$i r r ' r l . r , r .

6t t
QALZ-AHM
2s0
Duration: I hour
This question paper contains 50 questions
Do not write or narh arything on the question paper and refitrn the paper when you leave
No negative marking
All questions carry equal marks
All the Best
l. One ethical principle in managed care is the principle of non-maleficence, which holds
that health plans and their providers:
A. should allocate resources in a way that fairly distributes benefits and burdens
among the members
B. have a duty to present information honestly and are obligated to honor
commitnents
C. are obligated not to harm their members
D. should treat each plan member in a manner that respects his or her goals and values
2 Eleanor Giambi is covered by a typical 24-how managed care program. One
characteristic of this program is that it
A. provides Ms. Giambi with healthcare covenrge for any illness or injury, but only if
the cause of the illness or injury is work-related
B. combines the group health plan and disability plan offered by Ms. Giambi's
employer with workers' compensation coverage
C. requires Ms. Giambi and her employer to each pay half of the cost of this coverage
D. requires Ms. Giambi to pay specified deductibles and copayments before receiving
benefits under this program for any illness or injury
3. In the United States, the Department of Defense offers ongoing healthcare coverage to
military personnel
and their families ttuough the TRICARE health plan. One true statement
'about
TRICARE is that
A. active duty military personnel are automatically considered enrolled in TRICARE
Prime
B. TRIC{RE covers inpatient and outpatient services, physician and hospital charges,
and rrfdical supplies, but not mental health services
- . t r t , r . 6ar t r - . r oor - oa- r ,
t . . r r , r r
c' TRJCARE
enrollees
are not entitled
to appeal authorization
or coverage
decisions
D- hoqpitars participating
in the TRICARE
program
are exempttrom
JCAHO
accreditation
and Medicare
certification'
q--
4' The Neptune
Hospitar provides
medicar
car: to_pa)nng patients,
as weg as to peopre
udro either
have
no healtircare-coverage
,na:"*oot
afford
to pay
for the care by themselves
or
who
receive
services at reducrfo
rates because
,h";'#
"orr".ea
under govenrment- sponsored
healthcare
programs.
To subsidize
itr't"#"nlortrr"
patients,
Neptune
has a
ffiffJ,t**aaing
th"'e ,r*imuuoJt"t,
to its other puy*g patients.
This practice
is
A. cost shifting
B. antiselection
C. receivership
D. underwriting
5' Natalie
chan is a member
of the
ultra Healthplan.
whenever
she needs nonemergency medical
care,
she sees Dr. David
ciuig,
* i"r;"rii.'ri"icrr*
cannot self-refer
to a
specialist'
so she sawDr'
crais
"'t*
trrg experienced
treaoactres.
Dr. craig referred
her to
Dr' Ruth Lee'
a neurylogisg
rr[" h"d h.; u*irriJir.a
"tli,"-
Hospitar for tests. urtra
has con&acts
with
q. c;;,-Dt
;;, -j Ary-*
t-pr""ia"
medicar
services
to its
members'
The following
staiemenJut"
.19*
ulha's organized
system
of hearthcare. Select the amwer
choi".-"oor"i"iog
[.Lrr*
sratement:
A' within
ultra's system,
Ms. chan received
primary
care
from both Dr. craig and Dr.
"
i.ffi":::em
allows
its members
open
access to att of urtra's participating
c' within
uttra'1j1|te!;
Dl
-cqg
serves
as a coordinator
of care or gatekeeper
for the
medical
services
tirat Ms, c[-
*iu.r.
- - or
",r
or gatekeeper.
D' ulfra's
network
of providers
includes
Dr. craig and Dr. Lee but not Arrow Hospital.
6' Janet
Riva is covered
by a eaditional
indemnity
hearth ins.rance
plan
that specifies
a
$250 deductible
and incrudes a 2ogzo-cornn'ance
provision.
when
Ms. Riva was hospitalized,
$e incurred
$2,s00 in mealca
"*p.lo,
,r,;;;;;."fd
by her heatth pran.
she incurred
no othermedi"ur
"*pens"s
auri"g-ue
J;;;;
In this
situation,
the
i
arnount
that the insurer was obtigated to pay
was:
A.
B.
