Ahm 250

Question 1 of 75
Which statement about trends in health plan products is correct?

More types of plans are being offered, and the distinctions between them are
becoming blurred.
Question 6 of 75
Compared to indemnity insurance, health plans typically have
less extensive benefit packages but lower out-of-pocket costs.
Question 7 of 75
Which of these will be permitted under the Affordable Care Act (ACA) (healthcare
reform)?
Premiums based on age.
Question 9 of 75
What is the measurement of how long it takes a health plan member services
representative to complete a transaction requested by a member?
Turn-around time.
Question 12 of 75
In a health plan, what is underwriting?
Identifying and evaluating risks presented by individuals and groups.
Question 18 of 75
1
Which communication channel between a health plan and its members is being used less
and less?
Regular mail.
Question 19 of 75
Who owns a mutual insurance company?
The companys policyholders.
Question 20 of 75
Which type of quality data presents the most problems?
Outcomes measures.
Question 25 of 75
Under ERISA, does the federal government regulate employer-sponsored health plans?
It regulates self-funded but not fully insured plans.
Question 27 of 75
A health plan pays a hospital a certain amount for a hospitalization, according to the
classification of the case based on diagnosis, procedures, and other factors. This describes
diagnosis-related groups (DRGs).
Question 28 of 75
In the marketing of health plans, who is compensated by the party buying a product, not
the health plan selling it?
Brokers.
Question 31 of 75
Do states regulate utilization review organizations (UROs) and third-party administrators
(TPAs)?
Most states regulate both to some extent.
Question 35 of 75
When a health plan compensates a provider by capitation, which generally occurs?
The provider submits encounter reports to the plan.
Question 37 of 75
Which of these is an example of adverse selection (anti-selection)?
An employer is engaged in a hazardous business, and its employees are more likely
than average to be injured or become ill.
Question 38 of 75
Primary care providers compensated by fee-for-service have an incentive to
refer patients to specialists.
Question 40 of 75
Each patient has a strong, ongoing relationship with a personal physician who is
responsible for providing or coordinating her care. This is the core principle of
a patient-centered medical home (PCMH).
Question 43 of 75
It is most difficult to develop a comprehensive network in
rural areas.
Question 45 of 75
What is the most secure and restrictive level of behavioral healthcare?
Acute care.
Question 46 of 75
Which statement is correct about a flexible spending account (FSA)?
An employee can contribute to an FSA, using pretax dollars
Question 49 of 75
The main goals of HIPAA do not include
requiring all employers to sponsor health coverage.
Question 50 of 75
Workers compensation is
coverage for work-related injuries and illnesses that states require employers to
provide to their employees.
Question 51 of 75
Which health plan types do not normally pay benefits for out-of-network care?
Traditional HMOs and EPOs.
Question 52 of 75
Which statement about raising capital is correct?
Stock companies find it easier than mutual companies, and for-profit plans find it
easier than not-for-profit plans.
Question 53 of 75
Who receives Medicare Part D prescription drug coverage?
All Medicare beneficiaries have the option of enrolling and paying an additional
premium.
Question 57 of 75
In which health plan type do members not have to select how to receive services until
they use them?
Point-of-service (POS) product.
Question 59 of 75
Who regulates HMOs?
Both the federal government and the states heavily regulate HMOs.
Question 60 of 75
A panel of cardiologists evaluates the care provided by another cardiologist in a particular
case. This is an example of
peer review.
Question 61 of 75
A certain percentage of the members of a health plan have received a cholesterol
screening. What kind of quality measure is this?
Process measure.
Question 64 of 75
For small businesses buying a health plan, what is usually the key factor?
Premium price.
Question 66 of 75
Which is a common HMO compensation arrangement for hospitals but not physicians?
Diagnosis-related groups (DRGs).
Question 68 of 75
NCQA provides accreditation for
many types of health plans.
Question 70 of 75
In which of these provider organizations do physicians normally not own and operate
their own practices?
Consolidated medical group.
Question 71 of 75
The majority of U.S. employees with health coverage are enrolled in
a PPO.
Question 72 of 75
A health plan has an obligation to respect the right of its members to make decisions
about their own lives. This is the
autonomy.
Question 73 of 75
A health plans utilization review staff want to know how long a certain member can be
expected to remain in the hospital. They are most likely to use
length-of-stay guidelines.
Question 1 of 75
Healthcare providers routinely give patients information about procedures or treatment
options so that they can make informed choices. Shared decision-making programs
take this a step further by providing members with in-depth information about diseases,
procedures, and treatment alternatives and encouraging them to actively participate in
healthcare decisions. Some plans call this value-based healthcare because the
members decisions are based on her own personal values as applied to her situation,
including her age, general health or quality of life, and perception of the effects of a
treatment (such as chemotherapy).
Robert is diagnosed with prostate cancer. There are several treatment options, each with advantages and
disadvantages. His doctor informs him about these and discusses them with him, but she lets Robert make
the final decision based on his values. This is an example of
shared decision-making.
Question 2 of 75
Which kind of healthcare service generally does not require prior authorization?
CONFIRMED
A frequently performed service.
Question 3 of 75
Community rating is seldom used for large groups, except where required by state law,
because other rating methods are more competitive. However, the premium rate
obtained by the community rating method is often calculated first as a point of reference
for calculating the premium rate under other rating methods. On the other hand, several
federal and state initiatives have mandated community rating methods for small groups.
Small groups benefit from community rating because they incur less fluctuation in
premium rates and more stable health plan contract relationships.
For what type of group is community rating least commonly used?
Large groups.
Question 4 of 75
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Risk pools are another way of giving providers an incentive to deliver care themselves
and to promote prevention and wellness so that the need for non-primary care does not
develop. For example, a plan pays monthly capitation payments to PCPs, and it also
pays monthly capitation payments into three pools, one for specialty care, one for
hospital care, and one for ancillary services. The money in the pools is used to cover the
costs of these services, but if members do not use many services and there is money
left over, some of it is distributed to the PCPs. On the other hand, if members need
many services and the money in the pools is insufficient, physicians may have to make
up part of the shortfall.
At the end of the year, if there is more than enough money in a pool to cover specialty care, a health plans
primary care providers (PCPs) receive some of the excess. If there is not enough money to cover costs, they
must make up some of the deficit. This is an example of
a risk pool.
Question 5 of 75
In an IPA model HMO, each participating physician contracts with the IPA, and the IPA
contracts with the HMO. The HMO pays the IPA, and the IPA pays its members. The
IPA agrees to provide healthcare services to HMO members, and the IPAs physicians
become part of the HMOs network, agreeing to adhere to the terms of the IPA-HMO
contract. But IPA physicians remain independent practitioners who manage their own
offices and medical records; they usually see other patients besides HMO members and
may contract with other health plans. An HMO may contract with more than one IPA,
and an IPA may contract with more than one health plan.
In which HMO model is each physician an independent practitioner with her own office?
IPA model.
Question 6 of 75
The federal government is a payor and purchaser of healthcare benefits. It provides
health benefits directly or through grants, and it operates programs that serve
populations such as the elderly and disabled (Medicare), low-income people (Medicaid),
federal employees (FEHB), and active and retired members of the uniformed services
and their dependents (TRICARE). The federal government also plays an important role
in healthcare by maintaining standards for Medicare healthcare providers, federally
qualified HMOs, and health plans for federal employees, as well as quality standards for
hospitals, clinical laboratories, and many other healthcare entities. Most federal
healthcare functions are under the Department of Health and Human Services (HHS),
which includes the Centers for Medicare and Medicaid Services (CMS).
What population is eligible for health coverage from TRICARE?
Active and retired members of the military and their spouses and dependents.
Question 7 of 75
Internal standards are developed by the health plan itself and are based on the
Internal standards are developed by the health plan itself and are based on the
organizations historic performance levels. Health plans generally use internal
standards to measure the quality of administrative services, such as customer
standards to measure the quality of administrative services, such as customer
service, claims processing, etc.
Internal quality standards for health plans are
developed by the health plan itself and usually apply to administrative services.
Question 8 of 75
ACA creates a new healthcare system based on the following elements:
Most people will be required to have health coverage or pay a tax penalty.
Which of these is a provision of the Affordable Care Act of 2010 (ACA) (healthcare reform)?
Most people will have to have health coverage or pay a tax penalty.
Question 9 of 75
Payment in full. Most contracts include a no balance billing provision, which
requires the provider to accept the amount that the plan pays for medical
services as payment in full and to agree not to bill the plan member for additional
amounts except for copayments, coninsurance, and deductibles. Most contracts
also include a hold harmless provision, which forbids providers from seeking
compensation from patients if the health plan fails to compensate them because
of insolvency or for any other reason.
A contract between a health plan and its network providers requires providers to accept the plans
compensation as payment in full and prohibits them from billing plan members for additional amounts. What
contract provision is this?
No balance billing provision
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Question 10 of 75
Insurers also began to take note of the correlation between behaviors such as smoking,
lack of exercise, and overeating and certain medical conditions. In response, they began
to establish wellness programs, which help pay for smoking cessation, fitness, weightloss, and similar programs. As with preventive care, wellness program are cost-effective
in the long term. For instance, it costs much less to help an insured pay for a weight-loss
program than to treat diabetes later.
FeelGood Health Plan has a program that educates and supports members who are trying to lose weight,
exercise more, and/or stop smoking. This is a
wellness program
Question 11 of 75
HMO 8% LEAST.
Which type of dental plan has the least choice of providers but generally costs the least?
HMO.
Question 12 of 75
The major threat to data security in a network is not a small number of external hackers
but internal security breaches by employees or others authorized to use the network.
The employee motivated by curiosity or malice, the careless employee who unwittingly
provides an unauthorized user with access to a password, and the employee poorly
trained in the use of a system remain the greatest threat to data security in any
information network. Role-based security within an organization is essential to minimize
such security breaches.
What is the most important threat to a health plans computer network?
The plans employees.
Question 13 of 75
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Ethics are the principles and values that guide the actions of an individual or a
population when faced with questions of right and wrong. Ethics are not the same as
laws (although both reflect the values of a community)laws are enforceable in our
court system, but ethics are not. Ethics are a concern of both individuals and
organizations.
What are ethics?
Principles and values that guide a person or organization facing questions of right and wrong.
Question 14 of 75
Community rating is a rating method that sets premiums for financing medical care
according to the health plans expected costs of providing medical benefits to the
community as a whole rather than to any subgroup within the community. Both low-risk
and high-risk classes are factored into community rating, which spreads the expected
medical care costs across the entire community. If claim costs exceed the premiums
received, the plan is financially responsible for the additional costs.
A health plan sets premium rates for a group based on the expected cost of providing healthcare benefits to
the whole community rather than to that group. This is
community rating
Question 15 of 75
Any physician who meets the standards of GoodLife HMO is eligible to join its network. GoodLife does not
pay benefits for out-of-network care. Members must get a referral from their primary care provider (PCP) to
see a specialist. GoodLife has
In an open-panel HMO, any physician who meets the HMOs standards is

