EMT Practice Test

1. Question Content...

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Question1: A health plan may use one of several types of community rating methods to set premiums for a health plan. The following statements are about community rating. Select the answer choice containing the correct statement.

Question2: Which out of the three is accomplished through precertification?

Question3: In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:

Question4: In order to cover some of the gap between FFS Medicare coverage and the actual cost of services, beneficiaries often rely on Medicare supplements. Which of the following statements about Medicare supplements is correct?

Question5: Ronald Canton is a member of the Omega MCO. He receives his nonemergency medical care from Dr.
Kristen High, an internist. When Mr. Canton needed to visit a cardiologist about his irregular heartbeat, he first had to obtain a referral from Dr. High to see

Question6: Some states mandate that an independent enrollment broker or benefits counselor contractor selected by the state must manage enrollment of the eligible Medicaid population into managed care. In other states a health plan can engage independent brokers and

Question7: Health plans require utilization review for all services administered by its participating physicians.

Question8: Before an HMO contracts with a physician, the HMO first verifies the physician's credentials.
Upon becoming part of the HMO's organized system of healthcare, the physician is typically subject to

Question9: From the following choices, choose the definition that best matches the term health risk assessment (HRA)

Question10: The following statements are about the non-group market for managed care products in the United States.
Select the answer choice containing the correct statement.

Question11: The following statements describe two types, or models, of HMOs:
The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of the group practice, have an equity interest in the practice, and provide

Question12: The Citywide Health Group is a large provider-based health plan that includes physician groups, hospitals, and other facilities. In order to oversee and manage the operation of the organization, Citywide has established an enterprise scheduling system. The system should accomplish which of the following?

Question13: Individuals can use HSAs to pay for the following types of health coverage:

Question14: The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.

Question15: From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence

Question16: Paul Gilbert has been covered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began a new job and immediately enrolled in his new company's group health plan, which has a

Question17: By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an HMO provides comprehensive care include:

Question18: The Blaine Healthcare Corporation seeks to manage its quality by first identifying the best practices and best outcomes for a given procedure. Blaine can then determine areas in which it can emulate the best practices in order to equal or surpass the best

Question19: Janet Riva is covered by a traditional indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan.

Question20: During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, former broken ankle, and high blood pressure. Which of these conditions apply?

Question21: Identify the CORRECT statement(s):
(A) Smaller the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.
(B) Gender of the group's participants has no effect on the likelihood of loss.

Question22: Health savings accounts were created by which of the following laws:

Question23: The following sentence contains an incomplete statement with two missing words. Select the answer choice that contains the words that correctly fill in the missing blanks.
At its core, consumer choice involves empowering healthcare consumers to play a __

Question24: In the following sections, we will describe some of the measures health plans use to evaluate the quality of the services and healthcare they offer their members.
Which of the following is the best description of what a 'Process measure' evaluates?

Question25: An exclusive provider organization (EPO) operates much like a PPO. However, one difference between an EPO and a PPO is that an EPO

Question26: From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy

Question27: Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:

Question28: One typical characteristic of preferred provider organization (PPO) benefit plans is that PPOs:

Question29: In response to the demand for a method of assessing outcomes, accrediting organizations and other government and commercial groups have developed quantitative measures of quality that consumers, purchasers, regulators, and others can use to compare health

Question30: The following types of CDHPs allow federal tax advantages including the ability to roll funds from one year to the next:

Question31: The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be

Question32: Mr. George Bush is covered by a PBM plan that uses a closed formulary. This indicates that

Question33: For this question, select the answer choice containing the terms that correctly complete the blanks labeled A and B in the paragraph below.
NCQA offers Quality Compass, a national database of performance and accreditation information submitted by managed

Question34: A common physician-only integrated model is a group practice without walls (GPWW). One characteristic of a typical GPWW is that the

Question35: Medicare Part C can be delivered by the following Medicare Advantage plans:

Question36: In the United States, the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. One true statement about TRICARE is that

Question37: Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:

Question38: To address the problems associated with multiple data management systems, the Kayak Health Plan has begun to use a data warehouse. One likely characteristic of Kayak's data warehouse is that:

Question39: From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence

Question40: Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokers:

Question41: A health plan's ability to establish an effective provider network depends on the characteristics of the proposed service area and the needs of proposed plan members. It is generally correct to say that

Question42: Dr. Julia Phram is a cardiologist under contract to Holcomb HMO, Inc., a typical closed-panel plan. The following statements are about this situation. Select the answer choice containing the correct statement.