$1, 750
$1,800
c. $2,000
D. 52, 25A
7- Phillip Tsai is insured by both a traditional indemnity health insurance plan, which is his
Primary
plan, and a health plan, which is his secondary plan. Both plans have itoi."f
coordination
of benefits (COB) provisions,
but neithei has a nonduplication
ofGnefits
provision.
Mr. Tsai incurred $1,00O of medical expenses from a specialist and assigned
-b"nt!s
to the specialist, wlro filedclaims with bothplans. Theeaditional ptan paiiatotal
benefit amount of $600 and notified the health ptan
of ttris payment.
fftr fri"f6 pi-
determined that, if it haf beel Mr. Tsai's primary plan, it *bufa have paid u Uerriniamour,t
of $900. According
to the COB provision, the totul u*or-t that the frealtn plan owJ on
these medical expenses was:
A. S0
B. $300
c. $400
D. $900
8' Primary care case
Tan]gers
(PCCMs) provide
case management services to eligible
Medicaid recipients.
with regard to
pccMs
it is correct to sly that:
A' PCCMs
0ryically
receive a case management fee, rather than reimbursement
for
medical services on a FFS basis, for the services they provide to Medicaid
recipients
B' all Medicaid recipients who live in rural areas must be given a choice of at least
four
pCCMs
C' PCCMs receive a case management fee in addition to reimbursement
for medical
services on a FFS basis.
D' PCCMs
contacl directly with the federal governrnent
to provide case management
services to Medicaid recipients
9. Medicaret-
Choice product
options include:
/
f r t t t ar r . s! . ! l - r t oor - oa- a,
! . r r t r r t
A. Coordinated
care plans,
medical
savings.accounts
and
pFFS
.
B'
:ilffJ".
for service ptans,
hearth care prepayment
plans
and medicar savings
c- coordinated
care plans,
regionat
ppos
and'private
fec for service prans
D. cost contracts,
coordinated
care programs
and medicar
savings accounts
I0' one differcnce
between
the IPA's compensation
arrahgements
with participating
physicians
who are
pcps
and rh;;;;.
are speciarists
is that the
pcps:
A' receive
compensation
based on th; volume
and variety
of medical
services
they
perform
forHill plan
members,
qgreus *. r*il;
receive
compensation
based
solely on the number
of pran rnembeis
urho are *;;; f".G;firuffi;,
B' have no financial
incentive
to practice
preventive
care or to focus on improving
the
health of theirplan
members,
t4"..*
Ii" rp".rJril"huu.
u positive
incentive
to
help their plan
members
stayhealthy
c' receive
from the IPA the same monthl{
:gmpensation
for each Hill plan member
under
the PCP's
care, whereas the specialists
receive
compensation
based on a
percenrrge
discount
from their normal
fees
D' receive
compensation
based on a fee schedule,
whereas the specialists
receive
compensation
based on per diem charge"
-l-
"'-^-:
I l ' To deermine
fee reimbursements
to be paid-to
physicians,
the Triangte
Health
plan
assigns
a weighted
value to each mJcalprocedure
or service and multiplies the weighted value
bv a monev murtiprier-
lriad;
*a',m p;;";d;;g"i"r"
the varue of the
multiplier'
one problem
with the,ri
"itrtit
system
ilA;i&;;imbursements
for proced,ral
services,
such as
"*g..y,
td;
ryry
monetarr
varue than do reimbursemens
for cognitive
serviceg
such as om"" r.idt . Tlis inronnaiion
iidicates
that Triangle
determines
fee reimbursements
bt;td;
financing
arrangement
known as a:
A. diagnosis-related
group
(DRG)
system
8.. relative
value scale (RVS)
C. partial
capitation
arrangement
D. capped
fee system
I
I
l2 Yvonne
Garcia is an emproyee
of the Artamaha
Erecticat
company,
which has 30 employees.
In November
tigi,she
enrorted
f"r;r"d;;il
iiil*""
coverage
with the
Lynnwood Heatth Plan, a federally qualified HMO, during the open enrollment period. At
the time of her enrollment Ms. Garcia had two pre-existing rnedical conditions: diabetes,
for which she had been treated since 1992, and a knee injury, for which she had been
receiving treatnents for the two weeks prior to her enrollment.
