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NEW QUESTION 1
One way in which health plans differ from traditional indemnity plans is that health plans typically
- A. provide less extensive benefits than those provided under traditional indemnity plans
- B. place a greater emphasis on preventive care than do traditional indemnity plans
- 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
- 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
Answer: B
NEW QUESTION 2
Which of the following population groups are eligible for Medicare coverage
- A. Individuals aged 65 & above, regardless of income & medical history
- B. Individuals suffering from end stage renal disease, regardless of age
- C. Individuals aged 50 or above suffering from qualifying disabilities
- D. Both A & B
Answer: D
NEW QUESTION 3
Utilization review offers health plans a means of managing costs by managing
- A. Cost effectiveness of healthcare services.
- B. Cost of paying healthcare benefits.
- C. Both of the above
Answer: C
NEW QUESTION 4
Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:
- A. State that D
- B. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges.
- C. 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.
- D. Give D
- E. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network.
- F. Specify that Badger can terminate this provider contract without providing a reason, but only if Badger gives D
- G. Aldridge at least 90-days' notice of its intent to terminate the contract.
Answer: C
NEW QUESTION 5
The following statement(s) can correctly be made about the Joint Commission on Accreditation of Healthcare Organizations (JCAHO):
- A. JCAHO's accreditation process for MCOs and healthcare networks consists of complete on-site surveys conducted every three
- B. A only
- C. Neither A nor B
- D. Both A and B
- E. B only
Answer: A
NEW QUESTION 6
When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO), the agreement between the two parties specified that the plan would be a typical fully funded plan. Because Knoll had been covered under a previous
- A. 230
- B. 270
- C. 220
- D. 180
Answer: C
NEW QUESTION 7
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing i
- A. Lower
- B. Higher
- C. Same
- D. No change
Answer: B
NEW QUESTION 8
Which of the following is NOT a reason for conducting utilization reviews?
- A. Improve the quality and cost effectiveness of patient care
- B. Reduce unnecessary practice variations
- C. Make appropriate authorization decisions
- D. Accommodate special requirements of inpatient care
Answer: D
NEW QUESTION 9
A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must
- A. Provide significant benefit to the community
- B. Employ, rather than contract with, participating physicians
- C. Achieve economies of scale through facility consolidation and practice management
- D. Refrain from the corporate practice of medicine
Answer: A
NEW QUESTION 10
The following statements apply to health reimbursement arrangements. Select the answer choice that contains the correct statement.
- A. Only employers are permitted to establish and fund HRAs.
- B. The popularity of HRAs waned following a 2002 ruling by U.
- C. Treasury Department regarding their treatment in the tax code.
- D. HRAs must be offered in conjunction with a high-deductible health plan.
- E. The guaranteed portability feature of HRAs has contributed to their popularity.
Answer: A
NEW QUESTION 11
Exclusive provider organizations (EPO) is similar and operates like a PPO in administration, structure but however in an EPO an out-of-network care is
- A. Partially Covered
- B. Covered with more out of pocket
- C. Not covered
Answer: C
NEW QUESTION 12
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.
Answer: D
NEW QUESTION 13
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
- 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.
- B. Health plans are never allowed to medically underwrite individual market customers who are under age 65.
- C. To promote a health plan product to the individual market, health plans typically use captive agents who give sales presentations to potential customers, rather than using promotion tools such as direct mail, telemarketing, or advertising.
- D. Health plans typically are allowed to medically underwrite all individual market customers who are covered by Medicare and can refuse to cover such customers.
Answer: A
NEW QUESTION 14
Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of benefits provision
- A. 380
- B. 130
- C. 550
Answer: A
NEW QUESTION 15
The Acme HMO recruits and contracts directly with a wide range of physicians—both PCPs and specialists—in its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The
- A. an independent practice association (IPA) model HMO
- B. a staff model HMO
- C. a direct contract model HMO
- D. a group model HMO
Answer: C
NEW QUESTION 16
Phillip Tsai is insured by both a indemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication of benefits p
- A. $0
- B. $300
- C. $400
- D. $900
Answer: C
NEW QUESTION 17
The following statements are about issues associated with marketing healthcare plans to
small groups and large groups. Select the answer choice that contains the correct statement.
