Ahm Mock Test

5/7/2015 AHMMOCKTESTONLINE

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WebringyouthebestquestionaironAHM250,ifyoujustgothroughtherequestionsthereshouldnotbeanychancethatyou'llfailinexam.HopethiswillhelpyouingainingmoreknowledgeonhealthcaredomainandalsowllhelpyoucrackAHM250certificationprogram.Question1Thefollowingstatementsdescribetwotypes,ormodels,ofHMOs:TheQuestHMOhascontractedwithonlyonemultispecialtygroupofphysicians.Thesephysiciansareemployeesofthegrouppractice,haveanequityinterestinthepractice,andprovideChoiceA:acaptivegroupastaffmodelChoiceB:acaptivegroupanetworkmodelChoiceC:anindependentgroupanetworkmodelChoiceD:anindependentgroupastaffmodelAnswer:BQuestion2______________HMOscan'tmedicallyunderwriteanygroupinclsmallgroups.ChoiceA:StateChoiceB:NotforprofitChoiceC:ForprofitChoiceD:FederallyqualifiedAnswer:B

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Question3Acommonphysicianonlyintegratedmodelisagrouppracticewithoutwalls(GPWW).OnecharacteristicofatypicalGPWWisthattheChoiceA:GPWWcombinesmultipleindependentphysicianpracticesunderoneumbrellaorganizationChoiceB:GPWWgenerallyhasalesserdegreeofintegrationthandoesanIPAChoiceC:memberphysicianscannotowntheGPWWChoiceD:GPWW'smemberphysiciansmustperformtheirownbusinessoperationsAnswer:AQuestion4Ahealthplanmayuseoneofseveraltypesofcommunityratingmethodstosetpremiumsforahealthplan.Thefollowingstatementsareaboutcommunityrating.Selecttheanswerchoicecontainingthecorrectstatement.ChoiceA:Standard(pure)communityratingistypicallyusedforlargegroupsbecauseitisthemostcompetitiveratingmethodforlargegroups.ChoiceB:Understandard(pure)communityrating,ahealthplanchargesallemployersorothergroupsponsorsthesamedollaramountforagivenlevelofmedicalbenefitsorhealthplan,withoutadjustingforfactorssuchasage,gender,orexperience.ChoiceC:Inusingtheadjustedcommunityrating(ACR)method,ahealthplanmustconsidertheactualexperienceofagroupindevelopingpremiumratesforthatgroup.ChoiceD:TheCentersforMedicareandMedicaidServices(CMS)prohibitshealthplansthatassumeMedicareriskfromusingtheadjustedcommunityrating(ACR)meAnswer:BQuestion5Ahealthplan'sabilitytoestablishaneffectiveprovidernetworkdependsonthecharacteristicsoftheproposedserviceareaandtheneedsofproposedplanmembers.ItisgenerallycorrecttosaythatChoiceA:healthplanshavemorecontractingoptionsifprovidersareaffiliatedwithsingleentitiesthanifprovidersareaffiliatedwithmultipleentitiesChoiceB:urbanareasoffermoreflexibilityinprovidercontractingthandoruralareasChoiceC:consumersandpurchasersinmarketswithlittlehealthplanactivityarelikelytobemorereceptivetoHMOsthantolooselymanagedplanssuchasPPOsChoiceD:largeemployerstendtoadopthealthplansmore



slowlythandosmallcompaniesAnswer:BQuestion6AhealthsavingsaccountmustbecoupledwithanHDHPthatmeetsfederalrequirementsforminimumdeductibleandmaximumoutofpocketexpenses.Dollaramountsareindexedannuallyforinflation.For2006,theannualdeductibleforselfonlycoveragemustChoiceA:$525ChoiceB:$1,050ChoiceC:$2,100ChoiceD:$5,250Answer:BQuestion7Amedicalfoundationisanotforprofitentitythatpurchasesandmanagesphysicianpractices.Inordertoretainitsnotforprofitstatus,amedicalfoundationmustChoiceA:providesignificantbenefittothecommunityChoiceB:employ,ratherthancontractwith,participatingphysiciansChoiceC:achieveeconomiesofscalethroughfacilityconsolidationandpracticemanagementChoiceD:refrainfromthecorporatepracticeofmedicineAnswer:AQuestion8Aparticularhealthplanoffersahigherlevelofbenefitsforservicesprovidedinnetworkthanforoutofnetworkservices.Thishealthplanrequirespreauthorizationforcertainmedicalservices.Withregardtothestepsthatthehealthplan'sclaimseChoiceA:shouldassumethatallservicesrequiringpreauthorizationhavebeenpreauthorizedChoiceB:shouldinvestigateanyconflictsbetweendiagnosticcodesandtreatmentcodesbeforeapprovingtheclaimtoensurethattheappropriatepaymentismadefortheclaimChoiceC:neednotverifythattheproviderispartofthehealthplan'snetworkbeforeapprovingtheclaimattheinnetworklevelofbenefitsChoiceD:neednotdeterminewhetherthememberiscoveredbyanotherhealthplanthatallowsforcoordinationofbenefitsAnswer:BQuestion9Aphysicianhospitalorganization(PHO)maybeclassifiedasanopenPHOoraclosedPHO.WithrespecttoaclosedPHO,itiscorrecttosaythat



A.thespecialistsinthePHOaretypicallycompensatedonacapitationbasisChoiceA:thespecialistsinthePHOaretypicallycompensatedonacapitationbasisChoiceB:ittypicallylimitsthenumberofspecialistsbytypeofspecialtyChoiceC:itisavailabletoahospital'sentireeligiblemedicalstaffChoiceD:physicianmembershipinthePHOislimitedtoPCPsAnswer:BQuestion10Apublicemployer,suchasamunicipalityorcountygovernmentwouldbeconsideredwhichofthefollowing?ChoiceA:Employeremployeegroup.ChoiceB:Multipleemployergroup.ChoiceC:Affinitygroup.ChoiceD:Debtorcreditorgroup.Answer:AQuestion11AccordingtotheIRS,whichofthefollowingisnotanallowablepreventivecareservice:ChoiceA:Smokingcessationprograms.ChoiceB:Periodichealthexaminations.ChoiceC:Healthclubmemberships.ChoiceD:Immunizationsforchildrenandadults.Answer:CQuestion12Afterasomewhatmodeststartin2004,enrollmentinHSArelatedhealthplansmorethantripledin2005,makingthemtodaysfastestgrowingtypeofCDHP.AsofJanuary2006,enrollmentinHSAshadreachednearly:ChoiceA:1.2millionChoiceB:2.2millionChoiceC:3.2millionChoiceD:4.2millionAnswer:BQuestion13AlMarak,amemberoftheFrazierHealthPlan,hasaskedforatypicalLevelOneappealofadecisionthatFraziermaderegardingMr.Marak'scoverage.OnetruestatementaboutthisLevelOneappealisthatChoiceA:Mr.MarakhastherighttoappealtothenextleveliftheLevelOneappealupholdstheoriginaldecisionChoiceB:itrequiresFrazierandMr.Maraktosubmitto



arbitrationinordertoresolvethedisputeChoiceC:itisconsideredtobeaninformalappealChoiceD:itwillbehandledbyanindependentrevieworganization(IRO)Answer:AQuestion14AllCDHPproductsprovidefederaltaxadvantageswhileallowingconsumerstosavemoneyfortheirhealthcare.ChoiceA:TrueChoiceB:FalseChoiceC:ChoiceD:Answer:AQuestion15AllgoodMedical,Inc.,ahealthplan,hascontractedwithMercyMemorialHospitaltoprovideinpatientmedicalservicestoAllgood'splanmembers.ThetermsofthecontractspecifythatAllgoodwillreimburseMercyMemorialonthebasisofanegotiatedchChoiceA:perdiemagreementChoiceB:feeforserviceagreementChoiceC:withholdagreementChoiceD:diagnosticrelatedgroup(DRG)agreementAnswer:AQuestion16Althoughtheprocessisvoluntaryforhealthplans,externalaccreditationisbecomingmoreandmoreimportantasstatesandpurchasersrequirehealthplansundergoasmanystatesandpurchasersrequirehealthplansundergosometypeofexternalreviewprChoiceA:Isvoluntaryforhealthplans.ChoiceB:Requiresallchangeaccreditationorganizationstousethesamestandardsofaccreditation.ChoiceC:Typicallyrequirestheaccreditingorganizationtoconductamedicalrecordreviewandareviewofahealthplan'scredentialingprocesses,butnotanevaluationofthehealthplans'memberservicesystemsprocesses.ChoiceD:Cannotassurethatahealthplanmeetsaspecifiedlevelofquality.Answer:AQuestion17AmendmentstotheHMOact1973donotpermitfederallyqualifiedHMOstouse



ChoiceA:RetrospectiveexperienceratingChoiceB:AdjustedcommunityratingChoiceC:CommunityratingbyclassChoiceD:CommunityratingAnswer:AQuestion18Anexclusiveproviderorganization(EPO)operatesmuchlikeaPPO.However,onedifferencebetweenanEPOandaPPOisthatanEPOChoiceA:isregulatedunderfederalHMOlegislationChoiceB:generallyprovidesnobenefitsforoutofnetworkcareChoiceC:hasnoprovidernetworkofphysiciansChoiceD:isnotsubjecttostateinsurancelawsAnswer:BQuestion19AnHMOthatcombinescharacteristicsoftwoormoreHMOmodelsissometimesreferredtoasaChoiceA:networkmodelHMOChoiceB:groupmodelHMOChoiceC:staffmodelHMOChoiceD:mixedmodelHMOAnswer:DQuestion20Appropriatenessoftreatmentprovidedisdeterminedbydevelopingcriteriathatifunmetwillpromptfurtherinvestigationofaclaimwhicharealsocalled:ChoiceA:CodesChoiceB:ListsChoiceC:EditsChoiceD:ChecksAnswer:CQuestion21ArthurMoyeriscoveredunderhisemployer'sgrouphealthplan,whichmustcomplywiththeConsolidatedOmnibusBudgetReconciliationAct(COBRA).Mr.Moyeristerminatinghisemployment.Hehaselectedtocontinuehiscoverageunderhisemployer'sgroupChoiceA:18months,buthiscoverageunderCOBRAwillceaseifheobtainsgrouphealthcoveragethroughanotheremployer.ChoiceB:18months,evenifheobtainsgrouphealthcoveragethroughanotheremployer.ChoiceC:36months,buthiscoverageunderCOBRAwill



ceaseifheobtainsgrouphealthcoveragethroughanotheremployer.ChoiceD:36months,evenifheobtainsgrouphealthcoveragethroughanotheremployer.Answer:AQuestion22Aspartofitsqualitymanagementprogram,theLyricHealthPlanregularlycomparesitspracticesandserviceswiththoseofitsmostsuccessfulcompetitor.WhenLyricconcludesthatitscompetitor'spracticesorservicesarebetterthanitsown,LyricimChoiceA:Benchmarking.ChoiceB:Standardofcare.ChoiceC:Anadverseevent.ChoiceD:Casemixadjustment.Answer:AQuestion23Aspartofitsutilizationmanagement(UM)system,theCreoleHealthPlanusesaprocessknownascasemanagement.ThefollowingindividualsaremembersoftheCreoleHealthPlan:JillNovacek,whohasachronicrespiratorycondition.AbrahamRashad,ChoiceA:Ms.Novacek,Mr.Rashad,andMr.Devereaux.ChoiceB:Ms.NovacekandMr.Rashadonly.ChoiceC:Ms.NovacekandMr.Devereauxonly.ChoiceD:Noneofthesemembers.Answer:AQuestion24Aspartofitsutilizationmanagement(UM)system,thePoplarMCOusesaprocessknownascasemanagement.ThefollowingstatementsdescribeindividualswhoarePoplarplanmembers:BradVanNote,age28,istakingmanydifferent,costlymedicationsforChoiceA:Mr.VanNote,Mr.Albrecht,andMs.CromartieChoiceB:Mr.VanNoteandMs.CromartieonlyChoiceC:Mr.VanNoteandMr.AlbrechtonlyChoiceD:Mr.AlbrechtandMs.CromartieonlyAnswer:CQuestion25AshleyMartiniscoveredbyamanagedhealthcareplanthatspecifiesa$300deductibleandincludesa30%coinsuranceprovisionforallhealthcareobtainedoutsidetheplansnetworkofproviders.In1998,Ms.Martinbecameillwhileshewasonvacation,