Three months ago, Ms. Garcia suffered a shoke and was hospitalized for several weeks.
Lynnwood used prospective, concurren! and retrospective reviews to evaluate the health
care service and beatment plans that she received'
The parties to the contractual relationship that provides Lynnwood's
group health insurance
to Altamaha employees are:
A. Lynnwood, Altamaha and all covered Altamaha employees
B. Lynnwood and Altamaha only
C. Lynnwood and all covered Altamaha employees only
D. Altamahaand all covered Altamaha employees only
13. &l O'Brien has both Medicare Pa$ A and Part B coverage. He also has coverage under
a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals.
Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transfened by
ambulance to an extended-care facility and was placed on long-tenr1 medications to help
him recover from the aneurysm. Under Medicare Part A, Mr. O'Brien had coverage for the
cost of:
A. confinement in the extended-care facility after his hospitalization
B. hansportation by ambulance from the hospital to the extended-care facility
C. physicians'professional services while he was hospitalized
D. physicians'professional services while he was at the extended-care facility
14. The Titanium Health Plan and a third-party administrator (lPA) have entered into a
TPA agreement with regard to the adminishation of a particular health plan. This
agreement complies with all of the provisions of the NAIC TPA Model Law. One of the
TPA's responsibilities under this agreement is to:
hold all funds it receives on behalf of Titanium in trust
assume full responsibility for ensuring that the health plan is administered properly
obtain from the federal government a certificate of authority designating the
organization as a TPA
I
A.
B.
C.
- r r l t t t t t t 6 t t a t - . r o o t - o ' _ t t l a ' t r ! , r
D. assume full responsibility for determinirig the claim payment proceduies for the
plan
15. The NAIC adopted the HMO Model Act in order to provide a syslem of ongoing
regulatory monitoring of HMOs. All of the following statements are conect about the
HMO Model Act EXCEPT that it:
A. regulates HMO operations in two critical arcas: financial responsibility and
healthcare delivery
B. requires each HMO to send state regulators an annual report describing the HMO's
finances and operations
C. focuses on three key aspects of healthcare delivery: network adequacy, quality
assufttnce, and grievance procedures
D. requires state insurance departrnents to conduct annual examinations of an HMO's
operations, quality assurance programs, and provider networks
16. tf a state commissioner of insurance places an HMO under adminisuative supervision,
then the purpose of this action most likely is lo:
A. transfer all of the HMO's business to other carriers
B. allow the state commissioner, acting for a state court, to take contol of and
administer the HMO's assets and liabilities
C. sell the HMO's assets in order to satisfu the HMO's obligations
D. place the HMO's opemtions under the direction and conhol of the state
commissioner or.a person appointed by the commissioner
17. One tue statement about Hill's COA is that
A- Hill had to have an initial net worth of at least $1.5 million in order to obtain a COA
B. the COA most likely exempts Hill from any of State X's enabling statutes
C. Hill had to be organized as a partnership in order to obtain a COA
D. the COA in no way indicates that Hill has demonstrated that it is fiscally sound
18. The follgving statement(s) can correctly be made about the characteristics of a tlpical
HMO:
,
l. For delivering healthcare to its members, an HMO usually receives compensation
under a retrospective reimbursement system.
o. * r r ! t . r t ' l r
2. In order to provide its members with the maximum amount of convenience when
receiving ancillary services, an HMO typically contracts with as many ancillary service
providers as possible.
3. An HMO arftnges for lhe delivery of medical care and provides, or shares in
providing,the financing for that medical care.
A. l , 2, and3
B- I and2onl y
C. 2and3onl y
D. 3 only
19. The Libra Health Plan is a closed-panel HMO. This information most likely indicates
that Libra's healthcare providers
A. contact independently with Libra and can
join
the HMO network as long as they
meet Libra's standards of care
B. are either employees of Libra or belong to a group that confiacts with Libra
C. operate out of their individual oflices
D. treat both Libra plan members and individuals who are not members of an HMO
20.In the term'lPA model HMO,'what does IPA stand for?