Question43: The following programs are part of the Alcove MCO's utilization management (UM) program:
-A telephone triage program
-Preventive care initiatives
-A shared decision-making program
-A self-care program
With regard to the UM programs, it is most likely correct to say the Alcove's:

Question44: In health plan terminology, demand management, as used by health plans, can best be described as

Question45: Salient features of a Health Savings Account include all of the following except

Question46: In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of antiselection. Antiselection can correctly be defined as the

Question47: An HMO that combines characteristics of two or more HMO models is sometimes referred to as a

Question48: One true statement about community rating, a rating method commonly used by health plans, is that:

Question49: The contract between the Honolulu MCO and Beverley Hills Hospital contains a 90 day cure provision. The Beverley Hills Hospital breached one of the contract requirements on July 31, 2004. The hospital remedied the problem by October 31, 2004. Which of the following statements are true regarding this?

Question50: Amendments to the HMO act 1973 do not permit federally qualified HMO's to use

Question51: Greentree Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area. Abigail Davis, a recruiter for Greentree, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in Green

Question52: Which of the following is NOT a reason for conducting utilization reviews?

Question53: One factor the Sandpiper Health Plan uses to assess its quality is a clinician's bedside manner, i.e., how friendly and understanding the clinician is, whether the patient feels that the clinician listens to the patient's concerns, how well the clinical

Question54: By definition, the marketing process of defining a certain place or market niche for a product relative to competitors and their products and then using the marketing mix to attract certain market segments is known as:

Question55: The administrative simplification standards described under Title II of HIPAA include privacy standards to control the use and disclosure of health information. In general, these privacy standards prohibit

Question56: A physician-hospital organization (PHO) may be classified as an open PHO or a closed PHO. With respect to a closed PHO, it is correct to say that

Question57: From the following choices, choose the definition that best matches the term Screening

Question58: One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers' payment during a plan year. At the end of the plan year, the MCO may use the amount retained to offset or pay for any cost overruns for referral or hospital

Question59: One distinction that can be made between a staff model HMO and a group model HMO is that, in a staff model HMO, participating physicians are Back to Top

Question60: In the United States, the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. One true statement about TRICARE is that:

Question61: The Acme HMO recruits and contracts directly with a wide range of physicians-both PCPs and specialists
-in its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The type of model described here is known as a:

Question62: Most contracts between health plans and providers contain a provision which forbids providers from seeking compensation from patients if the health plan fails to compensate the provider because of insolvency or for any other reason. Such a provision is known as:

Question63: In claims administration terminology, a claims investigation is correctly defined as the process of

Question64: In 1999, the United States Congress passed the Financial Services Modernization Act, referred to as the Gramm-Leach-Bliley (GLB) Act. The primary provisions included under the GLB Act require financial institutions, including health plans, to take several

Question65: In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known as

Question66: The agreement by two or more independent competitors on the prices or fees that they will charge for services is known as:

Question67: The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.

Question68: ______________ HMOs can't medically underwrite any group - incl small groups.

Question69: If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info

Question70: Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transferred by:

Question71: The Clover Group is a for-profit MCO that operates in the United States. The Valentine Group owns all of Clover's stock. The Valentine Group's sole business is the ownership of controlling interests in the shares of other companies. This information indicates that Clover can correctly be characterized as a:

Question72: Medicare is the federal government program established under Title XVIII of the Social Security Act of
1965 to provide hospital, medical and other covered benefits to elderly and disabled persons. Medicare is available for:

Question73: Health plans may use different capitation arrangements for different levels of service. One typical capitation arrangement provides a capitation payment that may include primary care only, or both primary and secondary care, but not ancillary services. This type of capitation arrangement is known as a:

Question74: The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On

Question75: From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy

Question76: In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On October 23, Holt used the following information to calculate the bed days per

Question77: Khalyn Drury's employer includes managed dental care in its employee benefits package. During open enrollment, Ms. Drury enrolled in the dental plan, which provides dental services to its members in exchange for a prepayment (the premium). Dental services:

Question78: Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that:

Question79: The criteria used to identify and measure healthcare quality are generally divided into three categories:
structure, process, and outcomes measures. Structure measures, which relate to the nature and quality of the resources that a health plan has available

Question80: One type of physician-only integration model is a consolidated medical group. Typical characteristics of a consolidated medical group include

Question81: One device that PBM plans use to manage both the cost and use of pharmaceuticals is a formulary. A formulary is defined as

Question82: Parable Healthcare Providers, a health plan, recently segmented the market for a new healthcare service.
Parable began the process by dividing the healthcare market into two broad categories: non-group and group. Next, Parable further segmented the non-gr

Question83: PBM plans operate under several types of contractual arrangements. Under one contractual arrangement, the PBM plan and the employer agree on a target cost per employee per month. If the actual cost per employee per month is greater than the target cost, then the PBM will share in the cost overrun. On the other hand, if the cost per employee per month is less than the target, the PBM shares in the savings. This type of contractual arrangement is known as a

Question84: As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor's practices or services are better than its own, Lyric imports these policies and procedures for themselves. What is this called?

Question85: One HMO model can be described as an extension of a group model HMO because it contracts with multiple group practices, rather than with a single group practice. This HMO model is known as the

Question86: One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. One of the provisions of the Act was that it

Question87: After a somewhat modest start in 2004, enrollment in HSA-related health plans more than tripled in 2005, making them today's fastest growing type of CDHP. As of January 2006, enrollment in HSAs had reached nearly:

Question88: Member satisfaction is a critical element of a health plan's quality management program. A health plan can obtain information about member satisfaction with various aspects of the health plan from

Question89: Medicaid is a jointly funded federal and state program that provides hospital and medical expense coverage to low-income individuals and certain aged and disabled individuals. One characteristic of Medicaid is that

Question90: During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a group's geographic location, the size and gender mix of the group, and the level of participation in the group:

Question91: The Azure Group is a for-profit health plan that operates in the United States. The Fordham Group owns all of Azure's stock. The Fordham Group's sole business is the ownership of controlling interests in the shares of other companies. This information independently is held as a:

Question92: The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive Committee serves as a long-term advisory body on issues related to overall organizational policy. The Corporate Compliance Committee are convened to address specific management concerns. The following statement(s) can correctly be made about these committees:

Question93: Phillip Tsai is insured by both an indemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication of benefits p

Question94: Medicare Advantage product options include:

Question95: The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the highest and lowest rates that a health plan charges small groups, to a particular ratio.
According to the Model Act, for example, if the lowest rate an HMO charges a small group for a given set of medical benefits is $40, then the maximum rate the HMO can charge for the same set of benefits is

Question96: Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Dr. Ware's provider contract with Riverside contains a typical no-balance billing provision. One purpose of this provision is to:

Question97: General HMO is building a provider network and is considering Universal Hospital as an addition to its network. Minimum requirements that General should consider in determining whether Universal is qualified to participate in General's network include A.

Question98: Health plans use the following to determine the number of providers to add to a network:

Question99: In order to help review its institutional utilization rates, the Sahalee Medical Group, a health plan, uses the standard formula to calculate hospital bed days per 1,000 plan members for the month to date (MTD). On April 20, Sahalee used the following information to calculate this:
Current plan census - 375
Plan membership - 500,000
What is the bed days for a single day?

Question100: Health plans' use of the Internet to provide plan members with health-related information has grown rapidly in recent years. One advantage the Internet has over other forms of communication is that

Question101: Which of the following is CORRECT?

Question102: One of the most influential pieces of legislation in the advancement of managed care within the United States was the HMO Act of 1973. One provision of the HMO Act of 1973 was that it

Question103: Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

Question104: Primary care case managers (PCCMs) provide case management services to eligible Medicaid recipients.
With regard to PCCMs it is correct to say that:

Question105: Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

Question106: Bill Clinton is a member of Lewinsky's PBM plan which has a three-tier copayment structure. Bill fell ill and his doctor prescribed him AAA, a brand-name drug which was included in the Lewinsky's formulary; BBB, a non-formulary drug; and CCC, a generic drug. In which order, from most preferred to least, is the preferred drug of choice for this coverage?