eligible to join the HMOs network by contracting independently with it.
Closed access means that, to receive benefits, an HMO member must obtain
care from network providers, not out-of-network providers. Also, to receive care
from a specialist, even in-network, a member must obtain a referral from her
primary care physician (PCP).
an open panel and closed access.
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Question 16 of 75The HMO contracts with a single group practice. This describes
In a group model HMO (also called the group practice model), the HMO contracts with
a multi-specialty group practice of physicians. This group practice may be formed as a
corporation, partnership, professional association, or other legal entity. The physicians in
the group practice are employees of the group practice, and they may also have an
ownership interest in it. They generally share office space, support staff, medical
records, and medical equipment at a common medical center or clinic. While a multispecialty group practice includes PCPs and a variety of specialists, it may not have
specialists in every area, in which case it may subcontract with outside specialists to
provide some services to HMO members.
a group model HMO.
Question 17 of 75
Which statement about health plan claims processing is true?
Electronic claims processing systems perform routine and simple tasks, such as
verifying that an individual is a plan member or that a doctor is a network provider. And
most health plans also use such systems to make decisions that require more in-depth
analysis. A database containing member profiles, member benefit packages, provider
profiles, provider compensation arrangements, and other information is either integrated
with or part of an expert software system enabling the claims system to make higherlevel claims decisions. Such a system attempts to replicate the process an expert claims
examiner uses to solve a problem to arrive at the same decision that the expert would.
This process is commonly called auto-adjudication.
Electronic claims processing can handle only simple claim decisions.
Question 18 of 75
In 2007 health FSAs were available to about a third of all workers. But participation is not
highabout half of employees of large firms had access to them, but in 2008 only 22
percent participated.1 The limited popularity of FSAs is partly a result of design-related
restrictions on funding and use, including the following:
A survey of employers found that between 2 and 3 percent of workers covered by health
insurance were enrolled in an HRA between 2006 and 2009. 7 Although employees like
the rollover feature (when offered by their employer) and tax-free reimbursement, they
dislike that the fact that the account might not be portable if they change companies.
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How widespread are flexible spending accounts (FSAs) and health reimbursement arrangements (HRAs)?
Only a small minority of employees have either.
Question 19 of 75
Positioning is choosing a target market segment or niche for a product or organization
in relation to the other products or organizations in the marketplace. For example, a
health plan might offer a minimal benefit package at a low price to appeal to the small
group market. This plan would compete with similarly positioned plans, not with highquality, high-price plans. Or an organization might offer a wide range of health plan
products to compete in the large group market with organizations who do likewise.
A health plan decides to compete in the large group market instead of the small group market by offering a
variety of product lines. This is an example of
positioning
Question 20 of 75
Managed dental care accounts for
Managed dental care has grown, as more employers have sponsored dental benefits
and as those benefits have been increasingly provided by health plans. A large majority
(93 percent in 2008) of very large employers (500 or more employees) offer dental
coverage,2 and a majority (56.6 percent in 2007) of Americans have dental coverage. 3
And a large and growing majority of this coverage is managed care (see table).
a large majority of dental coverage and is growing.
Question 21 of 75
What happens when adverse selection occurs?
People more likely to need healthcare are more likely to obtain health coverage
Question 22 of 75
Under the Federal Employees Health Benefits (FEHB) program, employees
14
Federal employees can select from a large number of health plans offering a variety of
coverage types, benefit packages, and premiums amounts. In recent years more than
250 plans have participated in FEHB, although the number available to each employee
varies depending on where she lives. (While some plans operate nationally, others are
regional.) Plans include traditional fee-for-service insurance policies, PPOs, HMOs,
HMOs with a point-of-service (POS) feature, and high-deductible health plans.
choose from a large number of health plans and plan types.
Question 23 of 75
The perceptions of health plan members about the quality of the care they receive
While science and objective criteria take priority, consumer perceptions are also
important. They may reflect important aspects of care, such as a doctors communication
skills. And purchasers base their decisions about health plans in part on the perceptions
of the consumers they represent. Consequently, as we will see, while many quality
measures are based on scientific criteria, others reflect the perceptions of members.
should be considered because they reflect important aspects of healthcare not addressed by objective
measures.
Question 24 of 75
Provider compensation. Managed care generally seeks to replace fee-forservice compensation, which as we have seen gives healthcare providers
incentives to deliver more services than may be necessary. Health plans use
capitation and other compensation methods under which providers have
incentives to avoid excessive services. Health plans are also able to negotiate
lower payments to providers in exchange for supplying them with a large volume
of patients. In this course we will study in detail health plan compensation of
providers.
In traditional indemnity health insurance, how are healthcare providers paid by the insurer?
Capitation.
Question 25 of 75
What is the main purpose of the Childrens Health Insurance Program (CHIP)?
The Childrens Health Insurance Program (CHIP) is a federal-state program that pays
15
for healthcare for children from families not poor enough to qualify for Medicaid but too
poor to afford private-sector health coverage. As with Medicaid, the federal government
sets broad guidelines, and within those guidelines each state administers its own
program, establishes eligibility rules, and provides coverage. Also like Medicaid, CHIP is
jointly funded by the federal government and the states, but the federal government pays
a higher percentage of costs than for Medicaid.
To provide health coverage to children whose families cannot afford private-sector insurance but do not
qualify for Medicaid.
Question 26 of 75
Which of these is a feature of a health reimbursement arrangement (HRA)?
Health reimbursement arrangements (HRAs) were introduced by employers in 2000

(although they were not officially recognized as HRAs until 2002). The establishment
and funding of HRAs is limited exclusively to employers; self-employed individuals are
not eligible, and employees cannot make contributions. HRA funds may (at the option of
the employer) be rolled over from year to year tax-free, increasing their appeal. There is
some limited portability.
Only employer contributions.
Question 27 of 75
Which of these is a method used in market research?
To find out the answers to these questions, health plans use several marketing research
techniques including surveys, interviews, and focus groups. A focus group is a
structured but informal meeting of about six to ten people, led by a moderator who asks
questions to guide the group in an in-depth discussion of a given topic. Focus groups
give marketers insights into consumers opinions and attitudes.
Focus groups.
Question 28 of 75 doubt
Most regulation of health plans
In the last module we discussed various federal laws that govern health plans in their
roles as business entities and as participants in the delivery and financing of healthcare.
16
But the bulk of health plan regulation exists at the state level, and although the new
federal Affordable Care Act (ACA) will have an enormous impact on health plans, the
states will continue to take the leading role in regulating them. Moreover, as the
provisions of ACA go into effect in the coming years, states will be taking regulatory and
administrative actions to implement elements of the Act and address issues and
problems that arise in relation to it.
has been and continues to be at the state level.
Question 29 of 75
For which of these healthcare services is precertification (prior authorization) most likely to be required?
Precertification is normally required for a hospital admission and for some outpatient
services such as complex diagnostic tests. In some plans a PCP must obtain an
authorization to refer a member to a specialist for treatment.
A hospital admission.
Question 30 of 75
Which health plan types provide coverage of non-network care, but with higher cost-sharing?
Like an HMO, a PPO has a network, made up of its contracted providers. But
unlike a traditional HMO, a PPO does not cover only care received from network
providersmembers can go to outside of the network and still receive benefits.
However, members have strong incentives to use preferred (network) providers.
The benefit package for network care is typically richer than for non-network
carethat is, more procedures and services are covered. Also, members pay
more in cost-sharing when they go out of networkcopayments or coinsurance
is typically higher. And there may be a limit on a members out-of-pocket costs
for network care but no such limit for non-network care.
PPOs and POS products.
Question 31 of 75
17
A history of an individuals health and his encounters with the healthcare system that is owned by the
individual is
An electronic health record (EHR) is a provider-based history of care that compliments

