Chapter 1:

Contents
Chapter 1:...................................................................................................................................1
The Evolution of Health Plans.....................................................................................................1
Chapter 2:-- Basic Concepts of Health Insurance........................................................................3
Chapter 3:-- Health Plan Benefits and Networks........................................................................3
Chapter 4:-- Provider Compensation fee-for-service to value based care..................................5
Chapter 5:-- The Health Maintenance Organization (HMO).......................................................6
Chapter 6:- Types of HMOs and ACO Basics...............................................................................8
Chapter 7:-- PPOs and Other Health Plan Types.......................................................................10
Chapter 8:-- Health Plans for Specialty Services.......................................................................11
Chapter 9:-- Consumer-Directed Health Plans Part I................................................................13
Chapter 10:-- Types of Consumer-Directed Health Plans.........................................................14
Chapter 11:-- Provider Organizations and Compensation Models...........................................16
Chapter :- Health Plan Structure and Management.................................................................17
Chapter 12:- Network Structure and Management..................................................................18
Chapter 14- Utilization Management.......................................................................................20
Chapter 15 –Utilization Review................................................................................................21
Chapter 16- Quality Assessment and Improvement.................................................................23
Chapter 17: Quality Standards, Accreditation, and Performance Measures............................25
Chapter 18:- Marketing............................................................................................................26
Chapter 19:- Underwriting, Rating, and Financing...................................................................29
Chapter 20-Information Management.....................................................................................30
Chapter 21: Claims Administration...........................................................................................33

The Evolution of Health Plans

Which is not a cause of higher healthcare spending?
A younger population because of immigrations

Under the fee-for-service approach, health care providers have a financial incentive to provide
Most services

Which is not typical of managed care?

Fee-for-service compensation

Which will probably have the lowest premium?

A consumer-directed health plan

In relation to health plans, over the years the definition of quality

Has become broader

Which is not an accrediting organization?

HEDIS

Why is it useful in studying health plans to learn about indemnity insurance?

Some features of today’s health plans are inherited from indemnity insurance or designed to address its problems

Andy is covered by his employers group health insurance policy. Who is the policy holder of this policy?
The employer

Who pays the premium of an employer-sponsored group policy?

Employees may pay all or part, but they do so through the employer.

Latest from 2021:

1) A “health plan” can best be defined as an organization that

Integrates the delivery and financing of health care and seeks to manage health care costs, access and quality

2) The earliest version of health plans appeared in the

Early 1900s

3) Which is a very early type of health plan?

Prepaid group practice

4) Which was a provision of the HMO Act of 1973?

Federally qualified HMOs had access to federal funding

5) In the 1900s, HMO

Were popular because they held down costs, but people objected to the lack of provider choice

6) To receive benefits from her health plan, Janine must go to her primary care physician and remain within
the plan’s network for other health services. Janine is most likely to be covered by
A traditional health maintenance organization (HMO)

7) Jacob must pay $5,000 in health care expenses each year before he receives benefits from his health plan,
but he can use money from a tax-advantaged savings account. Jacob has
A consumer directed health plan (CDHP)

8) What is the involvement of the state and federal governments in health plans?
They legislate and regulate in this area and purchase health coverage

9) Under the fee-for-service compensation method, health care providers have a financial incentive to provide
More services

10) Which of these do health plans generally seek to replace?

Fee-for-service compensation

11) A consumer directed health plan seeks to lower premiums through

A high deductible

12) In relation to health plans, over the years the definition of quality
Has become broader

13) Which is an organization accrediting health plans?

NCQA
Chapter 2:-- Basic Concepts of Health Insurance
Latest from 2021

1) Why is it useful in studying health plans to learn about indemnity insurance?

Some features of today’s health plans are inherited from indemnity insurance or designed to address its problems

2) Andy and his family are covered by his employer’s group health insurance policy. Who is(are) the policy
holder(s) of this policy?
The employer

3) Who pays the premium of an employer-sponsored group policy?

Employees may pay part or all of the premium, but they do so through the employer

4) What happens in adverse selection?

People who need healthcare enroll in greater numbers than average people.

5) Which employee group is most likely to have a higher-than-average loss rate?

A group made up mostly of women

6) Which employee group presents a high risk of adverse selection?

In company A a small percentage of employees enroll.

7) In traditional indemnity health insurance, insureds

Can go to any provider they choose.

8) In traditional indemnity health insurance, how are providers compensated?

Fee-for-service.

9) Owen pays 20percent the cost of healthcare services covered by his policy. This describes
Coinsurance.

10) Which is not common in traditional indemnity health insurance?

Copayment

11) Coordination of benefits is designed to

Prevent duplication of benefits when a person is covered by more than one health insurance policy

12) Increasing cost-sharing

Shifts costs from insurer to insured
Can help to lower the level premium increases
Helps hold down health care expenditures through insured incentives
All of the above
13) According to the text, cost containment helps hold down health insurance premiums primarily by
Reducing unnecessary healthcare services.

14) Coverage of preventive care is

Cost-effective in the long run (and so has been adopted by insurers)

Chapter 3:-- Health Plan Benefits and Networks

1) In this course, “health plan” is defined as any entity that
Uses certain concepts or techniques to manage the cost, access, and quality of healthcare

2) What is the trend in health plan products?

More types are being offered, and the distinctions between them are becoming blurred
 3) Members do not have to select how to receive services until they use them. This describes a
Point-of-service (POS) product

4) A health savings account is combined with a high-deductible health plan. This describes a
Consumer-directed health plan (CDHP)

5) Which of these health plan types uses managed care techniques and concepts the most?
Health maintenance organization (HMO)

6) What goals do all health plan share?

Accessibility, cost-effectiveness, and quality

7) Organizations that finance or reimburse the cost of healthcare services are known as
Payors

8) How are the roles of the key players in health plan evolving?
Roles are overlapping and becoming less distinct

9) Compare to indemnity insurance, health plan benefit packages are typically

More extensive and encourage the use of preventive care

10) Mandated benefits are imposed

Both by states and the federal government and apply to both indemnity and managed care plans

11) Carla pays a flat $20 fee to her doctor for an office visit, regardless of the cost of the services she receives.
This is
A copayment

12) Jacob pays 20 percent of the cost of a hospital stay. This is

Coinsurance

13) Dan pays the first $1000 of his healthcare expenses each year, after which his health plan begins paying
benefits. This is
A deductible

14) In creating a provider network, health plans generally seek to ensure member access by
Considering number, type, and location of providers

15) Primary care physicians are typically involved in

Prevention, treatment of routine conditions, and care coordination

16) If a health plan has a network, members

Can elect to go in and or out of network, depending on the plan design

17) Compared to indemnity insurance, health plans generally require _______ out-of-pocket expenses by
members
Less

18) Managing the use of healthcare services so that patients receive necessary, appropriate, and high-quality
care in a cost-effective way is
Utilization management

19) Which of the following focuses on individuals with special needs or certain medical conditions?
a. Demand management
b. Case management
c. Disease management
d. Credentialing
B and C
 20) According to the text, which is a quality management technique?
Credentialing

Chapter 4:-- Provider Compensation fee-for-service to value

based care
1) In traditional indemnity health insurance, the main provider compensation method is
Fee-for-service

2) Under fee-for-service, providers have incentive to

Provide unnecessary care.

3) Under fee-for-service, who bears financial risk?

The insurer

4) Under capitation, provider compensation is based on

The number of members cared for

5)Teresa, a doctor, is paid by a health plan by capitation. One month she delivers very few services to plan
members, the next month she delivers about the projected amount, and the third month she delivers well
over the projected amount. Teresa is paid
The same amount for each month

6) Capitated physicians have incentives to

Not provide unnecessary services and promote prevention and wellness

7) Which statement about capitation is true?

It may be used for both primary and secondary care

Currently, capitation accounts for what portion of physician compensation?

A small minority

8) Under a fee schedule, a provider receives

No more than a listed amount

9) Under a fee schedule or discounted fee-for-service, if a provider’s normal fee is more than the amount
allowed by health plan
She must accept the plan’s amount as payment in full

10) A health plan assigns a certain value to a service and multiples this value by a negotiated dollar figure to
yield the payment amount. This describes
RVS

11) A member is hospitalized, her case is classified based on several factors, and the hospital is paid an amount
based on that classification. This describes
Diagnosis-related groups(DRGs)

12) A hospital is paid a set amount for each day a plan member is in the hospital. This is
Per diem payments

13) A plan holds back a percentage of PCP’s monthly capitation payments. At the end of the year, some of this
money is paid to the PCPs, but some is used to pay for higher-than-projected referrals. This is an example of
A withhold
 14) A plan pays money into a pool to cover hospitalization. At the end of the year, if there is money left over in
the pool, some is given to PCPs but if there is not enough money, PCPs must cover the same cost. This is an
example of
A risk pool

15) A group of providers is paid a single amount for all the care related to a surgery, both in the hospital and for
three months afterward. This is
An episode-based payment

16) If a doctor meets certain performance targets related to quality of care and patient satisfaction, she
receives a bonus. This is an example of
Pay for performance

17) Which compensation arrangement typically involves the most risk for providers?
Full risk global payment

18) Which compensation arrangement involves the least risk for a hospital?
Fee-for-service

19) Which payment model can best be described as paying providers for a portion of any savings achieved in
relation to an anticipated cost level for the care of a specified group of patients?
Shared savings

20) Which payment model provides a single payment to a provider for all the healthcare services associated
with a defined episode of care?
Bundled Payment

21) Which of the following statements are correct about Medicare and provider compensation under
Medicare?
a. Medical Parts A and B are sometimes referred to as Original Medicare
b. MACRA seeks to move Medicare to value-based payment system called Quality Payment Program
c. Providers can choose from two tracks as to how they want to participate in the Quality Payment
Program
d. The Merit-based Incentive Payment System (MIPs) entails greater assumption of risk by providers
than the Alternative Payment Models (APMs)
A,B,C

Chapter 5:-- The Health Maintenance Organization (HMO)

1) An HMO
Assumes or shares both financial and delivery risks

2) The HMO act of 1973

Was instrumental in the initial growth of HMOs

3) Which of the following statements are correct about the HMOs Act of 1973 and its amendments
a. To be federally qualified, an HMO could not exclude preexisting conditions
b. To be federally qualified, an HMO had to offer both basic and supplemental health services
c. To be federally qualified, an HMO had to opt-out of state licensing as an HMO
d. Federal qualified remains important for Medicare and large employer contracts
A,B & D

4) Which is not a key characteristic of a HMO?

Loose relationships with providers

5) Which of the following factors is an employer likely to consider in selecting an HMO?

 a. Financial strength of the HMO
b. Member satisfaction
c. Access to care
d. Cost
A, B, C, D

6) A person enrolls in an HMO

Most commonly through an employer, but sometimes individually

7) HMOs were traditionally marketed to

Large groups, but they now serve large and small groups and individuals.

8) HMOs typically provide

Comprehensive medical benefits and usually special services such as dental and vision care, mental health care and
prescription drugs

9) Compared to other health plan types, in HMOs member cost-sharing trends to be

Lower

10) HMOs typically provide

Extensive preventive care and charge little or no cost-sharing for it

11) An HMO provide medical care to its members by

Contracting with and/or employing providers.