Question107: In accounting terminology, the items of value that a company owns-such as cash, cash equivalents, and receivables-are generally known as the company's

Question108: One non-group market segment to which health plans market health plan products is the senior market, which is comprised mostly of persons over age 65 who are eligible for Medicare benefits. One factor that affects a health plan's efforts to market to the

Question109: Managed behavioral health organizations (MBHOs) use several strategies to manage the delivery of behavioral healthcare services. The following statements are about these strategies. Select the answer choice that contains the correct statement.

Question110: Following a report by the Institute of Medicine on the incidence and consequences of medical errors, a national task force recommended implementation of a nationwide mandatory system of collecting, analyzing, reporting standardized information about medical errors that result in death or serious harm be established. What kind of change will this system require?

Question111: From the answer choices below, select the response that correctly identifies the rating method that Mr.
Sybex used and the premium rate PMPM that Mr. Sybex calculated for the Koster group.

Question112: The Courtland PPO maintains computerized records that include clinical, demographic, and administrative data about individual plan members. The data in these records is available to plan providers, ancillary service departments, pharmacies, and others inventory systems. What type of system holds this information?

Question113: In most cases, medical errors are caused by breakdowns in the healthcare system rather than by provider mistakes.

Question114: Marlee Whitcomb was covered as a dependent under the group health plan provided by her father's employer. That health plan complied with the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. When Ms. Whitcomb married, she called her provider to ask about extending her coverage. Marlee can do which of the following?

Question115: John Kerry's employer has contracted to receive healthcare for its employees from the Democratic Healthcare System. Mr. Kerry visits his PCP, who sends him to have some blood tests. The PCP then refers Mr. Kerry to a specialist who hospitalizes him for on

Question116: One characteristic of the accreditation process for MCOs is that

Question117: In the paragraph below, a sentence contains two pairs of words enclosed in parentheses. Determine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you have chosen. Many pharmacy benefit

Question118: The Conquest Corporation contracts with the Apex health plan to provide basic medical and surgical services to Conquest employees. Conquest entered into a separate contract with the Bright Dental Group to provide and manage a dental care program for employee

Question119: Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause.
The primary purpose of this clause is to:

Question120: In large health plans, management functions such as provider recruiting, credentialing, contracting, provider service, and performance management for providers are typically the responsibility of the

Question121: Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included:

Question122: In preparation for its expansion into a new service area, the Regal MCO is meeting with Dr. Nancy Buhner, a cardiologist who practices in Regal's new service area, in order to convince her to become one of the plan's participating providers. As part of the

Question123: In addition to the credentialing activities that a health plan performs when initially accepting a provider into its network, the health plan must also perform recredentialing of the same providers on an ongoing basis.
Many of the same activities are per

Question124: A public employer, such as a municipality or county government would be considered which of the following?

Question125: In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice containing the two terms that you have chosen. For providers, (operational /

Question126: Using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider is called ______________.

Question127: Which of the following is WRONG?

Question128: Phillip Tsai is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication of

Question129: Several marketplace factors helped fuel the movement toward consumer choice. Which one of the following statements is NOT accurate with regard to these factors?

Question130: One way in which health plans differ from traditional indemnity plans is that health plans typically

Question131: HMOs typically employ several techniques to manage provider utilization and member utilization of medical services. One technique that an HMO uses to manage member utilization is

Question132: Emily Brown works for Integral Health Plan and represents the company as a board member for the board of directors. Which best describes Emily's position?

Question133: Which of the following statements about EPO & HMO models is FALSE?

Question134: Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of benefits provision

Question135: One of the distinguishing characteristics of healthcare marketing is that many of the markets for health plans are national, not local markets.

Question136: Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. For health plan partners what is required?

Question137: Many HMOs are compensated for the delivery of healthcare to members under a prepaid care arrangement. Under a prepaid care arrangement, a plan member typically pays:

Question138: A particular health plan offers a higher level of benefits for services provided in-network than for out-of- network services. This health plan requires preauthorization for certain medical services. With regard to the steps that the health plan's claims enforcement policy, clients:

Question139: The Polestar Company's sole business is the ownership of Polaris Medical Group, a health plan and subsidiary of Polestar. Some members of Polestar's board of directors hold positions with Polestar in addition to their positions on the board; the rest are

Question140: One true statement regarding ethics and laws is that the values of a community are reflected in

Question141: If a state commissioner of insurance places an HMO under administrative supervision, then the purpose of this action most likely is to:

Question142: Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example:

Question143: Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health dictate that staff be onsite at all times. What is needed for this type of care?