the personal health record by adding detailed information created by providers and
facilities (such as X-ray images, physicians notes, and information on compliance with
statutory or regulatory requirements) that are part of the legal and permanent
institutional records of patient care.
The personal health record (PHR).
Question 32 of 75
Which statement best summarizes the use of the Internet by health plans?
While health plans have historically lagged behind other industries in providing a high
level of service online, many plans have enhanced or are now enhancing their websites
and are providing a variety of self-service functions to consumers, providers, employers
and brokers. They are expanding into e-commerce, enabling consumers to shop for their
healthcare coverage needs, price their options, and buy products online.
Health plans have historically lagged behind compared to other industries but now conduct many
transactions online.
Question 33 of 75
The percentage of stroke patients who are able to walk and speak normally after two years is
Outcomes measures gauge the extent to which services succeed in improving

or maintaining patient health. A plan might calculate the percentage of patients
with a certain condition who are still alive five years later.
an outcomes measure.
Question 34 of 75
Which is not a rule of federal mental health parity laws?
Cross checked the points: big para
18
All health plans must provide behavioral health coverage.
Question 35 of 75
Why is it important for a health plan to deal adequately with member complaints?
general question:
To comply with regulations and accreditation requirements and to maintain member satisfaction and a
good public image
Question 36 of 75
In which HMO model are physicians salaried employees working in HMO facilities?
In a staff model HMO, the physicians who care for members are employees of the
HMO, and usually the facilities in which they work are owned and operated by the HMO.
Generally, a staff model HMO employs all the PCPs and specialists required to meet
members needs, but some plans contract with some outside specialists, who provide
services to members referred to them by the plans PCPs. The HMO also owns or
contracts with hospitals, pharmacies, and other entities to provide non-physician
healthcare services.
Staff model.
Question 37 of 75
The government plays another important role in health plansit is a major purchaser of
health coverage, financing healthcare for millions of Americans through several
programs. In 1965 the Medicare program for the elderly and disabled and Medicaid for
the poor were established, followed in 1997 by the Childrens Health Insurance Program
(CHIP). And the federal and state governments have long sponsored health coverage for
millions of government employees and members of the military and their families.
Government health coverage programs have helped drive the growth of health plans by
increasingly turning to them as alternatives to traditional indemnity insurance. By 2010
approximately 11.1 million Medicare beneficiaries (24 percent) were enrolled in a
Medicare Advantage health plan, 1 and about 70 percent of Medicaid enrollees received
some or all of their healthcare through managed care. 2
Does Medicare cover all healthcare expenses?
19
Medicare has substantial cost-sharing payments, but it covers nearly all health-related expenses.
Question 38 of 75
The primary purpose of Medicare Advantage is to offer
The most significant changes made by ACA in the area of quality pertain to Medicare
Advantage. Medicare Advantage (MA) plans are Medicare-approved private-sector
health plans that provide Medicare coverage and some other benefits. Medicare
beneficiaries have the option of enrolling in an MA plan instead of traditional Medicare,
and many do (currently 24 percent3). (MA plans are described in more detail in a later
module.)
the option of receiving Medicare coverage through a private-sector health plan.
Question 39 of 75
What does the Affordable Care Act do with regard to healthcare quality?
The Affordable Care Act (healthcare reform) promotes healthcare quality improvement in
a number of ways. It creates a variety of demonstration projects addressing provider
compensation, information collection and analysis, and financial disclosure. It funds
research on the comparative effectiveness of various medical treatments. It includes
medical malpractice initiatives and makes changes to the Medicare and Medicaid
programs intended to improve quality.
It provides quality incentives for Medicare Advantages plans and includes a variety of other quality
improvement provisions.
Question 40 of 75
Normally, what does a health plans ethics task force do?
to provide case consultation to providers, patients, and their families facing

ethical questions or conflicts
It provides a forum for discussion of ethical issues, promotes ethics education, and offers consultation
in specific ethical decisions.
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Question 41 of 75
The two main components typical of a consumer-directed health plan (CDHP) are
an employer-sponsored high-deductible health plan and an individual supplemental

insurance policy.
Question 42 of 75
How do PPOs most commonly compensate physicians?
Discounted fees.
Question 43 of 75
What coverage do Medicare Advantage plans provide?
Medicare Part A and Part B coverage, other benefits, and usually drug benefits.
Question 44 of 75
Dan has multiple medical conditions. A nurse is assigned to him to assess his needs, design a plan of care,
and coordinate and monitor the services he receives. This describes
utilization review.
Question 45 of 75
Who can make a contribution to a health savings account (HSA)?
An employer, an employee, or a self-employed person.
Question 46 of 75
21
Under the principle of beneficence, health plans must promote the good of their
individual members and their membership as a whole.
Question 47 of 75
Which type of physician-hospital provider organization is the least integrated?
The medical foundation.
Question 48 of 75
Whether a health plan has an open panel or a closed panel depends on whether
providers can provide care to non-plan members.
Question 49 of 75
Which of these is not covered by any Medigap policy?
Dental, vision, and hearing services and products.
Question 50 of 75
The most common HMO model today is the
IPA model.
Question 51 of 75
22
Which type of health plan needs the fewest providers per 1,000 members?
Highly managed and large plans.
Question 52 of 75
To be eligible for a health savings account (HSA), what health coverage must a person have
A qualified HDHP only, not other broad health coverage or Medicare.
Question 53 of 75
What is the standard code set for medical treatments and procedures?
CPT.
Question 54 of 75
What is HEDIS?
A set of performance measures for use in comparing the quality of different health plans.
Question 55 of 75
In the health plan market, large employers
are often self-funded.
Question 56 of 75
To calculate how much to pay a physician for a procedure, a health plan assigns a numerical value to the
procedure and multiplies this number by a dollar figure negotiated with providers. This describes
a relative value scale (RVS).
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Question 57 of 75
Which is a common position in a health plan but is not common in other types of companies?
Chief medical officer.
Question 58 of 75
What is the main source of the cost-savings of consumer-directed health plans?
Consumers making cost-effective healthcare choices.
Question 59 of 75
By the 1990s HMOs had become accepted by consumers and employers, but many people objected to their
lack of provider choice.
Question 60 of 75
The Affordable Care Act (ACA) (healthcare reform) will make tax credits available to
employers to help them sponsor coverage but not to individuals.
Question 61 of 75
Government regulation has the greatest impact on which aspect of health plan data?
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Security and privacy.
Question 62 of 75
The primary focus of a disease management program is
populations of people who have or are at risk for certain diseases.
Question 63 of 75
After Sarah has been in treatment for a respiratory condition for a few months, her health plan conducts an
evaluation to make sure the services she is receiving are necessary, appropriate, and cost-effective. This is
an example of
utilization review.
Question 64 of 75
May one use funds from a health savings account (HSA) for non-medical purposes?
Yes, but you will have to pay income tax on the money.
Question 65 of 75
What kind of risk does an HMO assume or share?
Both financial and delivery risks.
Question 66 of 75
25
In the United States, indemnity health insurance
has historically represented a minority of health coverage but has steadily grown in popularity over the
past few decades.
Question 67 of 75
Under the Affordable Care Act (ACA) (healthcare reform), are employers required to sponsor health
coverage?
No, but all employers are offered tax credits to do so
Question 68 of 75
Deborah needs to care for her mother, who has a serious illness. Under the Family and Medical Leave Act
(FMLA),
she has the right to 12 weeks of unpaid leave, including health coverage.
Question 69 of 75
Every time Doug visits his primary care physician, he pays the doctor $10, regardless of the cost of services
provided. This describes
a copayment.
Question 70 of 75
Reese is not required to choose a dentist or network during an annual open enrollment. She can choose
when she needs care. But if she uses a non-network dentist, she pays a higher copayment. What type of
plan does she have?
PPO.
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Question 71 of 75
What category of low-income people are not currently covered by Medicaid but will be covered under
healthcare reform?
Childless adults.
Question 72 of 75
A health plan identifies another plan with high immunization rates among children and adopts its practices in
this area. This is an example of
benchmarking.
Question 73 of 75
What is the main function that an independent practice association handles for its member physicians?
Contracting with health plans.
Question 74 of 75
An HMO contracts with eight group practices. This is an example of
a group model HMO.
Question 75 of 75
Which of these healthcare services is not likely to be subject to concurrent utilization review?
A visit to a neurologist.
1)Which personal healthcare account offers annual rollover of funds, tax-free investment
growth, and full portability? - HSA
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2. In utilization review (UR), who has the authority to deny authorization of payment for a
service based on medical necessity and appropriateness? - A physician only.
4.A health plan has an obligation to respect the right of its members to make decisions about
their own lives. This is the ethical principal of - autonomy
5.The main goals of HIPAA do not include - requiring all employers to sponsor health coverage.
6) Which statement is true about how health plans communicate with their members? - IVR
12) May one use funds from a health savings account (HSA) for non-medical purposes? - Yes,
but you will have to pay income tax and (if under 65) a tax penalty.
17.A health plan decides to compete in the large group market instead of the small group
market by offering a variety of product lines. This is an example of - positioning
17) The HMO contracts with a single group practice. This describes - ipa
24) Which type of quality data presents the most problems? - Outcomes measures.
25) Which statement is correct about a flexible spending account (FSA)? - An employee can
contribute to an FSA, using pretax dollars.
25. Which statement about trends in health plan products is correct? - More types of plans are
being offered, and the distinctions between them are becoming blurred.
28) Which statement about health plan claims processing is true - A plan must process and
investigate claims within timeframes set by regulation.
29) Which of these healthcare services is not likely to be subject to concurrent utilization
review? - A visit to a neurologist
32. Which statement about raising capital is correct? - Stock companies find it easier than
mutual companies, and for-profit plans find it easier than not-for-profit plans.
41. What coverage do Medicare Advantage plans provide? - Medicare Part A and Part B
coverage, other benefits, and usually drug benefits.
42. Which HMO model has high facility costs but greatest control of care management and
quality? - Staff model.
45. Robert is diagnosed with prostate cancer. There are several treatment options, each with
advantages and disadvantages. His doctor informs him about these and discusses them with
him, but she lets Robert make the final decision based on his values. This is an example of Shared decision-making.
28
51) Does one have to pay a premium for Medicare? - Most people receive Medicare Part A
premium-free, but everyone pays a premium for Part B
56
55) For which of these healthcare services is precertification (prior authorization) most likely
to be required - A hospital admission.
56) What is the standard code set for medical treatments and procedures? - CPT.
59. In the marketing of health plans, who is compensated by the party buying a product, not
the health plan selling it? - Employee benefits consultants.
62) To calculate how much to pay a physician for a procedure, a health plan assigns a
numerical value to the procedure and multiplies this number by a dollar figure negotiated with
providers. This describes
- RVS
63) Which of these is a feature of a health reimbursement arrangement (HRA)? EMPLOYER CONTRIBUTION
ONLY
65. Which is not typical of managed care - Fee-for-service compensation

