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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 im

  • A. Benchmarking.
  • B. Standard of care.
  • C. An adverse event.
  • D. Case-mix adjustment.

Answer: A


The following statements are about concepts related to the underwriting function within a health plan. Select the answer choice containing the correct statement.

  • A. Anti selection refers to the fact that individuals who believe that they have a less-than-
  • B. average likelihood of loss tend to seek healthcare coverage to a greater extent than do individuals who believe that they have an average or greater-than-average like
  • C. Federally qualified HMOs are required to medically underwrite all groups applying for coverage.
  • D. Typically, a health plan guarantees the premium rate for a group health contract for a period of five years.
  • E. When evaluating the risk for a group policy, underwriters typically focus on such factors as the size of the group, the stability of the group, and the activities of the group.

Answer: D


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

  • A. quality standards
  • B. accreditation decisions
  • C. standards of care
  • D. performance measures

Answer: D


The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the correct response.

  • A. The Women's Health and Cancer Rights Act (WHCRA) of 1998 requires health plans to offer mastectomy benefits.
  • B. The Health Care Quality Improvement Act (HCQIA) requires hospitals, group practices, and HMOs to comply with all standard antitrust legislation, even if these entities adhere to due process standards that are outlined in HCQIA.
  • C. The Newborns' and Mothers' Health Protection Act (NMHPA) of 1996 mandates that coverage for hospital stays for childbirth must generally be a minimum of 24 hours for normal deliveries and 48 hours for cesarean births.
  • D. Although the Mental Health Parity Act (MHPA) does not require health plans to offer mental health coverage, it imposes requirements on those plans that do offer mental health benefits.

Answer: D


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

  • A. True
  • B. False

Answer: A


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

  • A. staff model HMO
  • B. IPA model HMO
  • C. direct contract model HMO
  • D. network model HMO

Answer: D


The parties to the contractual relationship that provides Castle's group health coverage to Knoll employees are

  • A. Castle and Knoll only
  • B. Knoll and all covered Knoll employees only
  • C. Castle, Knoll, and all covered Knoll employees
  • D. Castle and all covered Knoll employees only

Answer: A


Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a 30% coinsurance provision for all healthcare obtained outside the plan’s network of providers. In 1998, Ms. Martin became ill while she was on vacation,

  • A. $300
  • B. $510
  • C. $600
  • D. $810

Answer: D


Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl

  • A. Low or stable costs.
  • B. Appropriate, rather than inappropriate, utilization rates.
  • C. A benefit that cannot be easily defined.
  • D. Defined patient population.

Answer: D


The provision of mental health and chemical dependency services is collectively known as behavioral healthcare. The following statements are about behavioral healthcare. Select the answer choice containing the correct statement.

  • A. In most preferred provider organizations (PPOs) and open access plans, plan members must receive a referral before accessing behavioral healthcare services from a specialist.
  • B. To manage the delivery of behavioral healthcare services, managed behavioral health organizations (MBHOs) typically use alternative treatment levels and alternative treatment methods rather than crisis intervention or alternative treatment settings.
  • C. Managed behavioral health organizations (MBHOs) typically are prohibited from negotiating with network providers for reduced fees in exchange for increased patient volume.
  • D. The treatment approaches for behavioral healthcare most often include drug therapy, psychotherapy, and counseling.

Answer: B


The NAIC designed a small group model law to enable small groups to obtain accessible, yet affordable, group health benefits. Specifically, the model law limits the rate spread. According to this model law, if the lowest rate that an HMO charges a small g

  • A. $80
  • B. $120
  • C. $160
  • D. $240

Answer: C


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

  • A. D
  • B. High serves as the coordinator of care for the medical services that M
  • C. Canton receives.
  • D. Omega's network of providers includes D
  • E. High, but not D
  • F. Miller.
  • G. Omega's system allows its members open access to all of Omega's participating providers.
  • H. Omega used a financing arrangement known as a relative value scale (RVS) to compensate D
  • I. Miller.

