Question 1

The following statements describe two types, or models, of

HMOs:

The Quest HMO has contracted with only one multi-specialty

group of physicians. These physicians are employees of the
group practice, have an equity interest in the practice, and
provide

Choice A: a captive group a staff model

Choice B: a captive group a network mode

Choice C: an independent group a network model

Choice D: an independent group a staff model

Question 2

______________ HMOs can't medically underwrite any group

incl small groups.

Choice A: State

Choice B: Not-for-profit

Choice C: For-profit

Choice D: Federally qualified

:B
Question 3

A common physician-only integrated model is a group practice

without walls (GPWW). One characteristic of a typical GPWW is
that the

Choice A: GPWW combines multiple independent physician

practices under one umbrella organization

Choice B: GPWW generally has a lesser degree of integration

than does an IPA

Choice C: member physicians cannot own the GPWW

Choice D: GPWW's member physicians must perform their

own business operations

:A

Question 4

A health plan may use one of several types of community

rating methods to set premiums for a health plan. The
following statements are about community rating. Select the
choice containing the correct statement.

Choice A: Standard (pure) community rating is typically used

for large groups because it is the most competitive rating
method for large groups.

Choice B: Under standard (pure) community rating, a health

plan charges all employers or other group sponsors the same
dollar amount for a given level of medical benefits or health
plan, without adjusting for factors such as age, gender, or
experience.

Choice C: In using the adjusted community rating (ACR)

method, a health plan must consider the actual experience of
a group in developing premium rates for that group.

Choice D: The Centers for Medicare and Medicaid Services

(CMS) prohibits health plans that assume Medicare risk from
using the adjusted community rating (ACR) me

:B
Question 5

A health plan's ability to establish an effective provider

network depends on the characteristics of the proposed
service area and the needs of proposed plan members. It is
generally correct to say that

Choice A: health plans have more contracting options if

providers are affiliated with single entities than if providers are
affiliated with multiple entities

Choice B: urban areas offer more flexibility in provider

contracting than do rural areas

Choice C: consumers and purchasers in markets with little

health plan activity are likely to be more receptive to HMOs
than to loosely managed plans such as PPOs

Choice D: large employers tend to adopt health plans more

slowly than do small companies

:B

Question 6

A health savings account must be coupled with an HDHP that

meets federal requirements for minimum deductible and
maximum out-of-pocket expenses. Dollar amounts are indexed
annually for inflation. For 2006, the annual deductible for self-
only coverage must

Choice A: $525

Choice B: $1,050

Choice C: $2,100

Choice D: $5,250

:B

Question 7
A medical foundation is a not-for-profit entity that purchases
and manages physician practices. In order to retain its not-for-
profit status, a medical foundation must

Choice A: provide significant benefit to the community

Choice B: employ, rather than contract with, participating

physicians

Choice C: achieve economies of scale through facility

consolidation and practice management

Choice D: refrain from the corporate practice of medicine

:A

Question 8

A particular health plan offers a higher level of benefits for

services provided in-network than for out-of-network services.
This health plan requires preauthorization for certain medical
services. With regard to the steps that the health plan's claims
e

Choice A: should assume that all services requiring

preauthorization have been preauthorized

Choice B: should investigate any conflicts between diagnostic

codes and treatment codes before approving the claim to
ensure that the appropriate payment is made for the claim

Choice C: need not verify that the provider is part of the health
plan's network before approving the claim at the in-network
level of benefits

Choice D: need not determine whether the member is covered

by another health plan that allows for coordination of benefits

:B

Question 9

A physician-hospital organization (PHO) may be classified as

an open PHO or a closed PHO. With respect to a closed PHO, it
is correct to say that

A. the specialists in the PHO are typically compensated on a

capitation basis

Choice A: the specialists in the PHO are typically compensated

on a capitation basis

Choice B: it typically limits the number of specialists by type of

specialty

Choice C: it is available to a hospital's entire eligible medical

staff

Choice D: physician membership in the PHO is limited to PCPs

:B

Question 10

A public employer, such as a municipality or county

government would be considered which of the following?

Choice A: Employer-employee group.

Choice B: Multiple-employer group.

Choice C: Affinity group.

Choice D: Debtor-creditor group.

:A

Question 11

According to the IRS, which of the following is not an allowable

preventive care service:

Choice A: Smoking cessation programs.

Choice B: Periodic health examinations.

Choice C: Health club memberships.

Choice D: Immunizations for children and adults.

:C

Question 12

After a somewhat modest start in 2004, enrollment in HSA-

related health plans more than tripled in 2005, making them
todays fastest growing type of CDHP. As of January 2006,
enrollment in HSAs had reached nearly:

Choice A: 1.2 million

Choice B: 2.2 million

Choice C: 3.2 million

Choice D: 4.2 million

:B

Question 13

Al Marak, a member of the Frazier Health Plan, has asked for a

typical Level One appeal of a decision that Frazier made
regarding Mr. Marak's coverage. One true statement about this
Level One appeal is that

Choice A: Mr. Marak has the right to appeal to the next level if
the Level One appeal upholds the original decision

Choice B: it requires Frazier and Mr. Marak to submit to

arbitration in order to resolve the dispute

Choice C: it is considered to be an informal appeal

Choice D: it will be handled by an independent review

organization (IRO)

:A

Question 14

All CDHP products provide federal tax advantages while

allowing consumers to save money for their healthcare.

Choice A: True

Choice B: False

Choice C:

Choice D:

:A

Question 15

Allgood Medical, Inc., a health plan, has contracted with Mercy

Memorial Hospital to provide inpatient medical services to
Allgood's plan members. The terms of the contract specify that
Allgood will reimburse Mercy Memorial on the basis of a
negotiated ch

Choice A: per diem agreement

Choice B: fee-for-service agreement

Choice C: withhold agreement

Choice D: diagnostic related group (DRG) agreement

:A

Question 16

Although the process is voluntary for health plans, external

accreditation is becoming more and more important as states
and purchasers require health plans undergo as many states
and purchasers require health plans undergo some type of
external review pr

Choice A: Is voluntary for health plans.

Choice B: Requires all change accreditation organizations to

use the same standards of

accreditation.
Choice C: Typically requires the accrediting organization to
conduct a medical record review and a review of a health
plan's credentialing processes, but not an evaluation of the
health plans' member service systems processes.

Choice D: Cannot assure that a health plan meets a specified

level of quality.

:A

Question 17

Amendments to the HMO act 1973 do not permit federally

qualified HMOs to use

Choice A: Retrospective experience rating

Choice B: Adjusted community rating

Choice C: Community rating by class

Choice D: Community rating

:A

Question 18

An exclusive provider organization (EPO) operates much like a

PPO. However, one difference between an EPO and a PPO is
that an EPO

Choice A: is regulated under federal HMO legislation

Choice B: generally provides no benefits for out-of-network

care

Choice C: has no provider network of physicians

Choice D: is not subject to state insurance laws

:B

Question 19
An HMO that combines characteristics of two or more HMO
models is sometimes referred to as a

Choice A: network model HMO

Choice B: group model HMO

Choice C: staff model HMO

Choice D: mixed model HMO

:D

Question 20

Appropriateness of treatment provided is determined by

developing criteria that if unmet will prompt further
investigation of a claim which are also called:

Choice A: Codes

Choice B: Lists

Choice C: Edits

Choice D: Checks

:C

Question 21

Arthur Moyer is covered under his employer's group health

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

Choice A: 18 months, but his coverage under COBRA will cease

if he obtains group health coverage through another employer.

Choice B: 18 months, even if he obtains group health coverage

through another employer.

Choice C: 36 months, but his coverage under COBRA will

cease if he obtains group health coverage through another
employer.

Choice D: 36 months, even if he obtains group health

coverage through another employer.

:A

Question 22

As part of its quality management program, the Lyric Health

Plan regularly compares its practices and services with those
of its most successful competitor. When Lyric concludes that
its competitor's practices or services are better than its own,
Lyric im

Choice A: Benchmarking.

Choice B: Standard of care.

Choice C: An adverse event.

Choice D: Case-mix adjustment.

:A

Question 23

As part of its utilization management (UM) system, the Creole

Health Plan uses a process known as case management. The
following individuals are members of the Creole Health Plan:

Jill Novacek, who has a chronic respiratory condition.

Abraham Rashad,

Choice A: Ms. Novacek, Mr. Rashad, and Mr. Devereaux.

Choice B: Ms. Novacek and Mr. Rashad only.

Choice C: Ms. Novacek and Mr. Devereaux only.

Choice D: None of these members.

:A
Question 24

As part of its utilization management (UM) system, the Poplar

MCO uses a process known as case management. The
following statements describe individuals who are Poplar plan
members:

Brad Van Note, age 28, is taking many different, costly

medications for

Choice A: Mr. Van Note, Mr. Albrecht, and Ms. Cromartie

Choice B: Mr. Van Note and Ms. Cromartie only

Choice C: Mr. Van Note and Mr. Albrecht only

Choice D: Mr. Albrecht and Ms. Cromartie only

:C

Question 25

Ashley Martin is covered by a managed healthcare plan that

specifies a $300 deductible and includes a 30% coinsurance
provision for all healthcare obtained outside the plans
network of providers. In 1998, Ms. Martin became ill while she
was on vacation,

Choice A: $300

Choice B: $510

Choice C: $600

Choice D: $810

:D

Question 26

Bart Vereen is insured by both a traditional indemnity health

insurance plan, which is his primary plan, and a managed care
plan. Both plans have a typical coordination of benefits (COB)
provision, but neither plan has a nonduplication of benefits
provisi

Choice A: 380

Choice B: 130

Choice C: 0

Choice D: 550

:A

Question 27

Because many patients with behavioral health disorders do

not require round-the-clock nursing care and supervision,
behavioral healthcare services can be delivered effectively in
a variety of settings. For example, post-acute care for
behavioral health di

Choice A: Hospital observation units or psychiatric hospitals.

Choice B: Psychiatric hospitals or rehabilitation hospitals.

Choice C: Subacute care facilities or skilled nursing facilities.

Choice D: Psychiatric units in general hospitals or hospital

observation units.

:C

Question 28

Before an HMO contracts with a physician, the HMO first

verifies the physician's credentials.

Upon becoming part of the HMO's organized system of

healthcare, the physician is typically subject to

Choice A: both recredentialing and peer review

Choice B: recredentialing only

Choice C: peer review only

Choice D: neither recredentialing nor peer review

:C

Question 29

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

Choice 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.

Choice B: 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 healthy.

Choice C: Receive from the IPA the same monthly

compensation for each Hill plan member under the PCP's care,
whereas the specialists receive compensation based on a
percentage discount from their normal fees.

Choice D: Receive compensation based on a fee schedule,

whereas the specialists receive compensation based on per
diem charges.

:C

Question 30

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

Choice A: Hill had to have an initial net worth of at least $1.5

million in order to obtain a COA.

Choice B: The COA most likely exempts Hill from any of State
X's enabling statutes.

Choice C: Hill had to be organized as a partnership in order to

obtain a COA

Choice D: The COA in no way indicates that Hill has

demonstrated that it is fiscally sound.

:A

Question 31

Before the Leo Health Maintenance Organization (HMO)

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

Choice A: receive compensation based on the volume and

variety for medical services they perform for Leo plan
members, whereas the specialists receive compensation
based solely on the number of plan members who are covered
for specific services

Choice B: 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 healthy

Choice C: receive from the IPA the same monthly

compensation for each Leo plan member under the PCP's care,
whereas the specialists receive compensation based on a
percentage discount from their normal fees

Choice D: receive compensation based on a fee schedule,

whereas the specialists receive compensation based on per
diem charges

:C
Question 32

Beginning in the early 1980s, several factors contributed to

increased demand for behavioral healthcare services. These
factors included

Choice A: increased stress on individuals and families

Choice B: increased availability of behavioral healthcare

services

Choice C: greater awareness and acceptance of behavioral

healthcare issues

Choice D: all of the above

:D

Question 33

Bill Clinton is a member of Lewinsky's PBM plan which has a

three-tier copayment structure. Bill fell ill and his doctor
prescribed him AAA, a brand-name drug which was included in
the Lewinsky's formulary; BBB, a non-formulary drug; and
CCC, a generic dr

Choice A: CCC, AAA, BBB

Choice B: BBB, CCC, AAA

Choice C: BBB, AAA, CCC

Choice D: CCC, BBB, AAA

:A

Question 34

Brokers are one type of distribution channel that health plans

use to market their health plans. One true statement about
brokers for health plan products is that, typically, brokers

Choice A: are not required to be licensed by the states in

which they market health plans
Choice B: are compensated on a salary basis

Choice C: represent only one health plan or insurer

Choice D: are considered to be an agent of the buyer rather

than an agent of the health plan or Insurer

:D

Question 35

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

Choice A: organizations and individuals involved in the

consumption of healthcare provided by the plan

Choice B: relative accessibility of the plan's providers to the

plan's participants

Choice C: group of physicians, hospitals, and other medical

care providers with whom the plan has contracted to deliver
medical services to its members

Choice D: integration of the plan's participants with the plan's

providers

:C

Question 36

By definition, the marketing process of defining a certain place

or market niche for a product relative to competitors and their
products and then using the marketing mix to attract certain
market segments is known as

Choice A: branding

Choice B: positioning

Choice C: database marketing

Choice D: personal selling

:B
Question 37

By offering a comprehensive set of healthcare benefits to its

members, an HMO ensures that its members obtain quality,
cost-effective, and appropriate medical care. Ways that an
HMO provides comprehensive care include

Choice A: coordinating care across a variety of benefits

Choice B: emphasizing preventive care by covering many

preventive services either in full or with a small copayment

Choice C: offering its members access to wellness programs

Choice D: All of the above

:D

Question 38

Col. Martin Avery, 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 Avery elects to participate in
TRICARE Prime, he will be

Choice A: able to obtain full benefits for services obtained from

network and non-network providers

Choice B: subject to copayment, deductible, and coinsurance

requirements for any medical care he receives

Choice C: required to formally enroll for coverage and pay an

enrollment fee

Choice D: assigned to a primary care manager who is

responsible for coordinating all his care

:D

Question 39

Consumer-directed health plans are not a new concept. They

actually got their start in the late 1970s with the advent of:

Choice A: Health savings accounts (HSAs)

Choice B: Health reimbursement arrangements (HRAs)

Choice C: Medical savings accounts (MSAs)

Choice D: Flexible spending arrangements (FSAs)

:D

Question 40

Dr. Julia Phram is a cardiologist under contract to Holcomb

HMO, Inc., a typical closed-panel plan. The following
statements are about this situation. Select the choice
containing the correct statement.

