity plan and managed indemnity plan –
more than one answer

11). A person has utilized the services of a provider and the provider submits the claim to
the insurer and the insurer reimburses him on Per-Diem basis. What is the service that the
patient has utilized – In-patient hospitalization

12). A fixed amount that is paid per member per month is – capitation

13). A member went to a specialist without referring to a specialist and she received the
benefits. Which of the below terms best suits the scenario - Member is having open
access

14). Member utilization follows -------- Answer: Referal Management

15).Plans that usually contract at discount prices with physicians -----Answer: PPO
(Discounted fee for service model)

16). An HMO Act of 1973, ----------Ans: Establish a process for to become federally
qualified.

17). To Maintain the provider network , HMO consider the following.

Answer: Access, Credentialing and Contractual relationships.

18). Plan model and staff model is type of which model ? Answer : Mixed Model

19).Advantages of PHO model(physician - Hospital model)

21) What is the suitable phras for "permanent and serve as long-term advisory bodies
on ongoing issues such as financial management, compliance, quality management,
utilization management, strategic planning, and compensation"
Ans) Standing committees

22) what is the suitable phras for "to address specific management concerns and
typically disbanded once the issue has been resolved"
Ans)Ad hoc committees (or special committees)
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23).which of the following administers the plan’s formulary and regularly reviews clinical
trial reports, drug utilization reports, current and proposed therapeutic guidelines, and
economic data on drugs.
Ans) Pharmacy and Therapeutics Committee (not sure)
24).Advisory bodies on ongoing issues such as financial management, compliance..etc,
which one related to this -> Answer: standing committee

25).A committee works on a special issue, which one belongs to this case -> Answer:
special committee

26.)consolidation means... all options seems to be very similar -->

Answer : the providers may combine to form a new organization, with all the original
companies being dissolved

27)Provider integration disadvantage (not direct questoin) ->Answer: loss of autonomy

28)casestdy
Some X organization owned by a group of investors that purchases physician practices
tangible assets
Some y organization owned by a group of investors that purchases physician practices
tangible assets + physician practice
options given as combination of MSO and PPM, need to select which organization belongs
to which practice
Answer --> PPM belongs to (tangible assets + physician practice) and MSO belongs to
tangible assets

29).compulsory condition to avail tax exemption -> Answer: they may not engaging in
lobbying or political activities

30)A company may convert from mutual to stock and vice versa ->Answer: True

31) Question about federal employee and HMO policy --> Answer: all the options are
correct

32) Claims Administration

Ans: Claims Administration or Claims Processing is the receiving, reviewing,
adjudicating, and paying of claims.

33) EDI and E-Commerce Definitions

Ans: Both definition is correct.

34)Mark incurs 1500 on treatment. Deductible is 500 and coinsurance is 20%.

How much the health plan will pay and how much Marc pays.
Ans: Health Plan - $800, Marc - $700
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35) Secret code is embedded (This question is Tactical, bit confusion with multiple
choices)Ans: Encryption

36) EMR Definition

Ans: Clinical Data, Demographic Data, Administrative data at site of care

37) Provider Profiling Definition

38) Contract Management (Look for word contract rules)

Ans: Contract Management System

39) Utilization Management Definition

40) What is the performance of the health plan when the First Contract Resolution Rate is
lesserAns: Best Plan

41) Group Representatives

Ans : Level Two Appeal Definition

42) One of the characteristics of Infinite EMR

Ans: Provide the health plan at Site Care

43) Enterprise Scheduling Definition

An enterprise scheduling system permits physician groups, hospitals, and other
facilities within an enterprise to function as a single organization in arranging access
to facilities and resources.

44) The two primary ways of measuring member satisfaction

Ans: The Member Satisfaction Surveys and Complaint Monitoring.

45) Which of the following increases the member plans head count
Ans: Off-Call hours of the health plan

46)what is enterprise scheduling-

An enterprise scheduling system permits physician groups, hospitals, and other
facilities within an enterprise to function as a single organization in arranging access
to facilities and resources.
47) third-party administrator (TPA) ANS: Administers only benefits

48) Plan divides its members into classes or groups based on demographic factors such as
geography, family composition, and age, and then charges all members of a class or group
the same premium. The plan cannot consider the experience of a class, group, or tier in
developing premium rates. -- ans:: adjusted community rating (ACR)
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49) What is anti selection -- ANS: less health care need more health coverage use.

50) Who does nt comes under regular group market :Ashish who left the company

51) What is income statement? summarize of the revenue and expenses occured for
the specific period.

52) What is Varience -- ANS: the difference obtained from subtracting actual results for
expected

53) Scenario:: ABC company -- Fully funded

54) Type of market research techniques -- focus groups

55) Renewal Underwriting consists of? renewal underwriting includes experience and
particiaption

57) A typical function of underwriting - Answer: It evaluates and assesses the risk

58)A company charges premium equally for all its employees. That Rating is called –
Answer:community rating
59). What is Underwriting ?
60). What is Anti-selection?
61). What Renewal Underwriting? Renewal underwriting includes experience and
particiaption.
62). Community rating, Manual Rating and Experienced Rating, retrospective experience
rating

63).What belongs to Research? Answer focussed group among other options.