69) To be eligible for a health savings account (HSA), what health coverage must a person
have - A qualified HDHP only, not other broad health coverage or Medicare.
71.Which type of quality data presents the most problems? - Outcomes measures.
72.Government regulation has the greatest impact on which aspect of health plan data? security and privacy
73) What is HEDIS - A set of performance measures for use in comparing the quality of
different health plans.
75) FeelGood Health Plan has a program that educates and supports members who are trying
to lose weight, exercise more, and/or stop smoking. This is a - WELLNESS PROGRAM
5.Which of these is a method used in market research?

Database marketing.
Positioning.
Focus groups.
Branding.
ans : focus groups
6.Under the Affordable Care Act (ACA) (healthcare reform), are employers required to sponsor
health coverage?
No, but all employers are offered tax credits to do so.
29
No, but all employers must generally pay fees if they do not.
No, but large employers must generally pay fees if they do not.
Yes, all employers must sponsor coverage. ans: 3
7.A health plan identifies another plan with high immunization rates among children and
adopts its practices in this area. This is an example of
benchmarking.
clinical practice guidelines.
provider profiling.
peer review.
9.The primary purpose of states financial responsibility standards for HMOs is to protect
shareholders from mismanagement of their investment.
providers from not receiving fair compensation for their services.
the state from nonpayment of taxes and fees.
insureds from the possibility that the HMO may become insolvent. ans: 4
Question 17 of 75
POS.
HMO.
Indemnity.
PPO.
ans: HMO
Question 26 of 75
Reese is not required to choose a dentist or network during an annual open enrollment. She
can choose when she needs care. But if she uses a non-network dentist, she pays a higher
copayment. What type of plan does she have?
PPO.
Indemnity.
POS.
HMO.
ans: POS
29.Managed dental care accounts for
a large majority of dental coverage but is declining.
a minority of dental coverage but is growing.
about half of dental coverage and is stable.
ans: large majority and growing
34.Normally, what does a health plans ethics task force do?
It only provides a forum for discussion of ethical issues.
It provides a forum for discussion of ethical issues, promotes ethics education, and offers
consultation in specific ethical decisions.
30
It provides a forum for discussion of ethical issues, promotes ethics education, and routinely
makes specific ethical decisions.
It provides a forum for discussion of ethical issues and promotes ethics education, but it does
not involve itself in specific ethical decisions.
ans: offers consultation
Question 36 of 75
Active
Active
Active
Active
and retired members of the military.

members of the military only.
members of the military and their spouses and dependents.
and retired members of the military and their spouses and dependents.
ans: active, retired and dependants

Question 38 of 75
has always been and continues to be the predominant form of health coverage.
has historically represented a minority of health coverage but has steadily grown in popularity
over the past few decades.
has always and continues to represent a minority of health coverage.
used to be the predominant form of health coverage but no longer is.
ans: predominant but no longer it is
Question 43 of 75
What is the main function that an independent practice association handles for its member
physicians?
Billing and collecting.
Medical record keeping.
Claims processing.
Contracting with health plans. - ans
Question 46 of 75
What cost-sharing structure is most common in a dental PPO?
Copayments of $10 to $50, but no deductibles, coinsurance, or annual limits.
An annual maximum ranging from $1,000 to $2,500, but no deductible, coinsurance, or
copayments.
An annual deductible, coinsurance, and an annual maximum benefit. - ANS
Coinsurance ranging from 20 to 50 percent based on the service, but no deductibles or annual
maximums.
Question 49 of 75
a tax-advantaged personal healthcare account and enrollment in a health maintenance
organization.
an individual high-deductible health plan and an employer-sponsored catastrophic plan.
a high-deductible health plan and a tax-advantaged personal healthcare account. - ans
31
an employer-sponsored high-deductible health plan and an individual supplemental insurance

policy.
Question 53 of 75
prescription drug coverage to Medicare beneficiaries.
a supplement to Medicare that covers many Medicare cost-sharing payments.
a form of Medicare with a high premium but no deductibles, coinsurance, or copayments.
ans: option 1
Question 64 of 75
When is utilization review conducted?
Before treatment is provided.
Before, during, and/or after treatment. - ans
After treatment is provided.
During the course of treatment.
Question 67 of 75
Under the Affordable Care Act (ACA) (healthcare reform), which may a health plan not
consider in setting a persons premiums?
Locality.
Smoking.
Health.
Age.
ANS: HEALTH
Database marketing.
Positioning.
Focus groups.
Branding.
ans : focus groups
health coverage?
benchmarking. - ans
provider profiling.
32
peer review.
Question 17 of 75
POS.
HMO.
Indemnity.
PPO.
ans: HMO
Question 26 of 75
PPO.
Indemnity.
POS.
HMO.
ans: POS
Question 36 of 75
Active and retired members of the military.
33
Active members of the military only.

Active members of the military and their spouses and dependents.
Question 38 of 75
Question 43 of 75
physicians?
Claims processing.
Question 46 of 75
copayments.
maximums.
Question 49 of 75
organization.
policy.
Question 53 of 75
ans: option 1
34
Question 64 of 75
Question 67 of 75
Locality.
Smoking.
Health.
Age.
ANS: HEALTH
4)What kind of risk does an HMO assume or share?

Neither financial nor delivery risks.
Both financial and delivery risks. - ans
Delivery risks only, not financial risks.
Financial risks only, not delivery risks.
5)In utilization review (UR), who has the authority to deny authorization of payment for a
service based on medical necessity and appropriateness?
A
A
A
A
plan benefit specialist only.

clinical UR staffer (physician or nurse).
UR staffer, clinical or nonclinical.
physician only.
7)A contract between a health plan and its network providers requires providers to accept the
plans compensation as payment in full and prohibits them from billing plan members for
additional amounts. What contract provision is this?
Cure provision.
Hold harmless provision.- ans
Due process clause.
No balance billing provision.
35
10. A panel of cardiologists evaluates the care provided by another cardiologist in a particular
provider profiling.
benchmarking.
peer review.
7. A contract between a health plan and its network providers requires providers to accept the
Cure provision.
Hold harmless provision - ans
Due process clause.
provider profiling.
benchmarking.
peer review - ans
11. Primary care providers compensated by fee-for-service have an incentive to

provide unnecessary services.
not provide needed services.
promote prevention and wellness.
13. Which physician-only provider organization is the most integrated?
The
The
The
The
independent practice association (IPA).

consolidated medical group - ANS
management services organization (MSO).
group practice without walls (GPWW).
14. What category of low-income people are not currently covered by Medicaid but will be
covered under healthcare reform?
Elderly people.
Pregnant women.
Disabled people.
Childless adults. - ANS
36
15. At the end of the year, if there is more than enough money in a pool to cover specialty
care, a health plans primary care providers (PCPs) receive some of the excess. If there is not
enough money to cover costs, they must make up some of the deficit. This is an example of
pay for performance.
capitation.
a risk pool. - ans
a withhold.
protecting the privacy of healthcare information.
increasing the availability and continuity of healthcare.
requiring all employers to sponsor health coverage. - ANS
facilitating data exchange between healthcare entities.
Which of these will be permitted under the Affordable Care Act (ACA) (healthcare reform)?
Annual benefit limits.
Lifetime benefit limits.
Preexisting condition exclusions. - ans
There are a certain number of beds in a health plans affiliated hospitals. What kind of quality
measure is this?
Process measure.
Outcomes measure.
Administrative measure.
Structure measure. - ans
Brokers.
Brokers and employee benefits consultants - ANS
Employee benefits consultants.
Agents and brokers.
20. Which type of physician-hospital provider organization is the least integrated?