Choice A: All members of Holcomb HMO must select Dr. Phram

as their primary care physician (PCP).

Choice B: Any physician who meets Holcomb's standards of

care is eligible to contract with Holcomb HMO as a provider.

Choice C: Dr. Phram is either an employee of Holcomb HMO or

belongs to a group of physicians that has contracted with
Holcomb HMO

Choice D: Holcomb HMO plan members may self-refer to Dr.

Phram at full benefits without first obtaining a referral from
their PCPs.

:A

Question 41

Dr. Milton Ware, a physician in the Riverside MCO's network of

providers, is reimbursed under a fee schedule arrangement for
medical services he provides to Riverside members. Dr. Ware's
provider contract with Riverside contains a typical no-balance
billi

Choice A: prevent Dr. Ware from requiring a Riverside

member to pay any coinsurance, copayment, or deductibles
that the member would normally pay under Riverside's plan

Choice B: require Dr. Ware to accept the amount that

Riverside pays for medical services as payment in full and not
to bill plan members for additional amounts

Choice C: prevent Dr. Ware from seeking compensation from

patients if Riverside fails to compensate him because of the
MCO's insolvency

Choice D: prevent Dr. Ware from billing a Riverside member

for medical services that are not included in Riverside's plan

:B

Question 42

Dr. Samuel Aldridge's provider contract with the Badger Health

Plan includes a typical due process clause. The primary
purpose of this clause is to:

Choice A: State that Dr. Aldridge's provider contract with

Badger will automatically

terminate if he loses his medical license or hospital privileges.

Choice B: Specify a time period during which the party that

breaches the provider contract must remedy the problem in
order to avoid termination of the contract.

Choice C: Give Dr. Aldridge the right to appeal Badger's

decision if he is terminated with

cause from Badger's provider network.

Choice D: Specify that Badger can terminate this provider

contract without providing a

reason, but only if Badger gives Dr. Aldridge at least 90-days'

notice of its intent

to terminate the contract.

:C
Question 43

During an open enrollment period in 1997, Amy Hadek

enrolled through her employer for group health coverage with
the Owl Health Plan, a federally qualified HMO. At the time of
her enrollment, Ms. Hadek had three pre-existing medical
conditions: angina, fo

Choice A: the angina, the high blood pressure, and the broken
ankle

Choice B: the angina and the high blood pressure only

Choice C: none of these conditions

Choice D: the broken ankle only

:A

Question 44

During the risk assessment process for a traditional indemnity

group insurance health plan, group underwriters consider such
characteristics as a groups geographic location, the size and
gender mix of the group, and the level of participation in the
grou

Choice A: Healthcare costs are typically higher in rural areas

than in large urban areas.

Choice B: The morbidity rate for males is higher than the

morbidity rate for females.

Choice C: The larger the group, the more likely it is that the
group will experience losses similar to the average rate of loss
that was predicted.

Choice D: All of the above

:C

Question 45
Each of the following statements describes a health plan that
is using a method of managing institutional utilization. Select
the choice that describes a health plan's use of
retrospective review to decrease utilization of hospital
services.

Choice A: The Serenity Healthcare Organization requires a plan

member or the provider in charge of the member's care to
obtain authorization for inpatient care before the member is
admitted to the hospital.

Choice B: UR nurses employed by the Friendship Health Plan

monitor length of stay to identify factors that might contribute
to unnecessary hospital days.

Choice C: The Optimum Health Group evaluates the medical

necessity and appropriateness of proposed services and
intervenes, if necessary, to redirect care to a more appropriate
care setting.

Choice D: The Axis Medical Group examines provider practice

patterns to identify areas in which services are being
underused, overused, or misused and designs strategies to
prevent inappropriate utilization in the future.

:D

Question 46

Ed Murray is a claims analyst for a managed care plan that

provides a higher level of benefits for services received in-
network than for services received out-of-network. Whenever
Mr. Murray receives a health claim from a plan member, he
reviews the claim

Choice A: A, B, C, and D

Choice B: A and C only

Choice C: A, B, and D only

Choice D: B, C, and D only

:A
Question 47

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

also has coverage under a PBM plan that uses a closed
formulary to manage the cost and use of pharmaceuticals.
Recently, Mr. O'Brien was hospitalized for an aneurysm. Later,
he was transferred by

Choice A: Confinement in the extended-care facility after his

hospitalization.

Choice B: Transportation by ambulance from the hospital to

the extended-care facility.

Choice C: Physicians' professional services while he was

hospitalized.

Choice D: physicians' professional services while he was at the

extended-care facility.

:A

Question 48

Eleanor Giambi is covered by a typical 24-hour managed care

program. One characteristic of this program is that it:

Choice A: Provides Ms. Giambi with healthcare coverage for

any illness or injury, but only if the cause of the illness or
injury is work-related.

Choice B: Combines the group health plan and disability plan

offered by Ms. Giambi's employer with workers' compensation
coverage.

Choice C: Requires Ms. Giambi and her employer to each pay

half of the cost of this coverage.

Choice D: Requires Ms. Giambi to pay specified deductibles

and copayments before receiving benefits under this program
for any illness or injury.

:B
Question 49

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

Choice A: Community Representative

Choice B: Inside Director

Choice C: Outside Director

Choice D: None of these

:B

Question 50

Employer-sponsored benefit plans that provide healthcare

benefits must comply with the Employee Retirement Income
Security Act (ERISA). One of the most significant features of
ERISA is that it

Choice A: contains a provision stating that the terms of ERISA

generally take precedence over any state laws that regulate
employee welfare benefit plans

Choice B: standardizes the conversion of group healthcare

benefits to individual healthcare benefits

Choice C: mandates that self-funded healthcare plans must

pay state premium taxes

Choice D: requires that all active employees, regardless of

age, must be eligible for coverage under employer-sponsored
benefit plans

:A

Question 51

Federal Employee Health Benefits Program (FEHBP) requires

health plans offering services to federal employees and their
dependents to provide

A. Immediate access to emergency services

B. Urgent Appointments within 24 hours

C. Routine appointments once a m

Choice A: D

Choice B: A

Choice C: B & C

Choice D: All of the listed options

:F

Question 52

Federal legislation has placed the primary responsibility for

regulating health insurance companies and HMOs that service
private sector (commercial) plan members at the state level.

This federal legislation is the

Choice A: Clayton Act

Choice B: Federal Trade Commission Act

Choice C: McCarran-Ferguson Act

Choice D: Sherman Act

:C

Question 53

Following a report by the Institute of Medicine on the incidence

and consequences of medical errors, a national task force
recommended implementation of a nationwide mandatory
system of collecting, analyzing, and reporting standardized
information about m

Choice A: random change

Choice B: structural change

Choice C: haphazard change

Choice D: reactive change

:D

Question 54

For providers, integration occurs when two or more previously

separate providers combine under common ownership or
control, or when two or more providers combine business
operations that they previously carried out separately and
independently. Such provi

Choice A: higher costs for health plans, healthcare purchasers,

and healthcare consumers

Choice B: improved provider contracting position with health

plans

Choice C: an increase in providers' autonomy and control over

their own work environment

Choice D: all of the above

:B

Question 55

For this question, select the choice containing the terms

that correctly complete the blanks labeled A and B in the
paragraph below.

NCQA offers Quality Compass, a national database of

performance and accreditation information submitted by
managed

Choice A: Health Plan Employer Data and Information Set

(HEDIS) mandatory

Choice B: Health Plan Employer Data and Information Set

(HEDIS) voluntary
Choice C: ORYX mandatory

Choice D: ORYX voluntary

:B

Question 56

From the choices below, select the response that correctly

identifies the rating method that Mr. Sybex used and the
premium rate PMPM that Mr. Sybex calculated for the Koster
group.

Choice A: Rating Method book rating Premium Rate PMPM

$132

Choice B: Rating Method book rating Premium Rate PMPM

$138

Choice C: Rating Method blended rating Premium Rate PMPM

$132

Choice D: Rating Method blended rating Premium Rate PMPM

$138

:C

Question 57

From the following choices, choose the description of the

ethical principle that best corresponds to the term Autonomy

Choice A: Health plans and their providers are obligated not to

harm their members

Choice B: Health plans and their providers should treat each

member in a manner that respects the member's goals and
values, and they also have a duty to promote the good of the
members as a group

Choice C: Health plans and their providers should allocate

resources in a way that fairly distributes benefits and burdens
among the members
Choice D: Health plans and their providers have a duty to
respect the right of their members to make decisions about
the course of their lives

:D

Question 58

From the following choices, choose the description of the

ethical principle that best corresponds to the term Autonomy

Choice A: Health plans and their providers are obligated not to

harm their members

Choice B: Health plans and their providers should treat each

member in a manner that respects the member's goals and
values, and they also have a duty to promote the good of the
members as a group

Choice C: Health plans and their providers should allocate

resources in a way that fairly distributes benefits and burdens
among the members

Choice D: Health plans and their providers have a duty to

respect the right of their members to make decisions about
the course of their lives

:D

Question 59

From the following choices, choose the description of the

ethical principle that best corresponds to the term Beneficence

Choice A: Health plans and their providers are obligated not to

harm their members

Choice B: Health plans and their providers should treat each

member in a manner that respects the member's goals and
values, and they also have a duty to promote the good of the
members as a group

Choice C: Health plans and their providers should allocate

resources in a way that fairly distributes benefits and burdens
among the members

Choice D: Health plans and their providers have a duty to

respect the right of their members to make decisions about
the course of their lives

:B

Question 60

From the following choices, choose the description of the

ethical principle that best corresponds to the term Beneficence

Choice A: Health plans and their providers are obligated not to

harm their members

Choice B: Health plans and their providers should treat each

member in a manner that respects the member's goals and
values, and they also have a duty to promote the good of the
members as a group

Choice C: Health plans and their providers should allocate

resources in a way that fairly distributes benefits and burdens
among the members

Choice D: Health plans and their providers have a duty to

respect the right of their members to make decisions about
the course of their lives

:B

Question 61

From the following choices, choose the definition that best

matches the term health risk assessment (HRA)

Choice A: A technique used to educate plan members on how

to distinguish between minor problems and serious conditions
and effectively treat minor problems themselves

Choice B: A technique used to determine if a health condition

is present even if a member has not experienced symptoms of
the problem
Choice C: A technique in which information about a plan
member's health status, personal and family health history,
and health-related behaviors is used to predict the member's
likelihood of experiencing specific illnesses or injuries

Choice D: A technique used to evaluate the medical necessity,

appropriateness, and cost-effectiveness of healthcare services
for a given patient

:C

Question 62

From the following choices, choose the definition that best

matches the term Screening

Choice A: A technique used to educate plan members on how

to distinguish between minor problems and serious conditions
and effectively treat minor problems themselves

Choice B: A technique used to determine if a health condition

is present even if a member has not experienced symptoms of
the problem

Choice C: A technique in which information about a plan

member's health status, personal and family health history,
and health-related behaviors is used to predict the member's
likelihood of experiencing specific illnesses or injuries

Choice D: A technique used to evaluate the medical necessity,

appropriateness, and cost-effectiveness of healthcare services
for a given patient

:B

Question 63

General HMO is building a provider network and is considering

Universal Hospital as an addition to its network. Minimum
requirements that General should consider in determining
whether Universal is qualified to participate in General's
network include
A.

Choice A: Both A and B

Choice B: A only

Choice C: B only

Choice D: Neither A nor B

:A

Question 64

Greentree Medical, a health plan, is currently recruiting PCPs

in preparation for its expansion into a new service area.
Abigail Davis, a recruiter for Greentree, has been meeting with
Melissa Cortelyou, M.D., in an effort to recruit her as a PCP in
Green

Choice A: Greentree is prevented by law from offering a

contract to Dr. Cortelyou until the credentialing process is
complete

Choice 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

Choice C: Greentree must offer a standard contract to Dr.