12) The delivery healthcare can be best described as primarily

Local

13) In building and maintaining an HMO network, the location of a healthcare provider is primary factor in
Access

14) To see a specialist, must an HMO member obtain a referral from her PCP?
Usually

15) Which statement best describes whether or not HMOs cover out-of-network services?
Traditionally they did not, but some HMOs now do at higher cost

16) Which statement best describes how HMOs are usually paid for providing healthcare?
HMOS are usually paid by means of a fixed monthly premium

17) Which are most common in HMOs

Copayments

18) Which are common HMO compensation arrangements for physicians?

a. DRGs
b. Capitation
c. Fee-for-service
d. Salary including benefits
B,C,D

19) A physician is compensated by an HMO by capitation, but once her total costs have reached a certain level,
additional costs are reimbursed by discounted FFS. This describes a
Stop-loss provision

20) Which utilization management techniques is used primarily for physicians?

Risk pools

21) In the area of quality management, HMOs are subject to

Strict state and federal legislation

HMOs are
Heavily regulated at both federal and state levels.

Which is an employer most likely to consider in selecting an HMO?

Access

A person enrolls in an HMO

Most commonly through an employer but sometimes individually

How are HMos usually paid for providing healthcare?

By means of fixed monthly premium

Which is not common HMO compensation arrangement by physician?

DRGs

Chapter 6:- Types of HMOs and ACO Basics

1) Which statement best describes an open-panel HMOs?
Any physician who meets the HMOs standards is eligible to join its network, but the HMO is not obligated to
contract with anyone

2) Which is true about closed-panel HMO?

Physicians are employees of the HMO or members of a contracted group

3) In an open-access HMO, members typically

Receive lower benefits for non-network care

4) Which is true about closed-access HMOs?

In the past most HMOs had closed access but this is no longer true

5) An HMO pays a doctor his services based on a fee schedule, this is an example of
Discounted fee-for-service

6) An HMO pays a doctor a certain amount per member per month to provide care needed by HMO members.
This describes
Capitation

7) In which compensation method do physicians assume risk?

Capitation

8) Which statement best describes a mixed model HMO

A mixed model HMO combines features of different HMO models

9) The current trend is toward

Mixed model HMOS

10) In an IPA model HMO, physicians are usually

Contracted with IPA, which contracts with the HMO

11) In which HMO model does each doctor manage her own office?
IPA model
 12) How are IPA physicians most commonly compensated?
Capitation for pcps and discounted fee-for-service or RBRVS for specialists

13) Which of the following statements best describes a disadvantage of the IPA model HMO?
The HMO has limited control of care management and quality

14) In a staff model HMO, physicians are normally

Employees of the HMO

15) In which HMO model do doctors normally work in a central facility owned and operated by the HMO?
Staff model

16) How do staff model HMOs normally compensate physicians?

Salary

17) Which is not an advantage of a staff model HMO?

Low facility costs

18) The HMO contracts with a single group practice. This describes
A group model HMO

19) In a group model HMO, physicians are

Employees (employee/owners) of the group practice

20) What is the most common compensation system in a group model HMO?
The HMO compensates the group practice by capitation and the group practice pays physicians salaries and
incentive payments

21) An HMO contracts with six group practices. This is an example of a

Network model HMO

22) What statement best describes an accountable care organization (ACO) ?

A group of healthcare providers who gives coordinated care and chronic disease management and improve the
quality of care patients receive which in turn results in cost savings

23) Which of the following do health plans hope to accomplish by encouraging the formation of ACOs and
participating in them?
a. Increased health awareness and engagement by members
b. Shared decision making between providers and members
c. Slower adoption of technology to lower both hardware and software outlays
d. Increased use of preventive services leading to lower healthcare costs
A,B,D

24) The ACO model offers private health plans opportunities to leverage their expertise to both improve the
quality of care and bend the cost curve. Which of the following statement describe these opportunities?
a. The opportunity to deploy medical management techniques beyond preventive healthcare
services
b. The opportunity to reduce unnecessary spending and waste in healthcare system
c. The opportunity to increase member satisfaction with the healthcare experience
d. The opportunity for increased administrative cooperation and clinical integration
A,B,C,D

25) Which of the following statements are correct about the Medicare Shared Savings Program (MSSP)?
a. MSSP is a voluntary program for which healthcare organizations must file applications
b. CMS approval is needed before a healthcare organization can participate in the program
c. MSSP involves the assumption of substantial downside risk by all participating organizations with
minimal opportunity to share in savings
 d. MSSP can trace its origins to the Affordable Care Act
A,B,D

The trend in network model HMOs is toward

A mix of capitation and discounted fee-for-service

The most common HMO model today is the

IPA model

Which HMO model normally has a closed panel?

Staff model

Chapter 7:-- PPOs and Other Health Plan Types

1) PPOs, EPOs and POS products are
In the middle of the managed care continuum, between tightly managed and unmanaged

2) PPO members receive

Lower benefits for no-network care

3) Which statement is true about a PPO?

a. Providers must participate in utilization review and quality management
b. Providers receive their full normal fees for service
c. Members must generally obtain a referral from their PCP to see a specialist
d. Members generally do not require a referral from their PCP
A,D

4) What portion of U.S. employees is covered by PPOs?

A majority, roughly 48 percent

5) A majority of PPOs are owned by

Insurance companies

6) Which statement is true about PPOs?

a. PPOs usually cover some specialty services
b. PPOs generally assume full risk
c. PPOs are normally highly centralized organizations
d. Affiliation with a PPO generally brings a high volume of patients
A,D

7) PPOs most commonly compensate physicians by means of

Discounted fees

8) Providers contracting with PPOs

May or may not assume risk

9) EPOs are generally like PPOS except that

There is no coverage for out-of-network care

10) A POS product offers

Reduced coverage of non-network care

11) Which statement(s) are correct in regard to how POS and HMO products are similar?
a. PCPs coordinate referrals to specialists in both HMOs and POS plans
b. Members cannot go out of network
c. POS Plans like HMOs emphasize preventive care
d. POS plans like HMOs usually require members to select PCP
A,C,D
 12) How many employees are covered by POS products?
A significant number, approximately 10 percent

13) Which of the following statements best describes an exclusive provider organization (EPO)?
An EPO is structured and operates like a PPO but out-of-network care is generally not covered

14) ABC health plan has no provider network and reimburses providers on a fee-for-service basis, but it
conducts precertification and utilization review. ABC can best be described as a
Managed indemnity plan

Chapter 8:-- Health Plans for Specialty Services

1) Historically, managed care plans
Focused on standard medical care (physician and hospital services)

2) Which of the following generally considered specialty healthcare services?

a. Chiropractic care
b. Hospital care
c. Home healthcare
d. Dental care
A,C,D

3) A health plan refers to another organization some (but not all) of the activities involved in delivering and
managing behavioral healthcare. This is best described as a
Partial carve-out arrangement

4) In a matured health plan market, compensation for a comprehensive carve-out is typically by

Capitation

5) Which of the following activities may be transferred in a comprehensive carve out arrangement?
a. Network Management
b. Quality Management
c. Utilization review
d. Claims administration
A,B,C,D

State laws
May restrict carve-outs

6) Managed dental care accounts for what portion of dental coverage?

A majority

7) According to the text, Managed dental care is

Growing

8) Plan members must, with a few exceptions, see a network dentist. This describes
An HMO

9) HMOs usually compensate dentists by means of

Capitation

10) Which is typically a dental HMO?

Copayments

11) PPOs commonly compensate dentists by means of

Discounted fee-for-service
 12) Which are typically a dental PPO?
Annual deductible, coinsurance and annual maximum benefit

13) Andre does not have to choose a dentist or network during annual open enrollment he can decide when he
needs a care. He has
A POS plan

14) Which dental plan type typically has the smallest network
HMO

15) Which dental plan type typically costs the least?

HMO

16) Vision plans typically cover which of the following

a. Lasik surgery for vision correction
b. Eye examination once every 12 months
c. Full cost of designer eyeglass frames
d. Eyeglass lenses
B,D

17) Which of the following statements is correct about vision care plans?
a. Many vision care plans are in the form of employer-sponsored group plans
b. Most vision care plans are individual policies purchased on the Affordable Care Act (ACA)
marketplaces
c. Discount vision plans simply offer discounts at participating providers
d. Vision benefits may be provided by a health insurance plan among with medical benefits
A,C,D

18) Some experts estimate that what percentage of Americans experience some sort of behavioral health
disorders?
18 percent

19) Douglas is in a substance abuse program. He spends most of his time in a facility but goes out during the day
to attend school. What level of behavioral healthcare is this?
Partial hospitalization

20) Lily receives 10 hours of therapy a week at a psychologists office, but she is not confined to a facility. What
level of behavioral healthcare is this?
Intensive outpatient care

21) Which is least common in health plans covering large number of employees today?
Members must get a referral from their primary care provider to access behavioral health care

22) Which sentence best summarizes the requirements of federal mental health parity under the provisions of
the Mental Health Parity Act of 1996 (MHPA) and Mental Health Parity and Addiction Equity Act (MHPAEA)?
MHPA and MHPAEA required large group plans that provided behavioral healthcare coverage to provide coverage
equivalent to medical coverage

23) Which statement best describes the provisions of the Affordable Care Act (ACA) and mental health parity?
The ACA Mandates coverage at parity for mental health and substance use disorders as one of the ten essential
health benefits

24) Which statement best describes prescription drugs and healthcare spending in the United States?
Prescription drugs accounts for a substantial portion of healthcare spending have been rising at a faster rate than
overall medical costs
 25) According to the text, how many health plans contract with pharmacy benefit managers (PBMs)?
A majority of health plans

26) Which of the following statements best describes pharmacy benefits management plans and with quality of
care?
PBMs are concerned with safe and effective drug use along with cost

27) A PBM notifies a doctor that he is prescribing a certain drug much more frequently than his peers and
educates him on its use and alternatives to it. This is an example of
Physician profiling

28) Repeated late refills indicate that Phil is not taking his low blood pressure medication as often as he should.
This is an example of
Drug utilization review

29) Patrice’s plan covers any drug her doctor prescribes, but she pays a higher copayment for drugs not on the
plan’s formulary. This is
An open formulary

30) A PBM requires a physician to obtain certification of medical necessity before prescribing a drug. This is
Prior authorization

31) Which of the following statements is correct about rebates and pharmacy benefit managers (PBMs)
Most PBMs enter into discount rebate agreements with pharmaceutical manufactures

32) A PBM provides all pharmacy services to an employee group in exchange for a fixed dollar amount per
employee per month. This is
Capitation

A pharmaceutical card is generally used in

Prior authorization

Start from here

Chapter 9:-- Consumer-Directed Health Plans Part I
1) A consumer-directed health plan consists of
A high deductible health plan and a tax advantaged account

2) Which statement is true about consumer-directed health plans?

Employees can reduce the shifting of costs to employees by contributing to employee accounts

3) Which statement is true about flexible spending accounts (FSAs)?

Both employer and employee contributions are not taxable income for the employee

4) Which statement is correct about annual rollover of FSA balances?

An employee may offer a grace period or limited rollover, but not both

5) Which of these questions is not up to the employer sponsoring a health reimbursement arrangement?
Will employees make contributions?

6) Which employer can sponsor QSEHRA?

Employer B has 40 employees and does not offer a group health insurance plan

7) Which of the following is allowed in a QSEHRA?

Older employees paying higher health insurance premiums receive more than younger employees.

What are recent trends in health care spending?

Annual increases were high in the 1980s, lower in the mid-1980s then high again since then

Beginning in the late 1990s there was a shift

To less restrictive forms of managed care in response to consumer demand

The consumer choice philosophy is based on giving consumers

More decision-making power and more responsibility for costs.