ChoiceA:$300ChoiceB:$510ChoiceC:$600ChoiceD:$810Answer:DQuestion26BartVereenisinsuredbybothatraditionalindemnityhealthinsuranceplan,whichishisprimaryplan,andamanagedcareplan.Bothplanshaveatypicalcoordinationofbenefits(COB)provision,butneitherplanhasanonduplicationofbenefitsprovisiChoiceA:380ChoiceB:130ChoiceC:0ChoiceD:550Answer:AQuestion27Becausemanypatientswithbehavioralhealthdisordersdonotrequireroundtheclocknursingcareandsupervision,behavioralhealthcareservicescanbedeliveredeffectivelyinavarietyofsettings.Forexample,postacutecareforbehavioralhealthdiChoiceA:Hospitalobservationunitsorpsychiatrichospitals.ChoiceB:Psychiatrichospitalsorrehabilitationhospitals.ChoiceC:Subacutecarefacilitiesorskillednursingfacilities.ChoiceD:Psychiatricunitsingeneralhospitalsorhospitalobservationunits.Answer:CQuestion28BeforeanHMOcontractswithaphysician,theHMOfirstverifiesthephysician'scredentials.UponbecomingpartoftheHMO'sorganizedsystemofhealthcare,thephysicianistypicallysubjecttoChoiceA:bothrecredentialingandpeerreviewChoiceB:recredentialingonlyChoiceC:peerreviewonlyChoiceD:neitherrecredentialingnorpeerreviewAnswer:CQuestion29BeforetheHillHealthMaintenanceOrganization(HMO)receivedacertificateofauthority(COA)tooperateinStateX,ithadtomeetthestate'slicensingrequirementsandfinancialstandardswhichwereestablishedbylegislationthatisidenticaltotheChoiceA:Receivecompensationbasedonthevolumeand



varietyofmedicalservicestheyperformforHillplanmembers,whereasthespecialistsreceivecompensationbasedsolelyonthenumberofplanmemberswhoarecoveredforspecificservices.ChoiceB:Havenofinancialincentivetopracticepreventivecareortofocusonimprovingthehealthoftheirplanmembers,whereasthespecialistshaveapositiveincentivetohelptheirplanmembersstayhealthy.ChoiceC:ReceivefromtheIPAthesamemonthlycompensationforeachHillplanmemberunderthePCP'scare,whereasthespecialistsreceivecompensationbasedonapercentagediscountfromtheirnormalfees.ChoiceD:Receivecompensationbasedonafeeschedule,whereasthespecialistsreceivecompensationbasedonperdiemcharges.Answer:CQuestion30BeforetheHillHealthMaintenanceOrganization(HMO)receivedacertificateofauthority(COA)tooperateinStateX,ithadtomeetthestate'slicensingrequirementsandfinancialstandardswhichwereestablishedbylegislationthatisidenticaltotheChoiceA:Hillhadtohaveaninitialnetworthofatleast$1.5millioninordertoobtainaCOA.ChoiceB:TheCOAmostlikelyexemptsHillfromanyofStateX'senablingstatutes.ChoiceC:HillhadtobeorganizedasapartnershipinordertoobtainaCOAChoiceD:TheCOAinnowayindicatesthatHillhasdemonstratedthatitisfiscallysound.Answer:AQuestion31BeforetheLeoHealthMaintenanceOrganization(HMO)receivedacertificateofauthority(COA)tooperateinStateX,ithadtomeetthestate'slicensingrequirementsandfinancialstandardswhichwereestablishedbylegislationthatisidenticaltotheChoiceA:receivecompensationbasedonthevolumeandvarietyformedicalservicestheyperformforLeoplanmembers,whereasthespecialistsreceivecompensationbasedsolelyonthenumberofplanmemberswhoarecoveredforspecificservicesChoiceB:havenofinancialincentivetopracticepreventivecareortofocusonimprovingthehealthoftheirplanmembers,whereasthespecialistshaveapositiveincentivetohelptheirplanmembersstayhealthyChoiceC:receivefromtheIPAthesamemonthlycompensation



foreachLeoplanmemberunderthePCP'scare,whereasthespecialistsreceivecompensationbasedonapercentagediscountfromtheirnormalfeesChoiceD:receivecompensationbasedonafeeschedule,whereasthespecialistsreceivecompensationbasedonperdiemchargesAnswer:CQuestion32Beginningintheearly1980s,severalfactorscontributedtoincreaseddemandforbehavioralhealthcareservices.ThesefactorsincludedChoiceA:increasedstressonindividualsandfamiliesChoiceB:increasedavailabilityofbehavioralhealthcareservicesChoiceC:greaterawarenessandacceptanceofbehavioralhealthcareissuesChoiceD:alloftheaboveAnswer:DQuestion33BillClintonisamemberofLewinsky'sPBMplanwhichhasathreetiercopaymentstructure.BillfellillandhisdoctorprescribedhimAAA,abrandnamedrugwhichwasincludedintheLewinsky'sformularyBBB,anonformularydrugandCCC,agenericdrChoiceA:CCC,AAA,BBBChoiceB:BBB,CCC,AAAChoiceC:BBB,AAA,CCCChoiceD:CCC,BBB,AAAAnswer:AQuestion34Brokersareonetypeofdistributionchannelthathealthplansusetomarkettheirhealthplans.Onetruestatementaboutbrokersforhealthplanproductsisthat,typically,brokersChoiceA:arenotrequiredtobelicensedbythestatesinwhichtheymarkethealthplansChoiceB:arecompensatedonasalarybasisChoiceC:representonlyonehealthplanorinsurerChoiceD:areconsideredtobeanagentofthebuyerratherthananagentofthehealthplanorInsurerAnswer:DQuestion35Bydefinition,ahealthplan'snetworkreferstotheChoiceA:organizationsandindividualsinvolvedintheconsumptionofhealthcareprovidedbytheplan



ChoiceB:relativeaccessibilityoftheplan'sproviderstotheplan'sparticipantsChoiceC:groupofphysicians,hospitals,andothermedicalcareproviderswithwhomtheplanhascontractedtodelivermedicalservicestoitsmembersChoiceD:integrationoftheplan'sparticipantswiththeplan'sprovidersAnswer:CQuestion36Bydefinition,themarketingprocessofdefiningacertainplaceormarketnicheforaproductrelativetocompetitorsandtheirproductsandthenusingthemarketingmixtoattractcertainmarketsegmentsisknownasChoiceA:brandingChoiceB:positioningChoiceC:databasemarketingChoiceD:personalsellingAnswer:BQuestion37Byofferingacomprehensivesetofhealthcarebenefitstoitsmembers,anHMOensuresthatitsmembersobtainquality,costeffective,andappropriatemedicalcare.WaysthatanHMOprovidescomprehensivecareincludeChoiceA:coordinatingcareacrossavarietyofbenefitsChoiceB:emphasizingpreventivecarebycoveringmanypreventiveserviceseitherinfullorwithasmallcopaymentChoiceC:offeringitsmembersaccesstowellnessprogramsChoiceD:AlloftheaboveAnswer:DQuestion38Col.MartinAvery,onactivedutyintheU.S.Army,iselegibletoreceivehealthcarebenefitsunderoneofthethreeTRICAREhealthplanoptions.IfColAveryelectstoparticipateinTRICAREPrime,hewillbeChoiceA:abletoobtainfullbenefitsforservicesobtainedfromnetworkandnonnetworkprovidersChoiceB:subjecttocopayment,deductible,andcoinsurancerequirementsforanymedicalcarehereceivesChoiceC:requiredtoformallyenrollforcoverageandpayanenrollmentfeeChoiceD:assignedtoaprimarycaremanagerwhoisresponsibleforcoordinatingallhiscareAnswer:DQuestion39



Consumerdirectedhealthplansarenotanewconcept.Theyactuallygottheirstartinthelate1970swiththeadventof:ChoiceA:Healthsavingsaccounts(HSAs)ChoiceB:Healthreimbursementarrangements(HRAs)ChoiceC:Medicalsavingsaccounts(MSAs)ChoiceD:Flexiblespendingarrangements(FSAs)Answer:DQuestion40Dr.JuliaPhramisacardiologistundercontracttoHolcombHMO,Inc.,atypicalclosedpanelplan.Thefollowingstatementsareaboutthissituation.Selecttheanswerchoicecontainingthecorrectstatement.ChoiceA:AllmembersofHolcombHMOmustselectDr.Phramastheirprimarycarephysician(PCP).ChoiceB:AnyphysicianwhomeetsHolcomb'sstandardsofcareiseligibletocontractwithHolcombHMOasaprovider.ChoiceC:Dr.PhramiseitheranemployeeofHolcombHMOorbelongstoagroupofphysiciansthathascontractedwithHolcombHMOChoiceD:HolcombHMOplanmembersmayselfrefertoDr.PhramatfullbenefitswithoutfirstobtainingareferralfromtheirPCPs.Answer:AQuestion41Dr.MiltonWare,aphysicianintheRiversideMCO'snetworkofproviders,isreimbursedunderafeeschedulearrangementformedicalservicesheprovidestoRiversidemembers.Dr.Ware'sprovidercontractwithRiversidecontainsatypicalnobalancebilliChoiceA:preventDr.WarefromrequiringaRiversidemembertopayanycoinsurance,copayment,ordeductiblesthatthememberwouldnormallypayunderRiverside'splanChoiceB:requireDr.WaretoaccepttheamountthatRiversidepaysformedicalservicesaspaymentinfullandnottobillplanmembersforadditionalamountsChoiceC:preventDr.WarefromseekingcompensationfrompatientsifRiversidefailstocompensatehimbecauseoftheMCO'sinsolvencyChoiceD:preventDr.WarefrombillingaRiversidememberformedicalservicesthatarenotincludedinRiverside'splanAnswer:BQuestion42Dr.SamuelAldridge'sprovidercontractwiththeBadgerHealthPlanincludesatypicaldueprocessclause.Theprimarypurposeofthisclauseisto:



ChoiceA:StatethatDr.Aldridge'sprovidercontractwithBadgerwillautomaticallyterminateifheloseshismedicallicenseorhospitalprivileges.ChoiceB:Specifyatimeperiodduringwhichthepartythatbreachestheprovidercontractmustremedytheprobleminordertoavoidterminationofthecontract.ChoiceC:GiveDr.AldridgetherighttoappealBadger'sdecisionifheisterminatedwithcausefromBadger'sprovidernetwork.ChoiceD:SpecifythatBadgercanterminatethisprovidercontractwithoutprovidingareason,butonlyifBadgergivesDr.Aldridgeatleast90days'noticeofitsintenttoterminatethecontract.Answer:CQuestion43Duringanopenenrollmentperiodin1997,AmyHadekenrolledthroughheremployerforgrouphealthcoveragewiththeOwlHealthPlan,afederallyqualifiedHMO.Atthetimeofherenrollment,Ms.Hadekhadthreepreexistingmedicalconditions:angina,foChoiceA:theangina,thehighbloodpressure,andthebrokenankleChoiceB:theanginaandthehighbloodpressureonlyChoiceC:noneoftheseconditionsChoiceD:thebrokenankleonlyAnswer:AQuestion44Duringtheriskassessmentprocessforatraditionalindemnitygroupinsurancehealthplan,groupunderwritersconsidersuchcharacteristicsasagroupsgeographiclocation,thesizeandgendermixofthegroup,andthelevelofparticipationinthegrouChoiceA:Healthcarecostsaretypicallyhigherinruralareasthaninlargeurbanareas.ChoiceB:Themorbidityrateformalesishigherthanthemorbidityrateforfemales.ChoiceC:Thelargerthegroup,themorelikelyitisthatthegroupwillexperiencelossessimilartotheaveragerateoflossthatwaspredicted.ChoiceD:AlloftheaboveAnswer:CQuestion45Eachofthefollowingstatementsdescribesahealthplanthatisusingamethodofmanaginginstitutionalutilization.Selectthe



answerchoicethatdescribesahealthplan'suseofretrospectivereviewtodecreaseutilizationofhospitalservices.ChoiceA:TheSerenityHealthcareOrganizationrequiresaplanmemberortheproviderinchargeofthemember'scaretoobtainauthorizationforinpatientcarebeforethememberisadmittedtothehospital.ChoiceB:URnursesemployedbytheFriendshipHealthPlanmonitorlengthofstaytoidentifyfactorsthatmightcontributetounnecessaryhospitaldays.ChoiceC:TheOptimumHealthGroupevaluatesthemedicalnecessityandappropriatenessofproposedservicesandintervenes,ifnecessary,toredirectcaretoamoreappropriatecaresetting.ChoiceD:TheAxisMedicalGroupexaminesproviderpracticepatternstoidentifyareasinwhichservicesarebeingunderused,overused,ormisusedanddesignsstrategiestopreventinappropriateutilizationinthefuture.Answer:DQuestion46EdMurrayisaclaimsanalystforamanagedcareplanthatprovidesahigherlevelofbenefitsforservicesreceivedinnetworkthanforservicesreceivedoutofnetwork.WheneverMr.Murrayreceivesahealthclaimfromaplanmember,hereviewstheclaimChoiceA:A,B,C,andDChoiceB:AandConlyChoiceC:A,B,andDonlyChoiceD:B,C,andDonlyAnswer:AQuestion47EdO'BrienhasbothMedicarePartAandPartBcoverage.HealsohascoverageunderaPBMplanthatusesaclosedformularytomanagethecostanduseofpharmaceuticals.Recently,Mr.O'Brienwashospitalizedforananeurysm.Later,hewastransferredbyChoiceA:Confinementintheextendedcarefacilityafterhishospitalization.ChoiceB:Transportationbyambulancefromthehospitaltotheextendedcarefacility.ChoiceC:Physicians'professionalserviceswhilehewashospitalized.ChoiceD:physicians'professionalserviceswhilehewasattheextendedcarefacility.Answer:AQuestion48