Cortelyou, without regard to the outcome of the credentialing
process

Choice D: Greentree will abandon the credentialing process

now that Dr. Cortelyou has agreed to participate in Greentree's
network

:B

Question 65

Health plans can organize under a not-for-profit form or a for-

profit form. One true statement regarding not-for-profit health
plans is that these organizations typically

Choice A: are exempt from review by the Internal Revenue

Service (IRS)

Choice B: are organized as stock companies for greater

flexibility in raising capital

Choice C: rely on income from operations for the large cash

outlays needed to fund long-term projects and expansion

Choice D: engage in lobbying or political activities in order to

maintain their tax-exempt status

:C

Question 66

Health plans may use different capitation arrangements for

different levels of service. One typical capitation arrangement
provides a capitation payment that may include primary care
only, or both primary and secondary care, but not ancillary
services. Th

Choice A: global capitation arrangement

Choice B: gatekeeper arrangement

Choice C: carve-out arrangement

Choice D: partial capitation arrangement

:D

Question 67

Health plans often program into their claims processing

systems certain criteria that, if unmet, will prompt further
investigation of a claim. In an automated claims processing
system, these criteria may signal the need for further review
when, for exampl

Choice A: Encounter reports

Choice B: Diagnostic codes

Choice C: Durational ratings

Choice D: Edits

:D

Question 68

Health plans require utilization review for all services

administered by its participating physicians.

Choice A: True

Choice B: False

Choice C:

Choice D:

:B

Question 69

Health plans sometimes contract with independent

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

Choice A: Low or stable costs.

Choice B: Appropriate, rather than inappropriate, utilization

rates.

Choice C: A benefit that cannot be easily defined.

Choice D: Defined patient population.

:D

Question 70
Health plans' use of the Internet to provide plan members with
health-related information has grown rapidly in recent years.
One advantage the Internet has over other forms of
communication is that

Choice A: users can access the Internet using a number of

different types of computer systems

Choice B: access to the Internet is available only to members

of the health plan's network

Choice C: the Internet is immune to internal security breaches

by employees or trading partners within the network

Choice D: users can contact a single controlling organization to

rectify disruptions in Internet service

:A

Question 71

Health plans use the following to determine the number of

providers to add to a network:

Choice A: Staffing ratios

Choice B: Drive time

Choice C: Geographic availability

Choice D: All of the above

:D

Question 72

Health savings accounts were created by which of the

following laws:

Choice A: COBRA

Choice B: HIPAA

Choice C: Medicare Modernization Act

Choice D: None of the Above

:C

Question 73

Historically most HMOs have been

Choice A: Closed-access HMO

Choice B: Closed-panel HMO

Choice C: Open-access HMO

Choice D: Open-panel HMO

:B

Question 74

HMOs typically employ several techniques to manage provider

utilization and member utilization of medical services. One
technique that an HMO uses to manage member utilization is

Choice A: the use of physician practice guidelines

Choice B: the requirement of copayments for office visits

Choice C: capitation

Choice D: risk pools

:B

Question 75

Ian Vladmir wants to have a routine physical examination to

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

Choice A: a traditional HMO plan

Choice B: a managed indemnity plan

Choice C: a point of service (POS) option

Choice D: an exclusive provider organization (EPO)

:C

Question 76

Identify the CORRECT statement(s):

(A) Smaller the group, the more likely it is that the group will
experience losses similar to the average rate of loss that was
predicted.

(B) Gender of the group's participants has no effect on the

likelihood of loss.

Choice A: All of the listed options

Choice B: B & C

Choice C: None of the listed options

Choice D: A & C

:C

Question 77

If a state commissioner of insurance places an HMO under

administrative supervision, then the purpose of this action
most likely is to:

Choice A: Transfer all of the HMO's business to other carriers.

Choice B: Allow the state commissioner, acting for a state

court, to take control of and administer the HMO's assets and
liabilities.

Choice C: Sell the HMO's assets in order to satisfy the HMO's

obligations.
Choice D: Place the HMO's operations under the direction and
control of the state commissioner or a person appointed by
the commissioner.

:D

Question 78

If left unresolved, member complaints about the actions or

decisions made by a health plan or its providers can lead to
formal appeals. One procedure health plans can use to
address formal appeals is to submit the original decision and
any supporting info

Choice A: a Level One appeal, and the member has the right
to a further appeal

Choice B: a Level Two appeal, and the reviewer's decision is

final and binding

Choice C: an independent external appeal, and the member

has the right to a further appeal

Choice D: arbitration, and the reviewer's decision is final and

binding

:A

Question 79

If most of the physicians, or many of the physicians in a

particular specialty, are affiliated with a single entity, then a
health plan building a network in the service area
________________________.

Choice A: Has many contracting options available.

Choice B: Should not contract with that entity

Choice C: Most likely needs to contract with that entity

Choice D: Should attempt to disband the existing affiliations

:C
Question 80

Immediate evaluation and treatment of illness or injury can be

provided in any of the following care settings:

A. Hospital emergency departments

B. Physician's offices

C. Urgent care centers

If these settings are ranked in order of the cost of providing c

Choice A: A, B, C

Choice B: A, C, B

Choice C: B, C, A

Choice D: C, A, B

:B

Question 81

In 1999, the United States Congress passed the Financial

Services Modernization Act, referred to as the Gramm-Leach-
Bliley (GLB) Act. The primary provisions included under the
GLB Act require financial institutions, including health plans, to
take several

Choice A: Notify customers of any sharing of non-public

personal financial information with nonaffiliated third parties.

Choice B: Prohibit customers from having the opportunity to

'opt-out' of sharing non-public personal financial information.

Choice C: Disclose to affiliates, but not to third parties, their

privacy policies regarding the sharing of nonpublic personal
financial information.

Choice D: Agree not to disclose personally identifiable financial

information or personally identifiable health information.
:A

Question 82

In 1999, the United States Congress passed the Financial

Services Modernization Act, which is referred to as the Gramm-
Leach-Bliley (GLB) Act. The following statement(s) can
correctly be made about this act:

A. The GLB Act allows convergence among the tra

Choice A: A only

Choice B: Both A and B

Choice C: B only

Choice D: Neither A nor B

:B

Question 83

In accounting terminology, the items of value that a company

ownssuch as cash, cash equivalents, and receivablesare
generally known as the company's

Choice A: revenue

Choice B: net income

Choice C: surplus

Choice D: assets

:D

Question 84

In addition to the credentialing activities that an health plan

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

Choice A: verification of a network provider's medical

education and residency

Choice B: performance of site inspections in a provider's

facilities

Choice C: review of information from a provider's quality

improvement activities

Choice D: verification of a provider's licensure and certification

:A

Question 85

In assessing the potential degree of risk represented by a

proposed insured, a health underwriter considers the factor of
antiselection. Antiselection can correctly be defined as the

Choice A: inability of a proposed insured to share with the

insurer the financial risks of healthcare coverage

Choice B: possibility that a proposed insured will profit from an

illness by receiving benefits that exceed the total amount of
his or her eligible medical expenses

Choice C: inability of a proposed insured to provide sufficient

evidence that proves he or she is an insurable risk

Choice D: tendency of people who have a greater-than-

average likelihood of loss to apply for or continue insurance
protection to a greater extent than people who have an
average or less than average likelihood of the same loss

:D

Question 86

In certain situations, a health plan can use the results of

utilization review to intervene, if necessary, to alter the course
of a plan member's medical care. Such intervention can be
based on the results of

A. Prospective review

B. Concurrent review

C.

Choice A: A, B, and C

Choice B: A and B only

Choice C: A and C only

Choice D: B only

:D

Question 87

In certain situations, a health plan can use the results of

utilization review to intervene, if necessary, to alter the course
of a plan member's medical care. Such intervention can be
based on the results of

A. Prospective review

B. Concurrent review

C.

Choice A: A, B, and C

Choice B: A and B only

Choice C: A and C only

Choice D: B only

:B

Question 88

In claims administration terminology, a claims investigation is

correctly defined as the process of
Choice A: reporting management information about services
provided each time a patient visits a provider for purposes of
analyzing utilization and provider practice patterns

Choice B: obtaining all the information necessary to determine

the appropriate amount to pay on a given claim

Choice C: routinely reviewing and processing a claim for either

payment or denial

Choice D: assigning to each diagnosis or treatment reported

on a claim special codes that briefly and specifically describe
each diagnosis and treatment

:B

Question 89

In health plan terminology, demand management, as used by

health plans, can best be described as

Choice A: an evaluation of the medical necessity, efficiency,

and/or appropriateness of healthcare services and treatment
plans for a given patient

Choice B: a series of strategies designed to reduce plan

members' needs to utilize healthcare services by encouraging
preventive care, wellness, member self-care, and appropriate
use of healthcare services

Choice C: a technique that prevents a provider who is being

reimbursed under a fee schedule arrangement from billing a
plan member for any fees that exceed the maximum fee
reimbursed by the plan

Choice D: a system of identifying plan members with special

healthcare needs, developing a healthcare strategy to meet
those needs, and coordinating and monitoring the care

:B

Question 90

In large health plans, management functions such as provider

recruiting, credentialing, contracting, provider service, and
performance management for providers are typically the
responsibility of the

Choice A: chief executive officer (CEO)

Choice B: network management director

Choice C: board of directors

Choice D: director of operations

:B

Question 91

In most cases, medical errors are caused by breakdowns in the

healthcare system rather than by provider mistakes.

Choice A: True

Choice B: False

Choice C:

Choice D:

:A

Question 92

In order to compensate for lost revenue resulting from

services provided free or at a significantly reduced cost to
other patients, many healthcare providers spread these
unreimbursed costs to paying patients or third-party payors.
This practice is known

Choice A: dual choice

Choice B: cost shifting

Choice C: accreditation

Choice D: defensive medicine

:B

Question 93

In order to cover some of the gap between FFS Medicare

coverage and the actual cost of services, beneficiaries often
rely on Medicare supplements. Which of the following
statements about Medicare supplements is correct?

Choice A: The initial ten (A-J) Medigap policies offer a basic

benefit package that includes coverage for Medicare Part A
and Medicare Part B coinsurance.

Choice B: Each insurance company selling Medigap must sell

all the different Medigap policies.

Choice C: Medicare SELECT is a Medicare supplement that

uses a preferred provider organization (PPO) to supplement
Medicare Part A coverage.

Choice D: Medigap benefits vary by plan type (A through L),

and are not uniform nationally.

:A

Question 94

In order to generate exchanges with consumers, healthcare

plan marketers use the four elements of the marketing mix:
product, price, place (distribution), and

Choice A: segmentation

Choice B: publicity

Choice C: promotion

Choice D: plan design

:C

Question 95
In order to help review its institutional utilization rates, the
Sahalee Medical Group, a health plan, uses the standard
formula to calculate hospital bed days per 1,000 plan
members for the month to date (MTD). On April 20, Sahalee
used the following inf

Choice A: 67

Choice B: 274

Choice C: 365

Choice D: 1,000

:B

Question 96

In order to measure the expenses of institutional utilization,

Holt Healthcare Group uses the standard formula to calculate
hospital bed days per 1,000 plan members per year. On
October 23, Holt used the following information to calculate
the bed days per

Choice A: 278

Choice B: 397

Choice C: 403

Choice D: 920

:B

Question 97

In preparation for its expansion into a new service area, the

Regal MCO is meeting with Dr. Nancy Buhner, a cardiologist
who practices in Regal's new service area, in order to convince
her to become one of the plan's participating providers. As
part of th

Choice A: ensure that Dr. Buhner complies with all of the

provisions of the Ethics in Patient Referrals Act
Choice B: learn whether Dr. Buhner is a licensed medical
practitioner

Choice C: confirm Dr. Buhner's membership in the National

Committee for Quality Assurance (NCQA)

Choice D: learn whether Dr. Buhner has had a medical

malpractice claim filed or other disciplinary actions taken
against her

:D

Question 98

In response to the demand for a method of assessing

outcomes, accrediting organizations and other government
and commercial groups have developed quantitative measures
of quality that consumers, purchasers, regulators, and others
can use to compare health

Choice A: quality standards

Choice B: accreditation decisions

Choice C: standards of care

Choice D: performance measures

:D

Question 99

In the following sections, we will describe some of the

measures health plans use to evaluate the quality of the
services and healthcare they offer their members.

Which of the following is the best description of what a

'Process measure' evaluates?

Choice A: The nature, quantity, and quality of the resources

that a health plan has available for member service and
patient care.

Choice B: The methods and procedures a health plan and its

providers use to furnish service and care.

Choice C: The extent to which services succeed in improving

or maintaining satisfaction and patient health.