Which is the oldest type of personal healthcare account?

The FSA, introduced in the 1970s

Who can contribute to an FSA?

Most commonly only employees contribute, but employers are allowed to

Which is not a feature of FSAs that has limited popularity?

Low limits on contributions

Who can contribute to an HRA?

Employers only

Which is a feature of an HRA?

Annual rollover

Which account offers annual rollover, full portability and tax-free investment growth?
HSA

To be eligible for a HSA, a person must be covered by

A qualified high deductible health plan

According to studies, switching to a CDHP brings cost-savings

Initially and probably in the long run as well

According to studies, the cost savings of CDHPs come mostly from

Consumers making cost-effective healthcare choices

What is the trend in CDHP enrollment?

Rapid growth, expected to continue

Chapter 10:-- Types of Consumer-Directed Health Plans

1) Which statement is true about health savings accounts (HSAs)?
Money can be withdrawn for non-health care expenses, but it is taxable

2) Who is eligible to contribute to a health savings account?

Isabel has a qualified high deductible health plan and also dental and vision care plans

3) Which premiums can be paid tax-free with HSA funds?

Medicare Advantage

4) Can a person use HSA funds to pay a non-health related expenses or premiums?
Yes, she may, but she must pay income tax and (if she is under 65) and excise tax
 5) Which tax-advantaged accounts is/are never portable?
FSA only

6) Which tax-advantaged accounts do/does not allow employee contributions?

HRA only

7) Which tax-advantaged accounts can be set up by an individual, without employer involvement?

HAS only

Which is not an element of consumer directed health plan?

Higher premiums for coverage

Most CDHPS are based on

A high-deductible health plan

Compared to traditional health coverage, the premiums of high-deductible health plans are generally
Lower

An FSA
May be coupled with an employer health plan or a stand-alone

How popular are FSAs?

Only a majority of workers have access to them, and most of those do not participate

Which statement is true about FSAs?

Employers can make contributions with pretax dollars

Which statement is true about HRAs?

An employer may offer annual rollover of funds

What portion of workers is covered by HRA?

Only a few percent

An HSA offers
Full portability, annual rollover and tax-free investment growth of account funds

To be eligible for an HSA, a person must be covered by

A qualified HDHP only, not other broad health coverage or Medicare

A qualified HDHP must have

A deductible of at least a certain amount and total out-of-pocket expenses no greater than a certain level

Which may be a qualified HDHP exclude from an annual deductible?

Preventive care

Who can contribute to an HSA?

An employer, an employee, a self employed person or a family member on behalf of an eligible person

An HSA account holder cannot use account funds tax-free to pay for
His HDHP premium

Which premiums cannot be paid tax-free with HSA funds?

Medigap insurance

Can a person 65 or older use HSA funds to pay non-medical expenses?

Yes, she may, but she must pay income tax and tax penalty
What is the impact of healthcare reform on CDHPs?
Probably modest-some rules will change, and HDHPs may be affected, depending on how regulations are written

Which provision of healthcare reform may stimulate growth in CDHPS?

The tax on high-value health plans

Chapter 11:-- Provider Organizations and Compensation Models

1) Two independent organizations are joined into one entity under common ownership and control. This is an
example of
Structural integration

2) An example of partial structural integration

A joint venture

3) A number of physicians join together and combine their billing and collections operations, this is an example
of
Partial operational integration

4) Which physician hospital model is the least integrated?

The physician-hospital organization

5) For a physician, what is the disadvantage of provider integration?

A loss of professional autonomy

For purchasers and consumers, what is not a potential advantage of provider integration?
Lower costs resulting from a stronger negotiating process

6) Which physician-only model is the least integrated?

The independent practice association

7) What does an IPA generally do for its member physicians?

Negotiates contracts with health plans

8) What is the structure of most IPAs?

Physicians contract with the IPAs and IPAs contract with the health plan

9) If an IPA spends more than $80000 a year providing care to a single individual, an insurance company covers
any amount over $80000, this is called
Stop-loss insurance

10) What is the main difference between group practice without walls and an independent practice
assosciation?
A GPWW handles business operations for members but an IPA does not

11) The main purpose of a management services organization is to

Provide management and administrative services to physicians

12) How does a physician practice management(PPM) company differ from a regular MSO?
It purchases physicians entire practices

13) What is the primary purpose of a physician-hospital organization (PHO)?

Contracting with health plans and marketing

14) When a physician-hospital organization (PHO) is formed, physician practices

Continue to be owned and operated by the physicians
 15) A hospital allows any of its admitting physicians to join its PHO. This is an example of
An open PHO

16) An integrated delivery system (IDS) may or may not be highly integrated
Structurally

17) What is the purpose of a medical foundation?

To set up something similar to an integrated delivery system in states that do not allow corporations to buy
physician practices

18) Compensation model for accountable care organizations (ACOs) typically:

Involve shared savings and assumption of risk- upside, downside, or both

19) A healthcare delivery model based on each patient having a personal physician who is responsible for
providing or coordinating her care on a ongoing basis is
A patient-centered medical home (PCMH)

20) The Affordable Care Act

Promoted accountable care organization (ACOs)

21) Which of the following statement are correct about the patient-centered medical home (PCMH) model?
a. Provider compensation is by pure capitation
b. Technology plays an important role
c. The personal physician coordinates a patient’s care not only in her office but in other settings such
as hospitals
d. Provider compensation may include enhanced fee for service payments for evaluation and
management of patient care
B,C,D

Why physician-only model most integrated?

The consolidated medical group

What distinguishes a corporation from other organizations?

It is a legal entity separated from its owners.

Company A exists for the purpose of owning of other companies and it owns company B among others. Company A is
A holding company and the parent company of company B

Which statement is true about a for-profit health plan compared to a non-profit plan?
It is better able to raise capital

Which statement is true about tax exemption of non-profit health plans?

Tax exempt plans pay premium taxes but no income tax

Who owns a mutual insurance company?

Its policyholders

Chapter :- Health Plan Structure and Management

What statement is true about mutual and stock insurance companies?

Most insurers are stock companies.

Most health plans are

Corporations

The ultimate source of authority in a health plan is

The owners
Which statement about health plans board of directors is true?
The board appoints the CEO

A health plan’s day-to-day operations are typically the responsibility of

Key senior managers reporting to the CEO

Which position is likely to increase in the coming years?

Chief information officer.

Who is responsible for advertising?

Chief marketing officer

Which position is typically found in health plans but not in corporations in other industries?
Network management director

Who is responsible for preventing misconduct in a health plan?

Chief compliance officer

A permanent committee to advise a health plan on compensation is an example of a

Standing committee

Which committee’s primary responsibility is reviewing cases of poor quality health care?
Peer review committee

Which committee administers a health plan’s drug formulary?

Pharmacy and therapeutics committee

A health plan determines that it wills not cover and experimental therapy requested by Sharon. If Sharon appeals this
decision, which committee will likely review the case?
Appeals review committee

Chapter 12:- Network Structure and Management

1) “Market maturity” refers to the

Level of health plan activity in a market

2) In market analysis, what is considered in regard to providers?

Provider number, types, locations, utilization, costs, referral patterns and relationships.

3) Which are generally most receptive to adopting and offering a choice health plans?
Large employers with 1000 or more employees

4) Where it is most difficult to develop a comprehensive network?

Rural areas
 5) Health plans that offer more than one type of plan typically have
Either separate networks or nested networks

6) Which statement best describes the “Network adequacy”

Whether the number, types and locations of providers are adequate to meet the needs

7) Which type of law might require a health plan to include a particular doctor in its network?
Any willing provider

8) “Open Panel” or “Closed panel” refers to whether a health plan’s

Providers can see non-plan members.

9) Devin is a neurologist who mostly provides outpatient care in his office. He is likely to be categorized by a
network as
Specialist

10) Which plan types need fewer providers per 1000 members?
Highly managed and large plans with geographically close membership

11) A health plan is developing a network, and it is believed that the most important consideration of potential
members is accessibility. The plan will likely
Create a large, very inclusive primary care panel.

12) Narrow network plans

a. Typically offer a smaller number of providers and in-network facilities than traditional provider
networks
b. Often feature lower premiums
c. Must comply with state and federal laws and regulatory requirements, including network
adequacy standards
All of the above

13) Which statement best describes the purpose of provider credentialing?

The purpose of credentialing is to select the most qualified providers, meeting accreditation standards, and
minimizing legal risks.

14) In Credentialing, do health plans verify information submitted by providers?

They generally do, before offering them a contract

15) The information that a health plan can obtain from the national practitioner data bank (NPDB) about a
provider primarily relates to
Malpractise, licensure and adverse actions.

16) A provider agrees to accept a health plan’s compensation as payment in full and not to also bill plan
members. What contract provision does this describe?
No balance billing provision.

17) A party that breaches a contract is given a certain amount of time to remedy the problem and avoid
termination of the contract. What contract provision does this describe?
Cure provision.

18) Can a health plan terminate its contract with a provider when there has been no problem with the
provider’s performance?
Yes, if the state permits termination without cause and this is allow by the contract.

19) A provider already in a health plan’s network is evaluated by another provider in the same specialty. This
describes
Peer review.

Chapter 14- Utilization Management

1) Medical management can be divided into three broad categories, which are
Utilization management, clinical practice management and quality management.

2) Managing the use of medical services so that plan members receive necessary and appropriate care in a
cost-effective manner is
Utilization management

3) A health plan conducts a health risk assessment (HRA) to determine a person’s likelihood of developing
certain illness. The purpose is to
Help her reduce her risk and thereby improves outcomes and reduce cost.

4) A health plan program seeks to determine if a member has a health condition even if he has no symptoms.
This is. This can be best described as a(n)
Screening program.

5) A program supports health plan members who want to stop smoking, lose weight, eat better and exercise
more. This can be best described as a
Wellness program.

6) A program teaches health plan members how to treat minor illnesses and distinguish from serious
conditions. This can be best described as a
Self-care program

7) Colleen can access data about different drugs and health care providers on her health plan’s websites. This
is an example of
Web-based decision support tools.

8) Telephone triage programs are typically staffed by

Nurses directed by physicians and supported by non professional personnel.

9) Clark’s doctor gives him information about the treatment options available to him, and Clarke makes the
final decision. This is an example of
Shared decision-making.

10) While Gloria is being treated for an illness, her health plan conducts an evolution of whether the services
she is receiving are necessary, appropriate and cost-effective. This is an example of
Concurrent utilization review.

11) Wilson is assigned a healthcare professional who assesses his needs, designs a plan care and coordinates
and monitors the services he receives. This describes
Case management.

12) Case management is typically used for

High risk, high cost and/or chronic cases.

13) Which of the following may serve as case managers?

a. Physicians
b. Nurses
c. Social Workers
d. Community health workers
A,B,C,D

Case managers are most commonly

Nurses.

14) Which type of UM program focuses on population instead of individuals?

Disease management.

15) Disease management focuses on

Chronic diseases.

16) Which statement is true about disease management programs?

They are typically an outreach and support program for plan members with certain diseases.

17) A doctor treating a patient with diabetes refers to guidelines for this condition in making decisions about
the most appropriate course of action. This describes
Clinical practice guidelines

18) Jill, a pediatrician, is considering prescribing a certain drug for Eric. She asks herself, “Is there research that
indicates that if Eric takes this drug he will likely get better quicker than if he did not? Jill is
Engaging in evidence-based healthcare

19) Laurie has diabetes. She wants to stay well and is willing to change her lifestyle, but sometimes she doesn’t
follow instructions about diet because she doesn’t understand. The problem here is
A lack of health literacy.