EleanorGiambiiscoveredbyatypical24hourmanagedcareprogram.Onecharacteristicofthisprogramisthatit:ChoiceA:ProvidesMs.Giambiwithhealthcarecoverageforanyillnessorinjury,butonlyifthecauseoftheillnessorinjuryisworkrelated.ChoiceB:CombinesthegrouphealthplananddisabilityplanofferedbyMs.Giambi'semployerwithworkers'compensationcoverage.ChoiceC:RequiresMs.Giambiandheremployertoeachpayhalfofthecostofthiscoverage.ChoiceD:RequiresMs.Giambitopayspecifieddeductiblesandcopaymentsbeforereceivingbenefitsunderthisprogramforanyillnessorinjury.Answer:BQuestion49EmilyBrownworksforIntegralHealthPlanandrepresentsthecompanyasaboardmemberfortheboardofdirectors.WhichbestdescribesEmily'sposition?ChoiceA:CommunityRepresentativeChoiceB:InsideDirectorChoiceC:OutsideDirectorChoiceD:NoneoftheseAnswer:BQuestion50EmployersponsoredbenefitplansthatprovidehealthcarebenefitsmustcomplywiththeEmployeeRetirementIncomeSecurityAct(ERISA).OneofthemostsignificantfeaturesofERISAisthatitChoiceA:containsaprovisionstatingthatthetermsofERISAgenerallytakeprecedenceoveranystatelawsthatregulateemployeewelfarebenefitplansChoiceB:standardizestheconversionofgrouphealthcarebenefitstoindividualhealthcarebenefitsChoiceC:mandatesthatselffundedhealthcareplansmustpaystatepremiumtaxesChoiceD:requiresthatallactiveemployees,regardlessofage,mustbeeligibleforcoverageunderemployersponsoredbenefitplansAnswer:AQuestion51FederalEmployeeHealthBenefitsProgram(FEHBP)requireshealthplansofferingservicestofederalemployeesandtheirdependentstoprovideA.ImmediateaccesstoemergencyservicesB.UrgentAppointmentswithin24hours



C.RoutineappointmentsonceamChoiceA:DChoiceB:AChoiceC:B&CChoiceD:AllofthelistedoptionsAnswer:FQuestion52FederallegislationhasplacedtheprimaryresponsibilityforregulatinghealthinsurancecompaniesandHMOsthatserviceprivatesector(commercial)planmembersatthestatelevel.ThisfederallegislationistheChoiceA:ClaytonActChoiceB:FederalTradeCommissionActChoiceC:McCarranFergusonActChoiceD:ShermanActAnswer:CQuestion53FollowingareportbytheInstituteofMedicineontheincidenceandconsequencesofmedicalerrors,anationaltaskforcerecommendedimplementationofanationwidemandatorysystemofcollecting,analyzing,andreportingstandardizedinformationaboutmChoiceA:randomchangeChoiceB:structuralchangeChoiceC:haphazardchangeChoiceD:reactivechangeAnswer:DQuestion54Forproviders,integrationoccurswhentwoormorepreviouslyseparateproviderscombineundercommonownershiporcontrol,orwhentwoormoreproviderscombinebusinessoperationsthattheypreviouslycarriedoutseparatelyandindependently.SuchproviChoiceA:highercostsforhealthplans,healthcarepurchasers,andhealthcareconsumersChoiceB:improvedprovidercontractingpositionwithhealthplansChoiceC:anincreaseinproviders'autonomyandcontrolovertheirownworkenvironmentChoiceD:alloftheaboveAnswer:BQuestion55Forthisquestion,selecttheanswerchoicecontainingthetermsthatcorrectlycompletetheblankslabeledAandBinthe



paragraphbelow.NCQAoffersQualityCompass,anationaldatabaseofperformanceandaccreditationinformationsubmittedbymanagedChoiceA:HealthPlanEmployerDataandInformationSet(HEDIS)mandatoryChoiceB:HealthPlanEmployerDataandInformationSet(HEDIS)voluntaryChoiceC:ORYXmandatoryChoiceD:ORYXvoluntaryAnswer:BQuestion56Fromtheanswerchoicesbelow,selecttheresponsethatcorrectlyidentifiestheratingmethodthatMr.SybexusedandthepremiumratePMPMthatMr.SybexcalculatedfortheKostergroup.ChoiceA:RatingMethodbookratingPremiumRatePMPM$132ChoiceB:RatingMethodbookratingPremiumRatePMPM$138ChoiceC:RatingMethodblendedratingPremiumRatePMPM$132ChoiceD:RatingMethodblendedratingPremiumRatePMPM$138Answer:CQuestion57Fromthefollowinganswerchoices,choosethedescriptionoftheethicalprinciplethatbestcorrespondstothetermAutonomyChoiceA:HealthplansandtheirprovidersareobligatednottoharmtheirmembersChoiceB:Healthplansandtheirprovidersshouldtreateachmemberinamannerthatrespectsthemember'sgoalsandvalues,andtheyalsohaveadutytopromotethegoodofthemembersasagroupChoiceC:HealthplansandtheirprovidersshouldallocateresourcesinawaythatfairlydistributesbenefitsandburdensamongthemembersChoiceD:HealthplansandtheirprovidershaveadutytorespecttherightoftheirmemberstomakedecisionsaboutthecourseoftheirlivesAnswer:DQuestion58Fromthefollowinganswerchoices,choosethedescriptionoftheethicalprinciplethatbestcorrespondstothetermAutonomyChoiceA:Healthplansandtheirprovidersareobligatednotto



harmtheirmembersChoiceB:Healthplansandtheirprovidersshouldtreateachmemberinamannerthatrespectsthemember'sgoalsandvalues,andtheyalsohaveadutytopromotethegoodofthemembersasagroupChoiceC:HealthplansandtheirprovidersshouldallocateresourcesinawaythatfairlydistributesbenefitsandburdensamongthemembersChoiceD:HealthplansandtheirprovidershaveadutytorespecttherightoftheirmemberstomakedecisionsaboutthecourseoftheirlivesAnswer:DQuestion59Fromthefollowinganswerchoices,choosethedescriptionoftheethicalprinciplethatbestcorrespondstothetermBeneficenceChoiceA:HealthplansandtheirprovidersareobligatednottoharmtheirmembersChoiceB:Healthplansandtheirprovidersshouldtreateachmemberinamannerthatrespectsthemember'sgoalsandvalues,andtheyalsohaveadutytopromotethegoodofthemembersasagroupChoiceC:HealthplansandtheirprovidersshouldallocateresourcesinawaythatfairlydistributesbenefitsandburdensamongthemembersChoiceD:HealthplansandtheirprovidershaveadutytorespecttherightoftheirmemberstomakedecisionsaboutthecourseoftheirlivesAnswer:BQuestion60Fromthefollowinganswerchoices,choosethedescriptionoftheethicalprinciplethatbestcorrespondstothetermBeneficenceChoiceA:HealthplansandtheirprovidersareobligatednottoharmtheirmembersChoiceB:Healthplansandtheirprovidersshouldtreateachmemberinamannerthatrespectsthemember'sgoalsandvalues,andtheyalsohaveadutytopromotethegoodofthemembersasagroupChoiceC:HealthplansandtheirprovidersshouldallocateresourcesinawaythatfairlydistributesbenefitsandburdensamongthemembersChoiceD:HealthplansandtheirprovidershaveadutytorespecttherightoftheirmemberstomakedecisionsaboutthecourseoftheirlivesAnswer:BQuestion61



Fromthefollowingchoices,choosethedefinitionthatbestmatchesthetermhealthriskassessment(HRA)ChoiceA:AtechniqueusedtoeducateplanmembersonhowtodistinguishbetweenminorproblemsandseriousconditionsandeffectivelytreatminorproblemsthemselvesChoiceB:AtechniqueusedtodetermineifahealthconditionispresentevenifamemberhasnotexperiencedsymptomsoftheproblemChoiceC:Atechniqueinwhichinformationaboutaplanmember'shealthstatus,personalandfamilyhealthhistory,andhealthrelatedbehaviorsisusedtopredictthemember'slikelihoodofexperiencingspecificillnessesorinjuriesChoiceD:Atechniqueusedtoevaluatethemedicalnecessity,appropriateness,andcosteffectivenessofhealthcareservicesforagivenpatientAnswer:CQuestion62Fromthefollowingchoices,choosethedefinitionthatbestmatchesthetermScreeningChoiceA:AtechniqueusedtoeducateplanmembersonhowtodistinguishbetweenminorproblemsandseriousconditionsandeffectivelytreatminorproblemsthemselvesChoiceB:AtechniqueusedtodetermineifahealthconditionispresentevenifamemberhasnotexperiencedsymptomsoftheproblemChoiceC:Atechniqueinwhichinformationaboutaplanmember'shealthstatus,personalandfamilyhealthhistory,andhealthrelatedbehaviorsisusedtopredictthemember'slikelihoodofexperiencingspecificillnessesorinjuriesChoiceD:Atechniqueusedtoevaluatethemedicalnecessity,appropriateness,andcosteffectivenessofhealthcareservicesforagivenpatientAnswer:BQuestion63GeneralHMOisbuildingaprovidernetworkandisconsideringUniversalHospitalasanadditiontoitsnetwork.MinimumrequirementsthatGeneralshouldconsiderindeterminingwhetherUniversalisqualifiedtoparticipateinGeneral'snetworkincludeA.ChoiceA:BothAandBChoiceB:AonlyChoiceC:BonlyChoiceD:NeitherAnorBAnswer:A



Question64GreentreeMedical,ahealthplan,iscurrentlyrecruitingPCPsinpreparationforitsexpansionintoanewservicearea.AbigailDavis,arecruiterforGreentree,hasbeenmeetingwithMelissaCortelyou,M.D.,inanefforttorecruitherasaPCPinGreenChoiceA:GreentreeispreventedbylawfromofferingacontracttoDr.CortelyouuntilthecredentialingprocessiscompleteChoiceB:anycontractsignedbyDr.CortelyoushouldincludeaclauserequiringthesuccessfulcompletionofthecredentialingprocesswithinadefinedtimeframeinorderforthecontracttobeeffectiveChoiceC:GreentreemustofferastandardcontracttoDr.Cortelyou,withoutregardtotheoutcomeofthecredentialingprocessChoiceD:GreentreewillabandonthecredentialingprocessnowthatDr.CortelyouhasagreedtoparticipateinGreentree'snetworkAnswer:BQuestion65Healthplanscanorganizeunderanotforprofitformoraforprofitform.OnetruestatementregardingnotforprofithealthplansisthattheseorganizationstypicallyChoiceA:areexemptfromreviewbytheInternalRevenueService(IRS)ChoiceB:areorganizedasstockcompaniesforgreaterflexibilityinraisingcapitalChoiceC:relyonincomefromoperationsforthelargecashoutlaysneededtofundlongtermprojectsandexpansionChoiceD:engageinlobbyingorpoliticalactivitiesinordertomaintaintheirtaxexemptstatusAnswer:CQuestion66Healthplansmayusedifferentcapitationarrangementsfordifferentlevelsofservice.Onetypicalcapitationarrangementprovidesacapitationpaymentthatmayincludeprimarycareonly,orbothprimaryandsecondarycare,butnotancillaryservices.ThChoiceA:globalcapitationarrangementChoiceB:gatekeeperarrangementChoiceC:carveoutarrangementChoiceD:partialcapitationarrangementAnswer:DQuestion67Healthplansoftenprogramintotheirclaimsprocessingsystems



certaincriteriathat,ifunmet,willpromptfurtherinvestigationofaclaim.Inanautomatedclaimsprocessingsystem,thesecriteriamaysignaltheneedforfurtherreviewwhen,forexamplChoiceA:EncounterreportsChoiceB:DiagnosticcodesChoiceC:DurationalratingsChoiceD:EditsAnswer:DQuestion68Healthplansrequireutilizationreviewforallservicesadministeredbyitsparticipatingphysicians.ChoiceA:TrueChoiceB:FalseChoiceC:ChoiceD:Answer:BQuestion69Healthplanssometimescontractwithindependentorganizationstoprovidespecialtyservices,suchasvisioncareorrehabilitationservices,toplanmembers.SpecialtyservicesthathavecertaincharacteristicsaregenerallygoodcandidatesforhealthplChoiceA:Loworstablecosts.ChoiceB:Appropriate,ratherthaninappropriate,utilizationrates.ChoiceC:Abenefitthatcannotbeeasilydefined.ChoiceD:Definedpatientpopulation.Answer:DQuestion70Healthplans'useoftheInternettoprovideplanmemberswithhealthrelatedinformationhasgrownrapidlyinrecentyears.OneadvantagetheInternethasoverotherformsofcommunicationisthatChoiceA:userscanaccesstheInternetusinganumberofdifferenttypesofcomputersystemsChoiceB:accesstotheInternetisavailableonlytomembersofthehealthplan'snetworkChoiceC:theInternetisimmunetointernalsecuritybreachesbyemployeesortradingpartnerswithinthenetworkChoiceD:userscancontactasinglecontrollingorganizationtorectifydisruptionsinInternetserviceAnswer:AQuestion71Healthplansusethefollowingtodeterminethenumberofproviderstoaddtoanetwork:



ChoiceA:StaffingratiosChoiceB:DrivetimeChoiceC:GeographicavailabilityChoiceD:AlloftheaboveAnswer:DQuestion72Healthsavingsaccountswerecreatedbywhichofthefollowinglaws:ChoiceA:COBRAChoiceB:HIPAAChoiceC:MedicareModernizationActChoiceD:NoneoftheAboveAnswer:CQuestion73HistoricallymostHMOshavebeenChoiceA:ClosedaccessHMOChoiceB:ClosedpanelHMOChoiceC:OpenaccessHMOChoiceD:OpenpanelHMOAnswer:BQuestion74HMOstypicallyemployseveraltechniquestomanageproviderutilizationandmemberutilizationofmedicalservices.OnetechniquethatanHMOusestomanagememberutilizationisChoiceA:theuseofphysicianpracticeguidelinesChoiceB:therequirementofcopaymentsforofficevisitsChoiceC:capitationChoiceD:riskpoolsAnswer:BQuestion75IanVladmirwantstohavearoutinephysicalexaminationtoascertainthatheisingoodhealth.Mr.Vladmirisamemberofahealthplanthatwillallowhimtoselectthephysicianofhischoice,eitherfromwithinhisplan'snetworkorfromoutsideofhChoiceA:atraditionalHMOplanChoiceB:amanagedindemnityplanChoiceC:apointofservice(POS)optionChoiceD:anexclusiveproviderorganization(EPO)Answer:CQuestion76IdentifytheCORRECTstatement(s):(A)Smallerthegroup,themorelikelyitisthatthegroupwillexperiencelossessimilartotheaveragerateoflossthatwas



predicted.(B)Genderofthegroup'sparticipantshasnoeffectonthelikelihoodofloss.(ChoiceA:AllofthelistedoptionsChoiceB:B&CChoiceC:NoneofthelistedoptionsChoiceD:A&CAnswer:CQuestion77IfastatecommissionerofinsuranceplacesanHMOunderadministrativesupervision,thenthepurposeofthisactionmostlikelyisto:ChoiceA:TransferalloftheHMO'sbusinesstoothercarriers.ChoiceB:Allowthestatecommissioner,actingforastatecourt,totakecontrolofandadministertheHMO'sassetsandliabilities.ChoiceC:SelltheHMO'sassetsinordertosatisfytheHMO'sobligations.ChoiceD:PlacetheHMO'soperationsunderthedirectionandcontrolofthestatecommissionerorapersonappointedbythecommissioner.Answer:DQuestion78Ifleftunresolved,membercomplaintsabouttheactionsordecisionsmadebyahealthplanoritsproviderscanleadtoformalappeals.OneprocedurehealthplanscanusetoaddressformalappealsistosubmittheoriginaldecisionandanysupportinginfoChoiceA:aLevelOneappeal,andthememberhastherighttoafurtherappealChoiceB:aLevelTwoappeal,andthereviewer'sdecisionisfinalandbindingChoiceC:anindependentexternalappeal,andthememberhastherighttoafurtherappealChoiceD:arbitration,andthereviewer'sdecisionisfinalandbindingAnswer:AQuestion79Ifmostofthephysicians,ormanyofthephysiciansinaparticularspecialty,areaffiliatedwithasingleentity,thenahealthplanbuildinganetworkintheservicearea________________________.ChoiceA:Hasmanycontractingoptionsavailable.ChoiceB:Shouldnotcontractwiththatentity



ChoiceC:MostlikelyneedstocontractwiththatentityChoiceD:ShouldattempttodisbandtheexistingaffiliationsAnswer:CQuestion80Immediateevaluationandtreatmentofillnessorinjurycanbeprovidedinanyofthefollowingcaresettings:A.HospitalemergencydepartmentsB.Physician'sofficesC.UrgentcarecentersIfthesesettingsarerankedinorderofthecostofprovidingcChoiceA:A,B,CChoiceB:A,C,BChoiceC:B,C,AChoiceD:C,A,BAnswer:BQuestion81In1999,theUnitedStatesCongresspassedtheFinancialServicesModernizationAct,referredtoastheGrammLeachBliley(GLB)Act.TheprimaryprovisionsincludedundertheGLBActrequirefinancialinstitutions,includinghealthplans,totakeseveralChoiceA:Notifycustomersofanysharingofnonpublicpersonalfinancialinformationwithnonaffiliatedthirdparties.ChoiceB:Prohibitcustomersfromhavingtheopportunityto'optout'ofsharingnonpublicpersonalfinancialinformation.ChoiceC:Disclosetoaffiliates,butnottothirdparties,theirprivacypoliciesregardingthesharingofnonpublicpersonalfinancialinformation.ChoiceD:Agreenottodisclosepersonallyidentifiablefinancialinformationorpersonallyidentifiablehealthinformation.Answer:AQuestion82In1999,theUnitedStatesCongresspassedtheFinancialServicesModernizationAct,whichisreferredtoastheGrammLeachBliley(GLB)Act.Thefollowingstatement(s)cancorrectlybemadeaboutthisact:A.TheGLBActallowsconvergenceamongthetraChoiceA:AonlyChoiceB:BothAandBChoiceC:BonlyChoiceD:NeitherAnorBAnswer:BQuestion83Inaccountingterminology,theitemsofvaluethatacompany



ownssuchascash,cashequivalents,andreceivablesaregenerallyknownasthecompany'sChoiceA:revenueChoiceB:netincomeChoiceC:surplusChoiceD:assetsAnswer:DQuestion84Inadditiontothecredentialingactivitiesthatanhealthplanperformswheninitiallyacceptingaproviderintoitsnetwork,thehealthplanmustalsoperformrecredentialingofthesameprovidersonanongoingbasis.ManyofthesameactivitiesareperChoiceA:verificationofanetworkprovider'smedicaleducationandresidencyChoiceB:performanceofsiteinspectionsinaprovider'sfacilitiesChoiceC:reviewofinformationfromaprovider'squalityimprovementactivitiesChoiceD:verificationofaprovider'slicensureandcertificationAnswer:AQuestion85Inassessingthepotentialdegreeofriskrepresentedbyaproposedinsured,ahealthunderwriterconsidersthefactorofantiselection.AntiselectioncancorrectlybedefinedastheChoiceA:inabilityofaproposedinsuredtosharewiththeinsurerthefinancialrisksofhealthcarecoverageChoiceB:possibilitythataproposedinsuredwillprofitfromanillnessbyreceivingbenefitsthatexceedthetotalamountofhisorhereligiblemedicalexpensesChoiceC:inabilityofaproposedinsuredtoprovidesufficientevidencethatprovesheorsheisaninsurableriskChoiceD:tendencyofpeoplewhohaveagreaterthanaveragelikelihoodoflosstoapplyfororcontinueinsuranceprotectiontoagreaterextentthanpeoplewhohaveanaverageorlessthanaveragelikelihoodofthesamelossAnswer:DQuestion86Incertainsituations,ahealthplancanusetheresultsofutilizationreviewtointervene,ifnecessary,toalterthecourseofaplanmember'smedicalcare.SuchinterventioncanbebasedontheresultsofA.ProspectivereviewB.ConcurrentreviewC.



ChoiceA:A,B,andCChoiceB:AandBonlyChoiceC:AandConlyChoiceD:BonlyAnswer:DQuestion87Incertainsituations,ahealthplancanusetheresultsofutilizationreviewtointervene,ifnecessary,toalterthecourseofaplanmember'smedicalcare.SuchinterventioncanbebasedontheresultsofA.ProspectivereviewB.ConcurrentreviewC.ChoiceA:A,B,andCChoiceB:AandBonlyChoiceC:AandConlyChoiceD:BonlyAnswer:BQuestion88Inclaimsadministrationterminology,aclaimsinvestigationiscorrectlydefinedastheprocessofChoiceA:reportingmanagementinformationaboutservicesprovidedeachtimeapatientvisitsaproviderforpurposesofanalyzingutilizationandproviderpracticepatternsChoiceB:obtainingalltheinformationnecessarytodeterminetheappropriateamounttopayonagivenclaimChoiceC:routinelyreviewingandprocessingaclaimforeitherpaymentordenialChoiceD:assigningtoeachdiagnosisortreatmentreportedonaclaimspecialcodesthatbrieflyandspecificallydescribeeachdiagnosisandtreatmentAnswer:BQuestion89Inhealthplanterminology,demandmanagement,asusedbyhealthplans,canbestbedescribedasChoiceA:anevaluationofthemedicalnecessity,efficiency,and/orappropriatenessofhealthcareservicesandtreatmentplansforagivenpatientChoiceB:aseriesofstrategiesdesignedtoreduceplanmembers'needstoutilizehealthcareservicesbyencouragingpreventivecare,wellness,memberselfcare,andappropriateuseofhealthcareservicesChoiceC:atechniquethatpreventsaproviderwhoisbeingreimbursedunderafeeschedulearrangementfrombillingaplanmemberforanyfeesthatexceedthemaximumfeereimbursed



bytheplanChoiceD:asystemofidentifyingplanmemberswithspecialhealthcareneeds,developingahealthcarestrategytomeetthoseneeds,andcoordinatingandmonitoringthecareAnswer:BQuestion90Inlargehealthplans,managementfunctionssuchasproviderrecruiting,credentialing,contracting,providerservice,andperformancemanagementforprovidersaretypicallytheresponsibilityoftheChoiceA:chiefexecutiveofficer(CEO)ChoiceB:networkmanagementdirectorChoiceC:boardofdirectorsChoiceD:directorofoperationsAnswer:BQuestion91Inmostcases,medicalerrorsarecausedbybreakdownsinthehealthcaresystemratherthanbyprovidermistakes.ChoiceA:TrueChoiceB:FalseChoiceC:ChoiceD:Answer:AQuestion92Inordertocompensateforlostrevenueresultingfromservicesprovidedfreeoratasignificantlyreducedcosttootherpatients,manyhealthcareprovidersspreadtheseunreimbursedcoststopayingpatientsorthirdpartypayors.ThispracticeisknownChoiceA:dualchoiceChoiceB:costshiftingChoiceC:accreditationChoiceD:defensivemedicineAnswer:BQuestion93InordertocoversomeofthegapbetweenFFSMedicarecoverageandtheactualcostofservices,beneficiariesoftenrelyonMedicaresupplements.WhichofthefollowingstatementsaboutMedicaresupplementsiscorrect?ChoiceA:Theinitialten(AJ)MedigappoliciesofferabasicbenefitpackagethatincludescoverageforMedicarePartAandMedicarePartBcoinsurance.ChoiceB:EachinsurancecompanysellingMedigapmustsellallthedifferentMedigappolicies.ChoiceC:MedicareSELECTisaMedicaresupplementthat



usesapreferredproviderorganization(PPO)tosupplementMedicarePartAcoverage.ChoiceD:Medigapbenefitsvarybyplantype(AthroughL),andarenotuniformnationally.Answer:AQuestion94Inordertogenerateexchangeswithconsumers,healthcareplanmarketersusethefourelementsofthemarketingmix:product,price,place(distribution),andChoiceA:segmentationChoiceB:publicityChoiceC:promotionChoiceD:plandesignAnswer:CQuestion95Inordertohelpreviewitsinstitutionalutilizationrates,theSahaleeMedicalGroup,ahealthplan,usesthestandardformulatocalculatehospitalbeddaysper1,000planmembersforthemonthtodate(MTD).OnApril20,SahaleeusedthefollowinginfChoiceA:67ChoiceB:274ChoiceC:365ChoiceD:1,000Answer:BQuestion96Inordertomeasuretheexpensesofinstitutionalutilization,HoltHealthcareGroupusesthestandardformulatocalculatehospitalbeddaysper1,000planmembersperyear.OnOctober23,HoltusedthefollowinginformationtocalculatethebeddaysperChoiceA:278ChoiceB:397ChoiceC:403ChoiceD:920Answer:BQuestion97Inpreparationforitsexpansionintoanewservicearea,theRegalMCOismeetingwithDr.NancyBuhner,acardiologistwhopracticesinRegal'snewservicearea,inordertoconvincehertobecomeoneoftheplan'sparticipatingproviders.AspartofthChoiceA:ensurethatDr.BuhnercomplieswithalloftheprovisionsoftheEthicsinPatientReferralsActChoiceB:learnwhetherDr.Buhnerisalicensedmedical



practitionerChoiceC:confirmDr.Buhner'smembershipintheNationalCommitteeforQualityAssurance(NCQA)ChoiceD:learnwhetherDr.BuhnerhashadamedicalmalpracticeclaimfiledorotherdisciplinaryactionstakenagainstherAnswer:DQuestion98Inresponsetothedemandforamethodofassessingoutcomes,accreditingorganizationsandothergovernmentandcommercialgroupshavedevelopedquantitativemeasuresofqualitythatconsumers,purchasers,regulators,andotherscanusetocomparehealthChoiceA:qualitystandardsChoiceB:accreditationdecisionsChoiceC:standardsofcareChoiceD:performancemeasuresAnswer:DQuestion99Inthefollowingsections,wewilldescribesomeofthemeasureshealthplansusetoevaluatethequalityoftheservicesandhealthcaretheyoffertheirmembers.Whichofthefollowingisthebestdescriptionofwhata'Processmeasure'evaluates?ChoiceA:Thenature,quantity,andqualityoftheresourcesthatahealthplanhasavailableformemberserviceandpatientcare.ChoiceB:Themethodsandproceduresahealthplananditsprovidersusetofurnishserviceandcare.ChoiceC:Theextenttowhichservicessucceedinimprovingormaintainingsatisfactionandpatienthealth.ChoiceD:NoneoftheaboveAnswer:BQuestion100Intheparagraphbelow,asentencecontainstwopairsofwordsenclosedinparentheses.Determinewhichwordineachpaircorrectlycompletesthesentence.Thenselecttheanswerchoicecontainingthetwowordsthatyouhavechosen.ManypharmacybenefitChoiceA:Therapeutic/alwaysChoiceB:Generic/alwaysChoiceC:Generic/neverChoiceD:Therapeutic/neverAnswer:AQuestion101