Choice D: None of the above

:B

Question 100

In the paragraph below, a sentence contains two pairs of

words enclosed in parentheses. Determine which word in each
pair correctly completes the sentence. Then select the
choice containing the two words that you have chosen. Many
pharmacy benefit

Choice A: Therapeutic / always

Choice B: Generic / always

Choice C: Generic / never

Choice D: Therapeutic / never

:A

Question 101

In the paragraph below, two statements each contain a pair of

terms enclosed in parentheses. Determine which term
correctly completes each statement. Then select the choice
containing the two terms that you have chosen.For providers,
(operational /

Choice A: operational / an acquisition

Choice B: operational / a consolidation

Choice C: structural / an acquisition

Choice D: structural / a consolidation

:D
Question 102

In the United States, the Department of Defense offers

ongoing healthcare coverage to military personnel and their
families through the TRICARE health plan. One true statement
about TRICARE is that

Choice A: hospitals participating in TRICARE program are

exempt from JCAHO accrediation and Medicare certification

Choice B: TRICARE enrollees are not entitiled to appeal

authorization coverage decisions

Choice C: active duty personnel are automatically considered

enrolled in TRICARE Prime

Choice D: TRICARE covers inpatient and outpatient services,

physician and hospital charges, and medical supplies, but not
mental health services

:C

Question 103

In the United States, the Department of Defense offers

ongoing healthcare coverage to military personnel and their
families through the TRICARE health plan. One true statement
about TRICARE is that:

Choice A: Active duty military personnel are automatically

considered enrolled in TRICARE Prime

Choice B: TRICARE covers inpatient and outpatient services,

physician and hospital charges, and medical supplies, but not
mental health services.

Choice C: TRICARE enrollees are not entitled to appeal

authorization or coverage decisions

Choice D: Hospitals participating in the TRICARE program are

exempt from JCAHO accreditation and Medicare certification.

:A
Question 104

Individuals can use HSAs to pay for the following types of

health coverage:.

Choice A: Qualified disability insurance

Choice B: COBRA continuation coverage.

Choice C: Medigap coverage (for those over 65).

Choice D: All of the above.

:B

Question 105

Janet Riva is covered by a indemnity health insurance plan

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

Choice A: $1,750

Choice B: $1,800

Choice C: $2,000

Choice D: $2,250

:B

Question 106

Janet Riva is covered by a traditional idemnity health

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

Choice A: $1,750
Choice B: $1,800

Choice C: $2,000

Choice D: $2,250

:B

Question 107

John Kerry's employer has contracted to receive healthcare for

its employees from the Democratic Healthcare System. Mr.
Kerry visits his PCP, who sends him to have some blood tests.
The PCP then refers Mr. Kerry to a specialist who hospitalizes
him for on

Choice A: a physician practice organisation

Choice B: a physician-hospital organisation

Choice C: a management services organisation

Choice D: an integrated delivery sysem

:D

Question 108

Katrina Lopez is a claims analyst for a health plan that

provides a higher level of benefits for services received in-
network than for services received out-of-network. Ms. Lopez
reviewed a health claim for s to the following questions:

Question A -

Choice A: A, B, C, and D

Choice B: A, B, and D only

Choice C: B, C, and D only

Choice D: A and C only

:A
Question 109

Katrina Lopez is a claims analyst for a health plan that

provides a higher level of benefits for services received in-
network than for services received out-of-network. Ms. Lopez
reviewed a health claim for s to the following questions:

Question A

Choice A: A, B, C, and D

Choice B: A, B, and D only

Choice C: B, C, and D only

Choice D: A and C only

:A

Question 110

Khalyn Drury's employer includes managed dental care in its

employee benefits package. During open enrollment, Ms.
Drury enrolled in the dental plan, which provides dental
services to its members in exchange for a prepayment (the
premium). Dental services

Choice A: dental preferred provider organization (PPO)

Choice B: traditional fee-for-service (FFS) dental plan

Choice C: plan with a dental point of service (POS) option

Choice D: dental health maintenance organization (DHMO)

:D

Question 111

Lansdale Healthcare, a health plan, offers comprehensive

healthcare coverage to its members through a network of
physicians, hospitals, and other service providers. Plan
members who use in-network services pay a copayment for
these services. The copayment

Choice A: specified dollar amount charge that a plan member

must pay out-of-pocket for a specified medical service at the
time the service is rendered

Choice B: percentage of the fees for medical services that a

plan member must pay after Magellan has paid its share of the
costs of those services

Choice C: flat amount that a plan member must pay each year
before Magellan will make any benefit payments on behalf of
the plan member

Choice D: specified payment for services that was negotiated

between the provider and Magellan

:A

Question 112

Managed behavioral health organizations (MBHOs) use several

strategies to manage the delivery of behavioral healthcare
services. The following statements are about these strategies.

Select the choice that contains the correct statement.

Choice A: MBHOs generally provide benefits for mental health

services but not for chemical dependency services.

Choice B: The level of care needed to treat behavioral

disorders is the same for all patients and all disorders.

Choice C: By using outpatient treatment more extensively,

MBHOs have decreased the use of costly inpatient therapies.

Choice D: PCP gatekeeper systems for behavioral healthcare

generally result in more accurate diagnoses, more effective
treatment, and more efficient use of resources than do
centralized referral systems.

:C
Question 113

Many HMOs are compensated for the delivery of healthcare to

members under a prepaid care arrangement. Under a prepaid
care arrangement, a plan member typically pays a

Choice A: fixed amount in advance for each medical service

the member receives

Choice B: a small fee such as $10 or $15 that a member pays

at the time of an office visit to a network provider

Choice C: a fixed, monthly premium paid in advance of the

delivery of medical care that covers most healthcare services
that a member might need, no matter how often the member
uses medical services

Choice D: specified amount of the member's medical expenses

before any benefits are paid by the HMO

:C

Question 114

Many of the credentialing standards and criteria used by

health plans are often taken from already existing standards
established by

Choice A: the National Practitioner Data Bank (NPDB)

Choice B: the National Association of Insurance Commissioners

(NAIC)

Choice C: the Centers for Medicare and Medicaid Services

(CMS)

Choice D: independent accrediting organizations

:D

Question 115

Marlee Whitcomb was covered as a dependent under the

group health plan provided by her father's employer. That
health plan complied with the provisions of the Consolidated
Omnibus Budget Reconciliation Act (COBRA) of 1986. When
Ms. Whitcomb married, she c

Choice A: can continue her group coverage for a period not to

exceed 48 months

Choice B: can continue her group coverage for a period not to

exceed 36 months

Choice C: cannot continue her group coverage, but has the

right to convert the group coverage to an individual health
plan

Choice D: can continue her group coverage indefinitely

:B

Question 116

Medicaid is a jointly funded federal and state program that

provides hospital and medical expense coverage to low-
income individuals and certain aged and disabled individuals.
One characteristic of Medicaid is that

Choice A: providers who care for Medicaid recipients must

accept Medicaid payment as payment in full for services
rendered

Choice B: Medicaid requires recipients to pay deductibles,

copayments, and coinsurance amounts for all services

Choice C: Medicaid is always the primary payor of benefits

Choice D: benefits offered by Medicaid programs are federally

mandated and do not vary by state

:A

Question 117

Medicare Advantage product options include:

Choice A: Coordinated care plans, medical savings accounts

and national PPOs.

Choice B: Private Fee for Service plans, health care

prepayment plans and medical savings accounts

Choice C: Coordinated care plans, regional PPOs and private

fee for service plans

Choice D: Cost contracts, coordinated care programs and

medical savings accounts.

:C

Question 118

Medicare is the federal government program established

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

Choice A: Persons age 63 or older.

Choice B: Persons with qualifying disabilities (over the age of

63)

Choice C: Persons with end-stage renal disease (ESRD)

Choice D: Low income individuals

:C

Question 119

Medicare Part C can be delivered by the following Medicare

Advantage plans:

Choice A: HCCP, HMO, PPO (local or regional), PFFS or MSA.

Choice B: CCPs , PFFS or MSA.

Choice C: HMO, HSA, PPO (local or regional), PFFS or MSA.

Choice D: HMO, PPO (local or regional), POS, or MSA.

:B
Question 120

Member satisfaction is a critical element of a health plan's

quality management program. A health plan can obtain
information about member satisfaction with various aspects of
the health plan from

Choice A: surveys completed by members following a visit to a

provider

Choice B: surveys sent to plan members who have not

received healthcare services during a specified time period

Choice C: periodic reports of complaints received by member

services personnel

Choice D: all of the above

:D

Question 121

Members who qualify to participate in a health plan's case

management program are typically assigned a case manager.
During the course of the member's treatment, the case
manager is responsible for

A. Coordinating and monitoring the member's care

B. Appro

Choice A: Both A and B

Choice B: A only

Choice C: B only

Choice D: Neither A nor B

:B

Question 122
Merle Spencer has coverage under both Medicare Part A and
Medicare Part B. Ms. Spencer recently was hospitalized for
chest pains, and she incurred charges for:

The cost of hospitalization for two days

Diagnostic tests performed in the hospital

Trans

Choice A: ambulance and the diagnostic tests

Choice B: ambulance, the diagnostic tests, and the

physician's professional services

Choice C: cost of hospitalization

Choice D: cost of hospitalization and the physician's

professional services

:D

Question 123

More procedures or services may be fully covered within the

PPO network than those out-of network.

Choice A: True

Choice B: False

Choice C:

Choice D:

:A

Question 124

Most contracts between health plans and providers contain a

provision which forbids providers from seeking compensation
from patients if the health plan fails to compensate the
provider because of insolvency or for any other reason. Such a
provision is kn
Choice A: due process provision

Choice B: cure provision

Choice C: hold-harmless provision

Choice D: risk-sharing provision

:C

Question 125

Mr. George Bush is covered by a PBM plan that uses a closed

formulary. This indicates that

Choice A: he can receive coverage for parmaceuticals only if

they are on the PBM plan's preferred list of drugs

Choice B: he must receive all of his pharmaceuticals from a

mail-order pharmacy program

Choice C: he can receive coverage for pharmaceuticals that

are on the PBM plan's preferred list of drugs, as well as for
pharmacueticals that are not on the preferred list

Choice D: the PBM plan cannot recive a rebate on any

pharmacueticals it obtains from the pharmaceuticalfacturer

:A

Question 126

Natalie Chan is a member of the Ultra Health Plan, a health

plan. Whenever she needs nonemergency medical care, she
sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to
a specialist, so she saw Dr. Craig when she experienced
headaches. Dr. Cr

Choice A: Within Ultra's system, Ms. Chan received primary

care from both Dr. Craig and Dr. Lee

Choice B: Ultra's system allows its members open access to all

of Ultra's participating providers.

Choice C: Within Ultra's system, Dr. Craig serves as a

coordinator of care or gatekeeper for the medical services that
Ms. Chan receives.

Choice D: Ultra's network of providers includes Dr. Craig and

Dr. Lee but not Arrow Hospital

:C

Question 127

Natalie Chan is a member of the Ultra Health Plan. Whenever

she needs non-emergency medical care, she sees Dr. David
Craig, an internist. Ms. Chan cannot self-refer to a specialist,
so she saw Dr. Craig when she experienced headaches. Dr.
Craig referred h

Choice A: Within Ultra's system, Ms. Chan received primary

care from both Dr. Craig and Dr. Lee.

Choice B: Ultra's system allows its members open access to all

of Ultra's participating providers.

Choice C: Within Ultra's system, Dr. Craig serves as a

coordinator of care or gatekeeper for the medical services that
Ms. Chan receives.

Choice D: Ultra's network of providers includes Dr. Craig and

Dr. Lee but not Arrow Hospital.

:C

Question 128

One characteristic of disease management programs is that

they typically

Choice A: focus on individual episodes of medical care rather

than on the comprehensive care of the patient over time

Choice B: are used to coordinate the care of members with

any type of disease, either chronic or nonchronic

Choice C: focus on managing populations of patients who have

a specific chronic illness or medical condition, but do not focus
on patient populations who are at risk of developing such an
illness or condition

Choice D: use clinical practice processes to standardize the

implementation of best practices among providers

:D

Question 129

One characteristic of the accreditation process for MCOs is

that

Choice A: an accrediting agency typically conducts an on-site

review of an MCO's operations, but it does not review an
MCO's medical records or assess its member service systems

Choice B: each accrediting organization has its own standards

of accreditation

Choice C: the accrediting process is mandatory for all MCOs

Choice D: government agencies conduct all accreditation

activities for MCOs

:B

Question 130

One component of information systems used by health plans

incorporates membership data and information about provider
reimbursement arrangements and analyzes transactions
according to contract rules. This information system
component is known as

Choice A: a contract management system

Choice B: a credentialing system

Choice C: a legacy system

Choice D: an interoperable communication system

:A
Question 131

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

Choice A: a listing of drugs classified by therapeutic category

or disease class that are considered preferred therapy for a
given managed population and that are to be used by a health
plan's providers in prescribing medications

Choice B: a reduction in the price of a particular

pharmaceutical obtained by the PBM from the pharmaceutical
manufacturer

Choice C: drugs ordered and delivered through the mail to the

PBM's plan members at a reduced cost

Choice D: an identification card issued by the PBM to its plan

members

:A

Question 132

One distinction that can be made between a staff model HMO

and a group model HMO is that, in a staff model HMO,
participating physicians are Back to Top

Choice A: employees of the HMO

Choice B: employees of a group practice that has contracted

with the HMO

Choice C: compensated primarily through capitation

Choice D: limited to primary care physicians (PCPs)

:A

Question 133

One distinguishing characteristic of a health maintenance

organization (HMO) is that, typically, an HMO

Choice A: arranges for the delivery of medical care and

provides, or shares in providing, the financing of that care

Choice B: must be organized on a not-for-profit basis

Choice C: may be organized as a corporation, a partnership, or

any other legal entity

Choice D: must be federally qualified in order to conduct

business in any state

:A

Question 134

One ethical principle in health plans is the principle of non-

maleficence, which holds that health plans and their providers:

Choice A: Should allocate resources in a way that fairly

distributes benefits and burdens among the members.

