AHM250 Mock Test

1.The practice of charging more for services provided to paying patients to compensate for lost revenue resulting from

services provided free or at a significantly reduced cost to other patients is known as

a.Cost sharing

b.Cost Shifting

c.All of the above

Ans b.Cost Shifting

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

a.Life Style of the people

b.Concentration of physicians in highly populated areas.

c.Advancement in information technology

Ans b.Concentration of physicians in highly populated areas.

3.The feature that formed the foundation of Health Maintance Act of 1973.

a.Federal Qualification Requirements

b.Exemption from state laws

c.All of the above

Ans c.All of the above

4.George was covered by a united health care insurance policy. This policy says that Geroge has to pay

$300 out of pocket for the medical expenses in that year before united health care will start to reimburse

the medical expense incurred for George. What is the term used to call the out of pocket payment made by george

a.Co-payment

b.Deductible

c.Coinsurance

d.None of the above

Ans b.Deductible

5.Each time a patient visits a provider he has to pay a fixed dollar amount?

a.Deductible

b.Copayment

c. Capitation

d.Co-insurance

Ans b.Copayment

6.Combined system of preventive, diagnostic and therapeutic measures that focuses on management

of specific chronic illness or medical conditions are

a.Utilization Review

b.Case Management

c.Demand Management

d.Disease management

Ans d.Disease management

AHM Consolidated List

7.Graff Scott is a member of the ABC Health Plan. Whenever she needs non-emergency medical care,

sees Dr. Michael Chan, an internist. Ms. Scott cannot self-refer to a specialist, so she saw Dr. Michael Chan

when she experienced headaches. Dr. Michael Chan referred her to Dr. Bruce Lee, a neurologist, who had

hospitalized at the Polo Hospital for tests. ABC has contracts with Dr. Michael Chan, Dr. Lee, and Polo

to provide medical services to its members. The following statements are about Polo's organized system

of healthcare. Select the answer choice containing the correct statement

a.With in Polo's system, Ms. Scott received primary care from both Dr. Michael Chan and Dr. Lee

b.Polo's system allows its members open access to all of Ultra's participating providers

c.Polo's network of providers includes Dr. Michael Chan and Dr. Lee but not Polo Hospital

d.within Polo's system, Dr. Michael Chan serves as a coordinator of care or gatekeeper for the

medical services that Ms. Scott receives

Ans d.within Polo's system, Dr. Michael Chan serves as a coordinator of care or gatekeeper for the medical services that Ms. Scott receives

8. The health plan determines what it considers to be the acceptable fee for a service or procedure

and the physician agrees to accept that amount as payment in full for the procedure

a.Usual, Customary, and Reasonable fee

b.Discounted FFS

c. Fee Maximum

d.Relative Value Scale

Ans b.Discounted FFS

9.System classifies hundreds of hospital services based on a number of criteria, such as primary and

secondary diagnosis, surgical procedures, age, gender, and the presence of complications.

a.Carve-out

b.DRG

c.Global capitation

d.Partial capitation

Ans b.DRG

10.In the CPT system, each service or procedure is identified by

a.Three-digit with decimal point

b.Three-digit

c.Five-digit with decimal point

d.Five-digit

Ans d.Five-digit

11.Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA)

to operate in State X, it had to meet the state's licensing requirements and financial standards

which were established by legislation that is identical to the National Association of Insurance

Commissioners (NAIC) HMO Model Act. Hill, an open-panel HMO that operates as a typical

independent practice association (IPA) model HMO, has a contract with one IPA that serves the