64).Can a Mutual company have stocks – false

65).A committee which is formed to address an issue and dissolved after resolution –
Adhoccomitee

66)For a Federal employee, what are the benefits that the health plan must provide – All
the options given were correct

67) Does PBM include the concept of quality of care – a. A little extent b. Yes c. No d. None
- Answer: B

68). Compensation for Comprehensive Carve-Outs in mature health plan market is typically
on --- 1.capitation basis 2. Fee for service 3.Copayment Answer : 1.Capitation Basis.
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69).A large majority of Americans have dental coverage—

Options: varies from state to state b) 50% c)>50% d) 0.5 Ans: c)>50% Ans: c)>50

70). Which of the following health plan now a days is getting declined: myAnswer: a

(a)Primary Care Providers assessed a member’s needs, gave her a referral to a

behavioural health care specialist

(b)Health plans have a Centralized behavioural healthcare referral system.

(c) None of the above

(d)people can be directed to appropriate behavioural health care services is through

assistance programs

71). Check the below options which is/are true for state laws

A. encourage curve-out facilities

B. they address the curve out facilities

c. varies from state to state

d. they do not encourage..

my-answer: c and d

73). Speciality services does not include (option: 1. Home healthcare, chiropractic, Hospital
, none of the above)myAnswer: Hospital

74)In PBM a fixed dollar amount per employee per month is called ? Ans. Capitation

75).For large and medium Health Plans, that MHPA and MHPAEA (Federal and State Laws)
do require that Health Plans that covers behaviour coverage must provide benefits, Cost-
sharing, out-of-network, etc. equivalent to those of Medical Coverage. This may be
confusing because one one of the options is that All Health plans must cover behaviour
coverage to the same extent as that of Medical coverage.

A very small case study: Andre Agasi is suffering from Substance abuse (Drug addiction),
she spends part of the day in a facility and remaining time in playing tennis:

What is her treatment levels? Ans. Partial hospitalization

76).Which is the least common in managed care Mangesdbehaviouralhelath plans? Ans. In

the past some plans required members to access behavioral healthcare services through a
primary care provider. The PCP assessed a member's needs, gave her a referral to a
behavioral healthcare specialist, and sometimes authorized payment for services - PCPs as
Gatekeeper.
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78).If a doctor prescribes drugs in which the patterns does not suit with his peers, the
doctor gets a call and he gets reviewed. This is called
a. Drug utilization review
b. Drug interaction
c. Physician staging
d. Physician Profiling -
Answer : Option d
72). If a doctor, prescribes same medicine for so many times and gets reviewed by his
peers, gets into a discussion of any alternative medicines. This is called.

a.Drug utilization review b. Drug interaction c. Physician staging d. Physician Profiling -

my Answer : Option d
79).Does PBM include the concept of quality of care – a. A little extent b. Yes c. No d. None
- Answer: B
80)question about ; cost-sharing about Mental health parity and normal medical plan..
Answer: cost sharing and out of pocket limits for behavioural care cannot be greater
than for medical care

81) A large majority of Americans have dental coverage ....

Options: varies from state to state b) 50% c)>50% d) 0.5
A: >50%
82).Comprehensive carve-out arrangement is what type of model.......
Options: 1.capitation basis 2. Fee for service 3.CopaymentA: Capitation Basis
83). Check the below options which is/are true for federal state laws
A. encourage curve-out facilities
B. they address the curve out facilities
C. varies from state to state
D. they do not encourage..
my answer: c and d
84) Dental PPO has which of the following –
a. copayment, co-insurance
b. Only co-payment and no co-insurance
c. Co-insurance and deductible
d. None – Answer :Option c
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77).Dental HMO has which of the following –

a. copayment
b. Only co-payment and co-insurance
c. Co-insurance and deductible
d. None –
Answer : Option A (co-payment)
86).In which cases card is not used –

a. prior authorization

b. Receive PBM Benefits

c. Claim electronic prescription

d. none –

Answer : Option a

87)PBM pays a fixed dollar amount per employee per month. What is this called as –

a. Risk-sharing option

b. Capitation

c. Per member per month plan

d. None - –Answer : Option b

88).Specialty services does not include (option: 1. Home healthcare, chiropractic, Hospital ,
none of the above)A: Hospital

89). A large majority of Americans have dental coverage have in dental plan....

Options: varies from state to state b) 50% c)>50% d) 0.5

A: >50%

90) Comprehensive carve-out arrangement is what type of model.......

Options: 1.capitation basis 2. Fee for service 3.Copayment

A: Capitation Basis

91).In DHMO, Members pay a small portion of costs by making --------

Options: co-payments/coinsurance/deductibles/Yearly Maximums

A: Co-payments
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94).In which cases card is not used – a. prior authorization b. Receive PBM Benefits c.
Claim electronic prescription d. none –

Answer : Option a

95).PBM pays a fixed dollar amount per employee per month. What is this called as – a.
Risk-sharing option b. Capitation c. Per member per month plan d. None - –

Answer : Option b

96)Feel good healthcare MCO uses the following outcomes measures to evaluate the quality
of the hypertension management program
MEASURE A-Ability of long term hypertensive patients to move around and perform
domestic tasks without assistance.
MEASURE B- Incidence of kidney disease as a complication of hypertension in long-term
hypertensive patients.
From the following answer choices,select the response that correctly identifies the type of
healthcare outcome addressed by each measure.
Answers:
a)Measure A-clinical status
Measure B-functional status
b) Measure A-patient perception
Measure B-clinical status
c) Measure A-functional status
Measure B- patient perception
d) Measure A-functional status
Measure B- clinical status

97) The lifeline healthcare corporation seeks to manage its quality among the best
practices and the outcomes for a given procedure. Lifeline can then determine the areas in
which it can emulate the best practices or surpass the best outcomes. This information
indicated that the Lifeline uses a method of quality management called:
a)quality assesment
b)provider pricing
c)peer review
d)benchmarking

98) Comprehensive carve-out arrangement is what type of model.......