The physician-hospital organization (PHO) - ans
Accountable care organization (ACO).
The integrated delivery system (IDS).
37
21. The percentage of stroke patients who are able to walk and speak normally after two years
is
an outcomes measure. - ans
a perception measure.
a structure measure.
a process measure.
The
The
The
The
member
provider
provider
member
submits
submits
submits
submits
claims to the plan.

claims to the plan.
encounter reports to the plan. ans
encounter reports to the plan.
25 .
small employers to help them sponsor coverage and individuals to help them pay premiums
and cost-sharing. - ANS
individuals to help them pay premiums but not to employers.
all employers to help them sponsor coverage and individuals to help them pay premiums and
cost-sharing.
26.
are all enrolled in the PPO for their state or region.
choose from a large number of health plans and plan types. -ANS
choose from one HMO, one PPO, and one fee-for-service plan in their state or region.
are all enrolled in the same fee-for-service group plan.
29. For what type of group is community rating least commonly used?
Small groups.
Employer groups.
Medium-size groups.
Large groups. - ans
31. In the United States, indemnity health insurance

used to be the predominant form of health coverage but no longer is. - ANS
38
over the past few decades
32. Which statement is correct about a flexible spending account (FSA)?

An employee can contribute to an FSA, using pretax dollars. ANS
If an employee leaves, she receives a cash payment of her FSA balance.
To be eligible for an FSA, an employee must be covered by an HDHP.
Any money left in an employees account at the end of a year is rolled over to the following
year.
34. Which statement about the tax exemption of health plans is correct?
Plans are exempt from both income and premium taxes.
Plans are exempt from federal but not state taxes.
Some not-for-profit plans are tax-exempt but others are not - ANS
All not-for-profit plans are tax-exempt.
36.
Dan has multiple medical conditions. A nurse is assigned to him to assess his needs, design a
plan of care, and coordinate and monitor the services he receives. This describes
case management. - ANS
utilization review.
value-based healthcare.
disease management.
37. A computer program discovers that, based on repeated early refills, a plan member seems
to be taking more of a pain reliever than he should. This is an example of
drug utilization review. - ANS
formulary management.
prior authorization.
physician profiling.
62.
Outside hackers.
The plans members.
The plans employees.- ANS
The plans providers.
64.
39

Mutual companies find it easier than stock companies, and for-profit plans find it easier than
not-for-profit plans.
Stock companies find it easier than mutual companies, and not-for-profit plans find it easier
than for-profit plans.
Mutual companies find it easier than stock companies, and not-for-profit plans find it easier
Stock companies find it easier than mutual companies, and for-profit plans find it easier than
65.
are not a valid or reliable measure and should not be considered.
should be given priority over objective measures, as they affect the financial survival of the
plan.
may be considered only if they do not conflict with objective, scientific data. ans
should be considered because they reflect important aspects of healthcare not addressed by
objective measures.
67.
Consumers making cost-effective healthcare choices. - ans
Consumers receiving less healthcare.
Employers receiving favorable tax-treatment.
Employers shifting costs to consumers.
40. Which type of quality data presents the most problems?

Customer satisfaction measures.
Structure measures.
Outcomes measures.
Process measures.
42.
Volume.
Quality.
Usability.
40
44.
more extensive benefit packages and lower out-of-pocket costs.
less extensive benefit packages and higher out-of-pocket costs.
more extensive benefit packages but higher out-of-pocket costs.
45.
Only employer contributions. ans
Full portability.
Pretax employee contributions.
Investment growth of account funds.
46.
Each patient has a strong, ongoing relationship with a personal physician who is responsible
for providing or coordinating her care. This is the core principle of
an integrated delivery system.
a medical foundation.
an accountable care organization (ACO).
ANS
48. Typically, who submits encounter reports instead of claims to a health plan?
Healthcare professionals compensated by fee-for-service.
Healthcare professionals compensated by capitation - ANS
All hospitals and facilities but not healthcare professionals.
All healthcare professionals but not hospitals and facilities.
49.
How widespread are flexible spending accounts (FSAs) and health reimbursement
arrangements (HRAs)?
About half of employees have one or the other.
A majority of employees have one or the other.
Nearly all employees have one or the other.
51. For small businesses buying a health plan, what is usually the key factor?
Healthcare quality.
Customization.
Premium price - ANS
Employee satisfaction.
41
53.
healthcare providers only.
many types of health plans. - ANS
preferred provider organizations only
health maintenance organizations only.
54.
How does electronic data interchange (EDI) differ from e-business?
EDI does not require a standardized data format.
EDI is an internal operation, not a transaction between two organizations.
EDI is the transfer of batches of data, not back-and-forth exchanges of information about a
transaction - ANS
EDI requires considerable human involvement, for instance for data entry.
Medicare Part D
charges a premium and has substantial cost-sharing.
charges a premium but has only nominal cost-sharing.
does not charge a premium and has only nominal cost-sharing.
does not charge a premium but has substantial cost-sharing.
56.
All health plans will have to be structured like an HMO.
Medicare will be available to anyone 50 or older.
All employers will have to sponsor a health insurance plan.
57.
In health plans the term network adequacy is usually used to indicate whether
compensation amounts and methods are attractive to a large number of providers.
the number, types, and locations of providers are sufficient to meet member needs.
contract provisions, policies, and procedures comply with laws, regulations, and the standards
of accrediting organizations.
premiums and cost-sharing are sufficient for financial viability
42
provide unnecessary services. - ANS

Database marketing.
Positioning.
Focus groups.
Branding.
ans : focus groups
health coverage?
benchmarking. - ans
provider profiling.
peer review.
Question 17 of 75
POS.
HMO.
Indemnity.
PPO.
ans: HMO
Question 26 of 75
43
PPO.
Indemnity.
POS.
HMO.
ans: POS
Question 36 of 75
Active
Active
Active
Active
and retired members of the military.

members of the military only.
members of the military and their spouses and dependents.
and retired members of the military and their spouses and dependents.

Question 38 of 75
In the United States, health insurance
Question 43 of 75
physicians?
44
Claims processing.
Question 46 of 75
copayments.
maximums.
Question 49 of 75
organization.
policy.
Question 53 of 75
ans: option 1
Question 64 of 75
Question 67 of 75
Locality.
Smoking.
Health.
Age.
ANS: HEALTH
45

5)In utilization review (UR), who has the authority to deny authorization of payment for a
A
A
A
A
plan benefit specialist only.

clinical UR staffer (physician or nurse).
UR staffer, clinical or nonclinical.
physician only.
7)A contract between a health plan and its network providers requires providers to accept the
Cure provision.
Due process clause.
provider profiling.
benchmarking.
peer review.
7. A contract between a health plan and its network providers requires providers to accept the
Cure provision.
Due process clause.
provider profiling.
46

benchmarking.
peer review - ans

The
The
The
The
independent practice association (IPA).

consolidated medical group - ANS
management services organization (MSO).
group practice without walls (GPWW).
14. What category of low-income people are not currently covered by Medicaid but will be
covered under healthcare reform?
Elderly people.
Pregnant women.
Disabled people.
care, a health plans primary care providers (PCPs) receive some of the excess. If there is not
enough money to cover costs, they must make up some of the deficit. This is an example of
capitation.
a risk pool. - ans
a withhold.
Which of these will be permitted under the Affordable Care Act (ACA) (healthcare reform)?
47
There are a certain number of beds in a health plans affiliated hospitals. What kind of quality
measure is this?
Process measure.
Outcomes measure.
Brokers.
Agents and brokers.

21. The percentage of stroke patients who are able to walk and speak normally after two years
is
a process measure.
The
The
The
The
member
provider
provider
member
submits
submits
submits
submits
claims to the plan.

claims to the plan.
encounter reports to the plan. ans
encounter reports to the plan.
25 .
small employers to help them sponsor coverage and individuals to help them pay premiums
and cost-sharing. - ANS
48

all employers to help them sponsor coverage and individuals to help them pay premiums and
cost-sharing.
26.
Small groups.
Employer groups.
Medium-size groups.
Large groups. - ans

over the past few decades

Any money left in an employees account at the end of a year is rolled over to the following
year.
49
36.
Dan has multiple medical conditions. A nurse is assigned to him to assess his needs, design a
plan of care, and coordinate and monitor the services he receives. This describes
utilization review.
disease management.
37. A computer program discovers that, based on repeated early refills, a plan member seems
to be taking more of a pain reliever than he should. This is an example of
62.
Outside hackers.
The plans members.
64.
Mutual companies find it easier than stock companies, and for-profit plans find it easier than
Stock companies find it easier than mutual companies, and not-for-profit plans find it easier
Mutual companies find it easier than stock companies, and not-for-profit plans find it easier
Stock companies find it easier than mutual companies, and for-profit plans find it easier than
65.
should be given priority over objective measures, as they affect the financial survival of the
plan.
should be considered because they reflect important aspects of healthcare not addressed by
objective measures.
50
67.