HMO's geographic area. Hill compensates the IPA for medical services on a capitation basis, and

the IPA in turn uses capitation to compensate participating physicians who are primary car

providers (PCPs). However, the IPA compensates participating physicians who are specialists on

a discounted fee-for-service (FFS) basis .The contract between the IPA and its participating physicians

contains a typical hold-harmless provision. Also, participating physicians agree to have their

performance evaluated by other providers who practice within the same medical specialty and

within the same geographic area This evaluation includes a comparison of the providers'

care to an accepted standard of care

One difference between the IPA's compensation arrangements with participating physicians who

are PCPs and those who are specialists is that the PCPs:

a.Receive compensation based on the volume and variety of medical services they perform for Hill plan

members, whereas the specialists receive compensation based solely on the number of plan members

who are covered for specific services

b.Receive from the IPA the same monthly compensation for each Hill plan member under the PCPs

care, whereas the specialists receive compensation based on a percentage discount from their normal fees

c.Receive compensation based on a fee schedule, whereas the specialists receive compensation based

on per diem charges

d.have no financial incentive to practice preventive care or to focus on improving the health of their plan

members, whereas the specialists have a positive incentive to help their plan members stay health

Ans b.Receive from the IPA the same monthly compensation for each Hill plan member under the PCPs care, whereas the specialists receive compensation based on a percentage discount from their normal fees

12.Certificate of Authority (COA) is subject to

a.Contract between health plan and employer

b.State laws require an HMO not to be organized as a corporation

c. Compliance with CMS

d.an HMO may have to be licensed as an HMO or insurance company in each state in which it conducts business

Ans d.an HMO may have to be licensed as an HMO or insurance company in each state in which it conducts business

13.Abbreviation for JCAHO is

a.Joint Coordination on Accreditation of Healthcare Organizations

b.Joint Commission on Accreditation of Healthcare Organizations

c.Joint Corporation on Accreditation of Healthcare Organizations

d.Joint Connection on Accreditation of Healthcare Organizations

Ans b.Joint Commission on Accreditation of Healthcare Organizations

14.Utilization management techniques that most HMOs use for hospital providers include:

a.Discharge planning

b.Case management

c.Co-payment for office visits

d.A&B

Ans d.A&B

15.Exclusive provider organizations (EPO) is similar and operates like a PPO in administration ,structure

but however in an EPO an out-of-network care is

a.Partially Covered

b.Covered with more out of pocket

c.Not covered

Ans c.Not covered

16.Common characteristics of POS products are

a.Lack of Freedom of choice

b.Absence of Primary care physician

c.Cost-cutting efforts and the structure of coverage

d.All of the above

Ans c.Cost-cutting efforts and the structure of coverage

17.Health plans often carve out specialty services that have one or more of the following characteristics

a.A poorly defined patient population

b.High or increasing costs

c.Appropriate utilization

d.All the above

Ans b.High or increasing costs

18.Ancillary services are

a.General medical care that is provided directly to a patient without referral from another physician

b.Also known as secondary care( Medical care that is delivered by specialist)

c.Supplemental services needed as part of providing other care

d.Outpatient services provided by a hospital or other qualified ambulatory care facility which require inpatient stay

Ans c.Supplemental services needed as part of providing other care

19.Bill the member for the balance of the fee above the maximum allowable amount under the fee schedule

reimbursement method

a.UCR fee

b.Capitation fee

c.Balance bill

d.Discounted fee-for-service

Ans c.Balance bill

20.What are the characteristics that the underwriter has to consider while determing the premium rate for

health insurance coverage for a group?

a.Level of benefits

b.Geographic location

c.Group size

d.All the above

Ans d.All the above

21.A differences between managed indemnity & traditional indemnity

a.Include precertification and utilization review techniques

b.Both are the same

c.Include network and quality review techniques

d.a&b

Ans c.Include network and quality review techniques

22. Which of the following statements about CDHPs is true?

d. All of the above

a. CDHPs combine a core contribution of funding by health plan alone with increased

choice & financial responsibility for members with respect to healthcare decisions.

b. CDHPs typically combine a high deductible health plan (HDHP) with a consumer

healthcare spending account subject to federal tax.

c. CDHPs have evolved in response to satisfying employers' need of offering low cost

healthcare coverage options to their employees

Ans

23. High deductible health plans (HDHP) are characterized by all of the following features except

a. A HDHPs have a higher deductible than other traditional insurance products such as HMOs & PPOs.

b. HDHPs generally cost more than traditional heathcare coverage.

c. Some HDHPs cover preventive care on a first-dollar coverage basis.

d. All of the above

Ans a. A HDHPs have a higher deductible than other traditional insurance products such as HMOs & PPOs.