Intheparagraphbelow,twostatementseachcontainapairoftermsenclosedinparentheses.Determinewhichtermcorrectlycompleteseachstatement.Thenselecttheanswerchoicecontainingthetwotermsthatyouhavechosen.Forproviders,(operational/ChoiceA:operational/anacquisitionChoiceB:operational/aconsolidationChoiceC:structural/anacquisitionChoiceD:structural/aconsolidationAnswer:DQuestion102IntheUnitedStates,theDepartmentofDefenseoffersongoinghealthcarecoveragetomilitarypersonnelandtheirfamiliesthroughtheTRICAREhealthplan.OnetruestatementaboutTRICAREisthatChoiceA:hospitalsparticipatinginTRICAREprogramareexemptfromJCAHOaccrediationandMedicarecertificationChoiceB:TRICAREenrolleesarenotentitiledtoappealauthorizationcoveragedecisionsChoiceC:activedutypersonnelareautomaticallyconsideredenrolledinTRICAREPrimeChoiceD:TRICAREcoversinpatientandoutpatientservices,physicianandhospitalcharges,andmedicalsupplies,butnotmentalhealthservicesAnswer:CQuestion103IntheUnitedStates,theDepartmentofDefenseoffersongoinghealthcarecoveragetomilitarypersonnelandtheirfamiliesthroughtheTRICAREhealthplan.OnetruestatementaboutTRICAREisthat:ChoiceA:ActivedutymilitarypersonnelareautomaticallyconsideredenrolledinTRICAREPrimeChoiceB:TRICAREcoversinpatientandoutpatientservices,physicianandhospitalcharges,andmedicalsupplies,butnotmentalhealthservices.ChoiceC:TRICAREenrolleesarenotentitledtoappealauthorizationorcoveragedecisionsChoiceD:HospitalsparticipatingintheTRICAREprogramareexemptfromJCAHOaccreditationandMedicarecertification.Answer:AQuestion104IndividualscanuseHSAstopayforthefollowingtypesofhealthcoverage:.ChoiceA:QualifieddisabilityinsuranceChoiceB:COBRAcontinuationcoverage.



ChoiceC:Medigapcoverage(forthoseover65).ChoiceD:Alloftheabove.Answer:BQuestion105JanetRivaiscoveredbyaindemnityhealthinsuranceplanthatspecifiesa$250deductibleandincludesa20%coinsuranceprovision.WhenMs.Rivawashospitalized,sheincurred$2,500inmedicalexpensesthatwerecoveredbyherhealthplan.SheincurreChoiceA:$1,750ChoiceB:$1,800ChoiceC:$2,000ChoiceD:$2,250Answer:BQuestion106JanetRivaiscoveredbyatraditionalidemnityhealthinsuranceplanthatspecifiesa$250deductibleandincludesa20%coinsuranceprovision.WhenMs.Rivawashospitalized,sheincurred$2,500inmedicalexpensesthatwerecoveredbyherhealthplan.ChoiceA:$1,750ChoiceB:$1,800ChoiceC:$2,000ChoiceD:$2,250Answer:BQuestion107JohnKerry'semployerhascontractedtoreceivehealthcareforitsemployeesfromtheDemocraticHealthcareSystem.Mr.KerryvisitshisPCP,whosendshimtohavesomebloodtests.ThePCPthenrefersMr.KerrytoaspecialistwhohospitalizeshimforonChoiceA:aphysicianpracticeorganisationChoiceB:aphysicianhospitalorganisationChoiceC:amanagementservicesorganisationChoiceD:anintegrateddeliverysysemAnswer:DQuestion108KatrinaLopezisaclaimsanalystforahealthplanthatprovidesahigherlevelofbenefitsforservicesreceivedinnetworkthanforservicesreceivedoutofnetwork.Ms.Lopezreviewedahealthclaimforanswerstothefollowingquestions:QuestionAChoiceA:A,B,C,andDChoiceB:A,B,andDonly



ChoiceC:B,C,andDonlyChoiceD:AandConlyAnswer:AQuestion109KatrinaLopezisaclaimsanalystforahealthplanthatprovidesahigherlevelofbenefitsforservicesreceivedinnetworkthanforservicesreceivedoutofnetwork.Ms.Lopezreviewedahealthclaimforanswerstothefollowingquestions:QuestionAChoiceA:A,B,C,andDChoiceB:A,B,andDonlyChoiceC:B,C,andDonlyChoiceD:AandConlyAnswer:AQuestion110KhalynDrury'semployerincludesmanageddentalcareinitsemployeebenefitspackage.Duringopenenrollment,Ms.Druryenrolledinthedentalplan,whichprovidesdentalservicestoitsmembersinexchangeforaprepayment(thepremium).DentalservicesChoiceA:dentalpreferredproviderorganization(PPO)ChoiceB:traditionalfeeforservice(FFS)dentalplanChoiceC:planwithadentalpointofservice(POS)optionChoiceD:dentalhealthmaintenanceorganization(DHMO)Answer:DQuestion111LansdaleHealthcare,ahealthplan,offerscomprehensivehealthcarecoveragetoitsmembersthroughanetworkofphysicians,hospitals,andotherserviceproviders.Planmemberswhouseinnetworkservicespayacopaymentfortheseservices.ThecopaymentChoiceA:specifieddollaramountchargethataplanmembermustpayoutofpocketforaspecifiedmedicalserviceatthetimetheserviceisrenderedChoiceB:percentageofthefeesformedicalservicesthataplanmembermustpayafterMagellanhaspaiditsshareofthecostsofthoseservicesChoiceC:flatamountthataplanmembermustpayeachyearbeforeMagellanwillmakeanybenefitpaymentsonbehalfoftheplanmemberChoiceD:specifiedpaymentforservicesthatwasnegotiatedbetweentheproviderandMagellanAnswer:AQuestion112



Managedbehavioralhealthorganizations(MBHOs)useseveralstrategiestomanagethedeliveryofbehavioralhealthcareservices.Thefollowingstatementsareaboutthesestrategies.Selecttheanswerchoicethatcontainsthecorrectstatement.ChoiceA:MBHOsgenerallyprovidebenefitsformentalhealthservicesbutnotforchemicaldependencyservices.ChoiceB:Thelevelofcareneededtotreatbehavioraldisordersisthesameforallpatientsandalldisorders.ChoiceC:Byusingoutpatienttreatmentmoreextensively,MBHOshavedecreasedtheuseofcostlyinpatienttherapies.ChoiceD:PCPgatekeepersystemsforbehavioralhealthcaregenerallyresultinmoreaccuratediagnoses,moreeffectivetreatment,andmoreefficientuseofresourcesthandocentralizedreferralsystems.Answer:CQuestion113ManyHMOsarecompensatedforthedeliveryofhealthcaretomembersunderaprepaidcarearrangement.Underaprepaidcarearrangement,aplanmembertypicallypaysaChoiceA:fixedamountinadvanceforeachmedicalservicethememberreceivesChoiceB:asmallfeesuchas$10or$15thatamemberpaysatthetimeofanofficevisittoanetworkproviderChoiceC:afixed,monthlypremiumpaidinadvanceofthedeliveryofmedicalcarethatcoversmosthealthcareservicesthatamembermightneed,nomatterhowoftenthememberusesmedicalservicesChoiceD:specifiedamountofthemember'smedicalexpensesbeforeanybenefitsarepaidbytheHMOAnswer:CQuestion114ManyofthecredentialingstandardsandcriteriausedbyhealthplansareoftentakenfromalreadyexistingstandardsestablishedbyChoiceA:theNationalPractitionerDataBank(NPDB)ChoiceB:theNationalAssociationofInsuranceCommissioners(NAIC)ChoiceC:theCentersforMedicareandMedicaidServices(CMS)ChoiceD:independentaccreditingorganizationsAnswer:DQuestion115MarleeWhitcombwascoveredasadependentunderthegrouphealthplanprovidedbyherfather'semployer.ThathealthplancompliedwiththeprovisionsoftheConsolidatedOmnibus



BudgetReconciliationAct(COBRA)of1986.WhenMs.Whitcombmarried,shecChoiceA:cancontinuehergroupcoverageforaperiodnottoexceed48monthsChoiceB:cancontinuehergroupcoverageforaperiodnottoexceed36monthsChoiceC:cannotcontinuehergroupcoverage,buthastherighttoconvertthegroupcoveragetoanindividualhealthplanChoiceD:cancontinuehergroupcoverageindefinitelyAnswer:BQuestion116Medicaidisajointlyfundedfederalandstateprogramthatprovideshospitalandmedicalexpensecoveragetolowincomeindividualsandcertainagedanddisabledindividuals.OnecharacteristicofMedicaidisthatChoiceA:providerswhocareforMedicaidrecipientsmustacceptMedicaidpaymentaspaymentinfullforservicesrenderedChoiceB:Medicaidrequiresrecipientstopaydeductibles,copayments,andcoinsuranceamountsforallservicesChoiceC:MedicaidisalwaystheprimarypayorofbenefitsChoiceD:benefitsofferedbyMedicaidprogramsarefederallymandatedanddonotvarybystateAnswer:AQuestion117MedicareAdvantageproductoptionsinclude:ChoiceA:Coordinatedcareplans,medicalsavingsaccountsandnationalPPOs.ChoiceB:PrivateFeeforServiceplans,healthcareprepaymentplansandmedicalsavingsaccountsChoiceC:Coordinatedcareplans,regionalPPOsandprivatefeeforserviceplansChoiceD:Costcontracts,coordinatedcareprogramsandmedicalsavingsaccounts.Answer:CQuestion118MedicareisthefederalgovernmentprogramestablishedunderTitleXVIIIoftheSocialSecurityActof1965toprovidehospital,medicalandothercoveredbenefitstoelderlyanddisabledpersons.Medicareisavailablefor:ChoiceA:Personsage63orolder.ChoiceB:Personswithqualifyingdisabilities(overtheageof63)ChoiceC:Personswithendstagerenaldisease(ESRD)ChoiceD:Lowincomeindividuals



Answer:CQuestion119MedicarePartCcanbedeliveredbythefollowingMedicareAdvantageplans:ChoiceA:HCCP,HMO,PPO(localorregional),PFFSorMSA.ChoiceB:CCPs,PFFSorMSA.ChoiceC:HMO,HSA,PPO(localorregional),PFFSorMSA.ChoiceD:HMO,PPO(localorregional),POS,orMSA.Answer:BQuestion120Membersatisfactionisacriticalelementofahealthplan'squalitymanagementprogram.AhealthplancanobtaininformationaboutmembersatisfactionwithvariousaspectsofthehealthplanfromChoiceA:surveyscompletedbymembersfollowingavisittoaproviderChoiceB:surveyssenttoplanmemberswhohavenotreceivedhealthcareservicesduringaspecifiedtimeperiodChoiceC:periodicreportsofcomplaintsreceivedbymemberservicespersonnelChoiceD:alloftheaboveAnswer:DQuestion121Memberswhoqualifytoparticipateinahealthplan'scasemanagementprogramaretypicallyassignedacasemanager.Duringthecourseofthemember'streatment,thecasemanagerisresponsibleforA.Coordinatingandmonitoringthemember'scareB.ApproChoiceA:BothAandBChoiceB:AonlyChoiceC:BonlyChoiceD:NeitherAnorBAnswer:BQuestion122MerleSpencerhascoverageunderbothMedicarePartAandMedicarePartB.Ms.Spencerrecentlywashospitalizedforchestpains,andsheincurredchargesfor:ThecostofhospitalizationfortwodaysDiagnostictestsperformedinthehospitalTransChoiceA:ambulanceandthediagnostictestsChoiceB:ambulance,thediagnostictests,andthephysician's



professionalservicesChoiceC:costofhospitalizationChoiceD:costofhospitalizationandthephysician'sprofessionalservicesAnswer:DQuestion123MoreproceduresorservicesmaybefullycoveredwithinthePPOnetworkthanthoseoutofnetwork.ChoiceA:TrueChoiceB:FalseChoiceC:ChoiceD:Answer:AQuestion124Mostcontractsbetweenhealthplansandproviderscontainaprovisionwhichforbidsprovidersfromseekingcompensationfrompatientsifthehealthplanfailstocompensatetheproviderbecauseofinsolvencyorforanyotherreason.SuchaprovisionisknChoiceA:dueprocessprovisionChoiceB:cureprovisionChoiceC:holdharmlessprovisionChoiceD:risksharingprovisionAnswer:CQuestion125Mr.GeorgeBushiscoveredbyaPBMplanthatusesaclosedformulary.ThisindicatesthatChoiceA:hecanreceivecoverageforparmaceuticalsonlyiftheyareonthePBMplan'spreferredlistofdrugsChoiceB:hemustreceiveallofhispharmaceuticalsfromamailorderpharmacyprogramChoiceC:hecanreceivecoverageforpharmaceuticalsthatareonthePBMplan'spreferredlistofdrugs,aswellasforpharmacueticalsthatarenotonthepreferredlistChoiceD:thePBMplancannotrecivearebateonanypharmacueticalsitobtainsfromthepharmaceuticalfacturerAnswer:AQuestion126NatalieChanisamemberoftheUltraHealthPlan,ahealthplan.Wheneversheneedsnonemergencymedicalcare,sheseesDr.DavidCraig,aninternist.Ms.Chancannotselfrefertoaspecialist,soshesawDr.Craigwhensheexperiencedheadaches.Dr.CrChoiceA:WithinUltra'ssystem,Ms.Chanreceivedprimary