Choice B: Have a duty to present information honestly and are

obligated to honor commitments.

Choice C: Are obligated not to harm their members.

Choice D: Should treat each plan member in a manner that

respects his or her goals and values.

:C

Question 135

One ethical principle in managed care is the principle of

justice/equity, which specifically holds that MCOs and their
providers have a duty to

Choice A: treat each member in a manner that respects his or

her own goals and values

Choice B: allocate resources in a way that fairly distributes

benefits and burdens among the members
Choice C: present information honestly to their members and
to honor commitments to their members

Choice D: make sure they do not harm their members

:B

Question 136

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

Choice A: a provider service quality issue

Choice B: an administrative service quality issuea healthcare

process quality issue

Choice C: a healthcare outcomes quality issue

Choice D: a healthcare process quality issue

:A

Question 137

One feature of the Employee Retirement Income Security Act

(ERISA) is that it:

Choice A: Requires self-funded employee benefit plans to pay

premium taxes at the state level.

Choice B: Contains a pre-emption provision, which typically

makes the terms of ERISA take precedence over any state
laws that regulate employee welfare benefit plans.

Choice C: Contains strict reporting and disclosure

requirements for all employee benefit plans except health
plans.

Choice D: Requires that state insurance laws apply to all

employee benefit plans except insured plans.
:B

Question 138

One HMO model can be described as an extension of a group

model HMO because it contracts with multiple group practices,
rather than with a single group practice. This HMO model is
known as the

Choice A: staff model HMO

Choice B: IPA model HMO

Choice C: direct contract model HMO

Choice D: network model HMO

:D

Question 139

One non-group market segment to which health plans market

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

Choice A: The Centers for Medicare and Medicaid Services

(CMS) must approve all marketing materials used by health
plans to market health plan products to the Medicare
population

Choice B: managed Medicare plans typically require Medicare

beneficiaries to purchase Medigap insurance to supplement
gaps in coverage

Choice C: managed Medicare plans can refuse to cover

persons with certain health problems

Choice D: the CMS prohibits health plans from using

telemarketing to market health plan products to the Medicare
population
:B

Question 140

One of the distinguishing characteristics of healthcare

marketing is that many of the markets for health plans are
national, not local markets.

Choice A: True

Choice B: False

Choice C:

Choice D:

:B

Question 141

One of the most influential pieces of legislation in the

advancement of health plans within the United States was the
Health Maintenance Organization (HMO) Act of 1973. One of
the provisions of the Act was that it

Choice A: exempted HMOs from all state licensure

requirements.

Choice B: required all employers that offered healthcare

coverage to their employees to offer

only one type of federally qualified HMO.

Choice C: eliminated funding that supported the planning and

start-up phases of new HMOs.

Choice D: established a process by which HMOs could obtain

federal qualification

:D

Question 142
One of the most influential pieces of legislation in the
advancement of managed care within the United States was
the HMO Act of 1973. One provision of the HMO Act of 1973
was that it

Choice A: emphasized compensating physicians based solely

on the volume of medical services they provide

Choice B: exempted HMOs from all state licensure

requirements

Choice C: established a process under which HMOs could

elect to be federally qualified

Choice D: required federally qualified HMOs to relate premium

levels to the health status of the individual enrollee or
employer group

:C

Question 143

One true statement about community rating, a rating method

commonly used by health plans, is that:

Choice A: It requires a health plan to set premiums for

financing medical care according to the health plan's expected
cost of providing medical benefits to a sub-group within the
community.

Choice B: A health plan usually uses community rating to set

premiums for large groups.

Choice C: It tends to lead to greater fluctuations in premium

rates than do other rating methods.

Choice D: A health plan seldom uses community rating to set

premiums for large groups.

:D

Question 144

One true statement regarding ethics and laws is that the

values of a community are reflected in

Choice A: both ethics and laws, and both ethics and laws are
enforceable in the court system

Choice B: both ethics and laws, but only laws are enforceable
in the court system

Choice C: ethics only, but only laws are enforceable in the

court system

Choice D: laws only, but both ethics and laws are enforceable
in the court system

:B

Question 145

One true statement regarding ethics and laws is that the

values of a community are reflected in

Choice A: both ethics and laws, and both ethics and laws are
enforceable in the court system

Choice B: both ethics and laws, but only laws are enforceable
in the court system

Choice C: ethics only, but only laws are enforceable in the

court system

Choice D: laws only, but both ethics and laws are enforceable
in the court system

:B

Question 146

One type of physician-only integration model is a consolidated

medical group. Typical characteristics of a consolidated
medical group include

Choice A: that it may be a single-specialty or multi-specialty

practice

Choice B: operates in one or a few facilities rather than in

many independent offices

Choice C: achieves economies of scale in the group's

integrated operations

Choice D: all of the above

:D

Question 147

One typical characteristic of an integrated delivery system

(IDS) is that an IDS.

Choice A: Is more highly integrated structurally than it is

operationally.

Choice B: Provides a full range of healthcare services,

including physician services, hospital services, and ancillary
services.

Choice C: Cannot negotiate directly with health plans, plan

sponsors, or other healthcare purchasers.

Choice D: Performs a single business function, such as

negotiating with health plans on behalf of all of the member
providers.

:B

Question 148

One typical characteristic of preferred provider organization

(PPO) benefit plans is that PPOs:

Choice A: Assume full financial risk for arranging medical

services for their members.

Choice B: Require plan members to obtain a referral before

getting medical services from specialists.

Choice C: Use a capitation arrangement, instead of a fee

schedule, to reimburse physicians.

Choice D: Offer some coverage, although at a higher cost, for

plan members who choose to use the services of non-network
providers.

:D

Question 149

One way in which a health plan can support an ethical

environment is by

Choice A: requiring organizations with which it contracts to

adopt the plan's formal ethical policy

Choice B: developing and maintaining a culture where ethical

considerations are integrated into decision making at the top
organizational level only

Choice C: establishing a formal method of managing ethical

conflicts, such as using an ethics task force or bioethics
consultant

Choice D: maintaining control of policy development by

removing providers and members from the process of
developing and implementing policies and procedures that
provide guidance to providers and members confronted with
ethical issues

:C

Question 150

One way in which a health plan can support an ethical

environment is by

Choice A: requiring organizations with which it contracts to

adopt the plan's formal ethical policy

Choice B: developing and maintaining a culture where ethical

considerations are integrated into decision making at the top
organizational level only

Choice C: establishing a formal method of managing ethical

conflicts, such as using an ethics task force or bioethics
consultant

Choice D: maintaining control of policy development by

removing providers and members from the process of
developing and implementing policies and procedures that
provide guidance to providers and members confronted with
ethical issues

:C

Question 151

One way in which health plans differ from traditional

indemnity plans is that health plans Typically

Choice A: provide less extensive benefits than those provided

under traditional indemnity plans

Choice B: place a greater emphasis on preventive care than do

traditional indemnity plans

Choice C: require members to pay a percentage of the cost of

medical services rendered after a claim is filed, rather than a
fixed copayment at the time of service as required by
indemnity plans

Choice D: contain cost-sharing requirements that result in

more out-of-pocket spending by members than do the cost-
sharing requirements in traditional indemnity plans

:B

Question 152

One way that MCOs involve providers in risk sharing is by

retaining a percentage of the providers' payment during a plan
year. At the end of the plan year, the MCO may use the
amount retained to offset or pay for any cost overruns for
referral or hospital

Choice A: withholds

Choice B: usual, customary, and reasonable (UCR) fees

Choice C: risk pools

Choice D: per diems

:A

Question 153

Parable Healthcare Providers, a health plan, recently

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

Choice A: channel segmentation

Choice B: geographic segmentation

Choice C: demographic segmentation

Choice D: product segmentation

:C

Question 154

Parul Gupta has been covered by a group health plan for

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

Choice A: can exclude coverage for treatment of Ms. Gupta's

diabetes for one year, because she did not have at least two
years of creditable coverage under her previous health plan

Choice B: cannot exclude Ms. Gupta's diabetes as a pre-

existing condition, because the one-year pre-existing condition
provision is offset by at least one year of continuous coverage
under her previous health plan

Choice C: can exclude coverage for treatment of Ms. Gupta's

diabetes for one year, because HIPAA does not impact a group
health plan's pre-existing condition provision

Choice D: can exclude coverage for treatment of Ms. Gupta's

diabetes for four months, because that is the length of time
she received treatment for this medical condition prior to her
enrollment in the new health plan

:B

Question 155

Patrick Flaherty's employer has contracted to receive

healthcare for its employees from the Abundant Healthcare
System. Mr. Flaherty visits his primary care physician (PCP),
who sends him to have some blood tests. The PCP then refers
Mr. Flaherty to a spe

Choice A: an integrated delivery system (IDS)

Choice B: a Management Services Organization (MSO)

Choice C: a Physician Practice Management (PPM) company

Choice D: a physician-hospital organization (PHO)

:A

Question 156

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

Choice A: Can exclude coverage for treatment of Mr. Gilbert's

angina for one year, because HIPAA does not impact a group
health plan's pre-existing condition provision.

Choice B: Can exclude coverage for treatment of Mr. Gilbert's

angina for one year, because Mr. Gilbert did not have at least
36 months of creditable coverage under his previous health
plan.
Choice C: Can exclude coverage for treatment of Mr. Gilbert's
angina for three months, because that is the length of time he
received treatment for this medical condition prior to his
enrollment in the new health plan.

Choice D: Cannot exclude his angina as a pre-existing

condition, because the one-year pre-existing condition
provision is offset by at least one year of continuous coverage
under his previous health plan.

:D

Question 157

PBM plans operate under several types of contractual

arrangements. Under one contractual arrangement, the PBM
plan and the employer agree on a target cost per employee
per month. If the actual cost per employee per month is
greater than the target cost, t

Choice A: fee-for-service arrangement

Choice B: risk sharing contract

Choice C: capitation contract

Choice D: rebate contract

:B

Question 158

Pharmacy benefit management (PBM) companies typically

interact with physicians and pharmacists by performing such
clinical services as physician profiling. Physician profiling from
a PBM's point of view involves

Choice A: ascertaining that physicians in the plan have the

necessary and appropriate credentials to prescribe
medications

Choice B: compiling data on physician prescribing patterns

and comparing physicians' actual prescribing patterns to
expected patterns within select drug categories

Choice C: monitoring patient-specific drug problems through

concurrent and retrospective review

Choice D: establishing protocols that require physicians to

obtain certification of medical necessity prior to drug
dispensing

:B

Question 159

Phillip Tsai is insured by both a indemnity health insurance

plan, which is his primary plan, and a health plan, which is his
secondary plan. Both plans have typical coordination of
benefits (COB) provisions, but neither has a nonduplication of
benefits p

Choice A: $0

Choice B: $300

Choice C: $400

Choice D: $900

:C

Question 160

Phillip Tsai is insured by both a traditional idemnity health

insurance plan, which is his primary plan, and a health plan,
which is his secondary plan. Both plans have typical
coordination of benefits (COB) provisions, but neither has a
nonduplication of

Choice A: $0

Choice B: $300

Choice C: $400

Choice D: $900
:C

Question 161

Phoebe Urich is covered by a traditional indemnity health

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

Choice A: 1900

Choice B: 2000

Choice C: 2400

Choice D: 2500

:B

Question 162

Primary care case managers (PCCMs) provide case

management services to eligible Medicaid recipients. With
regard to PCCMs it is correct to say that:

Choice A: PCCMs typically receive a case management fee,

rather than reimbursement for medical services on a FFS
basis, for the services they provide to Medicaid recipients.

Choice B: All Medicaid recipients who live in rural areas must

be given a choice of at least four PCCMs.

Choice C: PCCMs receive a case management fee in addition

to reimbursement for medical services on a FFS basis.

Choice D: PCCMs contract directly with the federal government

to provide case management services to Medicaid recipients.

:C

Question 163
Primary care case managers (PCCMs) provide managed
healthcare services to eligible Medicaid recipients. With regard
to PCCMs, it is correct to say that

Choice A: PCCMs contract directly with the federal

government to provide case management services to Medicaid
recipients

Choice B: all Medicaid recipients who live in rural areas must

be given a choice of at least four PCCMs

Choice C: Medicaid PCCM programs are exempt from the

Health Care Financing Administration's (HCFA's) Quality
Improvement System for Managed Care (QISMC) standards

Choice D: PCCMs typically receive a case management fee,

rather than reimbursement for medical services on a FFS
basis, for the services they provide to Medicaid recipients

:C

Question 164

Provider integration has two components: operational

integration and structural integration. An example of
operational integration in health plans is the:

Choice A: Acquisition of the Leopard Health Plan by the

Hickory Health Plan.

Choice B: Joint venture entered into by the Eclipse Health Plan

and a local hospital system to create a new health plan in
which Eclipse and the hospital system share ownership.