A. Independent Practitioner Association
B. Independent Practice Association
C. Internist Practice Association
D. Independent Practice Assessment
21. Paul Gilbert has been covercd by a group health plan for two years. He has been
uodergoing beatnent for angina for tbe past three months. Iast week" Mi. Gilbert began a
new
job
and immediately enrolled in his new company's goup health plaq wtrich has a
one-year pre-existing
condition provision. According to tbe Health lnsurance Portability
and Accountability
Act (tfIPAA) of 1996, the new health plan:
A. can exclude coverage for treatment of IVfr. Gilbert's angina for one year, because
HIPAA does not impact a group health plan's pre-existing condition provision
.?
t
. . r r r t a t t . q t r t - . t o a t - a a _ t ?
t a r r ! r r l
'
B' can exclude
fverage
ftir teatment
of I\rIr.
Girbert's uirgou
for one yea1,
because
Mr' Gilbert did not have at least 36 montbs
or"r"aituute
coverage
under
his
previous
health plan
c. can excrude
coverage
for teatnent
of r&.'Girb"rt,,
angina
for three months,
because thatls
the length of tirne
he received
or"**,
for this mdical condition
prior
to his enrollm"nt
in rbe new health
d;
---_-
D' cannot
excrude
his angina
as a pf-e.xfsting
condition,
because
the one_yearpre_
existing
condition
provision
is orset
uy
"ir*r,
"""'y"",
of
"o.,tinuous
corr"rage
under
his previous
heatth plan
22-t},e
following
statements
are about
federal
laws that affect
healthcare
organizations.
Select the answerchoice
containing
ril;il;;":
A' The women's
Health and canceS.Rights
Act (wHcRA)
of lggg requires
health plans
to offermastectomy
benefits
B. The Hearth
care
e,uarity
Improvement
Act (HCelA).requiles
hospitars, group
practices'
and
HMos t'o comply
with all rtuia*i*titmst
legislation,
even if
these entities
adhere
to due pruo,
srandards
;Jt are outrined
in HceIA.
c. The Newborns'and
Mothers'Hsarth protection
Act (NMHpA)
of 1996
mandates
that coverage
for hospitar
,"y;;ffir}uirr,;;
;";;tiu"
"
minimum
of24 hourcfor
normar ddir;;;tfi
hours for cesarean
births.
D' Although
rhe Mentar
Hearth *,Tg-o:,
(MH'A)
does not require
trearth
prans
to offer
mental
health coverage'
it imposes
requirements
on those plans
that do
offer
mental health benefit!.
-
23'In 1999'
the ululed
S-tates
congrery-passed
the Financiar
services
Modemization
Act, referred
to as the Gramm-Leach-Btii;v
rcrnlagr n;;;"*rprovisions
included under the GLB Act require
financial
i*i*;ioi,i..iyruaiic-od*
fi*,
to take severar steps ro
protect
the privacy
ofpersonal
i"f;;;".
on" or"n.r,
J"ir i, that financial
institutions must:
q.vev
DrePo
A' notifrcustomeN
ojany.sharing
ofnon-public
personar
financial
infonnation
with non-affi
liated thjrd parties
"
$*|}H:TtrffA::#,
the opportunity
to bpt_out,of
sharing
non-public
c' ajsclole
to affiriates,
but not to third.psr,
their privacy
poricies
regarding
the sharin[
of nonpublic
personal
nnanciaf information
E. t . r t t a"
. &t c st - t ' oOt ' o
D.agreenottodisclosepersonallyidentifiablefinancialinformationorpersonally -
iientifiable
health
information
24. Arthur
Moyer
is covered
under
his employer's
group.healh.llan,
which
must
comply
with the consotioatea-il[iUus
Budggt
R;il;fit"itt
(C'-BRA'
Mr' Mover
is
terminating
rrir.,nproilJJ.