carefrombothDr.CraigandDr.LeeChoiceB:Ultra'ssystemallowsitsmembersopenaccesstoallofUltra'sparticipatingproviders.ChoiceC:WithinUltra'ssystem,Dr.CraigservesasacoordinatorofcareorgatekeeperforthemedicalservicesthatMs.Chanreceives.ChoiceD:Ultra'snetworkofprovidersincludesDr.CraigandDr.LeebutnotArrowHospitalAnswer:CQuestion127NatalieChanisamemberoftheUltraHealthPlan.Wheneversheneedsnonemergencymedicalcare,sheseesDr.DavidCraig,aninternist.Ms.Chancannotselfrefertoaspecialist,soshesawDr.Craigwhensheexperiencedheadaches.Dr.CraigreferredhChoiceA:WithinUltra'ssystem,Ms.ChanreceivedprimarycarefrombothDr.CraigandDr.Lee.ChoiceB:Ultra'ssystemallowsitsmembersopenaccesstoallofUltra'sparticipatingproviders.ChoiceC:WithinUltra'ssystem,Dr.CraigservesasacoordinatorofcareorgatekeeperforthemedicalservicesthatMs.Chanreceives.ChoiceD:Ultra'snetworkofprovidersincludesDr.CraigandDr.LeebutnotArrowHospital.Answer:CQuestion128OnecharacteristicofdiseasemanagementprogramsisthattheytypicallyChoiceA:focusonindividualepisodesofmedicalcareratherthanonthecomprehensivecareofthepatientovertimeChoiceB:areusedtocoordinatethecareofmemberswithanytypeofdisease,eitherchronicornonchronicChoiceC:focusonmanagingpopulationsofpatientswhohaveaspecificchronicillnessormedicalcondition,butdonotfocusonpatientpopulationswhoareatriskofdevelopingsuchanillnessorconditionChoiceD:useclinicalpracticeprocessestostandardizetheimplementationofbestpracticesamongprovidersAnswer:DQuestion129OnecharacteristicoftheaccreditationprocessforMCOsisthatChoiceA:anaccreditingagencytypicallyconductsanonsitereviewofanMCO'soperations,butitdoesnotreviewanMCO'smedicalrecordsorassessitsmemberservicesystemsChoiceB:eachaccreditingorganizationhasitsownstandards



ofaccreditationChoiceC:theaccreditingprocessismandatoryforallMCOsChoiceD:governmentagenciesconductallaccreditationactivitiesforMCOsAnswer:BQuestion130Onecomponentofinformationsystemsusedbyhealthplansincorporatesmembershipdataandinformationaboutproviderreimbursementarrangementsandanalyzestransactionsaccordingtocontractrules.ThisinformationsystemcomponentisknownasChoiceA:acontractmanagementsystemChoiceB:acredentialingsystemChoiceC:alegacysystemChoiceD:aninteroperablecommunicationsystemAnswer:AQuestion131OnedevicethatPBMplansusetomanageboththecostanduseofpharmaceuticalsisaformulary.AformularyisdefinedasChoiceA:alistingofdrugsclassifiedbytherapeuticcategoryordiseaseclassthatareconsideredpreferredtherapyforagivenmanagedpopulationandthataretobeusedbyahealthplan'sprovidersinprescribingmedicationsChoiceB:areductioninthepriceofaparticularpharmaceuticalobtainedbythePBMfromthepharmaceuticalmanufacturerChoiceC:drugsorderedanddeliveredthroughthemailtothePBM'splanmembersatareducedcostChoiceD:anidentificationcardissuedbythePBMtoitsplanmembersAnswer:AQuestion132OnedistinctionthatcanbemadebetweenastaffmodelHMOandagroupmodelHMOisthat,inastaffmodelHMO,participatingphysiciansareBacktoTopChoiceA:employeesoftheHMOChoiceB:employeesofagrouppracticethathascontractedwiththeHMOChoiceC:compensatedprimarilythroughcapitationChoiceD:limitedtoprimarycarephysicians(PCPs)Answer:AQuestion133Onedistinguishingcharacteristicofahealthmaintenanceorganization(HMO)isthat,typically,anHMOChoiceA:arrangesforthedeliveryofmedicalcareand



provides,orsharesinproviding,thefinancingofthatcareChoiceB:mustbeorganizedonanotforprofitbasisChoiceC:maybeorganizedasacorporation,apartnership,oranyotherlegalentityChoiceD:mustbefederallyqualifiedinordertoconductbusinessinanystateAnswer:AQuestion134Oneethicalprincipleinhealthplansistheprincipleofnonmaleficence,whichholdsthathealthplansandtheirproviders:ChoiceA:Shouldallocateresourcesinawaythatfairlydistributesbenefitsandburdensamongthemembers.ChoiceB:Haveadutytopresentinformationhonestlyandareobligatedtohonorcommitments.ChoiceC:Areobligatednottoharmtheirmembers.ChoiceD:Shouldtreateachplanmemberinamannerthatrespectshisorhergoalsandvalues.Answer:CQuestion135Oneethicalprincipleinmanagedcareistheprincipleofjustice/equity,whichspecificallyholdsthatMCOsandtheirprovidershaveadutytoChoiceA:treateachmemberinamannerthatrespectshisorherowngoalsandvaluesChoiceB:allocateresourcesinawaythatfairlydistributesbenefitsandburdensamongthemembersChoiceC:presentinformationhonestlytotheirmembersandtohonorcommitmentstotheirmembersChoiceD:makesuretheydonotharmtheirmembersAnswer:BQuestion136OnefactortheSandpiperHealthPlanusestoassessitsqualityisaclinician'sbedsidemanner,i.e.,howfriendlyandunderstandingtheclinicianis,whetherthepatientfeelsthattheclinicianlistenstothepatient'sconcerns,howwellthecliniciaChoiceA:aproviderservicequalityissueChoiceB:anadministrativeservicequalityissueahealthcareprocessqualityissueChoiceC:ahealthcareoutcomesqualityissueChoiceD:ahealthcareprocessqualityissueAnswer:AQuestion137OnefeatureoftheEmployeeRetirementIncomeSecurityAct(ERISA)isthatit:



ChoiceA:Requiresselffundedemployeebenefitplanstopaypremiumtaxesatthestatelevel.ChoiceB:Containsapreemptionprovision,whichtypicallymakesthetermsofERISAtakeprecedenceoveranystatelawsthatregulateemployeewelfarebenefitplans.ChoiceC:Containsstrictreportinganddisclosurerequirementsforallemployeebenefitplansexcepthealthplans.ChoiceD:Requiresthatstateinsurancelawsapplytoallemployeebenefitplansexceptinsuredplans.Answer:BQuestion138OneHMOmodelcanbedescribedasanextensionofagroupmodelHMObecauseitcontractswithmultiplegrouppractices,ratherthanwithasinglegrouppractice.ThisHMOmodelisknownastheChoiceA:staffmodelHMOChoiceB:IPAmodelHMOChoiceC:directcontractmodelHMOChoiceD:networkmodelHMOAnswer:DQuestion139Onenongroupmarketsegmenttowhichhealthplansmarkethealthplanproductsistheseniormarket,whichiscomprisedmostlyofpersonsoverage65whoareeligibleforMedicarebenefits.Onefactorthataffectsahealthplan'seffortstomarkettotheChoiceA:TheCentersforMedicareandMedicaidServices(CMS)mustapproveallmarketingmaterialsusedbyhealthplanstomarkethealthplanproductstotheMedicarepopulationChoiceB:managedMedicareplanstypicallyrequireMedicarebeneficiariestopurchaseMedigapinsurancetosupplementgapsincoverageChoiceC:managedMedicareplanscanrefusetocoverpersonswithcertainhealthproblemsChoiceD:theCMSprohibitshealthplansfromusingtelemarketingtomarkethealthplanproductstotheMedicarepopulationAnswer:BQuestion140Oneofthedistinguishingcharacteristicsofhealthcaremarketingisthatmanyofthemarketsforhealthplansarenational,notlocalmarkets.ChoiceA:TrueChoiceB:FalseChoiceC:



ChoiceD:Answer:BQuestion141OneofthemostinfluentialpiecesoflegislationintheadvancementofhealthplanswithintheUnitedStateswastheHealthMaintenanceOrganization(HMO)Actof1973.OneoftheprovisionsoftheActwasthatitChoiceA:exemptedHMOsfromallstatelicensurerequirements.ChoiceB:requiredallemployersthatofferedhealthcarecoveragetotheiremployeestoofferonlyonetypeoffederallyqualifiedHMO.ChoiceC:eliminatedfundingthatsupportedtheplanningandstartupphasesofnewHMOs.ChoiceD:establishedaprocessbywhichHMOscouldobtainfederalqualificationAnswer:DQuestion142OneofthemostinfluentialpiecesoflegislationintheadvancementofmanagedcarewithintheUnitedStateswastheHMOActof1973.OneprovisionoftheHMOActof1973wasthatitChoiceA:emphasizedcompensatingphysiciansbasedsolelyonthevolumeofmedicalservicestheyprovideChoiceB:exemptedHMOsfromallstatelicensurerequirementsChoiceC:establishedaprocessunderwhichHMOscouldelecttobefederallyqualifiedChoiceD:requiredfederallyqualifiedHMOstorelatepremiumlevelstothehealthstatusoftheindividualenrolleeoremployergroupAnswer:CQuestion143Onetruestatementaboutcommunityrating,aratingmethodcommonlyusedbyhealthplans,isthat:ChoiceA:Itrequiresahealthplantosetpremiumsforfinancingmedicalcareaccordingtothehealthplan'sexpectedcostofprovidingmedicalbenefitstoasubgroupwithinthecommunity.ChoiceB:Ahealthplanusuallyusescommunityratingtosetpremiumsforlargegroups.ChoiceC:Ittendstoleadtogreaterfluctuationsinpremiumratesthandootherratingmethods.ChoiceD:Ahealthplanseldomusescommunityratingtosetpremiumsforlargegroups.Answer:D



Question144OnetruestatementregardingethicsandlawsisthatthevaluesofacommunityarereflectedinChoiceA:bothethicsandlaws,andbothethicsandlawsareenforceableinthecourtsystemChoiceB:bothethicsandlaws,butonlylawsareenforceableinthecourtsystemChoiceC:ethicsonly,butonlylawsareenforceableinthecourtsystemChoiceD:lawsonly,butbothethicsandlawsareenforceableinthecourtsystemAnswer:BQuestion145OnetruestatementregardingethicsandlawsisthatthevaluesofacommunityarereflectedinChoiceA:bothethicsandlaws,andbothethicsandlawsareenforceableinthecourtsystemChoiceB:bothethicsandlaws,butonlylawsareenforceableinthecourtsystemChoiceC:ethicsonly,butonlylawsareenforceableinthecourtsystemChoiceD:lawsonly,butbothethicsandlawsareenforceableinthecourtsystemAnswer:BQuestion146Onetypeofphysicianonlyintegrationmodelisaconsolidatedmedicalgroup.TypicalcharacteristicsofaconsolidatedmedicalgroupincludeChoiceA:thatitmaybeasinglespecialtyormultispecialtypracticeChoiceB:operatesinoneorafewfacilitiesratherthaninmanyindependentofficesChoiceC:achieveseconomiesofscaleinthegroup'sintegratedoperationsChoiceD:alloftheaboveAnswer:DQuestion147Onetypicalcharacteristicofanintegrateddeliverysystem(IDS)isthatanIDS.ChoiceA:Ismorehighlyintegratedstructurallythanitisoperationally.ChoiceB:Providesafullrangeofhealthcareservices,includingphysicianservices,hospitalservices,andancillaryservices.ChoiceC:Cannotnegotiatedirectlywithhealthplans,plan



sponsors,orotherhealthcarepurchasers.ChoiceD:Performsasinglebusinessfunction,suchasnegotiatingwithhealthplansonbehalfofallofthememberproviders.Answer:BQuestion148Onetypicalcharacteristicofpreferredproviderorganization(PPO)benefitplansisthatPPOs:ChoiceA:Assumefullfinancialriskforarrangingmedicalservicesfortheirmembers.ChoiceB:Requireplanmemberstoobtainareferralbeforegettingmedicalservicesfromspecialists.ChoiceC:Useacapitationarrangement,insteadofafeeschedule,toreimbursephysicians.ChoiceD:Offersomecoverage,althoughatahighercost,forplanmemberswhochoosetousetheservicesofnonnetworkproviders.Answer:DQuestion149OnewayinwhichahealthplancansupportanethicalenvironmentisbyChoiceA:requiringorganizationswithwhichitcontractstoadopttheplan'sformalethicalpolicyChoiceB:developingandmaintainingaculturewhereethicalconsiderationsareintegratedintodecisionmakingatthetoporganizationallevelonlyChoiceC:establishingaformalmethodofmanagingethicalconflicts,suchasusinganethicstaskforceorbioethicsconsultantChoiceD:maintainingcontrolofpolicydevelopmentbyremovingprovidersandmembersfromtheprocessofdevelopingandimplementingpoliciesandproceduresthatprovideguidancetoprovidersandmembersconfrontedwithethicalissuesAnswer:CQuestion150OnewayinwhichahealthplancansupportanethicalenvironmentisbyChoiceA:requiringorganizationswithwhichitcontractstoadopttheplan'sformalethicalpolicyChoiceB:developingandmaintainingaculturewhereethicalconsiderationsareintegratedintodecisionmakingatthetoporganizationallevelonlyChoiceC:establishingaformalmethodofmanagingethicalconflicts,suchasusinganethicstaskforceorbioethics