Options: 1.capitation basis 2. Fee for service 3.Copayment

99)The Meadows MCO uses a group’s past experience to estimate the experience for the
next period .what is this type of rating referred to?
a)Prospective experience rating
b) blended rating
c) Retrospective experience rating
d) Manual rating.
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100) Medicare is a federal government program established National security act of 1965
to provide hospital, medical and other covered benefits to elderly and disabled persons.
Medicare is available for:

a) Low income individuals

b) Persons with end stage renal disease (ESRD)
c) Persons age 63 or older
d) Persons with qualifying disabilities (over the age of 63)

101) 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 involved in patient care at the site of care. The type of information system that
Courtland uses to maintain patient information is best described as
A. a data warehouse

B. a decision support system

C. an outsourcing system

D. an electronic medical record (EMR) system-Answer

102) the following statements are about health information networks (HINs). Three of the
statements are true and one statement is false. Select the answer choice containing the
FALSE statement.

Most HINs are built on proprietary computer networks rather than being Internet-
A.
based.-Answer

While a HIN is for the exclusive use of one organization, a community health information
B.
network (CHIN) is shared by several organizations.

A health plan can use a secured extranet design or a distributed database approach for
C.
its HIN.

HINs have the potential to increase the quality of medical care because they make a
D.
patient's medical history readily available to each provider at the point of service.

103) The Advantage Health Plan recently added the following features to its member
services program:
1. IVR
2. Active member outreach program
Advantage's member services staffing needs are likely to increase as a result of
A. 1
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B. 2

C. 1 & 2

D. Neither 1 nor 2

104) the following statements describe individuals who are applying for individual health
insurance coverage:
 Six months ago, Wilbur Lee lost his health insurance coverage due to a reduction in work
hours and has exhausted his coverage under COBRA. Mr. Lee has been treated for asthma
for the last 20 years.
 Ronald Beeker changed jobs last month. Although Mr. Beeker was covered under a group
health insurance plan with his previous employer for many years, his current employer
offers no health insurance coverage. Mr. Beeker has no known health problems.
Under Title I of the Health Insurance Portability and Accountability Act (HIPAA) of 1996,
individual health insurance coverage would be obtainable, without a medical examination
and without regard to pre-existing conditions, by

A. both Mr. Lee and Mr. Beeker-Answer

B. Mr. Lee only

C. Mr. Beeker only

D. neither Mr. Lee nor Mr. Beeker

105). TheMilitary Health System of the Department of Defense offers ongoing healthcare
coverage to military personnel and their families through the

A. Health Care Quality Improvement Program (HCQIP)

B. Health Plan Management System (HPMS)

C. TRICARE healthcare system

D. Health Care Prepayment Plan (HCPP)

106) Check the below options which is/are true for federal state laws

A. encourage curve-out facilities

B. they address the curve out facilities
C. varies from state to state
D. they do not encourage..

my answer: c and d
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107) what is the suitable phras for "to address specific management concerns and
typically disbanded once the issue has been resolved"Ans)Ad hoc committees (or special
committees)
108) consolidation means... all options seems to be very similar -->
Answer :the providers may combine to form a new organization, with all the original
companies being dissolved

109) encryption(secret code is embedded)

110)Health plan sees that a particular hospital has higher rates of cancer survivors and
uses it. This is Benchmarking.

111)One gynecologist is doing a test more number of times than others. This is Provider
profiling.

112)Andy is assigned to a coordinator who manages, monitors and coordinates his health
condition. This is called Case Management.

113) Case management consists of high risk, high cost and/or chronic disease

114) quality management consists of quality assessment and quality improvement.

116)Maria treatment is going on. Meanwhile review is going on if the treatment is

necessary. This is called concurrent utilization review.

115) panel of pediatricians assess one pediatrician. This is peer review.

116).The evaluation of the providers performance is reviewed in process is termed asPeer

Review

117)Patient has chest pain but do not need immediate attention and is put on monitoring.
This is observation care unit.

118)which is fastest and less labor intensive data transmittal.(electronic transmittal)

119)why do we use clinical practice guidelines. (not sure of answer)

To reduce ineffective and unnecessary variation in treatment

120)which of following about NCQA is true(not sure of answer)

a)it has to achieve 5 levels of accreditation.

b)it has numeric rating.

c)health plan is either NCQA or not.

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121) no of pcp’s a health plan has-structure measures.

122) No of medical check up’s done in past two years-process measures.

123) After 5 years 80% of Cancer Patients are alive. This is known asProcess Measures
124)Can all services subject to UR(neither possible not desirable)

125)CEO of a stockholder corporation lost all his money in gambling.

Ans. Investors in the comapny will not be concerned at all by this incident becuase
corporation is seperate entity.

Investors in the comapny will not be concerned at all by this incident becuase corporation
continue exist beyond their owners (both of the options are correct).

126)What kind of comitee is formed to deal the sepcific management issue?

Ans: Special Commitee

127)Medicare Advantage requires what kind director operation?

Ans. Corporate Compliance Director.

128)Order in the most integrated to least integrated: (GPWW, CMG and PPM)

Ans. CMG, PPM, GPWW

130)In a market with little health plan activity, consumers and purchasers are likely to be
more receptive to loosely managed plans (such as PPOs) than to tightly managed plans
(HMOs).