Choice C: Formation of an organization by a group of providers

to carry out billing, collections, and contracting with health
plans for the entire group of providers.

Choice D: Consolidation of the Carver Health Plan and the

Limestone Health Plan.

:C
Question 165

Ronald Canton is a member of the Omega MCO. He receives

his nonemergency medical care from Dr. Kristen High, an
internist. When Mr. Canton needed to visit a cardiologist about
his irregular heartbeat, he first had to obtain a referral from Dr.
High to see

Choice A: Dr. High serves as the coordinator of care for the

medical services that Mr. Canton receives.

Choice B: Omega's network of providers includes Dr. High, but

not Dr. Miller.

Choice C: Omega's system allows its members open access to

all of Omega's participating providers.

Choice D: Omega used a financing arrangement known as a

relative value scale (RVS) to compensate Dr. Miller.

:A

Question 166

Several marketplace factors helped fuel the movement toward

consumer choice. Which one of the following statements is
NOT accurate with regard to these factors?

Choice A: After a period of relative stability, annual growth in

private health spending per capita began to increase rapidly in
2002.

Choice B: During the height of the recent cost upswing,

insurance premiums were increasing by more than 13%
annually.

Choice C: Increased utilization was the largest factor

contributing to the rise in premiums, accounting for 43% of
the increase.

Choice D: Employer payers began seeking ways to control

spiraling utilization rates and provide lowercost health
coverage options.

:A
Question 167

Some providers use electronic medical records (EMRs) to

document their patients' care in an electronic form. The
following statement(s) can correctly be made about EMRs:

A. EMRs are computerized records of a patient's clinical,

demographic, and administra

Choice A: B only

Choice B: Both A and B

Choice C: Neither A nor B

Choice D: A only

:D

Question 168

Some states mandate that an independent enrollment broker

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

Choice A: Many states have regulations that prohibit health

plans from using door-to-door and/or telephone solicitation to
market health plan products to the Medicaid population.

Choice B: Health plans are never allowed to medically

underwrite individual market customers who are under age 65.

Choice C: To promote a health plan product to the individual

market, health plans typically use captive agents who give
sales presentations to potential customers, rather than using
promotion tools such as direct mail, telemarketing, or
advertising.

Choice D: Health plans typically are allowed to medically

underwrite all individual market

customers who are covered by Medicare and can refuse to

cover such customers.

:A

Question 169

Specialty services that have certain characteristics generally

are good candidates for managed care approaches. These
characteristics generally include that the specialty service
should have

Choice A: appropriate, rather than inappropriate, utilization

Choice B: a defined patient population

Choice C: low, stable costs

Choice D: a benefit that cannot be easily defined

:B

Question 170

Specialty services with certain characteristics tend to make

good candidates for health plan approaches. One
characteristic used to identify a specialty service that may be
a good candidate for a health plan approach is that the service
should have

Choice A: a defined patient population

Choice B: a complex benefit structure

Choice C: low, stable costs

Choice D: appropriate utilization rates

:A

Question 171

The prudent layperson standard described in the Balanced

Budget Act (BBA) of 1997 requires all hospitals that receive
Medicare or Medicaid reimbursement to screen and, if
necessary, stabilize all patients who come to their emergency
departments.

Choice A: True

Choice B: False

Choice C:

Choice D:

:B

Question 172

The prudent layperson standard described in the Balanced

Budget Act (BBA) of 1997 requires all hospitals that receive
Medicare or Medicaid reimbursement to screen and, if
necessary, stabilize all patients who come to their emergency
departments.

Choice A: True

Choice B: False

Choice C:

Choice D:

:B

Question 173

The Acme HMO recruits and contracts directly with a wide

range of physiciansboth PCPs and specialistsin its
geographic area on a non-exclusive basis. There is no separate
legal entity that represents and negotiates the contracts for
the physicians. The

Choice A: an independent practice association (IPA) model

HMO

Choice B: a staff model HMO

Choice C: a direct contract model HMO

Choice D: a group model HMO

:C

Question 174

The administrative simplification standards described under

Title II of HIPAA include privacy standards to control the use
and disclosure of health information. In general, these privacy
standards prohibit

Choice A: all health plans, healthcare providers, and

healthcare clearinghouses from using any protected health
information for purposes of treatment, payment, or healthcare
operations without an individual's written consent

Choice B: patients from requesting that restrictions be placed

on the accessibility and use of protected health information

Choice C: transmission of individually identifiable health

information for purposes other than treatment, payment, or
healthcare operations without the individual's written
authorization

Choice D: patients from accessing their medical records and

requesting the amendment of incorrect or incomplete
information

:D

Question 175

The Advantage Health Plan recently added the following

features to its member services program:

IVR

Active member outreach program

Advantage's member services staffing needs are likely to

increase as a result of
Choice A: 1

Choice B: 2

Choice C: 1 & 2

Choice D: Neither 1 nor 2

:B

Question 176

The application of health plan principles to workers'

compensation insurance programs has presented some unique
challenges because of the differences between health plan for
traditional group healthcare and workers' compensation. One
key difference is tha

Choice A: limits coverage to eligible employees and excludes

part-time employees

Choice B: specifies an annual lifetime benefit maximum on

dollar coverage for medical costs

Choice C: provides benefits regardless of the cause of an

injury or illness

Choice D: provides benefits for both healthcare costs and lost

wages

:D

Question 177

The Ark Health Plan, is currently recruiting providers in

preparation for its expansion into a new service area. A
recruiter for Ark has been meeting with Dr. Nan Shea, a
pediatrician who practices in Ark's new service area, in order
to convince her to be

Choice A: Credentialing

Choice B: Accreditation
Choice C: A sentinel event

Choice D: A screening program

:A

Question 178

The Ark Health Plan, is currently recruiting providers in

preparation for its expansion into a new service area. A
recruiter for Ark has been meeting with Dr. Nan Shea, a
pediatrician who practices in Ark's new service area, in order
to convince her to be

Choice A: Has ever participated in any quality improvement

activities.

Choice B: Is a participating provider in a health plan that will

compete with Ark in its new service area.

Choice C: Meets the requirements of the Ethics in Patient

Referrals Act.

Choice D: Has had a medical malpractice claim filed or other

disciplinary actions taken against her.

:D

Question 179

The Azure Group is a for-profit health plan that operates in the

United States. The Fordham Group owns all of Azure's stock.
The Fordham Group's sole business is the ownership of
controlling interests in the shares of other companies. This
information ind

Choice A: A holding company of the Fordham Group.

Choice B: A sister corporation of the Fordham Group.

Choice C: A subsidiary of the Fordham Group.

Choice D: All of the above.

:C

Question 180

The Blaine Healthcare Corporation seeks to manage its quality

by first identifying the best practices and best outcomes for a
given procedure. Blaine can then determine areas in which it
can emulate the best practices in order to equal or surpass the
best

Choice A: provider profiling

Choice B: benchmarking

Choice C: peer review

Choice D: quality assessment

:B

Question 181

The Citywide Health Group is a large provider-based health

plan that includes physician groups, hospitals, and other
facilities. In order to oversee and manage the operation of the
organization, Citywide has established an enterprise
scheduling system. Th

Choice A: provide information to Citywide's management

regarding provider licensure, certification, and malpractice
history

Choice B: detect instances of overutilization, underutilization,

or inappropriate utilization of medical resources

Choice C: allow Citywide's different components to function as

a single organization in arranging access to facilities and
resources

Choice D: facilitate the processing of requests for

authorization of payment of benefits

:C
Question 182

The Cleopatra Group, a third-party administrator (TPA), has

entered into a TPA agreement with the Alexander MCO with
regard to the administration of a particular health plan. This
agreement complies with all of the provisions of the NAIC TPA
Model Law. On

Choice A: hold all funds it receives on behalf of Alexander in

trust

Choice B: assume full responsibility for determining the claim

payment procedures for the plan

Choice C: assume full responsibility for ensuring that the

health plan is administered properly

Choice D: obtain from the federal government a certificate of

authority designating the Cleopatra Group as a TPA

:A

Question 183

The Clover Group is a for-profit MCO that operates in the

United States. The Valentine Group owns all of Clover's stock.
The Valentine Group's sole business is the ownership of
controlling interests in the shares of other companies. This
information indic

Choice A: holding company of the Valentine Group

Choice B: sister corporation of the Valentine Group

Choice C: parent company of the Valentine Group

Choice D: subsidiary of the Valentine Group

:D

Question 184

The Conquest Corporation contracts with the Apex health plan

to provide basic medical and surgical services to Conquest
employees. Conquest entered into a separate contract with
the Bright Dental Group to provide and manage a dental care
program for emplo

Choice A: a negotiated rebate agreement

Choice B: a carve-out arrangement

Choice C: an indemnity plan

Choice D: PBM

:B

Question 185

The contract between the Honolulu MCO and Beverley Hills

Hospital contains a 90 day cure provision. The Beverley Hills
Hospital breached one of the contract reqirements on July 31,
2004. The hospital remedied the problem by October 31,
2004. Which of the

Choice A: The contract would not be terminated as Beverley

Hills hospital rectified the problem within 90 days.

Choice B: The contract would be terminated as Beverley Hills

hospital was required to notify Honolulu MCO about the
problem at least 90 days in advance.

Choice C: The contract would be terminated as Beverley Hills

hospital was required to rectify the problem within 90 days.

Choice D: The contract would not be terminated as Beverley

Hills hospital may escape adherence to the cure provision.

:C

Question 186

The Courtland PPO maintains computerized records that

include clinical, demographic, and administrative data about
individual plan members. The data in these records is
available to plan providers, ancillary service departments,
pharmacies, and others inv

Choice A: a data warehouse

Choice B: a decision support system

Choice C: an outsourcing system

Choice D: an electronic medical record (EMR) system

:D

Question 187

The criteria used to identify and measure healthcare quality

are generally divided into three categories: structure, process,
and outcomes measures. Structure measures, which relate to
the nature and quality of the resources that a health plan has
availab

Choice A: length of time patients have to wait at the office to

be seen by a provider

Choice B: percentage of plan physicians who are board-

certified

Choice C: percentage of children receiving immunizations

Choice D: number of patients contracting an infection in the

hospital

:B

Question 188

The data evaluation stage of utilization review (UR) includes

both administrative reviews and medical reviews. One true
statement about these types of reviews is that:

Choice A: An administrative review must be conducted by a

health plan staff member who is a medical professional.

Choice B: The primary purpose of an administrative review is

to evaluate the appropriateness of a proposed medical
service.

Choice C: UR staff members typically conduct a medical

review of a proposed medical service before they conduct an
administrative review for that same service.

Choice D: One purpose of a medical review is to evaluate the

medical necessity of a proposed medical service.

:D

Question 189

The Employee Retirement Income Security Act (ERISA)

requires health plan members who receive healthcare benefits
through employee benefit plans to file legal challenges
involving coverage decisions or plan administration at the
federal level. Under the te

Choice A: contract damages, which cover the cost of denied

treatment

Choice B: compensatory damages, which compensate the

injured party for his or her injuries

Choice C: punitive damages, which are designed to punish or

make an example of the wrongdoer

Choice D: all of the above

:A

Question 190

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

Choice A: Both 1 and 2

Choice B: 1 only
Choice C: 2 only

Choice D: Neither 1 nor 2

:B

Question 191

The Fairway Health Group contracted with the Empire

Corporation to provide behavioral healthcare services to
Empire employees. As a condition of providing behavioral
healthcare services, Fairway required Empire to contract with
Fairway for basic medical s

Choice A: horizontal group boycott

Choice B: price-fixing agreement

Choice C: horizontal division of markets

Choice D: tying arrangement

:D

Question 192

The following organizations are the primary sources of

accreditation of healthcare organizations:

A. National Committee for Qualty Assurance (NCQA)

B. American Accreditation HealthCare Commission/URAC

Of these organizations, performance data is included i

Choice A: A only

Choice B: B only

Choice C: A and B

Choice D: none of the above

:A
Question 193

The following paragraph contains an incomplete statement.

Select the choice containing the term that correctly
completes the statement. In early efforts to manage
healthcare costs, traditional indemnity health insurers
included in their health pla

Choice A: cost shifting

Choice B: deductibles

Choice C: underwriting

Choice D: copay

:B

Question 194

The following paragraph contains an incomplete statement.

Select the choice containing the term that correctly
completes the statement.Advances in computer technology
have revolutionized the processing of medical and drug
claims.Claims processing i

Choice A: Lower

Choice B: Higher

Choice C: Same

Choice D: No change

:B

Question 195

The following programs are part of the Alcove Health Plan's

utilization management (UM) program:

Preventive care initiatives

 A telephone triage program

A shared decision-making program

A self-care program

With regard to the UM programs, it is most

Choice A: Preventive care initiatives include immunization

programs but not health promotion programs.

Choice B: Telephone triage program is staffed by physicians

only.

Choice C: Shared decision-making program is appropriate for

virtually any medical condition.

Choice D: Self-care program is intended to complement

physicians' services, rather than to supersede or eliminate
these services.