24. Which of the following factors have contributed to the limited popularity of FSAs

a. "Use it or lose it" provision

b. Lack of portability

c. Only self-employed individuals are eligible for establishing FSAs.

d. Both a &b

Ans d. Both a &b

25. "Use it or lose it" provision in case of CDHPs refers to

b. Lack of portability of the account in the event of a job change.

c. Both a & b

d. None of the above

Ans

26. Salient features of a Health Savings Account include all of the following except

a. Funding by both employer & the employee

b. Employer account ownership

c. Account portability & roll over of funds from year to year

d. Investment opportunities

Ans b. Employer account ownership

a. 'Cash in ' Contribution

b. 'Catch in ' Contribution

c. 'Catch up ' Contribution

d. 'Encash' contribution

Ans c. 'Catch up ' Contribution

27. Individuals between the ages of 55 & 65 can make additional contributions to their HSAs that are

adjusted annually. This additional contribution is termed as-

29. The following statements pertain to the federal requirements for minimum deductible & maximum

out of pocket expeses for a high deductible health plan in the year 2006. Select the correct answer from

the options given below.

a. Minimum deductible - $ 1,050 for self only coverage ; maximum out of pocket expenses-

$ 2,100 for self only coverage

b. Minimum deductible - $ 1,050 for self only coverage ; maximum out of pocket expenses-

$ 10.500 for family coverage

c. Minimum deductible - $ 2,100 for self only coverage ; maximum out of pocket expenses-


c. CDHPs have evolved in response to satisfying employers' need of offering low cost

healthcare coverage options to their employees

a. Lack of provision for roll-over of fund balances from year to year with respect to

consumer healthcare spending acount.

a. Lack of provision for roll-over of fund balances from year to year with respect to

consumer healthcare spending acount.

Ans

29. FSA is funded by

a.Employers

b.Employee

c.a & b

Ans c.a & b

30. Flexible Spending Accounts (FSAs) can be established by

a. The employer alone

b. The employee alone

c. By both the employer & the employee

d. Self - employed individuals

Ans a. The employer alone

a. $2400

b. $2700

c. $5100


Ans a. $2400

32. Which of the following features differentiates a 'Clinic without walls' from a consolidated medical group?

c. Both a & b


Ans

a. Structural Integration

b. Operational Integration

c. Business Integration


Ans d. None of the above

a. Unlike a consolidated medical group, physicians in a 'Clinic without walls' maintain

their practices independently in multiple locations.

b. Unlike a consolidated medical group, a 'Clinic without walls' performs or arranges for

business operations for the member physicians.

33. Consolidation of patient information in a single location as in the case of a single medical record that

can be used by independent providers is an example of

a. Unlike a consolidated medical group, physicians in a 'Clinic without walls' maintain

their practices independently in multiple locations.

c. Minimum deductible - $ 2,100 for self only coverage ; maximum out of pocket expenses-


d. Minimum deductible - $ 2,100 for self only coverage ; maximum out of pocket expenses-

$ 5,250 for self only coverag

31. Trevor Jaques, a 44 year old healthcare consultant, had purchased a health plan (for individual

coverage) that had an annual deductible of $ 2,400 in the year 2006. Trevor had also established a Health

Savings Account in conjunction with the health plan he purchased in order to fund his medical

expenses.For the year 2006, the legal maximum Health Savings Account contribution amounts set was $

2,700 annually for individuals. For the same year, the maximum total contribution that Trevor could

b. Minimum deductible - $ 1,050 for self only coverage ; maximum out of pocket expenses-

$ 10.500 for family coverage

a. Physician Practice Management Company

b. Physician Hospital Organization

c. Consolidated Medical Group


Ans c. Consolidated Medical Group

a. Majestic's Executive Committee is an example of a Specific committee.

b. The Corporate Compliance Committee is an Example of an Adhoc company.

c. a&b

Ans b. The Corporate Compliance Committee is an Example of an Adhoc company.