Ans. True.

131)One question was that what are the parameters health plans will consider while
starting up their business:

options are: employer size, number of providers, geographic location.

Ans. all of the above.

132)EDI and e-commerce definition. Out of this only EDI definition is true...
133) Mark incurs 1500 on treatment. Deductible is 500 and coinsurance is 20%. How much
the health plan will pay and how much Marc pays. Ans: Health Plan - $800, Marc - $700
134)encrypton definition- answer has something like converting into secret code
135)Health Information Networks (HINs) - Choose the answer which is wrong about HIN
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138)Another question came with a case study with some options such as:
1. A high level of operational integration is always accompanied by a high level of structural
integration.
2. A high level of structural integration is always accompanied by a high level of
operational integration.
Ans. option 2

140)which of the following is/are not associated with the operational

management(practice management and administration management) that physician
outsource:
a) PPM b) GPWW c) Consolidated medical groups d) MHO (not sure)

141). Company X terminate contract "without cause" with the provider Y then what step
should be taken provider Y

142) provider X and Provider Y is providing services in same area and they are facing un
satisfaction from the patients
what type of provider integration model________ you advise them with the integration of
_________ operations
that the providers can perform ___________ operations at their own facility

143) Advantages of PHO model(physician - Hospital model)

145) Which of the following administers the plan’s formulary and regularly reviews
clinical trial reports, drug utilization reports, current and proposed therapeutic
guidelines, and economic data on drugs.
AnsPharmacy and Therapeutics Committee

146)The primary purpose of PHOs can be best described as

Contracting with Health Plans and Marketing

147)Lan& Lard (these key words are used in the question for type of integrations and 3
blanks were there to provide 3 answers)
Clinical Integration, MSO, Business Integration

148) The Health Plans which uses the credentialing based on the existing credentialing
standards done by third party. What type of process is called?
A. Primary Source Verification (right Answer),
B. Primary Physician Verification,
C. Primary Practitioner Verification

149) More Integrated to Less IntegratedCMG, PPM, GPWW

150)Company X wants to terminate ……..(Archer & Arts - look for these two key words and
also look for termination “without clause” key word)
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Archer wants to end his business and Arts has been provided with 90 days of time and she
can’t invoke “Cure of Provision”

151) For Health Plan to get a federally qualified, it must haveCorporate Compliance
Director

152) Administers the plan’s formulary and regularly reviews clinical trial reports, drug
utilization reports, current and proposed therapeutic guidelines.
Pharmacy and Therapeutics Committee

153) Suitable phrase for "permanent and serve as long-term advisory bodies on ongoing
issues such as financial management, compliance, quality management, utilization
management, strategic planning, and compensation"
Standing committees

144) Advisory bodies on ongoing issues such as financial management, compliance..etc,

which one related to this -> Ans: standing committee

154) A question with the below two options.

 A high level of operational integration MAY NOT BE ALWAYS accompanied by a high
level of structural integration.
 A high level of structural integration WILL NOT BE accompanied by a high level of
operational integration.Both are TRUE

155)The evaluation of the providers performance is reviewed in process is termed as

Peer Review
156) Question on Antitrust Violations - which option is not correct (Anti-selection)

157) What is the medicare plan which involves PPO – Medicare Select

158) Medicare Advantange is - an alternative to original Medicare

159) FEHB covers which options -- like HMO and PPO or only HMO.
160) Receivership - is a situation in which the commissioner, acting for a state court,
takes control of and administers an HMO’s assets and liabilities.
161) National Association of Insurance Commissioners (NAIC) handles -Insolvency
162) qustion on Individual Coverage Provisions - Answers having words "guaranteed
individual issue"
163)which of the following are true about CPT.(all the listed options are correct)

164) Phillip Tsai is insured by both a traditional indemnity health insurance plan, which is
hisprimary plan, and a health plan, which is his secondary plan. Both plans have typical
coordination of benefits (COB) provisions, but neither has a non-duplication of benefits
provision. Mr. Tsai incurred $1,000 of medical expenses from a specialist and assigned
benefits to the specialist, who filed claims with both plans. The traditional plan paid a
16

total benefit amount of $600 and notified the health plan of this payment. The health plan
determined that, if it had been Mr. Tsai's primary plan, it would have paid a benefit
amount of $900. According to the COB provision, the total amount that the health plan
owed on these medical expenses was (400 $)

165) weighted value to each medical procedure or service and multiplies the weighted
value by a money multiplier.( relative value scale (RVS))

166) HMO Act hampered the competitive position ofHMOs

167)A person visits a doctor 3 times in a year. It is estimated that $40 is the cost of each
visit. How much capitation will a health plan pay for that person per month.

168)An HMO Act of 1973, ----------Ans: Establish a process for to become federally
qualified.
169) To Maintain the provider network , HMO consider the following.
Answer: Access, Credentialing and Contractual relationships.
170) Member utilization follows -------- Answer: Referral Management

171) some types of flexible benefit plans (also called cafeteria plans) allow group members
to choose the types of benefits and coverage amounts they desire from a specified “menu”
of benefit options.

171)HMO contracts with more than one group practice of physicians or specialty groups. A
network model HMO is in effect an extension of a group model HMO in that the network
model HMO contracts with multiple group practices, rather than one group practice.-
network model

173)seth is a ceo of company of 100 members.Matt is ceo of company of 8 members.Whose

premium will be more.
(no of employees and premiums are inversely related. So matt’s premium is more)

174)Health plan sees that a particular hospital has higher rates of cancer survivors and
uses it.Benchmarking

175) One gynecologist refers the reports of another gynecologist…….