- A. In the large group market, 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.
- B. Because providing healthcare coverage for employees is often a burden for small businesses, price is typically the most critical consideration for small businesses in selecting a healthcare plan.
- C. health plans typically treat an employer purchasing coalition as a small group for marketing purposes.
- D. Large groups rarely use self-funding to finance their healthcare plans.
Answer: B
NEW QUESTION 18
Which of the following is(are) CORRECT?
(A) Staff model HMOs can achieve maximum economies of scale but are heavily capital intensive.
(B) Staff model HMOs are closed panel.
(C) Staff model HMOs operate out of ambulatory care facilities.
- A. A & B
- B. None of the listed options
- C. B & C
- D. All of the listed options
Answer: D
NEW QUESTION 19
Which of the following features differentiates a 'Clinic without walls1 from a consolidated medical group?
- A. Unlike a consolidated medical group, physicians in a 'Clinic without walls' maintain their practices independently in multiple locations.
- B. Unlike a consolidated medical group, a 'Clinic without walls' performs or arranges for business operations for the member physicians.
- C. Both A & B
Answer: A
NEW QUESTION 20
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
- A. $525
- B. $1,050
- C. $2,100
- D. $5,250
Answer: B
NEW QUESTION 21
Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokers
- A. Are not required to be licensed by the states in which they market health plans
- B. Are compensated on a salary basis
- C. Represent only one health plan or insurer
- D. Are considered to be an agent of the buyer rather than an agent of the health plan or Insurer
Answer: D
NEW QUESTION 22
Marlee Whitcomb was covered as a dependent under the group health plan provided by her father's employer. That health plan complied with the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. When Ms. Whitcomb married, she c
- A. can continue her group coverage for a period not to exceed 48 months
- B. can continue her group coverage for a period not to exceed 36 months
- C. cannot continue her group coverage, but has the right to convert the group coverage to an individual health plan
- D. can continue her group coverage indefinitely
Answer: B
NEW QUESTION 23
Wellborne HMO provides health-related information to its plan members through an
Internet Web site. Laura Knight, a Wellborne plan member, visited Wellborne's Web site to gather uptodate information about the risks and benefits of various treatment option
- A. shared decision making
- B. self-care
- C. preventive care
- D. triage
Answer: A
NEW QUESTION 24
The Robust Health Plan sometimes uses prospective experience rating to calculate the premiums for a group. Under prospective experience rating, Robust most likely will:
- A. At the end of a rating period, the financial gains and losses experienced by the group during that rating period and, 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 ratio
- B. Use Robust's average experience with all groups to calculate this particular group's premium.
- C. Use the group's past experience to estimate the group's expected experience for the next period.
- D. All of the above
Answer: C
NEW QUESTION 25
One feature of the Employee Retirement Income Security Act (ERISA) is that it:
- A. Requires self-funded employee benefit plans to pay premium taxes at the state level.
- 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.
- C. Contains strict reporting and disclosure requirements for all employee benefit plans except health plans.
- D. Requires that state insurance laws apply to all employee benefit plans except insured plans.
Answer: B
NEW QUESTION 26
Health plans require utilization review for all services administered by its participating physicians.
- A. True
- B. False
Answer: B
NEW QUESTION 27
In accounting terminology, the items of value that a company owns—such as cash, cash equivalents, and receivables—are generally known as the company's
- A. revenue
- B. net income
- C. surplus
- D. assets
Answer: D
NEW QUESTION 28
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. In 1998, Ms. Martin became ill while she was on vacation,
- A. $300
- B. $510
- C. $600
- D. $810
Answer: D
NEW QUESTION 29
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