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

Ans d.Polestar's relationship to Polaris: holding company:Type of board member:outside director

37. Medved Medical, a health plan, is currently recruiting PCPs in preparation for its expansion into a new service area.

Abigail Davis, a recruiter for medved, has been meeting with Melissa Cortelyou, M.D., in an effort to recruit

her as a PCP in medved's new service area. Dr. Cortelyou agreed to become a PCP with medvede, but the

credentialing process is not yet complete. In this situation, it is correct to say that

a) medved is prevented by law from offering a contract to Dr. Cortelyou until the credentialing process is complete

b) any contract signed by Dr. Cortelyou should include a clause requiring the successful completion of the credentialing

process within a defined time frame in order for the contract to be effective

c) medved must offer a standard contract to Dr. Cortelyou, without regard to the outcome of the credentialing process

d) medved will abandon the credentialing process now that Dr. Cortelyou has agreed to participate in medved's network

Ans b) any contract signed by Dr. Cortelyou should include a clause requiring the successful completion of the credentialing process within a defined time frame in order for the contract to be effective

38. Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area.

A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area,

in order to convince her to become one of the plan's providers. While these meetings have been taking place, Ark has

been obtaining, reviewing, and verifying Dr. Shea's documentation related to licenses, certifications, and training

in order to determine whether she meets Ark's pre-established criteria for participation in its provider network. As part

34. The Panacea Healthcare System is a single large medical practice based in Oakland, California. The

physicians of Panacea operate through a single office located in the Beverly Hills region of Oakland & do

have access to the same medical records. Panacea is owned by Queen's hospital & before Panacea

acquired the practices of its participating physicians, these physicians were independent practitioners.

Which of the following terms best describes Panacea?

35. The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements

of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive

Committee serves as a long-term advisory body on issues related to overall organizational policy. The

Corporate Compliance Committee are convened to address specific management concerns. The following

statement(s) can correctly be made about these committees:

36. 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 professionals in academia and businesspeople who

do not work for Polestar. Dr. Carolyn Porter, a university president, is on Polestar's board. From the

following answer choices, select the response containing the term that correctly identifies Polestar's

relationship to Polaris and the term that describes the type of board member represented by Dr. Porter.

of this process, Ark has consulted the National Practitioner Data Bank (NPDB). In this situation, the main reason that

Ark would consult the NPDB is to learn if Dr. Shea

a) has ever participated in any quality improvement activities

b) is a participating provider in a health plan that will compete with Ark in its new service area

c) meets the requirements of the Ethics in Patient Referrals Act

d) has had a medical malpractice claim filed or other disciplinary actions taken against her

Ans d) has had a medical malpractice claim filed or other disciplinary actions taken against her

39. Which out of the three is accomplished through precertification?

a.Concurrent review

b.Retrospective review

c.Prospective review

Ans c.Prospective review

40. In order to measure the expenses of institutional utilization , Holt Health care group uses standard formula

to calculate hospital bed stays per 1000 plan members.On 26 november, Holt uses the following information to:

calculate the bed days per 1000 members for the MTD

Total gross hospital bed days in MTD = 500

Plan membership = 15000

Calculate Holt's number of bed days per 1000 members for the month to date, rounded to the nearest whole number.

a. 468

b. 365

c. 920

d. 500

Ans a. 468

41. In order to be more effective, changes to structure and processes must be carefully

a. Planned

b. Implemented

c. Documented.

d. Evaluated

e. All the above.

Ans e. All the above.