Question144: For providers, integration occurs when two or more previously separate providers combine under common ownership or control, or when two or more providers combine business operations that they previously carried out separately and independently. Such provider integrations provide which benefit?

Question145: One true statement regarding ethics and laws is that the values of a community are reflected in

Question146: One typical characteristic of an integrated delivery system (IDS) is that an IDS.

Question147: Arthur Moyer is covered under his employer's group health plan, which must comply with the Consolidated Omnibus Budget Reconciliation Act (COBRA). Mr. Moyer is terminating his employment. He has elected to continue his coverage under his employer's group

Question148: Historically most HMOs have been

Question149: Primary care case managers (PCCMs) provide managed healthcare services to eligible Medicaid recipients. With regard to PCCMs, it is correct to say that

Question150: One way in which a health plan can support an ethical environment is by

Question151: Pharmacy benefit management (PBM) companies typically interact with physicians and pharmacists by performing such clinical services as physician profiling. Physician profiling from a PBM's point of view involves

Question152: Merle Spencer has coverage under both Medicare Part A and Medicare Part B Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for:
-The cost of hospitalization for two days
-Diagnostic tests performed in the hospital
-Trans

Question153: One component of information systems used by health plans incorporates membership data and information about provider reimbursement arrangements and analyzes transactions according to contract rules. This information system component is known as

Question154: Col. Martin Avery, on active duty in the U.S. Army, is eligible to receive healthcare benefits under one of the three TRICARE health plan options. If Col Avery elects to participate in TRICARE Prime, he will be:

Question155: Janet Riva is covered by an indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan. She incurred

Question156: Ian Vladmir wants to have a routine physical examination to ascertain that he is in good health. Mr. Vladmir is a member of a health plan that will allow him to select the physician of his choice, either from within his plan's network or from outside of h

Question157: Each of the following statements describes a health plan that is using a method of managing institutional utilization. Select the answer choice that describes a health plan's use of retrospective review to decrease utilization of hospital services.

Question158: All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.

Question159: The following sentence contains an incomplete statement with two missing words. Select the answer choice that contains the words that correctly fill the two blanks, respectively. The philosophy of consumer choice involves having consumers play a(n) ______

Question160: The following programs are part of the Alcove Health Plan's utilization management (UM) program:
-Preventive care initiatives
-A telephone triage program
-A shared decision-making program
-A self-care program
With regard to the UM programs, it is most

Question161: One way in which a health plan can support an ethical environment is by

Question162: Lansdale Healthcare, a health plan, offers comprehensive healthcare coverage to its members through a network of physicians, hospitals, and other service providers. Plan members who use in-network services pay a copayment for these services. The copayment Lunsford requires members to pay for in-network services is best defined as a

Question163: As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:
-Brad Van Note, age 28, is taking many different, costly medications for

Question164: According to the IRS, which of the following is not an allowable preventive care service?

Question165: By definition, a health plan's network refers to the:

Question166: If most of the physicians, or many of the physicians in a particular specialty, are affiliated with a single entity, then a health plan building a network in the service area _____________.

Question167: Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a
30% coinsurance provision for all healthcare obtained outside the plan's network of providers. In 1998, Ms.
Martin became ill while she was on vacation, was hospitalized, and incurred $2,000 for healthcare that she obtained outside her plan's network, but that is covered by the plan. Ms. Martin incurred no other out-of- network expenses during 1998. Of the $2,000 in covered out-of-network expenses that Ms. Martin incurred, she is responsible for paying a total of:

Question168: Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to

Question169: Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level. This federal legislation is the

Question170: The Fairway Health Group contracted with the Empire Corporation to provide behavioral healthcare services to Empire employees. As a condition of providing behavioral healthcare services, Fairway required Empire to contract with Fairway for basic medical services. This is known as a

Question171: The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential

Question172: Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a special

Question173: In order to generate exchanges with consumers, healthcare plan marketers use the four elements of the marketing mix: product, price, place (distribution), and

Question174: More procedures or services may be fully covered within the PPO network than those out of network.