Answer: A


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

  • A. an evaluation of the medical necessity, efficiency, and/or appropriateness of healthcare services and treatment plans for a given patient
  • B. a series of strategies designed to reduce plan members' needs to utilize healthcare services by encouraging preventive care, wellness, member self-care, and appropriate use of healthcare services
  • C. a technique that prevents a provider who is being reimbursed under a fee schedule arrangement from billing a plan member for any fees that exceed the maximum fee reimbursed by the plan
  • D. a system of identifying plan members with special healthcare needs, developing a healthcare strategy to meet those needs, and coordinating and monitoring the care

Answer: B


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

  • A. 230
  • B. 270
  • C. 220
  • D. 180

Answer: C


Utilization review offers health plans a means of managing costs by managing

  • A. Cost effectiveness of healthcare services.
  • B. Cost of paying healthcare benefits.
  • C. Both of the above

Answer: C


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

  • A. provide less extensive benefits than those provided under traditional indemnity plans
  • B. place a greater emphasis on preventive care than do traditional indemnity plans
  • C. require members to pay a percentage of the cost of medical services rendered after a claim is filed, rather than a fixed copayment at the time of service as required by indemnity plans
  • D. contain cost-sharing requirements that result in more out-of-pocket spending by members than do the cost-sharing requirements in traditional indemnity plans

Answer: B


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

  • A. A, B, C, and D
  • B. A and C only
  • C. A, B, and D only
  • D. B, C, and D only

Answer: A


The HMO Act of 1973 was significant in that the Act

  • A. mandated certain requirements that all HMOs had to meet in order to conduct business
  • B. required that all HMOs be licensed as insurance companies
  • C. offered HMOs federal financial assistance through grants and loans, and provided access to the employer-based insurance market
  • D. encouraged the use of pre-existing condition exclusion provisions in all HMO contracts

Answer: C


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)

  • A. Decreased … Increased
  • B. Increased … Decreased
  • C. Increased … Increased
  • D. Decreased … Decreased

Answer: C


The following statements pertain to the federal requirements for minimum deductible & maximum out of pocket expeses for a high deductible health plan in the year 2006. Select the correct answer from the options given below.

  • A. Minimum deductible - $ 1,050 for self only coverage ; maximum out of pocket expenses-$ 2,100 for self only coverage
  • B. Minimum deductible - $ 1,050 for self only coverage ; maximum out of pocket expenses-$ 10.500 for family coverage
  • C. Minimum deductible - $ 2,100 for self only coverage ; maximum out of pocket expenses-$ 10,500 for self only coverage
  • D. Minimum deductible - $ 2,100 for self only coverage ; maximum out of pocket expenses-$ 5,250 for self only coverage

Answer: B


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

  • A. treat each member in a manner that respects his or her own goals and values
  • B. allocate resources in a way that fairly distributes benefits and burdens among the members
  • C. present information honestly to their members and to honor commitments to their members
  • D. make sure they do not harm their members

Answer: B


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

  • A. An indemnity wraparound plan
  • B. A self-funded plan
  • C. An aggregate stop-loss plan
  • D. A fully funded plan

Answer: D


One among the following is a reason that limit access to health care for US people.

  • A. Life Style of the people
  • B. Concentration of physicians in highly populated areas.
  • C. Advancement in information technology

Answer: B


Which of the following statements is NOT a requirement for a service to be deemed a 'medically necessary service'?

  • A. Furnished in the least intensive type of medical care setting required by the member's condition.
  • B. Solely for the convenience of the member.
  • C. In accordance with the standards of good medical practice.
  • D. Consistent with the symptoms of the member's condition.

Answer: B


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

  • A. requiring organizations with which it contracts to adopt the plan's formal ethical policy
  • B. developing and maintaining a culture where ethical considerations are integrated into decision making at the top organizational level only
  • C. establishing a formal method of managing ethical conflicts, such as using an ethics task force or bioethics consultant
  • D. maintaining control of policy development by removing providers and members from the process of developing and implementing policies and procedures that provide guidance to providers and members confronted with ethical issues

Answer: C


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