This is Provider profiling.

176)Andy is assigned to a coordinator who manages, monitors and coordinates his health
condition.This is called Case Management.
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177) Case Management Consists ofhigh risk, high cost and/or chronic disease

178)UR main purpose is to?To provide the Quality of the health plan

179) Panel of pediatricians assess one pediatrician.This is peer review.

180) Which of the following is more controversial among providers.Provider Profiling

181)Patient has chest pain but do not need immediate attention and is put on monitoring.
Observation care unit.

182)Which is fastest way of intensive data transmittal.Electronic

183)Can all services subject to URNeither Possible nor Desirable

184) which of the following statements is true

Structure and Process measures results in Outcome measures

185) Dis-advantage of Structure Measures

The research shows it cannot be directly linked to outcomes

186) After 5 years 80% of Cancer Patients are alive. This is known asProcess Measures
186.1). ____________defines the number of provides available in the health planStructure
Process

187) The main purpose of HEDIS isStudy the complete HEDIS section

188) Andy looks Around the internet and gets the outcome of different providers and she
make them available on his web-site.Web-based supporting tools

189) A diabetic patient is treated with PCP who refers industrial material to treat him.
What is it called.Clinical Practice Guidelines

190)MCO's Income statement includes ______________

Ans:-revenue and expense activity during a specified period

191)Balance sheet contains __________

Ans:-Assets,Liabilites and Capital

192)ABC health plan bears the responsibility of paying for all incurred covered benefits,
and administering the health plan.This comes under __________
a)Partly Funded Plan b)Fully Funded Plan c)Self Funded d)Self Insured
Ans:- (b)Fully Funded Plan

193)ABC Company pays insurance for all the employees. If the total claims amount is more
than10Million Dollars, then Insurance company pays. This is called
18

a)Specific Stop-loss b)Group Stop-loss c)Aggregate Stop-Loss d)Individual Stop-loss

194)Health plan charges same premium for all employees called ___________
a)Community Rating b)Mannual Rating c)Blended Rating d)Experience Rating
Ans:- (a)Community Rating

195)Antiselection is _____________________
a)More health care need, more health care coverage needed
b)Less health care need, more health care coverage needed
c)More health care use, more health care coverage needed
d)Less health use need, more health care coverage needed
Ans:- (b)Less health care need, more health care coverage needed

196)Factors for Antiselection include

a)Occupation and Health status b)Health status and Gender c)Age,Gender,HealthStatus and
Occupation d)Gender and Occupation
Ans:- (c)Age,Gender,HealthStatus and Occupation

197)SmallBussinesses look for the following while taking Health Plan

a)Service b)Quality c)Price d)NetworkAns:- (c)Price

198)A health plan uses a group’s past experience to estimate the group’s expected
experience for the next period. The group’s actual experience during the rating period is
different than expected, the health plan absorbs the gains or losses. This is called
a)Retrospective Experience Rating
b)Manual Rating
c)Adjusted Community Rating
d)Prospective Experience Rating
Ans:- (d)Prospective Experience Rating

199)Which of the following is the Market Research

a)Advertising b)Publicity c)Focussed Group
Ans:- (c)Focussed Group

200)Definitions of Autonomy and Beneficence..(Only two options about them are correct)

201)The role and functions of an ethics task force

Correct options are
i)to provide a forum for the discussion of ethical issues
ii)to generate and review policy statements related to ethics
iii)to provide case consultation

202)which of the following doesnot comes under AntiViolation

Ans)Antiselection

203)The following statements describe individuals who are applying for individual health
insurance coverage:
19

• Six months ago, Wilbur Lee lost his health insurance coverage due to a reduction in work
hours and has exhausted his coverage under COBRA. Mr. Lee has been treated for asthma
for the last 20 years.
• RonaldBeeker changed jobs last month. Although Mr. Beeker was covered under a group
health insurance plan with his previous employer for many years, his current employer
offers no health insurance coverage. Mr. Beeker has no known health problems.
Under Title I of the Health Insurance Portability and Accountability Act (HIPAA) of 1996,
individual health insurance coverage would be obtainable, without a medical examination
and without regard to pre-existing conditions, by
A. both Mr. Lee and Mr. Beeker
B. Mr. Lee only
C. Mr. Beeker only
D. neither Mr. Lee nor Mr. Beeker--------ANS-A

204)cobra act-----Ans-Following termination or reduction in hours, an employee, his

or her spouse, and dependent children can continue coverage for up to 18 months.

205)2 QUESTIONS on HMO MODEL ACT

i)Regarding inSolvency---3 options are correct...(you can read them in Document)
ii)Regarding Receivership--- is a situation in which the commissioner, acting for a state
court, takes control of and administers an HMO’s assets and liabilities

206)Question on Network adequacy----->Ans-State regulators determinenetwork

adequacy by examining the description of the HMO’s service area andthe list of network
providers’ names, addresses, and license numbers included inthe HMO’s COA application.

207)MedicareAdvantange is - an alternative to original Medicare

208)What is the medicare plan which involves PPO – Medicare Select

209)Question on Medicare Risk

Ans--Health plans that participated in Medicare risk contracts received a specified
geographically based capitation payment from CMS each month for each plan member,
regardless of the amount or cost of services the member actually received.

