NEW QUESTION 1

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
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• A. Castle is responsible for paying for all incurred covered benefits
• B. Knoll is solely responsible for guaranteeing claim payments
• C. Knoll makes no premium payments to Castle
• D. Castle has no responsibilities for administering the health plan

Answer: A

NEW QUESTION 2

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

• A. Provide significant benefit to the community
• B. Employ, rather than contract with, participating physicians
• C. Achieve economies of scale through facility consolidation and practice management
• D. Refrain from the corporate practice of medicine

Answer: A

NEW QUESTION 3

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

• A. Improve the quality and cost effectiveness of patient care
• B. Reduce unnecessary practice variations
• C. Make appropriate authorization decisions
• D. Accommodate special requirements of inpatient care

Answer: D

NEW QUESTION 4

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

• A. Notify customers of any sharing of non-public personal financial information with nonaffiliated third parties.
• B. Prohibit customers from having the opportunity to 'opt-out' of sharing non-public personal financial information.
• C. Disclose to affiliates, but not to third parties, their privacy policies regarding the sharing of nonpublic personal financial information.
• D. Agree not to disclose personally identifiable financial information or personally identifiable health information.

Answer: A

NEW QUESTION 5

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. The number of specialists in Hill's network of providers.
• B. The price for the PPO product.
• C. Hill's ability to report utilization data.
• D. Hill's use of brokers to market its PPO product.

Answer: B

NEW QUESTION 6

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

• A. provide information to Citywide's management regarding provider licensure, certification, and malpractice history
• B. detect instances of overutilization, underutilization, or inappropriate utilization of medical resources
• C. allow Citywide's different components to function as a single organization in arranging access to facilities and resources
• D. facilitate the processing of requests for authorization of payment of benefits

Answer: C

NEW QUESTION 7

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

• A. Polestar's relationship to Polaris: partnership Type of board member: operations director
• B. Polestar's relationship to Polaris: partnership Type of board member: outside director
• C. Polestar's relationship to Polaris: holding company Type of board member: operations director
• D. Polestar's relationship to Polaris: holding company Type of board member: outside director

Answer: D

NEW QUESTION 8

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.

• A. M
• B. Novacek, M
• C. Rashad, and M
• D. Devereaux
• E. M
• F. Novacek and M
• G. Rashad only
• H. M
• I. Novacek and M
• J. Devereaux only
• K. None of these members

Answer: A

NEW QUESTION 9

To determine fee reimbursements to be paid to physicians, the Triangle Health Plan assigns a weighted value to each medical procedure or service and multiplies the weighted value by a money multiplier. Triangle and the providers negotiate the value of the

• A. Diagnosis-related group (DRG) system
• B. Relative value scale (RVS)
• C. Partial capitation arrangement
• D. Capped fee system

Answer: B

NEW QUESTION 10

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.

• A. True
• B. False

Answer: B

NEW QUESTION 11

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?

• A. The initial ten (A-J) Medigap policies offer a basic benefit package that includes coverage for Medicare Part A and Medicare Part B coinsurance.
• B. Each insurance company selling Medigap must sell all the different Medigap policies.
• C. Medicare SELECT is a Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part A coverage.
• D. Medigap benefits vary by plan type (A through L), and are not uniform nationally.

Answer: A

NEW QUESTION 12

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

• A. A captive group a staff model
• B. A captive group a network model
• C. An independent group a network model
• D. An independent group a staff model

Answer: B

NEW QUESTION 13

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 cor

• A. self-care program is intended to complement physicians' services, rather than to supercede or eliminate these services
• B. telephone triage program is staffed by physicians only
• C. shared decision-making program is appropriate for virtually any medical condition
• D. preventive care initiatives include immunization programs but not health promotion programs

Answer: A

NEW QUESTION 14

Janet Riva is covered by a 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

• A. $1,750
• B. $1,800
• C. $2,000
• D. $2,250

Answer: B

NEW QUESTION 15

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 a

• A. fixed amount in advance for each medical service the member receives
• B. a small fee such as $10 or $15 that a member pays at the time of an office visit to a network provider
• C. a fixed, monthly premium paid in advance of the delivery of medical care that covers most healthcare services that a member might need, no matter how often the member uses medical services
• D. specified amount of the member's medical expenses before any benefits are paid by the HMO

Answer: C

NEW QUESTION 16

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

NEW QUESTION 17

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

• A. both recredentialing and peer review
• B. recredentialing only
• C. peer review only
• D. neither recredentialing nor peer review

Answer: C

NEW QUESTION 18

The National Association of Insurance Commissioners' (NAIC's) Unfair Claims Settlement Practices Act specifies standards for the investigation and handling of claims. The Act defines unfair claims practices and notes that such practices are improper if the

• A. Both A and B
• B. A only
• C. B only
• D. Neither A nor B

Answer: A

NEW QUESTION 19

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

• A. Assume full financial risk for arranging medical services for their members.
• B. Require plan members to obtain a referral before getting medical services from specialists.
• C. Use a capitation arrangement, instead of a fee schedule, to reimburse physicians.
• D. Offer some coverage, although at a higher cost, for plan members who choose to use the services of non-network providers.

Answer: D

NEW QUESTION 20

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

• A. PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipients.
• B. All Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs.
• C. PCCMs receive a case management fee in addition to reimbursement for medical services on a FFS basis.
• D. PCCMs contract directly with the federal government to provide case management services to Medicaid recipients.

Answer: C

NEW QUESTION 21

Renewal underwriting involves a reevaluation of

• A. The group’s experience
• B. Level of participation in the health plan
• C. Both A and B
• D. None of the Above

Answer: C

NEW QUESTION 22

The following statements apply to enrollment statistics for HSAs. Select the answer choice that contains the CORRECT statement.

• A. HSAs have helped expand health care coverage to consumers who were previously uninsured.
• B. The vast majority of enrollees in HSA health plans are wealthy.
• C. Most people receiving coverage through HSA health plans are individuals rather than families.
• D. HSAs appeal primarily to young consumers.

Answer: A

NEW QUESTION 23

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

• A. Should allocate resources in a way that fairly distributes benefits and burdens among the members.
• B. Have a duty to present information honestly and are obligated to honor commitments.
• C. Are obligated not to harm their members.
• D. Should treat each plan member in a manner that respects his or her goals and values.

Answer: C

NEW QUESTION 24

The Internal Revenue Service has ruled that an HDHP coupled with an HSA may cover certain types of preventive care without a deductible or with a lower amount than the annual deductible applicable to all other services. According to IRS guidance, which on

• A. Immunizations for children and adults
• B. Tests and diagnostic procedures ordered with routine examinations
• C. Smoking cessation programs
• D. Gastric bypass surgery for obesity

Answer: D

NEW QUESTION 25

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

• A. specified dollar amount charge that a plan member must pay out-of-pocket for a specified medical service at the time the service is rendered
• B. percentage of the fees for medical services that a plan member must pay after Magellan has paid its share of the costs of those services
• C. flat amount that a plan member must pay each year before Magellan will make any
• D. benefit payments on behalf of the plan member
• E. specified payment for services that was negotiated between the provider and Magellan

Answer: A

NEW QUESTION 26
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