Structure measures.
Outcomes measures.
Process measures.
42.
Volume.
Quality.
Usability.
44.
45.
Full portability.
46.
Each patient has a strong, ongoing relationship with a personal physician who is responsible
for providing or coordinating her care. This is the core principle of
51

ANS
49.
Healthcare quality.
Customization.
Premium price - ANS
53.
54.
EDI is the transfer of batches of data, not back-and-forth exchanges of information about a
transaction - ANS
Medicare Part D
52

56.
57.
contract provisions, policies, and procedures comply with laws, regulations, and the standards
of accrediting organizations.

Any physician who meets the standards of GoodLife HMO is eligible to join its network.
GoodLife does not pay benefits for out-of-network care. Members must get a referral from
their primary care provider (PCP) to see a specialist. GoodLife has
a closed panel
an open panel
a closed panel
an open panel
and closed access.

and open access.
and open access.
and closed access - ans
Who regulates HMOs?

Neither the federal government nor the states substantially regulate HMOs.
Both the federal government and the states heavily regulate HMOs - ans
HMOs are regulated by the states but not the federal government.
HMOs are regulated under the federal HMO Act but not state laws.
53
Deborah needs to care for her mother, who has a serious illness. Under the Family and Medical
Leave Act (FMLA),
she
she
she
she
has
has
has
has
the right to 12 weeks of paid leave, including health coverage - ans

the right to 12 weeks of unpaid leave, including health coverage.
no right to leave.
the right to 12 weeks of unpaid leave, not including health coverage.
Which utilization review data transmittal method is the fastest and least labor-intensive but
also the most highly regulated?
Electronic - ans
Manual.
Paper.
Telephone.
network model.
group model.
staff model.
IPA model - ans
What form does cost-sharing generally take in traditional indemnity health insurance?
An annual deductible and coinsurance - ans
An annual deductible and copayments.
Coinsurance, but no deductible or copayments.
An annual deductible, coinsurance, and copayments.
A contract between a health plan and its network providers requires providers to
accept the plans compensation as payment in full and prohibits them from billing
plan members for additional amounts. What contract provision is this?
Cure provision.
Hold harmless provision.
Due process clause.
The physician-hospital organization (PHO).

54

requiring all employers to sponsor health coverage.
There are a certain number of beds in a health plans affiliated hospitals. What
kind of quality measure is this?
Process measure.
Outcomes measure.
Structure measure.
21. The percentage of stroke patients who are able to walk and speak normally
after two years is
an outcomes measure.
a process measure.
25 .
The Affordable Care Act (ACA) (healthcare reform) will make tax credits available
to

small employers to help them sponsor coverage and individuals to help them pay
premiums and cost-sharing.
all employers to help them sponsor coverage and individuals to help them pay
premiums and cost-sharing.
55

Some not-for-profit plans are tax-exempt but others are not.
All not-for-profit plans are tax-exempt
65.

should be given priority over objective measures, as they affect the financial
survival of the plan.
may be considered only if they do not conflict with objective, scientific data.
should be considered because they reflect important aspects of healthcare not
addressed by objective measures.

Structure measures.
Outcomes measures.
Process measures.

Question 9 of 75
based on industry benchmarks and usually apply to healthcare services.
developed by the health plan itself and usually apply to administrative services.
developed by the health plan itself and usually apply to healthcare services.
based on industry benchmarks and usually apply to administrative services.
Question 2
56
In utilization review (UR), who has the authority to deny authorization of payment for a
A clinical UR staffer (physician or nurse).
A physician only.
A plan benefit specialist only.
A UR staffer, clinical or nonclinical.
Question 24 of 75
Do HMOs cover out-of-network services?
Traditionally they did, but almost all HMOs no longer do so.
No, this is a defining characteristic of HMOs.
Traditionally they did not, but some HMOs now do so at no extra cost to members.
Traditionally they did not, but some HMOs now do so at a higher cost to members.
Question 26 of 75
Turn-around time.
Call abandonment rate.
Wait time.
First contact resolution rate.
Question 28
Excelsior Health Plan gives its members information about how to treat minor illnesses
and injuries and how to distinguish them from serious medical conditions. This is
a self-care program.
disease management.
a wellness program.
Question 34 of 75
A health plan sets premium rates for a group based on the expected cost of providing
healthcare benefits to the whole community rather than to that group. This is
blended rating.
community rating.
57
experience rating.
manual rating.
Question 36 of 75
Which kind of healthcare service generally does not require prior authorization?
A high-risk service.
A high-cost service.
A frequently performed service.
A service with a high authorization denial rate.
Question 48 of 75
In which health plan type do members not have to select how to receive services until they
use them?
Consumer-directed health plan (CDHP).
Preferred provider organization (PPO).
Point-of-service (POS) product.
Health maintenance organization (HMO).
Question 51 of 75
What portion of participants in Medicaid and the Childrens Health Insurance Program
(CHIP) are in managed care?
A small minority.
About a third.
A large majority.
About half.
Question 58 of 75
Which health plan designs are in the middle of the managed care
continuum, between tightly managed and unmanaged?
PPOs, EPOs, and POS products.
Traditional HMOs.
Indemnity insurance and EPOs.
Traditional HMOs and PPOs.
Question 64 of 75
Every time Doug visits his primary care physician, he pays the doctor $10, regardless of
the cost of services provided. This describes
58
a copayment.
coinsurance.
a capitation fee.
a deductible.
Question 67 of 75
Health plans have been in the forefront compared to other industries and conduct a wide
range of transactions online.
Few health plan transactions are suitable for being conducted online, so plans have only a
small web presence.
Few health plan transactions are suitable for being conducted online, but plans do offer
information on their websites.
Health plans have historically lagged behind compared to other industries but now
conduct many transactions online.
Question 70 of 75
Under traditional indemnity health insurance, insureds can receive
healthcare
from any provider with prior approval from the insurer.
from any provider they choose, but they pay higher cost-sharing for
nonnetwork providers.
only from a provider affiliated with the insurers network.
from any provider they choose.
Question 70 of 75
Under traditional indemnity health insurance, insureds can receive healthcare
from any provider they choose, but they pay higher cost-sharing for nonnetwork
providers.
from any provider they choose.
Database marketing.
Positioning.
Focus groups.
Branding.
59
ans : focus groups

6.Under the Affordable Care Act (ACA) (healthcare reform), are employers required to
sponsor health coverage?
benchmarking. - ans
provider profiling.
peer review.
Question 17 of 75
POS.
HMO.
Indemnity.
PPO.
ans: HMO
Question 26 of 75
Reese is not required to choose a dentist or network during an annual open enrollment.
She can choose when she needs care. But if she uses a non-network dentist, she pays a
higher copayment. What type of plan does she have?
PPO.
60
Indemnity.
POS.
HMO.
ans: POS
It provides a forum for discussion of ethical issues, promotes ethics education, and
routinely makes specific ethical decisions.
It provides a forum for discussion of ethical issues and promotes ethics education, but it
does not involve itself in specific ethical decisions.
Question 36 of 75
Active and retired members of the military.
Active members of the military only.
Active members of the military and their spouses and dependents.
Question 38 of 75
has historically represented a minority of health coverage but has steadily grown in
popularity over the past few decades.
61

Question 43 of 75
What is the main function that an independent practice association handles for its
member physicians?
Claims processing.
Question 46 of 75
copayments.
Coinsurance ranging from 20 to 50 percent based on the service, but no deductibles or
annual maximums.
Question 49 of 75
organization.
insurance policy.
Question 53 of 75
ans: option 1
62
Question 64 of 75
Question 67 of 75
Locality.
Smoking.
Health.
Age.
ANS: HEALTH

5)In utilization review (UR), who has the authority to deny authorization of payment for
a service based on medical necessity and appropriateness?
A physician only.
63
7)A contract between a health plan and its network providers requires providers to accept
the plans compensation as payment in full and prohibits them from billing plan members
for additional amounts. What contract provision is this?
Cure provision.
Due process clause.
10. A panel of cardiologists evaluates the care provided by another cardiologist in a
particular case. This is an example of
provider profiling.
benchmarking.
peer review.
7. A contract between a health plan and its network providers requires providers to accept
Cure provision.
Due process clause.
10. A panel of cardiologists evaluates the care provided by another cardiologist in a

particular case. This is an example of
provider profiling.
benchmarking.
peer review - ans
64

The independent practice association (IPA).
The consolidated medical group - ANS
The management services organization (MSO).
The group practice without walls (GPWW).
14. What category of low-income people are not currently covered by Medicaid but will
be covered under healthcare reform?
Elderly people.
Pregnant women.
Disabled people.
care, a health plans primary care providers (PCPs) receive some of the excess. If there is
not enough money to cover costs, they must make up some of the deficit. This is an
example of
capitation.
a risk pool. - ans
a withhold.
Which of these will be permitted under the Affordable Care Act (ACA) (healthcare
reform)?
65

There are a certain number of beds in a health plans affiliated hospitals. What kind of
quality measure is this?
Process measure.
Outcomes measure.
19. In the marketing of health plans, who is compensated by the party buying a product,
not the health plan selling it?
Brokers.
Agents and brokers.