210)Question on Medigap
ans)If a person is not entitled to guaranteed issue, the insurer has the right to conduct
underwriting, decline to offer her coverage, or charge her a higher-than-standard premium.

211)Question on Funding to Medicaid and CHIP plans

212)Traditional Fee for Services Support---->Ans-Protected Physicians

213)Question on workers Compensation

Ans)Workers’ compensation is a state-mandated insurance program that provides benefits
20

tocover healthcare costs and lost earnings for employees who suffer a work-related injury
or illness.

214)Health Reform emphasizes on Medicare Advantage about---

My Ans)Drug Benefits(Not sure)

215)The main impact of health care reform in MA

a)Funding
b)Enrolling
c)Drug benifits
d)Plan design

216)
I)MR X is a provider who refer his patient to a diagnostic center where his spouce works
and her compansetion based on
no.of people she treated
II)MR X is a provider who is forcing patient to select the purchase of drugs
a) we can file case for both case (my choice but not sure)
b) we can file case for case I
c) we can file case for case II
d) we can not file case any of the those

217)A question related to HMO and POS and their corresponding laws (read the following
carefully)
State laws regulating other types of health plans are far less uniform than those governing
HMOs and PPAs. For instance,state statutes traditionally prohibited HMOs from offering
point-of-service (POS) products, but recent pressure fromconsumers has led to an
increasing number of state mandates requiring existing HMOs to offer a POS option.
In some statesan HMO can offer a POS product directly, but in others it can offer it only as
an indemnity wraparound policy—an out-of-plan product that a health plan offers through
an agreement with an insurance company. The introduction of POS products has
created a regulatory challenge for most states, because these products have features of
both HMOs and indemnity insuranceand as such they can be subject to either state HMO
laws or state insurance laws.

218)utilization review organizations (UROs). They can be in-house departments of health

plans or external entities.
A)TRUE (Ans)
B) False

219) which of the following com under health plan accountability

Ans)hold covered persons harmless against provider collections and provide
continued coverage for uncompleted treatment inthe event of plan insolvency

220)which of the following offer drug benefits

A)MA
21

B)PDP
c)Medigap
d)Ma and PDP(Ans)

221)under Medicare Part A a member into the hospital

A)has to pay copayment from the first day
B)has to pay high deductible before getting Medicare benifits
C)has to pay nothing before 60 datys of in patient hospitalization
D)has to pay deductible and copayment from the first day

222) a question on Premium Assistance

Instead of providing Medicaid and CHIP recipients with health coverage (either fee-for-
service or managed care), a statehas another option—premium assistance. Persons who
qualify for Medicaid or CHIP but who also have access to employer-sponsored health
insurance enroll in the employer plan, and the state pays the premium. (Often the premium
for familymembers not eligible for Medicaid or CHIP is also paid.)

223) A question on Autonomy and BeneficenceAutonomy. Health plans and their providers
must respect the right of plan members to make decisions about the course oftheir lives.
Beneficence (doing good). Health plans and their providers must promote the good of both
individual plan members and themembers as a group.

224) Medicare advantage is anAlternative to original medicare

225)Tricare is forMilitary personal

226)NAIC HMO MODEL ACT is vaired upon 2 section of areas

Financial responsibility and healthcare delivery

227)Medicare Part D and PDPS must provideMust provide a minimal level of benefits

228)Workers compensation has to cover

Both the healthcare costs and lost earnings for employees

229)JohnBersen ( look for this word)

i) Refers to the diagnostic center
ii) Influencing the patient to get the surgery
Both Options (Check the Answer)
230) ReceivershipState Commissioner takes control.....

231) The main impact of health care reforms in MAFunding

232) FEHB mainly consist of which type of plans

All variety plans ( please look for this options)
22

233) Medicare riskEach member must be paid irrespective of the servies provided

234)The PPA Act must Requires the below

A. clearly identify any differences in benefit levels for services of preferred providers and
non-preferred providers,
B. establish the amount and manner of payment to preferred providers
C. include mechanisms for minimizing the cost of the health plan,
D. provide plan members with reasonable access to covered services.
All the above options

235) Traditional Fee for Services SupportProtected physicians

236) What is the medicare plan which involves PPOMedicare Select

237)COBRA act-----Following termination or reduction in hours, an employee, his or

her spouse, and dependent children can continue coverage for up to 18 months

238) Which of the following doesn’t comes under Anti-ViolationAntiselection

239)NAIC Third-Party Administrator (TPA) Model Act. must doMust provide the plan
with an accounting of all transactions performed on behalf of the health plan

240) TPA termination mainly depends on

A. TPA is financially unsound
B. Using practices that are harmful to insured persons or the public
Both are right

241) Medicare part a the patient needs to do in the hospital :Need not pay any out of
pocket benefits until 60 days
242)One of the most influential pieces of legislation in the advancement of health plan
withinthe United States was the Health Maintenance Organization (HMO) Act of 1973. One
ofthe provisions of the Act was that it:
A. exempted HMOs from all state licensure requirements
B. required all employers that offered healthcare coverage to their employees to offer
only one type of federally qualified HMO
C. Celiminated funding that supported the planning and start-up phases of new HMOs
D. established a process by which HMOs could obtain federal qualification
243). The process of calculating the appropriate premium to charge purchasers,given the
degree of risk represented by the individual or group, the expectedcosts to deliver medical
services, and the expected marketability andcompetitiveness of the health plan's plan, is
generally known as