:D

Question 196

The following programs are part of the Alcove MCO's utilization

management (UM) program: A telephone triage program
Preventive care initiatives A shared decision-making program
A self-care program

With regard to the UM programs, it is most likely cor

Choice A: self-care program is intended to complement

physicians' services, rather than to supercede or eliminate
these services

Choice B: telephone triage program is staffed by physicians

only

Choice C: shared decision-making program is appropriate for

virtually any medical condition

Choice D: preventive care initiatives include immunization

programs but not health promotion programs

:A
Question 197

The following programs are typically included in TRICARE

medical management efforts:

A. Utilization management

B. Self-care

C. Case management

Choice A: A and B only

Choice B: A and C only

Choice C: All of the listed options

Choice D: B and C only

:C

Question 198

The following sentence contains an incomplete statement with

two missing words. Select the choice that contains the
words that correctly fill in the missing blanks.

At its core, consumer choice involves empowering healthcare

consumers to play a __

Choice A: greater/lesser

Choice B: greater/greater

Choice C: lesser/greater

Choice D: lesser/lesser

:B

Question 199

The following sentence contains an incomplete statement with

two missing words. Select the choice that contains the
words that correctly fill the two blanks, respectively. The
philosophy of consumer choice involves having consumers
play a(n) ______

Choice A: Decreased Increased

Choice B: Increased Decreased

Choice C: Increased Increased

Choice D: Decreased Decreased

:C

Question 200

The following statement can be correctly made about

Medicare Advantage eligibility:

Choice A: Individuals enrolled in a MA plan must enroll in a

stand-alone Part D

prescription drug plan.

Choice B: Individuals enrolled in a MA plan do not have to be

eligible for Medicare Part A

Choice C: Individuals enrolled in an MSA plan or a PFFS plan

without Medicare drug

coverage can enroll in Medicare Part D.

Choice D: Individuals can enroll in MA plan in multiple regions.

:C

Question 201

The following statement(s) can correctly be made about

electronic data interchange (EDI):

A. EDI differs from eCommerce in that EDI involves back-and-

forth exchanges of information concerning individual
transactions, whereas eCommerce is the transfer of d
Choice A: Both A and B

Choice B: A only

Choice C: B only

Choice D: Neither A nor B

:C

Question 202

The following statement(s) can correctly be made about

Medicaid managed care plans:

A. A state may mandate health plan enrollment if it offers

enrollees in non-rural areas a choice of at least two health
plans and offers rural enrollees a choice of at lea

Choice A: Both A and B

Choice B: A only

Choice C: B only

Choice D: Neither A nor B

:A

Question 203

The following statement(s) can correctly be made about the

characteristics of reports that should be provided to managers
for use in managing a healthcare delivery system:

A. Users typically need access to all the raw data used to

generate reports

B. Info

Choice A: Both A and B

Choice B: A only

Choice C: B only
Choice D: Neither A nor B

:D

Question 204

The following statement(s) can correctly be made about the

Joint Commission on Accreditation of Healthcare Organizations
(JCAHO):

A. JCAHO's accreditation process for MCOs and healthcare

networks consists of complete on-site surveys conducted
every three

Choice A: A only

Choice B: Neither A nor B

Choice C: Both A and B

Choice D: B only

:A

Question 205

The following statements apply to Archer medical savings

accounts. Select the choice that contains the correct
statement.

Choice A: MSAs were established as a demonstration project

under the Medicare Modernization Act.

Choice B: MSAs were seen as an improvement over FSAs

because they are portable, allowing employees to take the
funds with them when they change jobs.

Choice C: The popularity of MSAs has been limited because

funds may not be rolled over from year to year.

Choice D: MSAs are one of the fastest growing Types of

Consumer-Directed Health Plans.

:B
Question 206

The following statements apply to enrollment statistics for

HSAs. Select the choice that contains the CORRECT
statement.

Choice A: HSAs have helped expand health care coverage to

consumers who were previously uninsured.

Choice B: The vast majority of enrollees in HSA health plans

are wealthy.

Choice C: Most people receiving coverage through HSA health

plans are individuals rather than families.

Choice D: HSAs appeal primarily to young consumers.

:A

Question 207

The following statements apply to flexible spending

arrangements. Select the choice that contains the correct
statement.

Choice A: FSAs were designed to help increase health

insurance coverage among self-employed individuals.

Choice B: Only employers may contribute funds to FSAs.

Choice C: The popularity of FSAs has been limited because

funds may not be rolled over from year to year.

Choice D: A popular feature of FSAs is their portability, which

allows employees to take the funds with them when they
change jobs.

:C

Question 208

The following statements apply to health reimbursement

arrangements. Select the choice that contains the correct
statement.

Choice A: Only employers are permitted to establish and fund

HRAs.

Choice B: The popularity of HRAs waned following a 2002

ruling by U.S. Treasury Department regarding their treatment
in the tax code.

Choice C: HRAs must be offered in conjunction with a high-

deductible health plan.

Choice D: The guaranteed portability feature of HRAs has

contributed to their popularity.

:A

Question 209

The following statements are about accreditation in health

plans. Select the choice that contains the correct
statement.

Choice A: Accreditation is typically performed by a panel of

physicians and administrators employed by the health plan
under evaluation.

Choice B: All accrediting organizations use the same standards

of accreditation.

Choice C: Results of accreditation evaluations are provided

only to state regulatory agencies and are not made available
to the general public.

Choice D: Accreditation demonstrates to an health plan's

external customers that the plan meets established standards
for quality care.

:D

Question 210

The following statements are about concepts related to the

underwriting function within a health plan. Select the
choice containing the correct statement.

Choice A: Antiselection refers to the fact that individuals who

believe that they have a less-than-average likelihood of loss
tend to seek healthcare coverage to a greater extent than do
individuals who believe that they have an average or greater-
than-average like

Choice B: Federally qualified HMOs are required to medically

underwrite all groups applying for coverage.

Choice C: Typically, a health plan guarantees the premium rate

for a group health contract for a period of five years.

Choice D: When evaluating the risk for a group policy,

underwriters typically focus on such factors as the size of the
group, the stability of the group, and the activities of the
group.

:D

Question 211

The following statements are about federal laws that affect

healthcare organizations. Select the choice containing the
correct response.

Choice A: The Women's Health and Cancer Rights Act (WHCRA)

of 1998 requires health plans to offer mastectomy benefits.

Choice B: The Health Care Quality Improvement Act (HCQIA)

requires hospitals, group practices, and HMOs to comply with
all standard antitrust legislation, even if these entities adhere
to due process standards that are outlined in HCQIA.

Choice C: The Newborns' and Mothers' Health Protection Act

(NMHPA) of 1996 mandates that coverage for hospital stays
for childbirth must generally be a minimum of 24 hours for
normal deliveries and 48 hours for cesarean births.

Choice D: Although the Mental Health Parity Act (MHPA) does

not require health plans to offer mental health coverage, it
imposes requirements on those plans that do offer mental
health benefits.
:D

Question 212

The following statements are about health information

networks (HINs). Three of the statements are true and one
statement is false. Select the choice containing the FALSE
statement.

Choice A: Most HINs are built on proprietary computer

networks rather than being

Internetbased.

Choice B: While a HIN is for the exclusive use of one

organization, a community health information network (CHIN)
is shared by several organizations.

Choice C: A health plan can use a secured extranet design or a

distributed database approach for its HIN.

Choice D: HINs have the potential to increase the quality of

medical care because they make a patient's medical history
readily available to each provider at the point of service.

:A

Question 213

The following statements are about information management

in health plans. Three of the statements are true and one
statement is false. Select the choice containing the FALSE
statement:

Choice A: Health plans find EDI useful for transmitting data

among different health plan locations.

Choice B: EDI is different from eCommerce in the EDI is the

transfer of data, typically in batches, while ecommerce is a
back-and-forth exchange of information concerning individual
transactions.

Choice C: The majority of health plan eCommerce occurs via

proprietary computer networks.

Choice D: Benefits that health plans can receive from using

electronic data interchange.

:C

Question 214

The following statements are about issues associated with

marketing healthcare plans to small groups and large groups.
Select the choice that contains the correct statement.

Choice A: In the large group market, large group accounts that

have employees in more than one geographic area who are
covered through a single national contract for healthcare
coverage are known as large local groups.

Choice B: Because providing healthcare coverage for

employees is often a burden for small businesses, price is
typically the most critical consideration for small businesses in
selecting a healthcare plan.

Choice C: health plans typically treat an employer purchasing

coalition as a small group for marketing purposes.

Choice D: Large groups rarely use self-funding to finance their

healthcare plans.

:B

Question 215

The following statements are about preferred provider

organizations (PPOs). Select the choice that contains the
correct statement.

Choice A: PPOs generally assume full financial risk for

arranging medical services for their members.

Choice B: PPOs generally pay a larger portion of a member's

medical expenses when that member uses in-network
providers than when the member uses out-of-network
providers.

Choice C: PPO networks may include primary care physicians

and hospitals, but generally do not include specialists.

Choice D: In a PPO, the most common method used to

reimburse physicians is capitation.

:B

Question 216

The following statements are about standards set forth in the

Quality Improvement System for Managed Care (QISMC),
established by the Health Care Financing Administration
(HCFA, now known as the Centers for Medicare and Medicaid
Services). Select the answ

Choice A: As a result of the Balanced Budget Refinement Act

(BBRA), PPOs are required to meet all QISMC quality
requirements.

Choice B: QISMC standards typically do not apply to such

Medicare services as mental health or substance abuse
services.

Choice C: Medicaid primary care case manager (PCCM)

programs are subject to the same QISMC quality standards
and performance measures as are all other Medicare and
Medicaid programs.

Choice D: QISMC standards and guidelines are required for

Medicare MCOs, but they are applicable to Medicaid MCOs at
the discretion of the individual states.

:D

Question 217

The following statements are about the accessibility of

healthcare coverage and medical care in the United States.
Select the choice that contains the correct statement.

Choice A: A persons employment status as a full-time

employee guarantees that person access to healthcare
coverage.

Choice B: Most people who have healthcare coverage are

covered under an individual insurance policy rather than a
group insurance plan.

Choice C: The percentage of the population without healthcare

coverage is evenly distributed throughout the United States.

Choice D: Hospital closings have occurred disproportionately

in rural areas and inner cities and have reduced access to
healthcare in these areas.

:D

Question 218

The following statements are about the make-up and function

of an HMO's board of directors.

Select the choice that contains the correct statement.

Choice A: The make-up of an HMO's board of directors is

prescribed by state regulations and does not vary according to
whether the plan is a for-profit or not-for-profit plan.

Choice B: The board of directors of a not-for-profit HMO is

exempt from liability for its actions.

Choice C: An HMO's board of directors is not responsible for

supervising the performance of its officers and outside
advisors.

Choice D: A primary function of the board of directors is to

approve and evaluate the organization's operational policies
and procedures.

:D

Question 219

The following statements are about the non-group market for

managed care products in the United States. Select the
choice containing the correct statement.

Choice A: In order to promote a product to the individual

market, MCOs typically rely on personal selling by captive
agents rather than on promotional tools such as direct mail,
telemarketing, and advertising.

Choice B: Managed Medicare plans typically are allowed to

reject a Medicare applicant on the basis of the results of
medical underwriting of the applicant.

Choice C: HCFA (now known as the Centers for Medicare and

Medicaid Services) must approve all membership and
enrollment materials used by MCOs to market managed care
products to the Medicare population.

Choice D: Managed care plans are not allowed to health

screen individual market customers who are under age 65,
even if the health screen could help prevent antiselection.

:C

Question 220

The following statements are about the underwriting function

within a health plan. Select the choice containing the
correct statement.

Choice A: The underwriting function in a health plan is

primarily concerned with ensuring that the group being
underwritten does not include any individuals who are likely to
have higher than averageutilization of medical services.

Choice B: Compared to a health plan with relaxed underwriting

requirements, a similar health plan with very strict
underwriting requirements can expect to experience increased
healthcare costs and to have significantly higher plan
enrollment.

Choice C: Typically, a health plan guarantees the premium rate

for a group health contract for a period of no more than six
months.

Choice D: In order to determine the actual premium to charge

a group, a group underwriter typically considers such factors
as level of participation, benefits, and the age and gender
distribution of group members.

:D

Question 221

The following statements describe common types of

physician/hospital integrated models: (A) The Alpha Company,
which is owned by a group of investors, is a for-profit legal
entity that buys entire physician practices, not just the
tangible assets of the p

Choice A: physician hospital orgnanisation physician practice

management company

Choice B: physician practice management company physician

hospital organisation

Choice C: medical foundation management services company

Choice D: physician hospital organisation medical foundation

:B

Question 222

The following statements describe common types of

physician/hospital integrated models:

The Iota Company, which is owned by a group of investors, is

a for-profit legal entity that buys entire physician practices,
not just the tangible assets of the practi

Choice A: Iota- physician hospital organization (PHO)Casa-

physician practice management (PPM) company.

Choice B: Iota- physician hospital organization (PHO)Casa-

medical foundation.

Choice C: Iota- physician practice management (PPM) Casa-

physician hospital organization (PHO) company.

Choice D: Iota- medical foundation Casa- management

services organization (MSO).

:C

Question 223

The following statements describe corporate transactions:

Transaction A An MCO acquired another MCO.