Chapter 15 –Utilization Review

1) Utilization review
May be conducted before, during or after treatment.

2) Which of the following is a primary focus of Utilization review?

Whether a healthcare service is medically necessary and appropriate.

3) Which of the following statements best describes the purpose of utilization review (UR)?
Ensure correct payment of benefits, promote quality and cost-effective care and collect data for utilization
management and other purposes.

4) UR staff decides what treatment

A health plan will pay for

5) UR programs use clinical practice guidelines to

Reduce unnecessary and ineffective practice variation.

6) If both prospective and retrospective reviews are possible, which is generally preferable?
Prospective review.

7) Precertification (prior authorization) is commonly used for

Hospital admissions.

8) The average number of days a patient with certain characteristics stays in a hospital. This best describes
Length of stay guidelines.

9) When are experience based criteria usually used?

When research based utilization guidelines are not available.

10) Testing needed for an inpatient treatment should be performed

Before admission to the hospital

11) For which is concurrent review commonly used?

a. A long hospital stay
 b. A visit to a specialist
c. A visit to primary care physician
d. A course of chemotherapy
A,D

12) Prior authorization is a feature of

Prospective review and sometimes concurrent review.

13) Retrospective review most commonly

Analyzes data to review utilization.

14) Which form of UR is most likely to discover billing errors and fraud?
Retrospective review.

15) In order to receive a larger payment, a doctor improperly and deliberately bills two procedures separately
instead of together. This is
Unbundling.

16) Subjecting all health care services to UR is

Neither possible nor desirable.

17) For which type of care is a health plan member most likely to need a referral or authorization?
Nonprimary care.

18) Which service is least likely to receive authorization?

A frequently performed service.

19) Which of the following statements are correct about emergency department (ED) use and health plan
coverage of such services
a. When immediate treatment of a service injury is needed it is usually best provided by an ED
b. A health plan can incur high costs if members use EDs unnecessary
c. Visit to EDs are usually less expensive than visits to urgent care centers
d. Many states require plans to use the prudent layperson’s standard in determining whether
emergency care was appropriate
A,B,D

Emergency department use

can increase or decrease health costs.

20) Is emergency department care subject to utilization review?

Some plans require retrospective review and authorization.

21) Which of the following statements are correct about visits urgent care centers?
a. An individual with a injury that is not a serious threat to health, such as a sprain, may best be
treated in an urgent care center
b. Almost all urgent care centers are physically located on-site within hospitals
c. The cost of care in an urgent care center is generally lower than in a hospital emergency
department
d. Many plans cover the costs of urgent care center visits
A,C,D

Do health plans cover urgent health care centers?

Some do, some do not

22) Bill has chest pain and is awaiting test results. He doesn’t need any treatment at this time but needs to be
monitored. What is probably the best care setting for him?
Observation care unit.
 23) Jack had a surgery. He doesn’t need full hospital care anymore, but he needs 25-hour nursing care under
supervision of doctor .what is probably the best care setting for him?
A subacute care facility or hospital step-down unit

24) Health plan generally pay for home health care for
Those recovering from acute injury or illness, but not those with chronic conditions.

25) Do health plans pay for hospice care?

Most do for those who have six months or less to live and who forego certain medical treatment.

26) Which UR data transmittal method has traditionally been favored by providers?
Manual.

27) Which UR data transmittal method is the fastest and least labor intensive?
Electronic

28) According to the text, which UR transmittal method is the most regulated?
Electronic

29) In the UR process, an administrative review focuses on whether a proposed service is

Covered.

30) In the UR process, an administrative review is performed by

Either, clinical professionals or nonclinical employees depending on the plan.

31) According to the text, who can deny authorization based on the necessity and appropriateness?
A physician only

32) May UR staff be able to specify different treatment for a member?

Yes, but only when consensus is reached with the treating physician

33) Which statement is not true?

Once a pcp has referred a patient to a specialist, specialist can generally provide whatever treatment or as many
visits as she sees fit.

Chapter 16- Quality Assessment and Improvement

1) The two main components of quality management are

Quality assessment and quality improvement

2) The two main categories of health plan quality are

Service quality and health care quality

3) Carol has an issue about her health coverage, she tries whole day and is unable to reach her health plan by
phone. This is an issue of
Service quality

4) Medical errors
Are both a patient safety issue and a cost issue
 5) The wrong medication is prescribed for a patient, causing an adverse event. This is an error of
Execution

6) The triple aim posits that health services are optimized when:
They simultaneously pursue improving the patient experience of care, improving the health of populations, and
reducing the per capita cost of healthcare

7) Which of the following statements best describes a medical error?

A medical error is a preventable adverse event

8) Which of the following are examples of hospital-acquired conditions (HACs)?

a. Objects left in a patient’s body during surgery
b. Provision of incompatible blood
c. Provision of medication following guidelines
d. Facture that occurs within the hospital facility
A,B,D

Which problem is being addressed by national databases?

Lack of coordination among parties concerned with medical errors.

9) Consumer predictions of healthcare quality

Are important because they reflect valid concerns and affect purchaser decisions

10) A health plan’s network has a certain number of primary care physicians. This is
A structure measure

11) The percentage of health plan members who have a received a medical checkup in the past two years is
A process measure

12) Five years after treatment, 80% of cancer patients are alive. This is
An outcomes measure

13) The trend in quality measures is toward greater use of

Outcomes measure

14) What is the relationship of structure, processes and outcomes?

Structure and process produce outcomes

15) The main disadvantage of structure measures is that

Their link to outcomes is generally not proven by research

The average claim processing time is a

Process measure of service quality

16) A certain percentage of patients are able to return to work two years after a stroke. This is a
Functional outcomes measure

Which is not a disadvantage of outcomes measure?

Outcomes are not directly related to quality

Which generally presents the most problems?

Clinical data

17) Which statement about quality improvements is true?

After actions are taken to improve quality, measurement and analysis of outcomes is repeated and ongoing
 18) A hospital identifies another hospital with high cancel survival rates and adopts its practices. This is
Benchmarking

19) A health plan analyses data from different geologists and notices that one of them performs a certain
procedure much more often than the rest. This is
Provider profiling

20) A panel of pediatricians evaluates the appropriateness and timeliness of the care provided by another
pediatrician in a particular case. This is an example of
Peer review

21) The data health plans collect for quality assessment is:
Based on three sources – financial data, clinical data, and customer satisfaction and experience data

22) Health plan use a variety of strategies and tools to improve quality. Some of the most common are:
a. Benchmarking
b. Monte carlo analysis
c. Clinical Practice guidelines
d. Peer Review
A,C,D

Which is most likely to be controversial among providers?

Provider profiling

Chapter 17: Quality Standards, Accreditation, and Performance Measures

1) Which statement is are true about health plan’s internal and external standards?
a. Internal standards are often based on a plan’s past performance
b. Internal standards are typically applied to administrative services
c. Benchmarks are an example of external standards
d. Internal standards usually used to evaluate healthcare services
A,B,C

2) NCQA accredits
Health plans of various types.

3) Nationally NCQA accreditation covers

A majority of health plan members
 4) The NCQA accreditation process
Includes both an onsite visit and offsite data review

5) What form does NCQA accreditation take?

A plan earns one of five accreditation levels.

6) Which statement best describes the organizations URAC accredits

URAC accredits Health plans, health networks and functional areas within organizations.

7) The URAC standards consist of components

These components are called elements of two types – “primary” and “secondary”

The URAC accreditation process

Includes both an onsite visit and offsite policy and procedure review

8) HEDIS is designed primarily to be used by purchasers and consumers to compare

The quality of different health plans

9) Quality compass is
A national database of performance and accreditation information

10) The agency of healthcare research and quality (AHRQ) is

A research branch of the department of health and human services

11) The affordable care act

Includes a variety of healthcare quality improvement provisions

12) What will the affordable care act do with regard to medicare advantage plans?
It sought to lower payments to MA plans overall but gives incentives to plans that meet quality criteria

13) Which of the following statements is correct about the Medicare star rating system?
a. The system has been sunset and will gradually phase-out under the provisions of MACRA
b. The star rankings are based on in part on HEDIS and CAHPS data
c. There are three possible rankings under the system
d. There are five possible rankings under the system
B,D

14) Which of the following statements is correct about Medicare Access and CHIP Reauthorization Act (MACRA)
a. MACRA is an example of bipartisan legislation
b. MACRA is intended to keep physicians and other healthcare professionals from leaving Medicare
c. MACRA seeks to move Medicare away from fee-for-service to a value-based system
d. Under the Merit-Based Incentive Incentive Payment System (MIPS) compensation may be
increased for good performance or decreased for poor performance

A,B,C,D

Chapter 18:- Marketing

1) The term “marketing mix” refers to

Product, price, promotion and distribution

2) Which of the following statements best describes a health plan’s potential customers
Employers, assosciations, employees, medicare and Medicaid beneficiaries and other individuals.

3) Which is a market research technique?

Focus groups

4) How is marketing in health plans different from marketing in many other industries?
Markets are generally local

5) Which of the following statements best describes how the Affordable Care Act (ACA) has affected product
development?
The ACA has affected product development in relation to benefit packages, cost-sharing, and other matters

6) Which of the following statements best describes why health plans develop multiple product lines?
The development of multiple product lines assists health plans in competing, particularly among large employers,
but it makes marketing more complicated

7) Which statement best describes the difference between advertising and publicity?
Advertising is paid for, publicity is not.

8) The term “promotion mix” is actually used for

Advertising, publicity, personal selling and sales promotion

9) Which distribution channel is made up of health plan employees?

Internal salesforce

10) Who are generally compensated by the buyer of a health plan not by the seller?
Employee benefit consultant

11) Who are considered to represent the health plan in the distribution of health insurance policies?
a. Captive agents
b. Independent agents
c. Brokers
d. Employee benefits consultants

A,B

12) Which of the following sells the products of only one company?
A captive agent

13) Who commonly work with individual rather than the large groups?
Agents

14) Which direct marketing method is commonly used today in the distribution of health insurance products?
Direct mail

15) Who of the following would not be considered a member of regular market group?
Joanne recently lost her job and her group health policy

16) Who of the following would be considered a member of the individual Market?
a. Adam whose small employer does not sponsor a health plan
b. Blake who choose not to enroll in the health plan offered by his employer
c. Charlie who is attending a vocational IT school who without student group coverage
d. Linda who is self-employed
A,B,C,D

20) The affordable care act has affected the marketing of all health plans, but it has had the greatest impact on
the
Individual market

21) Which is not true under the ACA?

The individual market will be eliminated and everyone will have group coverage

22) Which is a common distribution method in the senior market?

a. Direct marketing
b. Meetings that provide information about Medicare
c. Door-to-door selling
d. Unsolicited telephone calling
A,B

23) People eligible for medicare

May receive health and/or drug coverage through private-sector health plans

24) The group market is made up mostly of

Employers

25) Small businesses choosing a health plan usually focus strongly on

Price

26) Which is true of small employers?

Only one health plan is usually offered

27) Which is true of large employers?