A. Financing
B. rating
C. underwriting
D. Budgeting
23

244). Janet Riva is covered by a traditional indemnity health insurance plan that specifies a
$250 deductible and includes a 20% coinsurance provision. When Ms. Riva was
hospitalized, she incurred $2,500 in medical expenses that were covered by her health
plan. She incurred no other medical expenses during the calendar year. In this situation,
the amount that the insurer was obligated to pay was:
A. $1,750
B. $1,800
C. $2,000
D. $2,250

245).Paul Gilbert has been covered by a group health plan for two years. He has been
undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began
a new job and immediately enrolled in his new company's group health plan, which has a
one-year pre-existing condition provision. According to the Health Insurance Portability
and Accountability Act (HIPAA) of 1996, the new health plan:
A. can exclude coverage for treatment of Mr. Gilbert's angina for one year, because
HIPAA does not impact a group health plan's pre-existing condition provision
B. can exclude coverage for treatment of Mr. Gilbert's angina for one year, because
Mr. Gilbert did not have at least 36 months of creditable coverage under his
previous health plan
C. can exclude coverage for treatment of Mr. Gilbert's angina for three months,
because that is the length of time he received treatment for this medical condition
prior to his enrollment in the new health plan
D. cannot exclude his angina as a pre-existing condition, because the one-
year preexisting condition provision is offset by at least one year of continuous
coverage under his previous health plan

246). Arthur Moyer is covered under his employer's group health plan, which must comply
withthe Consolidated Omnibus Budget Reconciliation Act (COBRA). Mr. Moyer is
terminatinghis employment. He has elected to continue his coverage under his employer's
grouphealth plan, and he will have no other health coverage after his termination. In this
situation, COBRA holds that Mr. Moyer can continue his coverage after his termination
for a maximum period of
A. 18 months, but his coverage under COBRA will cease if he obtains group health
coverage through another employer
B. 18 months, even if he obtains group health coverage through another employer
C. 36 months, but his coverage under COBRA will cease if he obtains group health
coverage through another employer
D. 36 months, even if he obtains group health coverage through another employer

247)The Mosaic health plan uses a typical electronic medical record (EMR) to document
themedical care its members receive. One characteristic of Mosaic's EMR is that it:
A. does not provide any clinical decision support for Mosaic's providers
B. is designed to supply information at the site of care
C. contains a Mosaic member's clinical data only
24

D. is organized by the type of treatment or by provider

248) The process that Mr. 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
A. coinsurance
B. plan funding
C. underwriting
D. pooling

249). The following statements are about accreditation in health plans. Select the answer
choice that contains the correct statement.
A. Accreditation is typically performed by a panel of physicians and administrators
employed by the health plan under evaluation.
B. All accrediting organizations use the same standards of accreditation.
C. Results of accreditation evaluations are provided only to state regulatory agencies and
are not made available to the general public.
D. Accreditation demonstrates to an health plan's external customers that the plan
meets established standards for quality care.

250).An employee must be allowed to continue the group health coverage for up to 18
months following termination under COBRA.(ans:18 months)

251).PPA’s who are self funded are not subject to which laws(ans: state insurance laws)

252).A health plan sees that under a group coverage there are equal no of young,norisk,old
and high risk people equally(ans: Justice and equity)

253).Instead of fee for service plans use capitation. It benifits in terms of(not sure of the
answer) all
a.High costs.
b.more control of health plans over reimbursement techniques.
c.

254). Individuals who do not enroll in Part B when they first become eligible can they
enroll later.
Ans: yes but in the form of a higher premium

255).Under what conditions a medigap can be rejected.(not sure of the answer—please

read medigap enrollment)

256).Premium assistance can be offered to(ans : both CHIP and Medicaid)

At a minimum, renewal underwriting involves a reevaluation of two factors: the group’s

experience and the level of participation in the health plan.
25

The process of identifying and classifying the risk represented by an individual or group is
calledunderwriting.

quality management (QM).An organization-wide process of measuring and improving

thequality of the healthcare provided by a health plan.

Utilization management (UM).Managing the use of medical services to ensure that a

patientreceives necessary, appropriate, high-quality care in a cost-effective manner.

carve-out. The separation of a medical service (or a group of services) from the basic set of
benefits in some way.

1. Premium assistance can be offered to(ans : both CHIP and Medicaid)

2.Individuals who do not enroll in Part B when they first become eligible can they enroll
later. Ans: yes but in the form of a higher premium

3.A health plan sees that under a group coverage there are equal no of young,norisk,old and
high risk people equally(ans: Justice and equity)
4.PPA’s who are self funded are not subject to which laws(ans: state insurance laws)
5.An employee must be allowed to continue the group health coverage for up to 18
months following termination under COBRA.(ans:18 months)
6.Instead of fee for service plans use capitation. It benifits in terms of (not sure of the
answer)all a.High costs.b.more control of health plans over reimbursement techniques.
7.An employee must be allowed to continue the group health coverage for up to 18
months following termination under COBRA.(ans:18 months)
8.Medicare part a the patient needs to do in the hospital: Need not pay any out of pocket
benefits until 60 days
9. Health Maintenance Organization (HMO) Act of 1973: established a process by which
HMOs could obtain federal qualification
10.According to the Health Insurance Portabilityand Accountability Act (HIPAA) of 1996,
the new health plan: Cannot exclude his angina as a pre-existing condition, because
the one-year preexisting condition provision is offset by at least one year of
continuous coverage under his previous health plan
10. Medicare part A the patient needs to do in the hospital: Need not pay any out of
pocket benefits until 60 days
11.TPA termination mainly depends on
a. TPA is financially unsound
b. Using practices that are harmful to insured persons or the public Both are right
12.NAIC Third-Party Administrator (TPA) Model Act. must doMust provide the plan with
an accounting of all transactions performed on behalf of the health plan
13.Which of the following doesn’t comes under Anti-ViolationAntiselection
14.COBRA act-----Following termination or reduction in hours, an employee, his or
her spouse, and dependent children can continue coverage for up to 18 months
15.What is the medicare plan which involves PPOMedicare Select
26