21. The percentage of stroke patients who are able to walk and speak normally after two
years is
66
a process measure.
The member submits claims to the plan.
The provider submits claims to the plan.
The provider submits encounter reports to the plan. ans
The member submits encounter reports to the plan.
25 .
premiums and cost-sharing. - ANS
all employers to help them sponsor coverage and individuals to help them pay premiums
and cost-sharing.
26.
Small groups.
Employer groups.
Medium-size groups.
Large groups. - ans
67

has historically represented a minority of health coverage but has steadily grown in
popularity over the past few decades

Any money left in an employees account at the end of a year is rolled over to the
following year.
36.
Dan has multiple medical conditions. A nurse is assigned to him to assess his needs,
design a plan of care, and coordinate and monitor the services he receives. This describes
utilization review.
disease management.
37. A computer program discovers that, based on repeated early refills, a plan member
seems to be taking more of a pain reliever than he should. This is an example of
68

62.
Outside hackers.
The plans members.
64.
Mutual companies find it easier than stock companies, and for-profit plans find it easier
than not-for-profit plans.
Stock companies find it easier than mutual companies, and not-for-profit plans find it
easier than for-profit plans.
Mutual companies find it easier than stock companies, and not-for-profit plans find it
easier than for-profit plans.
Stock companies find it easier than mutual companies, and for-profit plans find it easier
than not-for-profit plans.
65.
should be given priority over objective measures, as they affect the financial survival of
the plan.
should be considered because they reflect important aspects of healthcare not addressed
by objective measures.
69
67.

Structure measures.
Outcomes measures.
Process measures.
42.
Volume.
Quality.
Usability.
44.
45.
70

Full portability.
46.
Each patient has a strong, ongoing relationship with a personal physician who is
responsible for providing or coordinating her care. This is the core principle of
a patient-centered medical home (PCMH). ANS
49.
Healthcare quality.
Customization.
Premium price - ANS
71
53.
54.
EDI is the transfer of batches of data, not back-and-forth exchanges of information about
a transaction - ANS
Medicare Part D
56.
Which of these is a provision of the Affordable Care Act of 2010 (ACA) (healthcare
reform)?
72
57.
contract provisions, policies, and procedures comply with laws, regulations, and the
standards of accrediting organizations.

AHM-250
A contract between a health plan and its network providers requires providers to accept
Cure provision.
Hold harmless provision.---- Ans
Due process clause.
The physician-hospital organization (PHO).--- ans
requiring all employers to sponsor health coverage.--- ans
73

There are a certain number of beds in a health plans affiliated hospitals. What kind of
quality measure is this?
Process measure.
Outcomes measure.
Structure measure.---- ans
21. The percentage of stroke patients who are able to walk and speak normally after two
years is
an outcomes measure.---- ans
a process measure.
25 .
premiums and cost-sharing.--ans
and cost-sharing.
Some not-for-profit plans are tax-exempt but others are not. --- ans
All not-for-profit plans are tax-exempt
65.
should be given priority over objective measures, as they affect the financial survival of
the plan.
74
may be considered only if they do not conflict with objective, scientific data.--ans
should be considered because they reflect important aspects of healthcare not addressed
by objective measures.
Structure measures.
Outcomes measures.
Process measures.
more extensive benefit packages and lower out-of-pocket costs.-- ans
Question 9 of 75
based on industry benchmarks and usually apply to healthcare services.
developed by the health plan itself and usually apply to administrative services.-- ans
developed by the health plan itself and usually apply to healthcare services.
based on industry benchmarks and usually apply to administrative services.
Question 2
In utilization review (UR), who has the authority to deny authorization of payment for a
A physician only.--- ans
Question 24 of 75
Do HMOs cover out-of-network services?
Traditionally they did, but almost all HMOs no longer do so.
No, this is a defining characteristic of HMOs.
75
Traditionally they did not, but some HMOs now do so at no extra cost to members.
Traditionally they did not, but some HMOs now do so at a higher cost to members. ---ans
Question 26 of 75
Turn-around time.---- ans
Call abandonment rate.
Wait time.
First contact resolution rate.
Question 28
Excelsior Health Plan gives its members information about how to treat minor illnesses
and injuries and how to distinguish them from serious medical conditions. This is
a self-care program.--- ans
disease management.
a wellness program.
Question 34 of 75
A health plan sets premium rates for a group based on the expected cost of providing
healthcare benefits to the whole community rather than to that group. This is
blended rating.
community rating.---ans
experience rating.
manual rating.
Question 36 of 75
Which kind of healthcare service generally does not require prior auth
orization?
A high-risk service.
A high-cost service.
A frequently performed service.--- ans
A service with a high authorization denial rate.
Question 48 of 75
76
In which health plan type do members not have to select how to receive services until
they use them?
Consumer-directed health plan (CDHP).
Preferred provider organization (PPO).
Point-of-service (POS) product.---ans
Health maintenance organization (HMO).
Question 51 of 75
What portion of participants in Medicaid and the Childrens Health Insurance Program
(CHIP) are in managed care?
A small minority.
About a third.
A large majority.--- ans
About half.
Question 58 of 75
Which health plan designs are in the middle of the managed care continuum, between
tightly managed and unmanaged?
PPOs, EPOs, and POS products.--ans
Traditional HMOs.
Indemnity insurance and EPOs.
Traditional HMOs and PPOs.
Question 64 of 75
Every time Doug visits his primary care physician, he pays the doctor $10, regardless of
the cost of services provided. This describes
a copayment.-- ans
coinsurance.
a capitation fee.
a deductible.
Question 67 of 75
77
Health plans have been in the forefront compared to other industries and conduct a wide
range of transactions online.
Few health plan transactions are suitable for being conducted online, so plans have only a
small web presence.
Few health plan transactions are suitable for being conducted online, but plans do offer
information on their websites.
Health plans have historically lagged behind compared to other industries but now
conduct many transactions online. --ans
Question 70 of 75
Under traditional indemnity health insurance, insureds can receive healthcare
from any provider they choose, but they pay higher cost-sharing for nonnetwork
providers.
from any provider they choose. --- ans
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Question 4 of 75
In establishing and maintaining provider networks, health plans generally try to ensure
member access to care by
recruiting as many providers of all types as they can.
considering the number, type, and location of providers needed.---ans
imposing no barriers or disincentives on the use of out-of-network care.
accepting all providers who meet minimal standards.
Question 11 of 75
Which of these is not covered by any Medigap policy?
Medicare deductibles.
Medicare coinsurance and copayments.
Health care received outside the United States.
Dental, vision, and hearing services and products.---- ans
Question 15 of 75
Robert is diagnosed with prostate cancer. There are several treatment options, each with
advantages and disadvantages. His doctor informs him about these and discusses them
78
with him, but she lets Robert make the final decision based on his values. This is an
example of
a self-care program.
utilization review.
disease management.
shared decision-making. --- ans
Question 28 of 75
A plan must pay benefits for a medically necessary service even if authorization was not
obtained.
A plan must process and investigate claims within timeframes set by regulation.---ans
Electronic claims processing can handle only simple claim decisions.
A plan may not deny a claim because it was submitted too long after the service was
provided.
Question 46 of 75
Coinsurance ranging from 20 to 50 percent based on the service, but no deductibles or
annual maximums.
copayments.
An annual deductible, coinsurance, and an annual maximum benefit. --- ans
52 of 75
A panel of cardiologists evaluates the care provided by another cardiologist in a particular
peer review.--- ans
provider profiling.
benchmarking.
Question 55 of 75
For which of these healthcare services is precertification (prior authorization) most likely
to be required?
79
A hospital admission.--- ans

A routine laboratory test.
A visit to a primary care provider.
A visit to a specialist.
Question 66 of 75
choose from a large number of health plans and plan types.--- ans
Question 67 of 75
What are ethics?
Character traits that dispose a person to act well toward other people.
Principles and values that guide a person or organization facing questions of right and
wrong.-- ans
Commonly held customs and beliefs that shape peoples expectations of business
conduct.
Written laws enforceable through the courts that govern professional and business
conduct
Question 70 of 75
A health plan decides to compete in the large group market instead of the small group
market by offering a variety of product lines. This is an example of
positioning.-- ans
marketing mix.
market segmentation.
branding.
Question 7 of 75
Which way of accessing behavioral healthcare services used to be common but no longer
is?
Centralized telephone referral system.
80
Employee assistance program (EAP).