They often use employee benefit consultants

28) Which statements are correct about health care consumerism?

a. Consumerism began as workers began to take increased notice of their out-of-pocket costs in the
early 2000s
b. The implementation of the Affordable Care Act (ACA) temporarily set-back the rise of
consumerism
c. Health plans should consider health care decision support tools as they seek to build connections
with individual consumers
d. Business-to-Business (B2B) is the forward looking business model for health care marketing
professionals to incorporate into their planning
A,C

Will the affordable care act affect product development?

Yes, in relation to benefit packages, cost-sharing and other matters.

Developing multiple product lines helps a health plan compete among

Large employers, but it makes marketing more complicated.

Who are considered to represent the health plan?

Agents

Dividing a market into smaller groups of customers is called

Market segmentation

Medicare benificiaries are generally considered part of the

Non-group market

A health plan decides to compete in small group market instead of the large group market by offering a basic and
inexpensive product. This is an example of
Positioning

Which is not common in distribution channel in individual market?

Brokers

Which is not a common distribution method in the senior market?

Door-to-door selling

Chapter 19:- Underwriting, Rating, and Financing

1) Underwriting involves
Identifying and assessing risks

2) Which statement best describes adverse selection(antiselection)?

Those more likely to need healthcare are more likely to obtain health coverage.

3) In health underwriting, what are the most important risk factors for individuals?
Age and gender, and sometimes health status or occupation

4) The Affordable Care Act permits the following factors to be considered in establishing rates?
a. Tobacco use
b. Age
c. Family size
d. Geographic location
A,B,C,D

5) Which of the following is prohibited by the Affordable Care Act(ACA)?

Annual and lifetime benefit limits

6) In renewal underwriting of a group, what are the two major factors have traditionally been taken into
account?
Experience and participation

7) In rating, what are the main considerations?

Risk and expected costs balanced by marketability and competitiveness

8)Setting premiums based on the expected costs of providing benefits to the community as a whole rather
than to any subgroup is called
Community rating

9) A helath plan sets premiums for a group based on the plan’s average experience with all groups rather than
that particular group. This describes
Manual rating

10) A health plan uses a group’s past experience to estimate its expected experience and if actual experience is
different, the plan absorb gains or losses. This describes
Prospective experience rating

11) An insurance company is financially responsible for paying healthcare benefits to the employees of High
plateau company. High plateau’s health plan is
A fully funded plan

12) Big river corporation takes responisibility for paying health care benefits to its employees, but if total claims
raises above $10million a year , an insurer pays any claims above this level. This is an example of
Aggregate stop-loss coverage

A health plan set premiums for classes of members based on age,family composition and geography but not
experience. This is an example of
Adjusted community rating
Which will be prohibited by PPACA?
Preexisting conditions exclusions

Which will be prohibited by PPACA?

Annual and lifetime benefit limits

Community rating is least likely to be used for

Large groups

Which will PPACA do regarding the rating as of 2014?

Limit premium differentials based on risk factors

An MCO’s income statement

Summarizes its revenue and expense activity during a specific period

The major categories of MCO’s balanced sheet are

Assets, liabilities and capital

State insurance regulators are primarily concerned with an HMO’s

Statutory solvency.

A variance is the difference between

Expected and actual revenues and expenses

A third party administrator generally

Administers benefits only

Chapter 20-Information Management

1) An IM system incorporates membership data and provider reimbursement arrangements and analyses
transactions according to contract rules. This describes a
Contract management system

2) A health plan has an automated system to facilitate the processing of requests for authorization of
payment. What kind of information management system is this?
Utilization management

3) An IM system identifies physicians who tend to provide fewer services than the norm in certain situations.
This is an example of
Provider profiling

4) The use of an MRI machine is expensive, so a health plan needs an efficiently coordinate utilization of
providers. What type of information management system addressees this need?
Enterprise scheduling

5) A health plan’s members can go the plan’s website to check on the status of their claims. What kind of
information management system is this?
Member services.

6) Which statement about the quality of health plan data is not true?
The use of codes largely eliminates problems of accuracy.

7) The data used by health plans is

Often in different databases and in incompatible formats.

8) Which aspect of information management in health plans is most strongly addressed by government
regulations?
Security and privacy

9) Which of the following represent challenges in managing information and data for health plans?
a. Health plans often receive data that is poor in quality
b. Mobile computing of medical records requires the development of security and compliance
protocols
c. Health plans IM systems must be able to produce many different types of reports
d. There is often a gap between the integration of patient care and administrative systems
A,B,C,D

10) Which of the following statements about HITRUST Common Security Framework (CSF) is correct?
a. It was developed as a way to reduce cyber breaches in the healthcare systems within the United
States
b. It was developed as a tool for both the financial and healthcare industries
c. It was developed to provide a framework for managing the security requirements of HIPAA
d. It is updated on a regular basis
A,B,D(not for both financial and healthcare industries)

11) According to the text, which term encompasses all types of electronic business functions?
e-business

In health plans, information management is

Somewhat authorized.

12) which statement best describes health plans and the internet?
Health plans have historically lagged behind other industries but are now handling many transactions online

13) A security device designed to block unauthorized access to private network is

A firewall

14) A computer network is accessible only the employees of a health plan. This is an
Intranet

15) According to the text, The main threat to health plan’s network is
Employees

16) Which of the following statements best describes the reason(s) for the rise of “retaliation” of healthcare?
It provides healthcare consumers with increased convenience and empowerment regarding their healthcare choices

17) How does electronic data interchange differ from e-business?

It is the transfer of the batches of data, exchanges about a transaction

18) Which generally results in more accurate data, manual process or EDI
EDI

19) The focus of business intelligence and decision support system is to

Help managers make decisions in specific cases

20) The main issue that a data warehouse is designed is to address

Data in multiple databases

21) Which statement best describes the focus of a data mart?

It is often focused on one or more specific lines of business

22) The main disadvantage of data warehouse is

The complexity and cost of implementing them

23) Medical information for an individual designed to be used at the site of care is
An electronic medical record

24) The main advantage of health information networks(HINs) and health information exchange (HIEs) is that
providers treating a patient
Have access to all of her medical records and health information

25) Which of the following statements best describes a health information network (HIN) or its operations?
A HIN is a computer network that gives the providers of a health plan access a database of medical information

26) How does a HIE differ from HIN?

An HIN shares information within a health plan network while an HIE shares it across healthcare entities.

27) Which of the following statements about personal health records (PHRs) are correct?
a. A PHR is a history of an individual’s health and encounters with healthcare system
b. A PHR is owned by the individual’s health plan and security maintained by that healthplan
c. A PHR is owned by the individual’s whose health history it records
d. Broad standards have been implemented which that the information in a PHR both interoperable
and portable
A,C

28) Which is owned by the individual?

The personal health record (PHR)

29) Personal health records are available from

Health plans and other organizations

30) Which of the following statements best describes a health information exchange (HIE) or its operations?
A HIE is the electronic sharing of clinical information among the information systems of various healthcare
organizations in a community

31) An electronic health record (EHR) can reduce the risk of data replication
True

32) Which of the following statements about cloud computing are correct?
a. Cloud computing means that instead of relying on computer hardware or software sitting on your
desk your computing needs are handled by a third party
b. Cloud computing provides the potential for reduced costs in the healthcare industry because
heavy capital expenditures can be avoided
c. The power of cloud computing makes it easier to undertake data analysis
d. One drawback of cloud computing for health plans is the potential for being locked into vendor
recommended systems
A,B,C,D
 33) Which of the following statements about blockchain are correct?
a. Blockchain has been in everyday use since mid 1970s
b. Blockchain is a log of transactions that is replicated and distributed across multiple decentralized
locations
c. A potential use for blockchain in the healthcare industry is claim adjudication
d. One of the benefits of blockchain is increased transactional speed
B,C

34) How does an electronic medical record differ from personal health record?
The EHR adds information from providers.

35) An example of insourcing-outsouring hybrid is

Cloud computing

Chapter 21: Claims Administration

1) In traditional indemnity health insurance, which is most common?

Claims are submitted by the provider to the healthplan.

2) When is an encounter report submitted instead of a claim?

When the provider is compensated by salary

3) Health plan claiming process is similar to that of traditional insurance for

Hospitals and many but not all healthcare professionals

4) About what percent of typical health plan’s claims are processed electronically?
80 to 90 percent

5) Which statement is true about electronic claims processing?

It is promoted by federal legislation

6) A health plan employee who deals with claims that have been paid incorrectly is a claims
Adjustor

7) A claims examiner’s responsibility generally includes

Reviewing and adjudicating claims not processed electronically

8) Under which type of provider compensation arrangement is most claims information needed?
Discounted fee-for-service

9) Which standardized claims form is used by physicians

CMS-1500

10) Which is the standard code set for diagnosis?

ICD-10

11) A claim triggers an edit. Usually a claim will be

Examined further.

12) In which situation is it not uncommon for a health plan to make a partial payment on a claim?
Authorization was not obtained

13) Which statement is true about claims processing?

If a provider bills more than 180 days after delivering a service, a plan is not required to pay

14) Coordination of benefits may apply when

A person is covered by more than one health plan

15) Most claim investigations

Are short and simple.

16) The primary focus of the NAIC unfair claims settlement practice act is
Ensuring that insurers handle claims fairly and promptly.

Chapter 22:-- Member Services

1) Which of the following statements is correct about health plan members education?
a. Many of the problems members experience with their coverage arise because they do not
understand the plans benefits
b. Proactive education about a plans requirements for authorization of payment can reduce disputes
about claims
c. Providing members with information about preventive care can enhance member satisfaction
d. Due to the opioid crisis health plans should not educate members about drug formularies in order
to reduce addition
A,B,C

2) Health plan member education may be directed at

a. All members on issues such as network providers, their locations, and credentials
b. Members with certain common characteristics such as gender but not age because would be
considered discriminately
c. Only at selected members for information regarding differences in benefit levels for in network
and out of network care
d. Members with certain common characteristics such as those suffering from a chronic disease
A,D

Health plan’s member education focuses on

Either administrative matters or health or both

Health plan’s member education is directed to

Both( members )

3) Which means of distributing information to health plan members Is declining?

Letters and newsletters sent by email

4) Jeff calls his health plan’s toll free number and is able, by following prompts and without talking to a person
to change his pcp. This is an example of
IVR

5) In health plan member services, when are paper documents sent by mail?
When required by regulations for important notifications

6) Which statement about health plan’s communication with members is true?

Members can not only obtain information from websites but also sometimes performs transactions

7) Contact centers may be

On-premise, hosted or cloud based

8) Which statement best describes why must a health plan adequately deal with complaints?
To comply with regulations, maintain member satisfaction, avoid bad publicity and reduce appeals

Why must a health plan adequately deal with complaints?

To comply with regulations maintain member satisfaction, avoid bad publicity and reduce appeals

9) A health plan’s complaint resolution procedures

Are generally subject to state and federal regulation and accreditation requirements

10) Who generally conducts a health plan’s level two appeal of a member complaint?
The appeals committee

11) What happens if a health plan member does not win a level two appeal?
She may have the right to appeal to the government agency or an external review organization

12) What are the two main ways of measuring member satisfaction with a health plan?
Member satisfaction surveys and complaint monitoring

13) What populations do health member satisfaction surveys target?

Members who have recently received services, all members and former members

14) Who conducts member satisfaction surveys?

Plan employees or outside companies but some accrediting bodies and purchasers require outside companies

15) Which statement about the structure of health plan member service is true?
Among plan types, small PPOs are least likely to have a dedicated member services department.

16) Which is likely to decrease the number of employees needed for adequate member services staffing?
The use of CTI

17) Which statement about member service representatives is true?