n" t*-"r""r"Jio.onti"ue
his coverage
under his employer's
soup
healrh
pr*, -f,t"-*ili;""_*
"*"*,;;;-""tl*gt
after iis termination'
In this
Iit*tion,
coBRA
t
"jir
,rr"t
Mr. Moyer
"un
contin,r"
his ioverage
after his termination
for
amaximum Period
of
A.lsmonths,buthiscoverageundercoBRAwillceaseifheobtainsglouphealth
coverzrge
through
another
employer
B.18months,evenifheobtainsgouphealthcoveragethroughanotheremployer
C.36months,buthiscoveragetldercoBRAwillcpaseifheobtainsgrouphealth
coverage
through
another
employer
D' 36months,evenifheobtainsgouPhealthcoveragethroughanotheremployer
25. one feat're of the Employee
Retirement
Income
security
Act @NSA)
is that it
A.requiresself-fundedemployeebenefitplanstopaypremiumtaxesatthestatelevel
B.containsapre-emptionprovision,whicirtypicallymakesthetermsofENsAtake
precedence;;;;
sdte
laws th";;gd;;
"-plovt"
welfarebenefit
plans
c. contains strict reporting
and disclosure
requirements
for all employee
benefit
plans
excePt health
Plans
D.requiresthatstateinsurancelawsapplytoatlemployeebenefitplansexceptinsured
plans
26'Thefollowingstate'grentsdescribeviolationsofantitrustlegislation:
sittration
A
-
Two health
plun, in u 'ingl" '"rvi"e
atea di'ttided
purchasers
into two
groups and agreeaio
"uJU
ot*t"i
ttreir proOuJS
to only one
purchaser
goup'
Sitrration B
-
A specialty
p.o"ia","go"p
"""*1,.i"'.'*.h
an health
plan for
oncology
services
required
the health
P;;
"in*"t
with the
group for other
services
as a
condi t i onf orrecei vi ngt hegt oup' soncol ogyservi ces. . r. l
From
the following
answer
choices,
select"trre
response
that best
identifies
the
*tii*"tuiolations-tlescribed
in these situations:
A. Situation A
-
horizontal
division
of markets
Situation
B
-
tYing
arrangement
B- Situfion A
-
horizontal
division
of markets
SituationB-pricefixing
C. Situation A
-
horizontal group boycott
Sihration B
-
tying arrangement
D. Situation A
-
horizontal group boycott
Situation B
-
price fixing
27. Beforc the Hill Health Maintenance Organization (I{i\4O) received a certificate of
lthority
(COA) to operate in State X, it had to meet tlie state's licensing requirements and
financial standards wtrich were established by legislation that is identical to the National
Association oflnsurance Commissioners (NAIci
HMO Model Act Hill, an open-panel
HMO that operates as a typical independent practice
association (PA) model ittuto, h*
" contract with one IPA that servqs the HMO's geogrqphic
area. Hill compensates *e tpe for
medical services on a capitation basis, and the IPA in tum uses capitation to compensate
participating physicians
who are primary carcproviders (pcps). Iiowu"r, the lpi
comPensates participating physicians who are specialists on a discounted fee-for-service
(FFS) basis.
The contract between the IPA and its participating physicians contains a typical hold-
harmless provision.
Also, participating physicians agree to have tneir perfoimance
evaluated by otherproviders who practice
within the same medical spgcialty and within &e
same geographic
area. This evaluation includes a comparison of the providirs'care
to an
accepted standard of care.
Because it operates as both a tlpical IpA model HMo and an open-panel HMo, Hill:
A. should be able to achieve economies of scale more easily than staffmodel or group
model HMOs
B. can also be characterized as a direct contract model HMO
C. cannot use withholds to control costs and to involve participating physicians who
are PCPs in risk sharing
D. has a provider
network in which participating physicians
remain independent
practitioners
who can see otherpatients in addition to Hill plan members
28. which of the following statements is tue of staffmoder HMos?
A. Staffmodel HMO physicians
do not receive a salary.
B. Staffmodel HMO use an open-panel plan.
C. Staff model HMOs use fee-for-service payment systems.
j
D. In staffmodel
HMOs, the HMO assumes the risk
- . r . l t t t t t . q t t t l - t 2 o o t _ o r _ t t r ' r t l r t r
29. Employers in a certain city have the following HMO options for providing gouP health
coverage
for their emPloYees:
withinits
geogmphic service are4 the sycamore HMO_, all oPen-panel
plan, has
conmcts witftLvetaf
goup practicris of physicians and several specialty groups.
physicians
in the
group pta"ti""s provide medical services to members of Sycamore
and to non'members.
Physicians on the Elm HMO's
panel of,provld9rs work in an ambulatory care
aiinty
(ACF) and are salaried employees of &e plan'
From the answer choices below, select the responsi: that conectly indicates the types of
HMO models represented by Sycamore and Elm.