consultantChoiceD:maintainingcontrolofpolicydevelopmentbyremovingprovidersandmembersfromtheprocessofdevelopingandimplementingpoliciesandproceduresthatprovideguidancetoprovidersandmembersconfrontedwithethicalissuesAnswer:CQuestion151OnewayinwhichhealthplansdifferfromtraditionalindemnityplansisthathealthplansTypicallyChoiceA:providelessextensivebenefitsthanthoseprovidedundertraditionalindemnityplansChoiceB:placeagreateremphasisonpreventivecarethandotraditionalindemnityplansChoiceC:requirememberstopayapercentageofthecostofmedicalservicesrenderedafteraclaimisfiled,ratherthanafixedcopaymentatthetimeofserviceasrequiredbyindemnityplansChoiceD:containcostsharingrequirementsthatresultinmoreoutofpocketspendingbymembersthandothecostsharingrequirementsintraditionalindemnityplansAnswer:BQuestion152OnewaythatMCOsinvolveprovidersinrisksharingisbyretainingapercentageoftheproviders'paymentduringaplanyear.Attheendoftheplanyear,theMCOmayusetheamountretainedtooffsetorpayforanycostoverrunsforreferralorhospitalChoiceA:withholdsChoiceB:usual,customary,andreasonable(UCR)feesChoiceC:riskpoolsChoiceD:perdiemsAnswer:AQuestion153ParableHealthcareProviders,ahealthplan,recentlysegmentedthemarketforanewhealthcareservice.Parablebegantheprocessbydividingthehealthcaremarketintotwobroadcategories:nongroupandgroup.Next,ParablefurthersegmentedthenongrChoiceA:channelsegmentationChoiceB:geographicsegmentationChoiceC:demographicsegmentationChoiceD:productsegmentationAnswer:C



Question154ParulGuptahasbeencoveredbyagrouphealthplanforeighteenmonths.Forthepastfourmonths,shehasbeenundergoingtreatmentfordiabetes.Lastweek,Ms.Guptabegananewjobandimmediatelyenrolledinhernewcompany'sgrouphealthplan,whichChoiceA:canexcludecoveragefortreatmentofMs.Gupta'sdiabetesforoneyear,becauseshedidnothaveatleasttwoyearsofcreditablecoverageunderherprevioushealthplanChoiceB:cannotexcludeMs.Gupta'sdiabetesasapreexistingcondition,becausetheoneyearpreexistingconditionprovisionisoffsetbyatleastoneyearofcontinuouscoverageunderherprevioushealthplanChoiceC:canexcludecoveragefortreatmentofMs.Gupta'sdiabetesforoneyear,becauseHIPAAdoesnotimpactagrouphealthplan'spreexistingconditionprovisionChoiceD:canexcludecoveragefortreatmentofMs.Gupta'sdiabetesforfourmonths,becausethatisthelengthoftimeshereceivedtreatmentforthismedicalconditionpriortoherenrollmentinthenewhealthplanAnswer:BQuestion155PatrickFlaherty'semployerhascontractedtoreceivehealthcareforitsemployeesfromtheAbundantHealthcareSystem.Mr.Flahertyvisitshisprimarycarephysician(PCP),whosendshimtohavesomebloodtests.ThePCPthenrefersMr.FlahertytoaspeChoiceA:anintegrateddeliverysystem(IDS)ChoiceB:aManagementServicesOrganization(MSO)ChoiceC:aPhysicianPracticeManagement(PPM)companyChoiceD:aphysicianhospitalorganization(PHO)Answer:AQuestion156PaulGilberthasbeencoveredbyagrouphealthplanfortwoyears.Hehasbeenundergoingtreatmentforanginaforthepastthreemonths.Lastweek,Mr.Gilbertbegananewjobandimmediatelyenrolledinhisnewcompany'sgrouphealthplan,whichhasaChoiceA:CanexcludecoveragefortreatmentofMr.Gilbert'sanginaforoneyear,becauseHIPAAdoesnotimpactagrouphealthplan'spreexistingconditionprovision.ChoiceB:CanexcludecoveragefortreatmentofMr.Gilbert'sanginaforoneyear,becauseMr.Gilbertdidnothaveatleast36monthsofcreditablecoverageunderhisprevioushealthplan.ChoiceC:CanexcludecoveragefortreatmentofMr.Gilbert'sanginaforthreemonths,becausethatisthelengthoftimehe



receivedtreatmentforthismedicalconditionpriortohisenrollmentinthenewhealthplan.ChoiceD:Cannotexcludehisanginaasapreexistingcondition,becausetheoneyearpreexistingconditionprovisionisoffsetbyatleastoneyearofcontinuouscoverageunderhisprevioushealthplan.Answer:DQuestion157PBMplansoperateunderseveraltypesofcontractualarrangements.Underonecontractualarrangement,thePBMplanandtheemployeragreeonatargetcostperemployeepermonth.Iftheactualcostperemployeepermonthisgreaterthanthetargetcost,tChoiceA:feeforservicearrangementChoiceB:risksharingcontractChoiceC:capitationcontractChoiceD:rebatecontractAnswer:BQuestion158Pharmacybenefitmanagement(PBM)companiestypicallyinteractwithphysiciansandpharmacistsbyperformingsuchclinicalservicesasphysicianprofiling.PhysicianprofilingfromaPBM'spointofviewinvolvesChoiceA:ascertainingthatphysiciansintheplanhavethenecessaryandappropriatecredentialstoprescribemedicationsChoiceB:compilingdataonphysicianprescribingpatternsandcomparingphysicians'actualprescribingpatternstoexpectedpatternswithinselectdrugcategoriesChoiceC:monitoringpatientspecificdrugproblemsthroughconcurrentandretrospectivereviewChoiceD:establishingprotocolsthatrequirephysicianstoobtaincertificationofmedicalnecessitypriortodrugdispensingAnswer:BQuestion159PhillipTsaiisinsuredbybothaindemnityhealthinsuranceplan,whichishisprimaryplan,andahealthplan,whichishissecondaryplan.Bothplanshavetypicalcoordinationofbenefits(COB)provisions,butneitherhasanonduplicationofbenefitspChoiceA:$0ChoiceB:$300ChoiceC:$400ChoiceD:$900Answer:CQuestion160



PhillipTsaiisinsuredbybothatraditionalidemnityhealthinsuranceplan,whichishisprimaryplan,andahealthplan,whichishissecondaryplan.Bothplanshavetypicalcoordinationofbenefits(COB)provisions,butneitherhasanonduplicationofChoiceA:$0ChoiceB:$300ChoiceC:$400ChoiceD:$900Answer:CQuestion161PhoebeUrichiscoveredbyatraditionalindemnityhealthinsuranceplanthatspecifiesa$500calendaryeardeductibleandincludesa20%coinsuranceprovision.WhenMs.Urichwashospitalized,sheincurred$3,000inmedicalexpensesthatwerecoveredbyChoiceA:1900ChoiceB:2000ChoiceC:2400ChoiceD:2500Answer:BQuestion162Primarycarecasemanagers(PCCMs)providecasemanagementservicestoeligibleMedicaidrecipients.WithregardtoPCCMsitiscorrecttosaythat:ChoiceA:PCCMstypicallyreceiveacasemanagementfee,ratherthanreimbursementformedicalservicesonaFFSbasis,fortheservicestheyprovidetoMedicaidrecipients.ChoiceB:AllMedicaidrecipientswholiveinruralareasmustbegivenachoiceofatleastfourPCCMs.ChoiceC:PCCMsreceiveacasemanagementfeeinadditiontoreimbursementformedicalservicesonaFFSbasis.ChoiceD:PCCMscontractdirectlywiththefederalgovernmenttoprovidecasemanagementservicestoMedicaidrecipients.Answer:CQuestion163Primarycarecasemanagers(PCCMs)providemanagedhealthcareservicestoeligibleMedicaidrecipients.WithregardtoPCCMs,itiscorrecttosaythatChoiceA:PCCMscontractdirectlywiththefederalgovernmenttoprovidecasemanagementservicestoMedicaidrecipientsChoiceB:allMedicaidrecipientswholiveinruralareasmustbegivenachoiceofatleastfourPCCMsChoiceC:MedicaidPCCMprogramsareexemptfromthe



HealthCareFinancingAdministration's(HCFA's)QualityImprovementSystemforManagedCare(QISMC)standardsChoiceD:PCCMstypicallyreceiveacasemanagementfee,ratherthanreimbursementformedicalservicesonaFFSbasis,fortheservicestheyprovidetoMedicaidrecipientsAnswer:CQuestion164Providerintegrationhastwocomponents:operationalintegrationandstructuralintegration.Anexampleofoperationalintegrationinhealthplansisthe:ChoiceA:AcquisitionoftheLeopardHealthPlanbytheHickoryHealthPlan.ChoiceB:JointventureenteredintobytheEclipseHealthPlanandalocalhospitalsystemtocreateanewhealthplaninwhichEclipseandthehospitalsystemshareownership.ChoiceC:Formationofanorganizationbyagroupofproviderstocarryoutbilling,collections,andcontractingwithhealthplansfortheentiregroupofproviders.ChoiceD:ConsolidationoftheCarverHealthPlanandtheLimestoneHealthPlan.Answer:CQuestion165RonaldCantonisamemberoftheOmegaMCO.HereceiveshisnonemergencymedicalcarefromDr.KristenHigh,aninternist.WhenMr.Cantonneededtovisitacardiologistabouthisirregularheartbeat,hefirsthadtoobtainareferralfromDr.HightoseeChoiceA:Dr.HighservesasthecoordinatorofcareforthemedicalservicesthatMr.Cantonreceives.ChoiceB:Omega'snetworkofprovidersincludesDr.High,butnotDr.Miller.ChoiceC:Omega'ssystemallowsitsmembersopenaccesstoallofOmega'sparticipatingproviders.ChoiceD:Omegausedafinancingarrangementknownasarelativevaluescale(RVS)tocompensateDr.Miller.Answer:AQuestion166Severalmarketplacefactorshelpedfuelthemovementtowardconsumerchoice.WhichoneofthefollowingstatementsisNOTaccuratewithregardtothesefactors?ChoiceA:Afteraperiodofrelativestability,annualgrowthinprivatehealthspendingpercapitabegantoincreaserapidlyin2002.ChoiceB:Duringtheheightoftherecentcostupswing,insurancepremiumswereincreasingbymorethan13%



annually.ChoiceC:Increasedutilizationwasthelargestfactorcontributingtotheriseinpremiums,accountingfor43%oftheincrease.ChoiceD:Employerpayersbeganseekingwaystocontrolspiralingutilizationratesandprovidelowercosthealthcoverageoptions.Answer:AQuestion167Someprovidersuseelectronicmedicalrecords(EMRs)todocumenttheirpatients'careinanelectronicform.Thefollowingstatement(s)cancorrectlybemadeaboutEMRs:A.EMRsarecomputerizedrecordsofapatient'sclinical,demographic,andadministraChoiceA:BonlyChoiceB:BothAandBChoiceC:NeitherAnorBChoiceD:AonlyAnswer:DQuestion168SomestatesmandatethatanindependentenrollmentbrokerorbenefitscounselorcontractorselectedbythestatemustmanageenrollmentoftheeligibleMedicaidpopulationintomanagedcare.InotherstatesahealthplancanengageindependentbrokersandChoiceA:Manystateshaveregulationsthatprohibithealthplansfromusingdoortodoorand/ortelephonesolicitationtomarkethealthplanproductstotheMedicaidpopulation.ChoiceB:Healthplansareneverallowedtomedicallyunderwriteindividualmarketcustomerswhoareunderage65.ChoiceC:Topromoteahealthplanproducttotheindividualmarket,healthplanstypicallyusecaptiveagentswhogivesalespresentationstopotentialcustomers,ratherthanusingpromotiontoolssuchasdirectmail,telemarketing,oradvertising.ChoiceD:HealthplanstypicallyareallowedtomedicallyunderwriteallindividualmarketcustomerswhoarecoveredbyMedicareandcanrefusetocoversuchcustomers.Answer:AQuestion169Specialtyservicesthathavecertaincharacteristicsgenerallyaregoodcandidatesformanagedcareapproaches.ThesecharacteristicsgenerallyincludethatthespecialtyserviceshouldhaveChoiceA:appropriate,ratherthaninappropriate,utilization