They are subject to high stress and burn-out, so retention is a concern.

18) Which statement about member service technology is not true?

IVR systems and websites can only provide information not handle transactions.

19) The amount of time required to complete a transaction requested by a member is

Turn-around time

20) Which is a measure of both quality and cost effectiveness?

First contact resolution rate

Which is considered a measure of cost-effectiveness rather than quality?

Average time per contact

Chapter 23: Federal Laws and Regulation

1) The medical laboratories in a community get together and decide how much they will all charge health
plans for various tests. This is probably a case of
Price-fixing

2) A physician group refuses to provide certain speciality services to a health plan unless the plan agrees to
contract with the group of all the services the group offers. This many be a case of
A trying arrangement

3) Which is an important provision of the Financial services modernization act?

The protection of personal financial information

4) ERISA applies to
Employer and union-sponsored health plans
 5)Under ERISA, what are the roles of the federal and state governments in regulating government-sponsored
health plans?
A employer health plan is regulated by the federal government, but any insurer involved is regulated by the state.

6) Under ERISA, an individual challenging a coverage decision by an employer-sponsored health plan

Must sue in federal court and may not receive punitive damages

7) If an employee is laid off, under COBRA she has the right to continue her employee-sponsored health
coverage
For up to 18 months

8) Bill is covered under his wife Lorie’s employee-sponsored health plan. What right does bill have under
COBRA to continue this coverage?
He has rights if Lorie’s employment is terminated, she dies or they are divorced.

9) Noah has been laid off and is contributing his employer health coverage under COBRA. Who pays?
Noah pays the full cost of coverage, and the employer may charge him up to 2 percent for administrative costs.

10) Which of the following statements regarding the HIPAA are correct?
a. Title I provisions are designed to help workers maintain insurance coverage if they lose or leave
their jobs
b. Title II provisions are aimed at combatting fraud, waste, and abuse
c. Title III contains provisions related to long term care (LTC) insurance
d. Issues concerning privacy rights and technology generally fall under Title II
A,B,C,D

11) Which of the following statements is correct under the provisions of HIPAA?
Healthcare providers must generally obtain an individuals written consent to use protected health information

12) Which of the following statements is correct about 21st Century Cures Act?
a. The Cures Act is primarily focused on the curing heart disease
b. The cures Act provides substantial support to the states to address opioid abuse
c. The cures Act seeks to improve the interoperability of electronic health records (EHRs)
d. The cures Act contains provisions allowing large employers to fund health reimbursement
arrangements (HRAs) for select employees
B,C

What is the impact of the HMO act of 1973?

HMOs that wish to be federally qualified must meet the standards, and while qualification is less important today,
many HMOs are qualified.

Under ADEA, an employer sponsoring health coverage

May not decline to offer health coverage to older employees nor change them more.

Under FMLA, an employee who is ill or needs to care for a family member has the right to 12 weeks of
Unpaid leave, including health coverage.

Which is not one of the main goals of HIPAA?

Expanding Medicaid eligibility.

HIPAA applies to
The individual and group markets

Under HIPAA, guaranteed individual issue of health insurance generally applies to person who
Have lost group coverage and are not currently eligible for it

Which is not a provision of HIPAA for group health plans?

They must provide mental health coverage.

HIPAA’s administrative simplification standards apply to

Health plans, healthcare providers and healthcare clearinghouses.

Which is not true under HIPAA privacy and security standards?

Health plans may not use healthcare information for their own treatment, payment or operations without
obtaining the individual’s consent.

Chapter 24:-- The Affordable Care Act

1) With regard to health coverage, the main concerns addressed by ACA are
Access, affordability and comprehensiveness

2) Under the ACAs guarantees issue rule, when an individual with serious health problem applies for health
coverage, a health plan
Cannot deny coverage, charge a higher premium, or exclude coverage for the preexisting condition

3) Which statements is correct about ACA rules?

As of 2019, consumers will no longer have to pay a tax penalty if they have no health coverage

4) The ACA Medicaid expansion extends eligibility primarily to

More low-income nonelderly adults

5) Trey is a student. Jack is financially dependent on his parents but does not live with them. Amber is married.
Paul could enroll in health plan offered by his employer. They are all 25 years old. Their parents all have
health plans that offer dependent coverage for children. Who has the right to be covered under their
parents plan?
a. Trey only
b. Trey and Jack
c. Everyone but Paul
d. All of them
All of them

6) Which essential health benefits (EHB) category is required only for children, not adults
Vision and dental care

7) Which statement is true about the essential health benefits (EHBs) required for some health plans by the
ACAs?
Annual or lifetime limits are generally prohibited for EHBs but still allowed for non-EHB benefits

8) Which statement is true about the levels of coverage offered by plans under the ACA?
Of the metal plans, Bronze plans tend to charge the lowest premiums

9) Which statement is true about ACA rules for individual premiums?

Individuals cannot be charged more because they have a medical condition

10) Who is likely eligible for a premium tax credit under the ACA?
Sophia’s income is about 300 percent of the federal poverty level, and she enrolled in a gold plan through
Marketplace

11) Who is likely eligible for cost sharing reductions under the ACA?
Quinn’s income is about 200 percent of the federal poverty level, and he enrolled in a silver plan through Marketplace

12) Living Well health is a small group health plan. What percentage of the money it receives in premiums must
it spend on members healthcare and quality improvement?
80 percent
Which of these is a component of the healthcare reform?
The requirement that most people have health coverage or pay a tax penalty.

When will the new healthcare financing system become operational?

Most of the major components become operational in 2014, but some provisions go into effect earlier or later.

With some expectations, individuals who do not have health coverage will
Have to pay an income tax penalty

Large employers are

Required to sponsor health coverage or pay fees.

Small employers are

Not required to sponsor health coverage but may be eligible for tax credit if they do.

Tax credits will be available to help people pay for

Both premiums and cost-sharing payments

Under the new requirements for health insurance plans, which of these will be permitted?
Premiums based on age.

Under the new requirements for health insurance plans, cannot be considered in setting premiums?
Health

Chapter 25:-- State Laws and Regulation

1) Which of the following statements about the impact of the ACA on the regulation of health plans is correct?
The ACA allows for regulatory flexibility which is likely to result in additional variation in state laws

2) At which level of government is there the most health plan regulation?

At the state level

3) State financial standards for HMOs are intended primarily to

Protect consumers from the risk of plan insolvency.

4) If a health plan risks becoming insolvent, what can an insurance commissioner do?
Intervene in the plan’s operations, take over its management and liquidate it

5) The primary goal of receivership of a health plan is to

Return the normal to plan operation
 6) Which statements best describes the scope of state regulation of health insurance regulation
States regulate entities accepting financial risk and other entities performing services for health plans

7) Which plan type subject to the least state’s regularly authority?

Employer self-funded plans

8) Have states enacted laws to regulate PPOs?

Most have

9) Which statement best describes regulation of entities covering only limited benefits?
States generally require these organizations to obtain a certificate of authority, regulate their solvency and provide
for further oversight of their activities

10) Which statement best describes state’s regulation of utilization review organization?
Most states license them, require certification and regulate them to some extent.

11) Which statement best describes states’ regulation of third-party administrators (TPAs)?
Most states have various requirements including a certificate of authority.

12) Which is required by NAICs Health Care Professional Credentialing Verification Model Act?
a. If a provider meets a plans credentialing criteria, she must be contracted by the plan
b. Providers must be allowed to review and correct credentialing procedures
c. Providers must be given access to written credentialing procedures
d. Recredentialing is required every three years
B,C,D

13) The same consumer protection laws apply regardless of whether an individual has employer based
insurance or purchases it individually
False

14) State law focuses solely on consumer protection

False

15) Which statement is true about state regulation of the privacy of health information?
Health plans should be aware that state law may be more restrictive than federal law with regard to the allowable
uses and disclosures of health information

State regulations review the description of HMO’s service area and the list of network providers. The regulators are
concerned with
Network adequacy

States generally regulate

HMOs,PPOS and EPOs

Which plan type is often not governed by a state’s regular insurance code?
HMO

An HMO with a point-of-service option

May be regulated under either, depending on the state

Which is not required by NAIC’s Health care professional crediting verification model act?
If a provider meets a plan’s credentialing criteria, she must be contracted by a plan

Which statement is true about the NAIC’s privacy of consumer financial and health information model regulation?
It addresses disclosure of nonpublic personal health information

Chapter 26:-- Government Programs Medicare

 1) Original medicare consists of
Part A and partB (hospital and medical coverage)

2) The main purpose of medicare part c is

To provide medicare coverage through private-sector health plans.

3) Medicare part D prescription drug coverage is

Made available to medicare beneficiaries at an extra cost

4) Medicare part A beneficiaries who go into the hospital

Must pay a large deductible before medicare pays any benefits

5) Medicare Part A skilled nursing facility and home health care benefits are paid
For a limited time to those recovering from an illness or injury

6) Medicare Part A is available to persons 65 and older

But those who did not pay into the medicare system pay a premium

7) For a disabled person to qualify for medicare, her disability

Must be total and long-term

8) Medicare part A is funded primarily by

Medicare payroll taxes.

9) Does Medicare part B cover services provided by dentists, podiatrists, optometrists and chiropractors?
Only limited services are covered and only when restrictive conditions are met

10) Medicare Part B charges

An annual deductible and coinsurance of 20 percent for most items.

11) For medicare part B

Most individual pay a monthly premium

12) For medicare part B

Most people pay a standard premium but those with high incomes pay more.

13) Which of the following statements correctly describes enrollment in medicare Part A?
Those collecting social security benefits are automatically enrolled in Medicare when they become eligible

14) Tim decides not to enroll in Medicare part B when he first becomes eligible, even though he has no
employer sponsored health coverage. Can he enroll later?
Yes, he can, but he may have to pay a premium penalty equal to 10 percent for each 12 month period he waits to
enroll

15) Which is best describes as Medicare advantage is

MA is an alternative to original medicare

16) Medicare advantage plans provide

Part A and part B coverage and usually other benefits.

17) Which statement is correct about MA plans?

Premiums and cost sharing payments differ from plan to plan

18) Medicare part D prescription drug coverage is provided

By private-sector prescription drug plans(PDPs) and MA plans
 19) Medicare part D prescription drugs coverage is offered by
Most but not all MA plans usually for an additional cost

20) Medicare part D prescription drug plans(PDPs)

Must all provide a minimal level of benefits

21) Which statement is correct about Part D prescription drug plans?

PDPs may have different deductibles(or no deductibles) and coinsurance and copayment amounts vary

22) In a typical medicare part D PDP, after PDP and the beneficiary have together paid a certain amount of
drugs, the beneficiary pays
All costs until catastrophic coverage is triggered.

23) Clarice describes not to enroll in medicare part D when she becomes eligible even though she has no
employer-sponsored drug coverage.Can she enroll later?
Yes, she can, but she will pay a higher premium due to late enrollment penalty.

24) What is the recent trend in medicare health plan enrollment?

it has been steadily rising in recent years

25) Managed care was introduced into medicare by

TEFRA in 1982

26) What is the main aspect of medicare managed care that the MMA of 2003 changed?
Types of plans available

27) As enacted, what was the main impact of the Affordable Care Act (ACA) on Medicare Advantage?
Reduced Funding

28) Which of the following statements are correct about medicare supplement (Medigap) policies?
a. Medigap policies are standardized offering the same benefits and using the same definition
b. Medigap policies currently sold include prescription drug benefits
c. Medigap policies can be combined with Medicare advantage Part D plan to offer seniors a
comprehensive package of healthcare coverage
d. Massachusetts, Minnesota and Wisconsin have their own Medigap regulations
A,D

What is the main impact of healthcare reform on medicare advantage?