A. Sycamore
=
captive
gouP
Elm= staff
Sycamore: network
Elm
=
group
Sycamore: network
Elm
=
staff
D. Sycamore: staff
Elm
=network
30 .One
qryical characteristic of prefened
provider organization
@PO)
benefit plans is that
PPOs:
A. assume full financial risk for arranging medical services for their members
B. require plan membirs to obtain a referral before
getting medical services from
specialists
C. use a capitation arrangement, instead of a fee schedule, to reimburse
physicians
D. offer some coverage, althougb at a higher cos! for plan members urho choose to use
the services of non-network
providen
3l. How do PPOs usually pay physicians?
Salary
Fee-for-service
Capitation
Fee cap or maximum allowable fee
I
B.
c.
A.
B.
C.
D.
i3oy"n
of the choices
bilow is the characteristic
ofariEpo
that distinguishes
it froin a
A. Administation
B. Structure
C. Oper at i ons , ,
,
'
1- '
D. Out-of-network
care
33' The Argyle
Heatth Plan has established
tpicalcomplaint
resolution
procedures
(cRps) to manage
disnutel,lth
members.-Argylr
n#t""eiuJi
r",,'r one appeal from
Nicole Benoit,
an Argvre pl.tg:-u"r.
arso,"Lg{g
has
;;;;;;iration with ano&erpran
member,
peter
rendl.
with regard
tihd diqput"i-iii.
LoJtik;ft;;;il
*i *"r,
A' both M* Benoit
and tv1r. Lendl are prevented
by Argyle,s
cRps from being present
when their
cases are heard and from presenting
th;;;"np*ctives
b' only the decision
made on Mr. Lendt's
case is a finar, binding decision
c' only
Ms' Benoit's
appear
is an exampre
of an informar
appear
D' only
Ms. Benoit's
appear wit be heard by an impartiar
third party
34'
The
Manor
Heatth PIan uses an automated
system that answers telephone
calls with recorded
or synthesized
spegch
una prompt,
the carier J,..rpo"a
," a _enu
of options
by entering
information
tt tougn
","*f.r"GilrJil;;ffihg
into the phone.
-Each
response
takes the caller to the next
"pp-pri"t
*"rru',rlriit
cailer receives
the desired information
from thl system,
hangs ui]oiselects
theopion
tJ speak to a representative.
The squire
Health
Plan uJs u i*i",
td;;;
,"r"orr*.
carts with a recorded messase
and then routes
cars to th9 approp.1ilil;;iT*,
at squire.
Ifno representative
in the appropriate
*it i, uuuil{L;4!,
;;,i;;aces
the cail in a queue
to be answered
when
a representative
becomes
available.
fi;[f'"*ng
statement(9
can to".,ryi.
made about the technorogy
used by Manor
and
A- Manor's
system
is best described
as an automated
cail distributor
(ACD).
t
*?S}fflilii.""t
and Squtue's
device
are applications
of computer/terephone
c. srfre's
device
is best described.as
an interactive
voice
response
(IVR) system.
D. All of these
statemenb
are correct.
35. Katrina LnWz is a claims analyst for a health plan plan that provides
a higher level of
benefits for services received in-network than for services received out-of-neivork.
Ms.
I.oWz reviewed a health clarm for answers to the following questions:
Question
A
-
was the provider a participant in the plan's network?
Question
B
-
Does the member have other healthcare coverage?
Question
C
-
Is the premium paid or not?
Question
D
-
What benefits are payable?