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

a.Rating

b.Antiselection

c.Underwriting

d.None of the above

Ans c.Underwriting

43.Renewal underwriting involves a reevaluation of

a.the groups experience

b.level of participation in the health plan

c.Both a and b

d.None of the Above

Ans c.Both a and b

44.The contract between an employer and an insurer or other TPA is called

a.Claims

b.Bond

c.ASO

d.None of the above

Ans c.ASO

45.What is a mathematical process that involves using a number of hypothetical situations that, in total, will

reasonably reflect an event that will occur in real life

a.Forecasting

b.Modelling

c.Both a and b

d.None of the above

Ans b.Modelling

46.Advantages of EDI over manual data management systems

a.speed of data trfer

b.Loss of data integrity

c.All of the above

d.None of the above

Ans a.speed of data trfer

47.IROs stands for

a.Internal Review Organisations

b.International review Organisations.

c. Independent review organizations

d.None of the above

Ans c. Independent review organizations

48. The agreement by two or more independent competitors on the prices or fees that they will charge

for services is known as:

a. tying arrangements

b. price fixing

c. horizontal group boycott

d. horizontal division of markets

Ans b. price fixing

49.The act which requires each group health plan to allow employees and certain dependents to continue their group

coverage for a stated period of time following a qualifying event that causes the loss of group health coverage is:

a. ERISA

b. COBRA

Ans b. COBRA

50.The situation wherein two hospitals agree to each refuse to contract with a health plan until the health plan ceases

contract negotiations with a competing hospital is known as

a. Horizontal division of markets

b. Tying arrangements

c. Horizontal group boycott

d. Price fixing

Ans c. Horizontal group boycott

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

a. Contains strict reporting and disclosure requirements for all employee benefit pl except health pl

b. Contains a pre-emption provision, which typically makes the terms of ERISA take precedence over any state laws

that regulate employee welfare benefit pl

c. Requires self-funded employee benefit pl to pay premium taxes at the state level

d. Requires that state insurance laws apply to all employee benefit pl except insured pl

Ans b. Contains a pre-emption provision, which typically makes the terms of ERISA take precedence over any state laws that regulate employee welfare benefit pl

52. Jack Geller is under his employer's group health plan, which must comply with the Consolidated Omnibus Budget

Reconciliation Act (COBRA). He has now obtained group health coverage through another employer which of the following

statements regarding coverage under COBRA are correct:

a. His coverage under COBRA will continue till a period of 18months

b. His coverage under COBRA will continue till a period of 36months.

c. His coverage under COBRA will cease.

d. His coverage under COBRA will cease but his dependants will continue to be covered till a period of 18months.

Ans c. His coverage under COBRA will cease.

53.An HMOs quality assurance program must include

a.A statement of the HMOs goals and objectives for evaluating and improving enrollees health status

b.Documentation of all quality assurance activities

c.system for periodically reporting program results to the HMOs board of directors, its providers, and regulators

d.all the above

Ans d.all the above

54.In Order to act as a TPA an organization must

a.Establish written procedures for adverse determinations and appeals

b.Obtain a certificate of authority from the state insurance department

designating the organization as a TPA

c.All of the above

Ans b.Obtain a certificate of authority from the state insurance department designating the organization as a TPA

55. Keith Murray is a 45 year old chartered accountant & is employed in Livingstone

consultancy firm. He has been paying payroll taxes for the past 15 years. Which

of the following statements is true regarding Medicare Part A entitlement?