Primary care provider (PCP) referral - ans
Direct access.
uestion 19 of 75
The primary focus of a disease management program is
populations of people who have or are at risk for certain diseases- ans
immunizations for common childhood diseases.
individuals with complicated and high-cost diseases.
providers who are not following clinical practice guidelines for certain diseases.
Question 27 of 75
Indemnity.
PPO.
POS.
HMO - ans
Question 30 of 75
premiums and cost-sharing ans
and cost-sharing.
32. Medicare Part D
charges a premium but has only nominal cost-sharing - ans
Question 34 of 75
Under capitation, the amount a provider is paid is based on
the number of services she performs.
81
the number of hours she works.

the number of members she is responsible for - ans
the cost of the services she performs
Question 40 of 75
Who can receive Medicare coverage?
People 65 or older only.
People 65 or older and younger people with disabilities - ans
People 65 or older and younger people with severe, long-term disabilities or a few
diseases.
People 65 or older and younger people with low incomes.
Question 44 of 75
In the health plan market, large employers
are often self-funded.
tend to focus almost solely on price.
usually offer employees only one health plan.
tend to change health plans more frequently than small plans - ans
Question 28 of 75
A plan must pay benefits for a medically necessary service even if authorization was not
obtained.
A plan must process and investigate claims within timeframes set by regulation.
Electronic claims processing can handle only simple claim decisions - ans
A plan may not deny a claim because it was submitted too long after the service was
provided.
Question 54 of 75
Which is a common HMO compensation arrangement for hospitals but not physicians?
Diagnosis-related groups (DRGs) - ans
82
Discounted fee-for-service.
Capitation.
Fee-for-service.
Question 57 of 75
the number, types, and locations of providers are sufficient to meet member needs -ans
premiums and cost-sharing are sufficient for financial viability.
Question 58 of 75
network model.
IPA model - ans
group model.
staff model.
uestion 64 of 75
What coverage do Medicare Advantage plans provide?
Medicare Part A and Part B coverage only, but without cost-sharing.
The coverage of one of the standard Medigap plans.
Medicare Part A and Part B coverage only.
Medicare Part A and Part B coverage, other benefits, and usually drug benefits - ans
Question 65 of 75
By the 1990s HMOs had become accepted by consumers and employers, but many
people objected to their
high premiums.
high coinsurance and deductibles.
limited benefit packages.
lack of provider choice - ans
83
Question 67 of 75
What are ethics?
Character traits that dispose a person to act well toward other people.
Principles and values that guide a person or organization facing questions of right and
wrong.
Commonly held customs and beliefs that shape peoples expectations of business
conduct.
Written laws enforceable through the courts that govern professional and business
conduct
Question 71 of 75
In which of these provider organizations do physicians normally not own and operate
Consolidated medical group - ans
Group practice without walls (GPWW).
Physician-hospital organization (PHO).
Independent practice association (IPA).
Question 72 of 75
What are the trends in healthcare quality?
The definition of quality has become narrower, and employers have taken a less active
role in seeking quality.
The definition of quality has become broader, and employers have taken a more active
role in seeking quality - ans
The definition of quality has become broader, and employers have taken a less active role
in seeking quality.
The definition of quality has become narrower, and employers have taken a more active
role in seeking quality.
Question 70 of 75
A health plan decides to compete in the large group market instead of the small group
market by offering a variety of product lines. This is an example of
positioning - ans
84
marketing mix.
market segmentation.
branding.
Question 1 of 75
The majority of U.S. employees with health coverage are enrolled in
a PPO. ans
a POS plan.
a traditional indemnity plan.
an HMO.
Question 3 of 75
more extensive benefit packages and lower out-of-pocket costs. - ans
2.In utilization review (UR), who has the authority to deny authorization of payment for a
A physician only. ans
Question 12 of 75
In which HMO model are physicians salaried employees working in HMO facilities?
Staff model - ans
Group model.
IPA model.
Network model.
Question 18 of 75
Under the principle of beneficence, health plans must promote the good of their
85
individual members and their membership as a whole - ans

stockholders only.
individual members.
membership as a whole.
Question 23 of 75
What is the best definition of a health plan?
An organization that provides health coverage to a group of people, most commonly the
employees of a business.
An organization that maintains a network of affiliated healthcare providers and pays
benefits only for services rendered by those providers.
An organization that integrates the delivery and financing of healthcare and seeks to
manage healthcare costs, access, and quality.- ans
An organization that combines employer funding of a core set of health benefits,
employee financial responsibility, and provider accountability.
27. Which type of health plan needs the fewest providers per 1,000 members?
Loosely managed and large plans.
Highly managed and small plans.
Loosely managed and small plans.
Highly managed and large plans - ans
Question 30 of 75
Primary care providers compensated by fee-for-service have an incentive to
provide unnecessary services. ans
Question 35 of 75
A health plan pays a hospital a certain amount for a hospitalization, according to the
classification of the case based on diagnosis, procedures, and other factors. This describes
diagnosis-related groups (DRGs) ANS
per diem payments.
86
a relative-value scale (RVS).

episode-based payments.
Question 40 of 75
premiums and cost-sharing are sufficient for financial viability.
the number, types, and locations of providers are sufficient to meet member needs.- ANS
Question 43 of 75
Under ERISA, does the federal government regulate employer-sponsored health plans?
It regulates self-funded but not fully insured plans.
It regulates neither self-funded nor fully insured plans.
It regulates fully insured but not self-funded plans.
It regulates both self-funded and fully insured plans. ANS
49. In which of these provider organizations do physicians normally not own and operate
Consolidated medical group - ANS
Physician-hospital organization (PHO).
Independent practice association (IPA).
Group practice without walls (GPWW).
Question 57 of 75
By the 1990s HMOs had become accepted by consumers and employers, but many
people objected to their
high coinsurance and deductibles.
lack of provider choice. - ANS
high premiums.
limited benefit packages.
Question 60 of 75
87
Separate healthcare providers are brought under common ownership and control. This
describes
structural integration - ANS
business integration.
operational integration.
clinical integration.
63.The two main components typical of a consumer-directed health plan (CDHP) are
insurance policy.
organization.
a high-deductible health plan and a tax-advantaged personal healthcare account - ANS
Question 66 of 75
Which is not a rule of federal mental health parity laws?
All health plans must provide behavioral health coverage. ANS
Cost-sharing for behavioral healthcare cannot be more than for medical care.
Annual and lifetime benefit caps cannot be lower than for medical care.
Limitations on coverage of behavioral healthcare cannot be more restrictive than for
medical care.
Question 69 of 75
Which is an important factor driving increased healthcare spending?
Consumer-directed health plans.
A younger population because of immigration.
New drugs and technology. ANS
Defensive medicine.
Question 74 of 75
Which communication channel between a health plan and its members is being used less
and less?
88
Email.
Regular mail.
Social media.
Website.
Question 7 of 75
Which way of accessing behavioral healthcare services used to be common but no longer
is?
Centralized telephone referral system.
Employee assistance program (EAP).
Primary care provider (PCP) referral - ans
Direct access.
89
90
91

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Question 1 of 75

Which statement about trends in health plan products is correct?

less extensive benefit packages but lower out-of-pocket costs.

Premiums based on age.

Most states regulate both to some extent.

The provider submits encounter reports to the plan.

a patient-centered medical home (PCMH).

requiring all employers to sponsor health coverage.

Traditional HMOs and EPOs.

Point-of-service (POS) product.

NCQA provides accreditation for

many types of health plans.

Consolidated medical group.

No balance billing provision

In an open-panel HMO, any physician who meets the HMOs standards is

an open panel and closed access.

a group model HMO.

Electronic claims processing can handle only simple claim decisions.

Only a small minority of employees have either.

a large majority of dental coverage and is growing.

Health reimbursement arrangements (HRAs) were introduced by employers in 2000

Only employer contributions.

has been and continues to be at the state level.

An electronic health record (EHR) is a provider-based history of care that compliments

The personal health record (PHR).

Outcomes measures gauge the extent to which services succeed in improving

All health plans must provide behavioral health coverage.

to provide case consultation to providers, patients, and their families facing

an employer-sponsored high-deductible health plan and an individual supplemental

An employer, an employee, or a self-employed person.

The medical foundation.

providers can provide care to non-plan members.

Dental, vision, and hearing services and products.

Highly managed and large plans.

a relative value scale (RVS).

Consumers making cost-effective healthcare choices.

lack of provider choice.

employers to help them sponsor coverage but not to individuals.

Security and privacy.

Both financial and delivery risks.

In the United States, indemnity health insurance

No, but all employers are offered tax credits to do so

Contracting with health plans.

65. Which is not typical of managed care - Fee-for-service compensation

5.Which of these is a method used in market research?

and retired members of the military.

ans: active, retired and dependants

an employer-sponsored high-deductible health plan and an individual supplemental insurance

Active members of the military only.

4)What kind of risk does an HMO assume or share?

plan benefit specialist only.

11. Primary care providers compensated by fee-for-service have an incentive to

independent practice association (IPA).

20. Which type of physician-hospital provider organization is the least integrated?

claims to the plan.

31. In the United States, indemnity health insurance

32. Which statement is correct about a flexible spending account (FSA)?

Which statement about raising capital is correct?

40. Which type of quality data presents the most problems?

11. Primary care providers compensated by fee-for-service have an incentive to

provide unnecessary services. - ANS

and retired members of the military.