If this was
A bpical
claim, then Ms. Lr:irrlrwas correct to seek answers to questions:
A. A, B, C, and D
B. A, B, and D only
C. B, C, and D only
D. AandConl y
36 The Mosaic heatth plan uses a typical elecfonic medical record (ElvfR)
to document the
medical care its members receive. One characteristic of Mosaic's EMR is that it:
A. does not provide
any clinical decision support for Mosaic's providers
B- is designed to supply information at the site of care
C. contains a Mosaic member,s clinical data only
D. is organized by the type of treatnent or by provider
l] I:
address the problems associated with multiple data management systems, the Kayak
Health Plan has begun to use a data warehouse
One likely charlteristic of Kayaks data
warehouse is that
A. it requires Kayak's individual databases to store large amounts of data that are not
needed for daily operations
B. it contains data frsm internal sources only
C. it stores historicat data rather than current data
D- the data in the warehouse are linked by a common subject
3E- Th9l----------------* Company was interested inpurchasing PPO coverage for its 90 employees and
asked Hill to determine
a premium rate for the coverage. Hill would administe; the plan
and guaranteeclaim
payments
by panng all incurred
Lvered benefits, and Jet would make
monthly
O*Tu*
payments
to Hill for the PPO coverage. Because Jet had been covered
under
a previouS
heatth
plan,
Hill w,
premiwn*,..ir11a9ffi
ilili;T"J"ffi
t.*'t;tE:"J**?l*A"d*
ff",
and that
rot.**,il#*r"
**
srs,
p;pfi
La *u ,",
" ".iiiirity
factor
or
Because
Hill
would
be responsible
fi
: ,
ppopranrorret's;;;';;",1;,'jffiTffijfj:f;
;$:r'Jff#ffi
*rsteringthe
A. an indemnity
waparound
plan
B. a self_firnded
plan
C. an aggrcgate
stop_loss
plan
D.
a fully
firnded
ptan
39.
The
Robust
Heatth
plan
sometimes
premi
ums
for a group-
u,o"i
oi"-,*",
"H#fifrrTffi ffin::
;*1
f#;;iij"
*"
^f;ffi';'ffi*Ei,:tl;'ffi
ifl
iilUlftr31l:::sexperiencedby
is better
th:
experience*,"Jffiff"f
"n*"r'r'"fffi
oi"'JrXff TT:*ff
:ffi
*";
B.
use Robustl
premium
s average
experience
with
alt groups
to calcurate
this particurar
group,s
".
_T.*goup,s
pastexperience
to
next period
r
v
va! s^;rcro''c
to estimate
the group's
expected
experience
for the
D.
al.l ofthe
above
40'-To
be successfur-in
marketing
the
ppo
product
to the
sma'
trn'#.,ff
fl':$;tT,#r=*tf;
#t#f;
r.TJ*F,lli,!ffi
i:ffit
most
likely
was
nucat
consideration
in setecting
"
i"Jin'or*
A. the
number
of specialists
in
Hill,s network
of providers
B. the price
for
the
ppo
product
C.
Hill's
ability
to report
utilization
data
D.
Hilt's
yie
of brokers
to market
its
ppo
producr
li ,ffi:|,l:ffi'j:i?,t
below
contains
the
four
toors
used
in by rnarketers
that
make
' t b l r . l - r : o s t - o
A. Advertising, personal selling, sales promotion, and publicity
B. Advertising, pribe, sates promotion, and publicity
C. Admissions, personal selling, sales promotion, and publicity
D. Advertising personal selling, sales promotion, and privacy
42.TbE main purpose of the Health PIan Employer Dataand Inforrnation Set (HEDIS) is to
provide
A. expert consultation to end-users for solving speciatized and complex healthc.are
problems ttuough the use of a knowledge-based computer system
B. a mathematical model that can predict future conditions or eyents in the healthcare
industry
C- measurements of plan performance and effectiveness that potential healthcare
purchasers can use to compare the quality offered by different healthcare plans
D. a comprehensive accreditation for PPOs
43. One characteristic of the accreditation process for health plans is that this process:
A. is voluntary for health plans-
B. requircs all change accrcditation organizations to use the same slandards of
accreditation
C. typically requires the accrediting organization to conduct a medical record review
and a review of a hbalth plan's credentialing processes, but not an evaluation of the
health plans'member
service systems processes
D. cannot assure that a health plan meets a specified level of quality
44. As pa* of its quallty management program, the Lyric Health Plan regularly compares
its practices and senices withthose of its most successful competitor. When Lyric
concludes that its competito/s practices or services are better than its own, Lyric
implements the changes necessary to achieve overall qualit), improvement. This
information indicates that Lyric assesses its performance by using a method known as:
A. benchmarking
B. standard of care
I
A
C. an adverse
everit
D. case-mix
adjustnent
45'
which
of the
foltowing
is the best
description
of what
a ?rocess
rneasure,
evaruates?