Funding

A medigap policy is available to those enrolled in

Both medicare part A and part B

Which of these is covered by some medigap policies?

Health care received outside the united states.

Medigap policies
Must provide one of a few standard benefit packages.

Can an insurer deny medigap coverage to an eligible medicare beneficiary or charge him a higher-than-standard
premium?
It cannot do this if he enrolls when he first becomes eligible or otherwise qualifies for guaranteed issue, but
otherwise it can.

Chapter 27:- Government Programs Medicaid, CHIP, FEHB, TRICARE, and Workers’ Compensation

1) Which of the following statements best describes state variation in Medicaid coverage of benefits?
Benefits Vary somewhat from state to state, within federal guidelines

2) Currently, Medicaid is available in all states and the district of Columbia

Primarily to low-income children, pregnant women,elderly and disabled people, and a few parents

3) The Affordable care Act (ACA) as written sought to make Medicaid available in all states
All people with incomes below 133 (138 adjusted) percent of the federal poverty level (FPL)

4) Which of the following is mandated benefit under Medicaid?

Inpatient hospital service

Under PPACA, Medicaid will be available

All people with income below a certain level.

5) If a health care is fully covered by both medicare and Medicaid, who pays?
Medicare

6) The primary purpose of CHIP is to provide health coverage to children who

Are from families with incomes too high to qualify for Medicaid but too poor to afford health coverage

7) Alex,logan , kaitlyn and are all 14-years old. Who may be eligible for CHIp?
Alex’s family’s income is about twice the FPL.

8) Which of the following would be considered acceptable coverage packages under CHIP?
a. The state provides the same coverage as the standard Blue Cross/Blue Shield plan preferred
provider service plan offered to federal employees
b. The state provides the same coverage as that offered to state employees
c. The state provides coverage equivalent to that offered by the largest carrier of short term plans
(up to 364 days) in the state
d. The state provides coverage under a plan approved by the secretary of health and human services
(HHS)
A,B,D

States have the option of offering CHIP coverage to pregnant women,

But most do not

9) Under CHIP
Copayments and premiums can be charged within limits

10) Which of the following statements best describes the Children Health Insurance Program (CHIP)?
CHIP is not an entitlement program and is heavily dependent on federal reauthorization of funding

Over the years the importance of managed care in Medicaid has

Increased

Currently, what portion of Medicaid recipients are in managed care?

A large majority

Which is currently a rule governing Medicaid managed care?

Health plans serving Medicaid recipients must meet certain requirements related to quality and enrollee protection

Which is not a challenge generally faced by health plans serving the Medicaid population?
Most people in Medicaid managed care are elderly or disabled.

11) The portion of Medicaid recipients enrolled in manages care is

Growing and is now a sizable majority
 12) Which of the following Medicaid managed care arrangements provides comprehensive coverage?
Managed Care Organization (MCOs)

13) Which of the following statements about Medicaid managed care is correct?
Both an MCO and a prepaid health plan are paid by capitation and assume financial risk

14) The central focus of this innovative health models is on coordinating services for those with multiple chronic
conditions.
Medical Health Home (HH)

15) A group of providers agrees to share savings and (sometimes) losses with a payor, based on a benchmark.
Accountable Care Organization (ACO)

16) TRICARE serves

Active and retired members of the uniformed services and their spouses and dependent children

17) TRICARE coverage takes the form of

Fee-for-service or HMO coverage

18) Who pays the premium for TRICARE?

Most participants except for activity duty service members.

19) TRICARE young adult is a type of plan available to

Single young adults up to age 26 whose coverage under “regular” TRICARE has ended

States can offer premium assistance instead of health coverage to

Both Medicaid and CHIP recipients although it may be voluntary

Under FEHB, health coverage is provided by

A large number of health plans that employees choose from

FEHB health plans include

A variety of plan types.

FEHB health plans

Must offer at least a minimal benefit package

What is workers compensation?

State programs that require employers to provide benefits for work-related injuries and illnesses.

Worker’s compensation pays benefit to cover

Both medical expenses and lost income

Which is a feature of worker’s compensation?

No coverage of non-work-related injuries and illnesses

An employee is eligible for worker’s compensation benefits

Whether or not the employer is at fault for her injury or illness, but even if the employer is at fault, she cannot sue
it for damages.

Chapter 28: Ethics

1) “Ethics” can best be defined as

Principles and values that guide decisions of right and wrong

2)Health plans and their providers must respect the right of plan members to make decisions about the
course of their lives. This is the ethical principal of
Autonomy

3) Character traits that dispose people to act well toward others are
Virtues

4) Health plans have an ethical obligation to promote the good of

Both individual members and the membership as a whole

5) A health plan ethics task force provides

A forum for discussion of ethical issues and offers consultations when physicians and families face ethical decisions

6) A health plans code of conduct requires recognizing and addressing conflicts of interest. In doing so, it
addresses
Integrity

7) Which of these actions by a health plan is most likely ethical?

Allowing patient preference to override recommendation generated by predictive analytics in some cases

8) Jill, Devin, and Mark are insurance agents. Jill sells client policies that are no better (but no worse) that the
ones they already have. Devin coaches clients to give answers on insurance applications that will give them
lowest premium, even if they are not strictly true. Mark signs the insurance application for a client who is
unable to do so. Who is behaving unethically?
All three

Extra Important Questions: ----------

A health plan pays a certain amount of hospitalization, according to the classification based on diagnosis, procedures and other
factors. This describes
Diagnosis-related groups

What is the most secure and restrictive level of behavioral health care?
Acute care

The two main components of consumer-directed health plan(CDHP) are

A high deductible health plan and tax-advantaged personal healthcare account

Who can make a contribution to health savings account(HSA)?

An employer,an employee, a self-employed person or family member on behalf of an eligible person

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

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

What kind of a risk does an HMO assume or share?

Both financial and delivery risks

Managed dental care accounts for

A large majority of dental coverage and is growing

Under traditional indemnity health insurance, insured’s can receive healthcare

From any provider they choose

Which statement about traditional health plan products is correct?

More health plan products are being offered, and the distinctions between them are becoming sharper.
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.

The primary purpose of state’s financial responsibility standards for the HMOs is to protect
Insureds from the possibility that the HMO may become insolvent

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

An employee can contribute to FSA,using pretax dollars

When a health plan compensates a provider by capitation, which generally occurs?

The provider submits encounter reports to the plan

Which statement about health plan claims processing is true?

Electronic claims processing can handle only simple claim decisions.

For small businesses buying a health plan, what is usually the key factor?
Premium price

Which is not typical of managed care?

Fee-for-service compensation

Which type of quality data presents the most problems?

Outcomes measures.

At the end of the year, if there is more than enough money in a pool to cover specialty care, a health plan’s 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

Which health plan types provide coverage of non-network care, but with higher-cost sharing?
PPOs and POS products

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

Provide unnecessary services
In establishing and maintaining provider networks, health plans generally to ensure member access to care by
Considering the number, type and location of providers needed.

For what type of group is community rating least commonly used?

Large groups

Which is not a rule of federal health parity laws?

Cost-sharing for behavioral healthcare cannot be more than for medical care

Which is a provision of the HMO act of 1973?

Federally qualified HMOs had to meet less rigorous standards other than health plans

The perceptions of health plan members about the quality of the care they receive
Should be considered because they reflect important aspects of health care not addressed by objective measures.

In the united states, indemnity health insurance

Used to be the predominant form of health coverage but no longer is

Do HMOs typically provide preventive care?

They provide extensive preventive care and charge little or no cost-sharing for it

In traditional indemnity health insurance, how are healthcare providers paid by the insurer?
Fee-for-service

Under the principle of beneficence, health plans must promote the good of their
Individual members and their membership as a whole

Typically, who submits encounter reports instead of claims to a health plan?

Healthcare professionals compensated by capitation
What cost-sharing structure is most common in a dental PPO?
An annual deductible, coinsurance and an annual maximum benefit

A contract between a health plan and its network providers requires to accept the plan’s compensation as payment in full and
prohibits them from billing plan members for additional amounts. What contract provision is this?
No balance billing provision

Which is a common HMO compensation arrangement for hospitals but not physicians?
Diagnosis-related groups (DRGs)

Which of these is a method used in market research?

Focus groups

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?
POS

In the health plan market, large employers

Tend to change health plans more frequently than small plans.

What portion of participants in Medicaid and the children’s Health Insurance Program (CHIP) are in managed care?
A large majority

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 provides. This describes
A relative value scale (RVS)

Which is an important factor dividing increased healthcare spending?

Defensive medicine.

Does medicare cover all healthcare expenses?

Medicare has substantial cost-sharing payments, and it does not cover routine dental, vision and healthcare and some other
items.

Bhramastra:

1) What coverage do medicare advantage plans provide?