16.Traditional Fee for Services SupportProtected physicians

17.The PPA Act must Requires the below
E. clearly identify any differences in benefit levels for services of preferred providers and
non-preferred providers,
F. establish the amount and manner of payment to preferred providers
G. include mechanisms for minimizing the cost of the health plan,
H. provide plan members with reasonable access to covered services.
All the above options
18.Medicare riskEach member must be paid irrespective of the servies provided
19.The main impact of health care reforms in MAFunding
20.ReceivershipState Commissioner takes control.....
21.Workers compensation has to cover :Both the healthcare costs and lost earnings for
employees
22.Medicare Part D and PDPS must provideMustprovide a minimal level of benefits
23.NAIC HMO MODEL ACT is vaired upon 2 section of areasFinancial responsibility and
healthcare delivery
24.Medicare advantage is anAlternative to original medicare
25.Tricare is forMilitary personal
26.Medicare advantage is anAlternative to original medicare
27.which of the following offer drug benefits
A)MAB)PDPc)Medigapd)Ma and PDP(Ans)
28.Health Reform emphasizes on Medicare Advantage about---Ans)Drug Benefits
28.which of the following com under health plan accountability : hold covered persons
harmless against provider collections and provide continued coverage for
uncompleted treatment inthe event of plan insolvency
29.The main impact of health care reform in MA
a)Fundingb)Enrollingc)Drug benefits d)Plan design
30.Question on workers Compensation :Workers’ compensation is a state-mandated
insurance program that provides benefits tocover healthcare costs and lost earnings for
employees who suffer a work-related injury or illness
31.Traditional Fee for Services Support---->Ans-Protected Physicians
32.Question on Medigap : if a person is not entitled to guaranteed issue, the insurer has
the right to conduct underwriting, decline to offer her coverage, or charge her a higher-
than-standard premium.
33.Question on Medicare Risk :Health plans that participated in Medicare risk contracts
received a specified geographically based capitation payment from CMS each month for
each plan member, regardless of the amount or cost of services the member actually
received.
34.What is the medicare plan which involves PPO – Medicare Select
35.Medicare Advantange is - an alternative to original Medicare
36.which of the following doesnot comes under AntiViolation : Antiselection
37.Factors for Antiselectioninclude :c)Age,Gender,HealthStatus and Occupation
38.Antiselectionis :Less health care need, more health care coverage needed
39.which of the following statements is true : Structure and Process measures results in
Outcome measures
27

40.Dis-advantage of Structure Measures :The research shows it cannot be directly

linked to outcomes
41.After 5 years 80% of Cancer Patients are alive. This is known asProcess Measures
42.____________defines the number of provides available in the health planStructure
Process
43.HMO Act hampered the competitive position ofHMOs
44.National Association of Insurance Commissioners (NAIC) handles -Insolvency
45.Medicare Advantange is - an alternative to original Medicare
47.What is the medicare plan which involves PPO – Medicare Select
49) FEHB covers which options -- like HMO and PPO or only HMO.
50) Receivership - is a situation in which the commissioner, acting for a state court,
takes control of and administers an HMO’s assets and liabilities.
51) National Association of Insurance Commissioners (NAIC) handles -Insolvency
52) Question on Individual Coverage Provisions - Answers having words "guaranteed
individual issue"
53)More Integrated to Less Integrated CMG, PPM, GPWW
54)The primary purpose of PHOs can be best described as Contracting with Health Plans
and Marketing
55)Which of the following health plan now a days is getting declined: Primary Care
Providers assessed a member’s needs, gave her a referral to a behavioral health care
specialist
56)Which of the following increases the member plans head count: Off-Call hours of the
health plan

57)Group Representatives: Level Two Appeal Definition

58)The health plans are getting more costly because of – Increasing customer needs and
increase in the technology

1.Medicare part A the patient needs to do in the hospital: Need not pay any out of pocket
benefits until 60 days
2.Individuals who do not enroll in Part B when they first become eligible can they enroll
later. Ans: yes but in the form of a higher premium
3.Medicare Part D and PDPS must provideMust provide a minimal level of benefits

9. Health Maintenance Organization (HMO) Act of 1973: established a process by which

HMOs could obtain federal qualification
10.According to the Health Insurance Portabilityand Accountability Act (HIPAA) of 1996,
the new health plan: Cannot exclude his angina as a pre-existing condition, because
the one-year preexisting condition provision is offset by at least one year of
continuous coverage under his previous health plan
32.Question on Medigap : if a person is not entitled to guaranteed issue, the insurer has
the right to conduct underwriting, decline to offer her coverage, or charge her a higher-
than-standard premium.
33.Question on Medicare Risk :Health plans that participated in Medicare risk contracts
received a specified geographically based capitation payment from CMS each month for
28

each plan member, regardless of the amount or cost of services the member actually
received.
34.Receivership - is a situation in which the commissioner, acting for a state court,
takes control of and administers an HMO’s assets and liabilities.