a. Keith shall be entitled to Part A benefits when he attains 65 years of age

b. Keiths wife shall be entitled to Part A benefits when she attains 65 years of age

c. Keiths wife shall be required to pay a monthly premium in order to receive

Medicare Part A benefits

d. Both a & b

Ans d. Both a & b

56.Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage

under a PBM plan that uses a closed formulary to manage the cost and use of

pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was

trferred by ambulance to an extended-care facility and was placed on long-term

medications to help him recover from the aneurysm. Under Medicare Part A, Mr. O'Brien

had coverage for the cost of

a. Confinement in the extended-care facility after his hospitalization

b.Trportation by ambulance from the hospital to the extended-care facility

c. Physici' professional services while he was hospitalized

d. Physici' professional services while he was at the extended-care facility

Ans a. Confinement in the extended-care facility after his hospitalization

57.Which of the following statements is true regarding Medicare Part C

a) Medicare Part C was introduced by the Balanced Budget Act of 1997

b) Medicare Part C offered managed care alternatives to fee-for-service

Medicare through the Medicare+Choice (M+C) program

c) Under Medicare Part C as amended by the Medicare Modernization Act (MMA),

licensed private health pl can provide a Medicare HMO, Preferred Provider

Organization (PPO), Point of Service (POS), Private Fee-for-Service (PFFS) or

Medical Savings Account (MSA) option as alternatives for beneficiaries on a

regional or local basis.

d) All of the above

Ans a) Medicare Part C was introduced by the Balanced Budget Act of 1997

58.Prescription drug benefits in Medicare can be obtained through:

a.Stand alone prescription drug pl (PDPs)

b.Traditional fee for service (FFS) Medicare

c. Medicare Advantage pl

d.Both a & c

Ans a.Stand alone prescription drug pl (PDPs)

59.Which of the following population groups are eligible for Medicare coverage

a.Individuals aged 65 & above, regardless of income & medical history

b.Individuals suffering from end stage renal disease, regardless of age

c.Individuals aged 50 or above suffering from qualifying disabilities

d.Both a & b

Ans d.Both a & b

60.Who will be covered by TRICARE PRIME by applying for enrollment

a. Active duty military personnel

b. Active duty Dependents

c. Reteirres

d. b and c

Ans d. b and c

61.Select the correct statement regarding TRICARE Extra plan options to military personnels.

a. Out of pocket expenses are generally high in tricare extra than TRICARE standard

b. Enrollment is not necessary to participate in TRICARE Extra

c. TRICARE Extra provides coordinated care managed by primary care case manager

c. TRICARE Extra provides coordinated care managed by primary care case manager

62.The following statements can correctly be made about Medicaid managed care pl

a.Only Fedral government funds Medicaid program

b.States always had the option to enroll medicaid recipients in health pl on voluntary

basis.

c.States require copayment for emergency or family planning sercices.

d. None of the above.

b.States always had the option to enroll medicaid recipients in health pl on voluntary

63.Medigap policies were standardized into ten standard benefit pl ranging from A-J by the ____

a.Omnibus Budget Reconciliation Act (OBRA) of 1990

b.Tax Equity & Fiscal Responsibility Act (TEFRA) of 1982

c.Medicare Modernization Act (MMA) of 2003

d.Balanced Budget Act (BBA) of 1997

Ans: a.Omnibus Budget Reconciliation Act (OBRA) of 1990

64. Which of the following is an example of physician only model of operational integration?

a. Consolidated medical group

b. Integrated Delivery System

c. Medical Foundation

d. Both b & c

Ans a. Consolidated medical group

65. Arrange the following provider organizations in the order ranging from least integrated.

I. Physician Practice Management (PPM) company

II. Integrated Delivery System (IDS)

III. Group Practice Without Walls (GPWW)

IV. Independent Practice Association (IPA)

a. I, II, III, IV

b. IV,III, I, II

c. I, II, IV, III

d. I, IV, II, III

Ans b. IV,III, I, II

66. Integration of provider organizations is said to occur when

a. Previously separate providers combine & come under common ownership or control.

b. Two or more providers combine their business operations that they previously carried out separately.

c. Both a & b


Ans c. Both a & b

67. Maternity management programs are commonly included in?.

a.Screening Programs

b.Healthpromotion Programs

c.Immunization programs

Ans c.Immunization programs

67. Disease management is typically set up as a voluntary outreach and support program for plan members with certain _____ diseases

a. Acute

b. Chronic

c. None of the above

Ans b. Chronic

68.Calculate the hospial bed days per 1000 members for the Month to date (MTD) on 25 April, with plan membership of