Medicare Part A and Part B coverages, other benefits and usually drug benefits
2) The two main components typical of a consumer-directed health plan( CDHP) are :
A high deductible health plan and a tax-advantaged personal healthcare account.
3) A health plan projects the cost of providing benefits to a group based party on the plan’s rate manual and partly on the
group’s experience. This describes: blended rating
4) Which communication channel between a health plan and its members is being used less and less? Regular mail
5) A panel of cardiologists evaluates the care provided by another cardiologist in a particular case. This is an example of :
peer review
6) Typically, who submits encounter reports instead of claims to a health plan?
Health care professionals compensated by capitation
7) In the marketing of health plans, who is compensated by the party buying a product, not the health plan selling it?
Brokers and employee benefits consultants
8) Why it is important for a health plan to deal adequately with member complaints?
To comply with regulations and accreditation requirements and to maintain member satisfaction and a good public
image.
9) What is HEDIS? A set of performance measures for use in comparing the quality of different health plans
10) In a health plan, what is underwriting? Identifying and evaluating risks presented by individuals and groups
11) Managed dental care accounts for : a large majority of dental coverage and is growing.
12) Which type of quality data presents the most problems? Customer satisfaction measures.
13) How do PPOs most commonly compensate physicians? Discounted fees
14) Who receives medicare part D prescription drug coverage? All medicare beneficiaries have the option of enrolling and
paying an additional premium.
15) In traditional indemnity health insurance, how are healthcare providers paid by the insurer? Fee-for-service
16) Which health plan types do not normally pay benefits for out-of-network care? Traditional HMOs and EPOs
17) How widespread are flexible spending accounts (FSAs) and health reimbursement arrangements (HRAs)?
Only a small minority of employees have one or the other.
18) What form does cost-sharing generally take in traditional indemnity health insurance?
 An annual deductible and coinsurance
19) A health plan’s 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
20) For which of these healthcare services is precertification (prior authorization) most likely to be required?
A hospital admission
21) The majority of U.S employees with health coverage are enrolled in : a PPO
22) What population is eligible for health coverage from TRICARE?
Active and retired members of the military and their spouses and dependents
23) NCQA provides accreditation for : many types of health plans.
24) Which physician-only provider organization is the most integrated? The consolidated medical group
25) By the 1990s HMOs had become accepted by consumers and employers, but many people objected to their :
lack of provider choice
26) In the united states, indemnity health insurance : used to be the predominant form of health coverage but no longer is
27) Which statement about the tax exemption of not-for-profit health plans is correct?
Some not-for-profit plans are tax-exempt but others are not.
28) When is utilization review conducted? Before,during and/or after treatment
29) A health plan has an obligation to respect the right of its members to make decisions about their own lives. This is ethical
principal of : autonomy.
30) Government regulation has the greatest impact on which aspect of health plan data? Security and privacy.
31) The main goals of HIPAA do not include : requiring all employers to sponsor health coverage.
32) What is the most secure and restrictive level of behavioral healthcare? Acute care
33) In which of these provider organizations do physicians normally not own and operate their own practices?
Consolidated medical group
34) An HMO contracts with eight group practices. This is an example of : a network model HMO
35) What is the most important threat to a health plan’s computer network? The plan’s employees.
36) Which of these is an example of adverse selection ( anti-selection)?
A higher percentage of unhealthy employees enroll in an employer’s health plan compared to healthy employees.
37) Under the principle of beneficence, health plans must promote the good of their :
individual members and their membership as a whole.
38) What is the characteristic feature of a corporation that makes it different from other organizations?
It is a legal entity separate from its owners.
39) Which statement about state regulation is correct?
Most states does not have laws specifically addressing HMOs or PPOs, but regulate them through the regular insurance
code.
40) Which statement best summarizes the use of the internet by health plans?
Health plans have historically lagged behind compared to other industries but now conduct many transactions online.
41) 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 : manual rating.
42) For what type of group is community rating least commonly used? Large groups.
43) Under ERISA, does the federal government regulate employer-sponsored health plans?
It regulates neither self-funded nor fully insured plans.
44) Which is not a rule of federal mental health parity laws? All health plans must provide behavioral health coverage.
45) The HMO contracts with a single group practice. This describes : a group model HMO.
46) Which health plan types generally require a referral from a primary care physician to see a specialist?
Traditional HMOs.
47) 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
48) In the health plan market, large employers : are often self-funded.
49) Which statement is true about how health plans communicate their members?
Some interactive voice response (IVR) telephone systems enable members to conduct certain transactions without
talking to a person.
50) To calculate how much to pay a physician for a procedure, a health plan assigns a numerical value and multiplies this
number by a dollar figure negotiated with providers. This describes : a relative value scale (RVS)
51) 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.
52) How does electronic data interchange (EDI) differ from e-business ?
EDI is the transfer of batches of data, not back-and-forth exchanges of information about a transaction
53) Under capitation, the amount a provider Is paid is based on : the number of members she is responsible for
54) A history of an individual’s health and his encounters with the healthcare system that is owned by the individual is :
The personal health record
55) Why has the popularity of flexible spending accounts (FSAs) been limited?
The “Use it or lose it” rule and the lack of portability
56) Which is a common position in a health plan but is not common in other types of companies? Chief medical officer
57) Whether a health plan has an “open panel” or a “closed panel” depends on whether :
providers can provide care to non-plan members.
58) Which is a provision of the HMO Act of 1973?
 Federally qualified HMOs were exempted from state laws that restricted their development
59) Under the Federal Employees Health Benefits( FEHB) program, employees :
choose from a large number of health plans and plan types
60) In which health plan type do members not have to select how to receive services until they use them?
Point-of-Service (POS) product.
61) Most regulation of health plans : has been at the state level but after the
Affordable Care Act ( ACA) will be at the federal level.
62) Under traditional indemnity health insurance, insureds can receive healthcare : from any provider they choose.
63) Under the Affordable Care Act ( ACA) (healthcare reform), which may a health plan not consider in setting a person’s
premiums? : Health
64) 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.
65) 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.
66) A health plan’s utilization review staff make decisions about what healthcare services : the plan will pay for
67) After Sarah has been in treatment for a respiratory condition for 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
68) The perceptions of health plan members about the quality of the care they receive :
should be considered because they reflect important aspects of healthcare not addressed by objective measures.
69) Under which compensation arrangement do providers assume the greatest financial risk? Capitation
70) Which is not typical of managed care? Fee-for-service compensation
71) A Certain percentage of the members of a health plan have received a cholesterol screening.What kind of quality
measure is this? Process measure.
72) When a health plan compensates a provider by capitation, which generally occurs?
The provider submits encounter reports to the plan
73) Which HMO model has high facility costs but greatest control of care management and quality? Staff model
74) Normally, what does a health plan’s ethics task force do?
It provides a forum for discussion of ethical issues, promotes ethics education and offers consultation in specific ethical
decisions
75) Every time doug visits his primary care physician, he pays the doctor $10, regardless of the cost of the services provided.
This describes : Copayment.

RAMBAAN:

1) Do states regulate utilization review organizations(UROs) and third-party administrators (TPAs) ?

most states regulate to both to some extent
2) 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
3) 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.
4) 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 provides. This
describes :A relative value scale (RVS)
5) Which is a common position in a health plan but is not common in other types of companies?
Chief medical officer
6) What is the characteristic feature of a corporation that makes it different from other organizations?
It is a legal entity separate from its owners.
7) Which statement about the tax exemption of not-for-profit health plans is correct?
Some not-for-profit plans are tax-exempt but others are not.
8) Under the Affordable Care Act ( ACA) (healthcare reform), which may a health plan not consider in setting a person’s
premiums? : Health
9) Under ERISA, does the federal government regulate employer-sponsored health plans?
It regulates neither self-funded nor fully insured plans.
10) Who receives medicare part D prescription drug coverage?
All medicare beneficiaries have the option of enrolling and paying an additional premium.
11) The primary purpose of medicare advantage is to offer :
the option of receiving medicare coverage through a private-sector health plan
12) Most regulation of health plans : has been at the state level but after
the Affordable Care Act ( ACA) will be at the federal level
13) In health plans, the term “network adequacy” is usually used to indicate whether :
the number, types and locations of providers are sufficient to meet the member needs
14) A contract between health plan and its network providers requires providers to accept the plan’s compensation as
payment in full and prohibits them from billing plan members for additional amounts. What contract provision is this?
 No balance billing provision
15) In which health plan type do members not have to select how to receive services until they use them?
Point-of-service (POS) product.
16) Which statement best summarizes the use of the internet by health plans?
Health plans have historically lagged behind compared to other industries but now conduct many transactions online.
17) What is the main purpose of the children’s health insurance policy (CHIP)?
To provide health coverage to children whose families cannot afford private-sector insurance but do not qualify for
Medicaid
18) Diane is a member of private-sector health plan. She disagrees with a decision made by the plan. A level one review by
the plan’s medical director and a level two review by its appeals committee both uphold the plan’s original decision.
What are Diane’s options? She may have the right to appeal to the state insurance department or an external review
organization (depending on state laws)
19) 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? POS
20) Under the Federal Employees Health Benefits( FEHB) program, employees :
choose from a large number of health plans and plan types
21) At the end of the year, if there is more than enough money in a pool to cover specialty care, a health plan’s 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
22) A health plan has an obligation to respect the right of its members to make decisions about their own lives. This is ethical
principal of : autonomy.
23) A panel of cardiologists evaluates the care provided by another cardiologist in a particular case. This is an example of :
peer review
24) Which type of dental plan has the least choice of providers but generally costs the least? HMO
25) Who can make a contribution to health savings account(HSA)?
An employer,an employee, a self-employed person or family member on behalf of an eligible person
26) Under capitation, the amount a provider Is paid is based on : the number of members she is responsible for
27) Which physician-only provider organization is the most integrated? The consolidated medical group
28) In utilization review (UR), who has the authority to deny authorization of payment for a service based on medical
necessity and appropriateness? A clinical UR staffer (physician or nurse)
29) In which HMO model are physicians salaried employees working in HMO facilities? Staff model
30) What population is eligible for health coverage from TRICARE? Active and retired members of the military and their
spouses and dependents
31) Which of these is not covered by any medigap policy? Dental, vision and hearing services and products
32) 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
33) URAC provides accreditation for : health plans and health networks
34) What is the main problem a data warehouse is intended to solve? Data in multiple databases
35) How widespread are flexible spending accounts (FSAs) and health reimbursement arrangements (HRAs)?
Only a small minority of employees have either.
36) Separate healthcare providers are brought under common ownership and control. This describes :
Structural integration
37)
What is the most secure and restrictive level of behavioral health care? Acute care
38) In establishing and maintaining provider networks, health plans generally to ensure member access to care by :
Considering the number, type and location of providers needed.
39) 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
40) Medicare part D : charges premium and has substantial cost-sharing
41) Compared to indemnity insurance, health plans typically have :
more extensive benefit packages and lower out-of-pocket costs.
42) What is the main source of the cost-savings of consumer-directed health plans?
Consumers making cost-effective healthcare choices
43) A health plan’s utilization review staff make decisions about what health care services: the plan will pay for
44) The majority of U.S employees with health coverage are enrolled in : a PPO
45) How do PPOs most commonly compensate physicians? Discounted fees
46) An HMO contracts with eight group practices. This is an example of : a network model HMO
47) 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 physician (PCP) to see a
specialist. Goodlife has : an open panel and closed access
48) When is utilization review conducted? Before,during and/or after treatment
49) 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.
50) What are ethics? Principles and values that guide a person or organization facing questions of right and wrong.
51) Typically, who submits encounter reports instead of claims to a health plan?
 Healthcare professionals compensated by capitation
52) Which statement is true about how health plans communicate their members? Some interactive voice response (IVR)
telephone systems enable members to conduct certain transactions without talking to a person.
53)
Which is a provision of the HMO act of 1973?
Federally qualified HMOs had to meet less rigorous standards other than health plans
54) Do HMOs cover out-of-network services? No, this is a defining characteristic of HMOs
55) What form does cost-sharing generally take in traditional indemnity health insurance?
An annual deductible and coinsurance
56) Why has the popularity of flexible spending accounts (FSAs) been limited?
The “Use it or lose it” rule and the lack of portability
57) Worker’s compensation is :
state programs that help pay for medical expenses and lost wages resulting from a work-related injury or illness
58) What coverage do medicare advantage plans provide?
Medicare Part A and Part B coverages, other benefits and usually drug benefits
59) After Sarah has been in treatment for a respiratory condition for 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
60) Under which compensation arrangement do providers assume the greatest financial risk? Capitation
61) 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
62) It is most difficult to develop a comprehensive network in : rural areas
63) The percentage of stroke patients who are able to walk and speak normally after two years is :
an outcomes measure
64) In which of these provider organizations do physicians normally not own and operate their own practices?
Independent practice association (IPA)
65) The primary purpose of states’ financial responsibility standards for HMOs is to protect :
insureds from the possibility that the HMO may become insolvent
66) What does affordable care act do with regard to healthcare quality?
It provides quality incentive for medicare advantage plans and includes a variety of other quality improvement
provisions
67) Who can receive medicare coverage? People 65 or older and younger people with severe, long-term disabilities or a
few diseases
68) For which of these healthcare services is precertification (prior authorization) most likely to be required?
A hospital admission
69) The HMO contracts with a single group practice. This describes: a group model HMO
70)
In the united states, indemnity health insurance
Used to be the predominant form of health coverage but no longer is
71) Which is an important factor driving increased healthcare spending? New drugs and technology
72) A health plan projects the cost of providing benefits to a group based party on the plan’s rate manual and partly on the
group’s experience. This describes: blended rating
73) What happens when adverse selection occurs?
People more likely to need healthcare are more likely to obtain health coverage
74) What kind of healthcare service generally does not require prior authorization?
A frequently performed service
75) The main goals of HIPAA do not include : requiring all employers to sponsor health coverage.