ChoiceB:adefinedpatientpopulationChoiceC:low,stablecostsChoiceD:abenefitthatcannotbeeasilydefinedAnswer:BQuestion170Specialtyserviceswithcertaincharacteristicstendtomakegoodcandidatesforhealthplanapproaches.OnecharacteristicusedtoidentifyaspecialtyservicethatmaybeagoodcandidateforahealthplanapproachisthattheserviceshouldhaveChoiceA:adefinedpatientpopulationChoiceB:acomplexbenefitstructureChoiceC:low,stablecostsChoiceD:appropriateutilizationratesAnswer:AQuestion171TheprudentlaypersonstandarddescribedintheBalancedBudgetAct(BBA)of1997requiresallhospitalsthatreceiveMedicareorMedicaidreimbursementtoscreenand,ifnecessary,stabilizeallpatientswhocometotheiremergencydepartments.ChoiceA:TrueChoiceB:FalseChoiceC:ChoiceD:Answer:BQuestion172TheprudentlaypersonstandarddescribedintheBalancedBudgetAct(BBA)of1997requiresallhospitalsthatreceiveMedicareorMedicaidreimbursementtoscreenand,ifnecessary,stabilizeallpatientswhocometotheiremergencydepartments.ChoiceA:TrueChoiceB:FalseChoiceC:ChoiceD:Answer:BQuestion173TheAcmeHMOrecruitsandcontractsdirectlywithawiderangeofphysiciansbothPCPsandspecialistsinitsgeographicareaonanonexclusivebasis.Thereisnoseparatelegalentitythatrepresentsandnegotiatesthecontractsforthephysicians.TheChoiceA:anindependentpracticeassociation(IPA)modelHMO



ChoiceB:astaffmodelHMOChoiceC:adirectcontractmodelHMOChoiceD:agroupmodelHMOAnswer:CQuestion174TheadministrativesimplificationstandardsdescribedunderTitleIIofHIPAAincludeprivacystandardstocontroltheuseanddisclosureofhealthinformation.Ingeneral,theseprivacystandardsprohibitChoiceA:allhealthplans,healthcareproviders,andhealthcareclearinghousesfromusinganyprotectedhealthinformationforpurposesoftreatment,payment,orhealthcareoperationswithoutanindividual'swrittenconsentChoiceB:patientsfromrequestingthatrestrictionsbeplacedontheaccessibilityanduseofprotectedhealthinformationChoiceC:transmissionofindividuallyidentifiablehealthinformationforpurposesotherthantreatment,payment,orhealthcareoperationswithouttheindividual'swrittenauthorizationChoiceD:patientsfromaccessingtheirmedicalrecordsandrequestingtheamendmentofincorrectorincompleteinformationAnswer:DQuestion175TheAdvantageHealthPlanrecentlyaddedthefollowingfeaturestoitsmemberservicesprogram:IVRActivememberoutreachprogramAdvantage'smemberservicesstaffingneedsarelikelytoincreaseasaresultofChoiceA:1ChoiceB:2ChoiceC:1&2ChoiceD:Neither1nor2Answer:BQuestion176Theapplicationofhealthplanprinciplestoworkers'compensationinsuranceprogramshaspresentedsomeuniquechallengesbecauseofthedifferencesbetweenhealthplanfortraditionalgrouphealthcareandworkers'compensation.OnekeydifferenceisthaChoiceA:limitscoveragetoeligibleemployeesandexcludesparttimeemployeesChoiceB:specifiesanannuallifetimebenefitmaximumondollarcoverageformedicalcosts



ChoiceC:providesbenefitsregardlessofthecauseofaninjuryorillnessChoiceD:providesbenefitsforbothhealthcarecostsandlostwagesAnswer:DQuestion177TheArkHealthPlan,iscurrentlyrecruitingprovidersinpreparationforitsexpansionintoanewservicearea.ArecruiterforArkhasbeenmeetingwithDr.NanShea,apediatricianwhopracticesinArk'snewservicearea,inordertoconvincehertobeChoiceA:CredentialingChoiceB:AccreditationChoiceC:AsentineleventChoiceD:AscreeningprogramAnswer:AQuestion178TheArkHealthPlan,iscurrentlyrecruitingprovidersinpreparationforitsexpansionintoanewservicearea.ArecruiterforArkhasbeenmeetingwithDr.NanShea,apediatricianwhopracticesinArk'snewservicearea,inordertoconvincehertobeChoiceA:Haseverparticipatedinanyqualityimprovementactivities.ChoiceB:IsaparticipatingproviderinahealthplanthatwillcompetewithArkinitsnewservicearea.ChoiceC:MeetstherequirementsoftheEthicsinPatientReferralsAct.ChoiceD:Hashadamedicalmalpracticeclaimfiledorotherdisciplinaryactionstakenagainsther.Answer:DQuestion179TheAzureGroupisaforprofithealthplanthatoperatesintheUnitedStates.TheFordhamGroupownsallofAzure'sstock.TheFordhamGroup'ssolebusinessistheownershipofcontrollinginterestsinthesharesofothercompanies.ThisinformationindChoiceA:AholdingcompanyoftheFordhamGroup.ChoiceB:AsistercorporationoftheFordhamGroup.ChoiceC:AsubsidiaryoftheFordhamGroup.ChoiceD:Alloftheabove.Answer:CQuestion180TheBlaineHealthcareCorporationseekstomanageitsquality



byfirstidentifyingthebestpracticesandbestoutcomesforagivenprocedure.BlainecanthendetermineareasinwhichitcanemulatethebestpracticesinordertoequalorsurpassthebestChoiceA:providerprofilingChoiceB:benchmarkingChoiceC:peerreviewChoiceD:qualityassessmentAnswer:BQuestion181TheCitywideHealthGroupisalargeproviderbasedhealthplanthatincludesphysiciangroups,hospitals,andotherfacilities.Inordertooverseeandmanagetheoperationoftheorganization,Citywidehasestablishedanenterpriseschedulingsystem.ThChoiceA:provideinformationtoCitywide'smanagementregardingproviderlicensure,certification,andmalpracticehistoryChoiceB:detectinstancesofoverutilization,underutilization,orinappropriateutilizationofmedicalresourcesChoiceC:allowCitywide'sdifferentcomponentstofunctionasasingleorganizationinarrangingaccesstofacilitiesandresourcesChoiceD:facilitatetheprocessingofrequestsforauthorizationofpaymentofbenefitsAnswer:CQuestion182TheCleopatraGroup,athirdpartyadministrator(TPA),hasenteredintoaTPAagreementwiththeAlexanderMCOwithregardtotheadministrationofaparticularhealthplan.ThisagreementcomplieswithalloftheprovisionsoftheNAICTPAModelLaw.OnChoiceA:holdallfundsitreceivesonbehalfofAlexanderintrustChoiceB:assumefullresponsibilityfordeterminingtheclaimpaymentproceduresfortheplanChoiceC:assumefullresponsibilityforensuringthatthehealthplanisadministeredproperlyChoiceD:obtainfromthefederalgovernmentacertificateofauthoritydesignatingtheCleopatraGroupasaTPAAnswer:AQuestion183TheCloverGroupisaforprofitMCOthatoperatesintheUnitedStates.TheValentineGroupownsallofClover'sstock.TheValentineGroup'ssolebusinessistheownershipofcontrollinginterestsinthesharesofothercompanies.Thisinformationindic



ChoiceA:holdingcompanyoftheValentineGroupChoiceB:sistercorporationoftheValentineGroupChoiceC:parentcompanyoftheValentineGroupChoiceD:subsidiaryoftheValentineGroupAnswer:DQuestion184TheConquestCorporationcontractswiththeApexhealthplantoprovidebasicmedicalandsurgicalservicestoConquestemployees.ConquestenteredintoaseparatecontractwiththeBrightDentalGrouptoprovideandmanageadentalcareprogramforemploChoiceA:anegotiatedrebateagreementChoiceB:acarveoutarrangementChoiceC:anindemnityplanChoiceD:PBMAnswer:BQuestion185ThecontractbetweentheHonoluluMCOandBeverleyHillsHospitalcontainsa90daycureprovision.TheBeverleyHillsHospitalbreachedoneofthecontractreqirementsonJuly31,2004.ThehospitalremediedtheproblembyOctober31,2004.WhichoftheChoiceA:ThecontractwouldnotbeterminatedasBeverleyHillshospitalrectifiedtheproblemwithin90days.ChoiceB:ThecontractwouldbeterminatedasBeverleyHillshospitalwasrequiredtonotifyHonoluluMCOabouttheproblematleast90daysinadvance.ChoiceC:ThecontractwouldbeterminatedasBeverleyHillshospitalwasrequiredtorectifytheproblemwithin90days.ChoiceD:ThecontractwouldnotbeterminatedasBeverleyHillshospitalmayescapeadherencetothecureprovision.Answer:CQuestion186TheCourtlandPPOmaintainscomputerizedrecordsthatincludeclinical,demographic,andadministrativedataaboutindividualplanmembers.Thedataintheserecordsisavailabletoplanproviders,ancillaryservicedepartments,pharmacies,andothersinvChoiceA:adatawarehouseChoiceB:adecisionsupportsystemChoiceC:anoutsourcingsystemChoiceD:anelectronicmedicalrecord(EMR)systemAnswer:DQuestion187



Thecriteriausedtoidentifyandmeasurehealthcarequalityaregenerallydividedintothreecategories:structure,process,andoutcomesmeasures.Structuremeasures,whichrelatetothenatureandqualityoftheresourcesthatahealthplanhasavailabChoiceA:lengthoftimepatientshavetowaitattheofficetobeseenbyaproviderChoiceB:percentageofplanphysicianswhoareboardcertifiedChoiceC:percentageofchildrenreceivingimmunizationsChoiceD:numberofpatientscontractinganinfectioninthehospitalAnswer:BQuestion188Thedataevaluationstageofutilizationreview(UR)includesbothadministrativereviewsandmedicalreviews.Onetruestatementaboutthesetypesofreviewsisthat:ChoiceA:Anadministrativereviewmustbeconductedbyahealthplanstaffmemberwhoisamedicalprofessional.ChoiceB:Theprimarypurposeofanadministrativereviewistoevaluatetheappropriatenessofaproposedmedicalservice.ChoiceC:URstaffmemberstypicallyconductamedicalreviewofaproposedmedicalservicebeforetheyconductanadministrativereviewforthatsameservice.ChoiceD:Onepurposeofamedicalreviewistoevaluatethemedicalnecessityofaproposedmedicalservice.Answer:DQuestion189TheEmployeeRetirementIncomeSecurityAct(ERISA)requireshealthplanmemberswhoreceivehealthcarebenefitsthroughemployeebenefitplanstofilelegalchallengesinvolvingcoveragedecisionsorplanadministrationatthefederallevel.UndertheteChoiceA:contractdamages,whichcoverthecostofdeniedtreatmentChoiceB:compensatorydamages,whichcompensatetheinjuredpartyforhisorherinjuriesChoiceC:punitivedamages,whicharedesignedtopunishormakeanexampleofthewrongdoerChoiceD:alloftheaboveAnswer:AQuestion190TheexistingcommitteesattheMajesticHealthPlan,ahealthplanthatissubjecttotherequirementsofHIPAA,includetheExecutiveCommitteeandtheCorporateComplianceCommittee.TheExecutiveCommitteeservesasalongtermadvisorybodyonissues



ChoiceA:Both1and2ChoiceB:1onlyChoiceC:2onlyChoiceD:Neither1nor2Answer:BQuestion191TheFairwayHealthGroupcontractedwiththeEmpireCorporationtoprovidebehavioralhealthcareservicestoEmpireemployees.Asaconditionofprovidingbehavioralhealthcareservices,FairwayrequiredEmpiretocontractwithFairwayforbasicmedicalsChoiceA:horizontalgroupboycottChoiceB:pricefixingagreementChoiceC:horizontaldivisionofmarketsChoiceD:tyingarrangementAnswer:DQuestion192Thefollowingorganizationsaretheprimarysourcesofaccreditationofhealthcareorganizations:A.NationalCommitteeforQualtyAssurance(NCQA)B.AmericanAccreditationHealthCareCommission/URACOftheseorganizations,performancedataisincludediChoiceA:AonlyChoiceB:BonlyChoiceC:AandBChoiceD:noneoftheaboveAnswer:AQuestion193Thefollowingparagraphcontainsanincompletestatement.Selecttheanswerchoicecontainingthetermthatcorrectlycompletesthestatement.Inearlyeffortstomanagehealthcarecosts,traditionalindemnityhealthinsurersincludedintheirhealthplaChoiceA:costshiftingChoiceB:deductiblesChoiceC:underwritingChoiceD:copayAnswer:BQuestion194Thefollowingparagraphcontainsanincompletestatement.Selecttheanswerchoicecontainingthetermthatcorrectlycompletesthestatement.Advancesincomputertechnologyhaverevolutionizedtheprocessingofmedicalanddrugclaims.Claimsprocessingi



ChoiceA:LowerChoiceB:HigherChoiceC:SameChoiceD:NochangeAnswer:BQuestion195ThefollowingprogramsarepartoftheAlcoveHealthPlan'sutilizationmanagement(UM)program:PreventivecareinitiativesAtelephonetriageprogramAshareddecisionmakingprogramAselfcareprogramWithregardtotheUMprograms,itismostChoiceA:Preventivecareinitiativesincludeimmunizationprogramsbutnothealthpromotionprograms.

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