A.
The
natu:
member::;'xHr.$T;**,Tl?
of the resources
that
a hearthpran
has avairabre
for
t
ff#ods
and procedtues
a health plan
and its providers
use
to furnish
service
C-
The extent
to which
services
succeeJ in i--_ .;_^
patient
health.
-'tcceed
in improving
or maintaining
satisfaction
and
46' The
data evaluation
stage
of utilization:"]"y
(uR)
inctudes
both
administrative
reviews
and
medicar
rui"rir.6rrlr#'*,emenr
about
these gpes
ofreviews
is that:
^
*:m:#:'#fr'"*
must
be conducted
by a hearth ptan
staffmember
who
is a
B. the prinrary
$rno1e
of an administrative
review
is to of a proposed
medical
,"JJ*"q4uvti
revlew
ts to evaluate
the
appropriateness
c'
uR staffmem!,ers
gpicarty
cond,ucl
a medicar
review
of a proposed
medicar
service
before
*rey conauci
*
"a.r,t"*irir.i"Tr",
that
same
service
" a"alffi;::a
medicar
review
is to evaruate
the
medical
necessity
of a proposed
ffilillffii#,"#;f
l:#rTffi.#J,:;ff
3ffiffi3:ff
:tffi
;;
A' requirement
that
Ms. Garcia's
physician
notis the plan
prior
to her hospital
ization
t
;*if;TJ$l|!]#f
stav (Los)
estirnates
and discharge
pranning
ror
Ms.
l'
*rtent
of a uM
nurse
to
monitor
Ms- Garcia's
care
during
her hospitalization
p'
revrw'
after
Ms'
Garcia
is discharged,
of the entire
b'r
for her hospitarization
t
b. . , t t t . l t ' s ! 3 t l - ' t o' ?_o
A. 67
B. 274
c. 365
48. In order to help review
is institutional
utilization
rates' the Sahalee
Medical
Group'
a
heatth
plan, uses tr," ,t-i*a
formula
t" #;lttt
notpitalbed
days
per l'000
plan
members
for the torr',ilJ
au'"
f*tm)
Ott eptit
20' dahalee
';e0 *ie following
information
to calculate
hospital
bed days
per_1,000
members for thqMTD:
Plan membership
-.. -.
" "'
" "'
-"
" " " " " " " "
"20'000
i;;;;;
t"spital
bed davs in MrD
""-""300
This informution
inoiiJtJir,ulon
April
zo,'3rrt"r*s
numberof
bed days per l'000
plan
;;;tt
for the month to date was approximately:
,r. ilJff:*
plans are now integrating
diqease management
into their medical
management
progrur*]O""-"t
-u"ietistic
of disease management
ls that it
A.tendstokmoreappropriateforheatingmedjcalconditionsthathavemany
complications
*t ii,il cannot
U"
pr"t"ntfu rather than condi{ions
that have a high
rate bf preventable
complications
B. standardizes
care as much
as possiblcto
ensrue
that all phypicians
in the
program
provide tr," ,uiJ
;; ;i"*;
* d;.;;;hyri"i-t
wlo-rloutinelv
achieve
the best
outcomes
c. focuses on individual
episodes
of medical
care ftrther than on
the comprehensive
care of the
Patient
over time
D. focuses on treating
medical
conditions
that show a l9w rategf
variabilily
in pattems
of heatrnent
ilo*?u,i"n
to patient and from
physician
to physician
50. Provider integration
has rwo components:
operational
integration
and structural
integrarion.
A" *"-;i; ;#;ilr,a
itrt"gution
in health
plans [s the:
A.acquisitionoftheLeopardHealthPlanbytheHickoryHealttrPlan
B.
joint venture enterd
into by the Eclipse
Healrh.Plan
and e
local
hospital
system
to
create a new health
plan in *rri"r, rr'ripr.
-4,n" hospital
system
share ownership
C.forurationofanorganizationbyagroupgfnrlvrr\ntocapryoutbilling' ' .
coltections,ffi;;ilffiil',h
f,Jtti
plans for the entire
gouP of providers
D. consolidation
of the carver Health
Plan
and the Limestone
Health
Plan
J
t