Question175: Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of:

Question176: Advantages of EDI over manual data management systems

Question177: Phoebe Urich is covered by a traditional indemnity health insurance plan that specifies a $500 calendar- year deductible and includes a 20% coinsurance provision. When Ms. Urich was hospitalized, she incurred
$3,000 in medical expenses that were covered by

Question178: The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be

Question179: When the Knoll Company purchased group health coverage from the Castle Health Maintenance Organization (HMO), the agreement between the two parties specified that the plan would be a typical fully funded plan. Because Knoll had been covered under a previous

Question180: Natalie Chan is a member of the Ultra Health Plan, a health plan. Whenever she needs nonemergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Chan can do which of the following for?

Question181: One characteristic of disease management programs is that they typically

Question182: The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing is increasingly being performed electronically, which has resulted in (lower/higher) administrative costs.

Question183: As part of its utilization management (UM) system, the Creole Health Plan uses a process known as case management. The following individuals are members of the Creole Health Plan:
-Jill Novacek, who has a chronic respiratory condition. -Abraham Rashad.

Question184: The application of health plan principles to workers' compensation insurance programs has presented some unique challenges because of the differences between health plan for traditional group healthcare and workers' compensation. One key difference is that

Question185: Specialty services with certain characteristics tend to make good candidates for health plan approaches.
One characteristic used to identify a specialty service that may be a good candidate for a health plan approach is that the service should have

Question186: System classifies hundreds of hospital services based on a number of criteria, such as primary and secondary diagnosis, surgical procedures, age, gender, and the presence of complications.

Question187: Employer-sponsored benefit plans that provide healthcare benefits must comply with the Employee Retirement Income Security Act (ERISA). One of the most significant features of ERISA is that it:

Question188: The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. In early efforts to manage healthcare costs, traditional indemnity health insurers included in their health plans such features as coinsurance and (cost shifting / deductibles).

Question189: Parul Gupta has been covered by a group health plan for eighteen months. For the past four months, she has been undergoing treatment for diabetes. Last week, Ms. Gupta began a new job and immediately enrolled in her new company's group health plan, which

Question190: A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For
2006, the annual deductible for self-only coverage must

Question191: Although the process is voluntary for health plans, external accreditation is becoming more and more important as states and purchasers require health plans undergo some type of external review process.
This process:

Question192: A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must

Question193: The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true statement about these types of reviews is that:

Question194: One ethical principle in managed care is the principle of justice/equity, which specifically holds that MCOs and their providers have a duty to

Question195: The Advantage Health Plan recently added the following features to its member services program:
1. IVR
2. Active member outreach program
Advantage's member services staffing needs are likely to increase as a result of growth. Which of the items shown above will be most beneficial to accommodate this growth?

Question196: The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive Committee serves as a long-term advisory body on issues

Question197: One feature of the Employee Retirement Income Security Act (ERISA) is that it:

Question198: Many of the credentialing standards and criteria used by health plans are often taken from already existing standards established by

Question199: The process of identifying and classifying the risk represented by an individual or group is called

Question200: Provider integration has two components: operational integration and structural integration. An example of operational integration in health plans is the:

Question201: Specialty services that have certain characteristics generally are good candidates for managed care approaches. These characteristics generally include that the specialty service should have

Question202: The following statement can be correctly made about Medicare Advantage eligibility:

Question203: Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not- for-profit health plans is that these organizations typically:

Question204: All good Medical, Inc., a health plan, has contracted with Mercy Memorial Hospital to provide inpatient medical services to Allgood's plan members. The terms of the contract specify that Allgood will reimburse Mercy Memorial on the basis of a negotiated charge for each inpatient day allocated to one of its members.
This negotiated charge represents a percentage discount that increases as patient volume increases. In this situation, the type of compensation agreement between Allgood and Mercy Memorial is best identified as a:

Question205: Which of the following is NOT a preventive care initiative often used by health plans?

Question206: The Employee Retirement Income Security Act (ERISA) requires health plan members who receive healthcare benefits through employee benefit plans to file legal challenges involving coverage decisions or plan administration at the federal level. which are designed to punish or make an example of the wrongdoer

Question207: One ethical principle in health plans is the principle of non-malfeasance, which holds that health plans and their providers:

Question208: Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim

Question209: One distinguishing characteristic of a health maintenance organization (HMO) is that, typically, an HMO