25,000 and total gross hospital bed days in MTD is 300 for an XYZ Health plan?

a. 175

b. 480

c. 1000

d. 365

Ans a. 175

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

a. Cost effectiveness of healthcare services.

b. Cost of paying healthcare benefits.

c.Both of the above

Ans c.Both of the above

70 Which facility would best meet the need of Jack who fell on road and sprained his ankle?

a. Emergencey Department

b.Urgent Care Centre

c. Home health care


Ans b.Urgent Care Centre

71.Diabetic patients with high glucose levels requiring stabilization following treatment of an acute attack would best be served in

an _____

a. Emergencey Department

b.Urgent Care Centre

c. Hospice Care

d. Observation Care Unit

Ans d. Observation Care Unit

72.Col. Mark Calvin, on active duty in the U.S. Army, is elegible to receive healthcare benefits under one of the three

TRICARE health plan options. If Col calvin elects to participate in TRICARE Prime, he will be

a.able to obtain full benefits for services obtained from network and non-network providers

b.subject to copayment, deductible, and coinsurance requirements for any medical care he receives

c.required to formally enroll for coverage and pay an enrollment fee

d.assigned to a primary care manager who is responsible for coordinating all his care

Ans d.assigned to a primary care manager who is responsible for coordinating all his care

73.The following statements are about the various Health Plan Accountability Models adopted by the NAIC.

Select the answer choice containing the correct statement.

a.Under the terms of the Health Plan Network Adequacy Model Act, all health plans would be

required to hold covered persons harmless against provider collections and provide continued

coverage for uncompleted treatment in the event of plan insolvency

b.The Health Carrier Grievance Procedure Model Act requires all health carriers to maintain a

first-level grievance review, but it does not require any second-level review

c.According to the Health Care Professional Credentialing Verification Model Act, a health plan

must select all providers who meet the plan's credentialing criteria

d.The Quality Assessment and Improvement Model Act exempts closed plans from

implementing a quality improvement program.

Ans a.Under the terms of the Health Plan Network Adequacy Model Act, all health plans would be required to hold covered persons harmless against provider collections and provide continued coverage for uncompleted treatment in the event of plan insolvency

74.The scandent Health Group contracted with the Empire Corporation to provide behavioral healthcare services to.

Empire employees. As a condition of providing behavioral healthcare services, scandent required Empire to

contract with scandent for basic medical services scandent's actions constituted the type of antitrust violation known as a

a.horizontal group boycott

b.price-fixing agreement

c.horizontal division of markets

d.tying arrangement

Ans d.tying arrangement

75.The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small

groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the

difference between the highest and lowest rates that a health plan charges small groups, to a particular ratio.

According to the Model Act, for example, if the lowest rate an HMO charges a small group for a given set of medical benefits

is $40, then the maximum rate the HMO can charge for the same set of benefits is

a.$60

b.$80

c$120

d.$160

Ans b.$80

d.within Polo's system, Dr. Michael Chan serves as a coordinator of care or gatekeeper for the medical services that Ms. Scott receives

b.Receive from the IPA the same monthly compensation for each Hill plan member under the PCPs care, whereas the specialists receive compensation based on a percentage discount from their normal fees

b) any contract signed by Dr. Cortelyou should include a clause requiring the successful completion of the credentialing process within a defined time frame in order for the contract to be effective

b. Contains a pre-emption provision, which typically makes the terms of ERISA take precedence over any state laws that regulate employee welfare benefit pl

a.Under the terms of the Health Plan Network Adequacy Model Act, all health plans would be required to hold covered persons harmless against provider collections and provide continued coverage for uncompleted treatment in the event of plan insolvency

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AHM250 Mock Test