Transaction B A group of providers formed an organization to

carry out billings, collections, and contracting with MCOs for
the entire group of provi

Choice A: A and C only

Choice B: A, B, and C

Choice C: B and C only

Choice D: A and B only

:A

Question 224

The following statements describe healthcare services

delivered to health plan members by plan providers. Select
the statement that describes a service that would most likely
require utilization review and authorization.

Choice A: Adele Farnsworth visited a dermatologist to have a

mole removed from her arm.

Choice B: Jonathan Lang underwent an electrocardiogram

(EKG) during an office visit with his cardiologist.

Choice C: Corinne Maxwell underwent physical therapy after

being hospitalized for hip replacement surgery.

Choice D: Jose Redriguez, a 70-year-old Medicare patient,

received a flu shot as part of his annual physical examination.

:C
Question 225

The following statements describe individuals who are

applying for individual health insurance coverage:

Six months ago, Wilbur Lee lost his health insurance coverage
due to a reduction in work hours and has exhausted his
coverage under COBRA. Mr. Lee has

Choice A: both Mr. Lee and Mr. Beeker

Choice B: Mr. Lee only

Choice C: Mr. Beeker only

Choice D: neither Mr. Lee nor Mr. Beeker

:A

Question 226

The following statements describe violations of antitrust

legislation:

Situation A - Two health plans in a single service area divided

purchasers into two groups andagreed to each market their
products to only one purchaser group.

Situation B - A spec

Choice A: Situation A - horizontal division of markets

Situation B - tying arrangement.

Choice B: Situation A - horizontal division of markets

Situation B - price fixing.

Choice C: Situation A - horizontal group boycott

Situation B - tying arrangement.

Choice D: Situation A - horizontal group boycott

Situation B - price fixing.

:A

Question 227

The following types of CDHPs allow federal tax advantages

including the ability to roll funds from one year to the next:

Choice A: MSAs, HRAs, HSAs

Choice B: FSAs, MRAs, HRAs

Choice C: FSAs, HRAs, HSAs

Choice D: FSAs, MRAs HSAs

:A

Question 228

The Gable MCO sometimes experience-rates small groups by

underwriting a number of small groups as if they constituted
one large group and then evaluating the experience of the
entire large group. This practice, which allows small groups to
take advantage

Choice A: prospective experience rating

Choice B: pooling

Choice C: retrospective experience rating

Choice D: positioning

:B

Question 229

The Granite Health Plan is a coodinated care plan (CCP) that

partcipates in the Medicare+Choice program. This information
indicates that Granite

Choice A: must comply with all state-mandated benefits and

provider requirements
Choice B: must offer each of its enrollees a Medicare
supplement

Choice C: places primary care t the cener of the delivery

system and focuses on manaing patient care at all levels

Choice D: most likely must cover Medicare Part A, but not

Medicare Part B, benefits

:C

Question 230

The Helm MCO segmented the non-group market for its new
healthcare product by using factors such as education level,
gender, and household composition. The Amberly MCO
segmented the non-group market for its products based on the
approaches by which it sol

Choice A: demographic product or benefit

Choice B: geographic distribution channel

Choice C: demographic distribution channel

Choice D: geographic product or benefit

:C

Question 231

The Hill Health Plan designed a set of benefits that it packaged

in the form of a PPO product. Hill then established a pricing
structure that allowed its product to compete in the small
group market, and it developed advertising designed to inform
potenti

Choice A: A decision as to which exclusions or limitations

would apply for this product.

Choice B: A decision as to how to establish the network of

participating providers for this product

Choice C: A determination of the level at which this product

would cover out-of-network services.

Choice D: All of the above.

:D

Question 232

The Hill Health Plan designed a set of benefits that it packaged

in the form of a PPO product. Hill then established a pricing
structure that allowed its product to compete in the small
group market, and it developed advertising designed to inform
potenti

Choice A: $140

Choice B: $170

Choice C: $180

Choice D: $210

:B

Question 233

The Hill Health Plan designed a set of benefits that it packaged

in the form of a PPO product. Hill then established a pricing
structure that allowed its product to compete in the small
group market, and it developed advertising designed to inform
potenti

Choice A: An indemnity wraparound plan

Choice B: A self-funded plan

Choice C: An aggregate stop-loss plan

Choice D: A fully funded plan

:D

Question 234
The Hill Health Plan designed a set of benefits that it packaged
in the form of a PPO product. Hill then established a pricing
structure that allowed its product to compete in the small
group market,and it developed advertising designed to inform
potentia

Choice A: The number of specialists in Hill's network of

providers.

Choice B: The price for the PPO product.

Choice C: Hill's ability to report utilization data.

Choice D: Hill's use of brokers to market its PPO product.

:B

Question 235

The HMO Act of 1973 was significant in that the Act

Choice A: mandated certain requirements that all HMOs had to

meet in order to conduct business

Choice B: required that all HMOs be licensed as insurance

companies

Choice C: offered HMOs federal financial assistance through

grants and loans, and provided access to the employer-based
insurance market

Choice D: encouraged the use of pre-existing condition

exclusion provisions in all HMO contracts

:C

Question 236

The Houston Company, a United States company, offers its

eligible employees health insurance coverage through a group
health plan. Houston hired the Dallas Company to handle the
plan's claim administration and membership services, but
Houston is financial
Choice A: Houston is required to purchase stop-loss insurance
to cover its losses under this group health plan

Choice B: Houston's plan is a self-funded plan

Choice C: Dallas is the plan's sponsor

Choice D: Houston's plan is not exempt from any state

insurance regulations under ERISA

:B

Question 237

The Internal Revenue Service has ruled that an HDHP coupled

with an HSA may cover certain types of preventive care
without a deductible or with a lower amount than the annual
deductible applicable to all other services. According to IRS
guidance, which on

Choice A: Immunizations for children and adults

Choice B: Tests and diagnostic procedures ordered with routine

examinations

Choice C: Smoking cessation programs

Choice D: Gastric bypass surgery for obesity

:D

Question 238

The Koster Company plans to purchase a health plan for its

employees from Intuitive HMO. Intuitive will administer the
plan and will bear the responsibility of guaranteeing claim
payments by paying all incurred covered benefits. Koster will
pay for the he

Choice A: fully funded plan

Choice B: stop-loss plan

Choice C: self-pay plan

Choice D: self-funded plan

:A

Question 239

The Links Company, which offers its employees a self-funded

health plan, signed a contract with a third party administrator
(TPA) to administer the plan. The TPA handles the group's
membership services and claims administration. The contract
between Links

Choice A: a manual rating contract

Choice B: a funding vehicle contract

Choice C: an administrative services only (ASO) contract

Choice D: a pooling contract

:C

Question 240

The Mabry County Hospital negotiated a contract with Wellfolk

HMO. Mabry negotiated the inclusion of a provision in the
contract whereby Mabry agreed to capitated compensation
from Wellfolk up to a specified total cost of providing medical
services for an

Choice A: quality assurance provision

Choice B: performance-based financial provision

Choice C: dual-choice provision

Choice D: stop-loss provision

:D

Question 241

The Madison Health Plan, a national MCO, and a local hospital

system that operates its own managed healthcare network
recently created a new and separate managed healthcare
organization, the Pineapple Health Plan. Madison and the
hospital system share own

Choice A: a consolidation

Choice B: a joint venture

Choice C: a merger

Choice D: an acquisition

:B

Question 242

The main advantage of using outcomes measures to evaluate

healthcare quality is that they Typically

Choice A: are easy to identify and report

Choice B: demonstrate improved clinical and functional status

over time

Choice C: are insensitive to changes in structures or processes

Choice D: provide meaningful feedback on care delivery even

when the delay between treatment and outcome stretches
over several years

:B

Question 243

The main purpose of the Health Plan Employer Data and

Information Set (HEDIS) is to provide

Choice A: expert consultation to end-users for solving

specialized and complex healthcare problems through the use
of a knowledge-based computer system

Choice B: a comprehensive accrediation for PPOs

Choice C: measurements of plan performance and

effectiveness that potential healthcare purchasers can use to
compare quality offered by different healthcare plans

Choice D: a mathemetical model that can predict future claim

payments and premiums

:C

Question 244

The Meadowcreek Group is an organization comprised of

individual physicians and physicians in small group practices.
Meadowcreek enters into contracts with health plans, and then
Meadowcreek contracts separately with its physician
members. In situations w

Choice A: a group practice without walls (GPWW)

Choice B: a messenger model

Choice C: an individual practice association (IPA)

Choice D: a Physician Practice Management (PPM) company

:C

Question 245

The measures used to evaluate healthcare quality are

generally divided into three categories: process, structure and
outcomes. An example of a process measure that can be used
to evaluate an MCO's performance is the

Choice A: percentage of baord certified physicians within the

MCO's network

Choice B: number of hospital admissions for plan members

with certain medical conditions

Choice C: number of plan members contracting an infection in

the ospital

Choice D: percentage of adult plan members who receive

regular medical checkups
:D

Question 246

The measures used to evaluate healthcare quality are

generally divided into three categories: process, structure, and
outcomes. An example of a process measure that can be used
to evaluate a health plan's performance is the:

Choice A: Percentage of adult plan members who receive

regular medical checkups.

Choice B: Number of plan members contracting an infection in

the hospital.

Choice C: Percentage of board certified physicians within the

health plan's network.

Choice D: Number of hospital admissions for plan members

with certain medical conditions.

:A

Question 247

The Military Health System of the Department of Defense

offers ongoing healthcare coverage to military personnel and
their families through the

Choice A: Health Care Quality Improvement Program (HCQIP)

Choice B: Health Plan Management System (HPMS)

Choice C: TRICARE healthcare system

Choice D: Health Care Prepayment Plan (HCPP)

:C

Question 248

The Mirror Health Plan uses a form of computer/telephony

integration (CTI) to manage telephone calls coming into its
member services department. When a member calls the plan's
central telephone number, a device s the call with a
recorded message and

Choice A: a member outreach program

Choice B: a complaint resolution procedure (CRP)

Choice C: an automatic call distributor (ACD)

Choice D: an interactive voice response (IVR) system

:C

Question 249

The Mosaic health plan uses a typical electronic medical

record (EMR) to document the medical care its members
receive. One characteristic of Mosaic's EMR is that it:

Choice A: Does not provide any clinical decision support for

Mosaic's providers.

Choice B: Is designed to supply information at the site of care.

Choice C: Contains a Mosaic member's clinical data only.

Choice D: Is organized by the type of treatment or by provider.

:B

Question 250

The NAIC adopted the HMO Model Act in order to provide a

system of ongoing regulatory monitoring of HMOs. All of the
following statements are correct about the HMO Model Act
EXCEPT that it:

Choice A: Regulates HMO operations in two critical areas:

financial responsibility and healthcare delivery.

Choice B: Requires each HMO to send state regulators an

annual report describing the HMO's finances and operations.

Choice C: Focuses on three key aspects of healthcare delivery:

network adequacy, quality assurance, and grievance
procedures.

Choice D: Requires state insurance departments to conduct

annual examinations of an HMO's operations, quality
assurance programs, and provider networks.

:D

Question 251

The NAIC designed a small group model law to enable small

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

Choice A: $80

Choice B: $120

Choice C: $160

Choice D: $240

:C

Question 252

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 hi

Choice A: $60

Choice B: $80

Choice C: $120

Choice D: $160

:B
Question 253

The National Association of Insurance Commissioners' (NAIC's)

Unfair Claims Settlement Practices Act specifies standards for
the investigation and handling of claims. The Act defines
unfair claims practices and notes that such practices are
improper if th

Choice A: Both A and B

Choice B: A only

Choice C: B only

Choice D: Neither A nor B

:A

Question 254

The National Committee for Quality Assurance (NCQA) is a

nonprofit organization that accredits health plans and other
healthcare organizations. Under the current NCQA
accreditation program, a health plan's accreditation score is
determined, in part, by pe

Choice A: is a performance-measurement tool designed to

help healthcare purchasers and consumers compare quality
offered by different plans.

Choice B: divides performance measures into 8 domains, and

organizes reporting measures under these domains.

Choice C: is updated annually and measures are changed or

new measures added.

Choice D: all of the above

:D

Question 255

The nature of the claims function within health plans varies by

type of plan and by the compensation arrangement that the
plan has made with its providers. For example, it is generally
correct to say that, in a

A. Preferred provider organization (PPO), th

Choice A: Both A and B

Choice B: A only

Choice C: B only

Choice D: Neither A nor B

:A

Question 256

The Neptune Hospital provides medical care to paying

patients, as well as to people who either have no healthcare
coverage and cannot afford to pay for the care by themselves
or who receive services at reduced rates because they are
covered under governme

Choice A: cost shifting

Choice B: Antiselection

Choice C: receivership

Choice D: Underwriting

:A

Question 257

The Oriole MCO uses a typical diagnosis-related groups (DRGs)

payment method to reimburse the Isle Hospital for its
treatment of Oriole members. Under the DRG payment
method, whenever an Oriole member is hospitalized at Isle,
Oriole pays Isle

Choice A: an amount based on the weighted value of each

medical procedure or service that Isle provides, and the
weighted value is determined by the appropriate current
procedural terminology (CPT) code for the procedure or
service

Choice B: a fixed rate based on average expected use of

hospital resources in a given geographical area for that DRG

Choice C: a retrospective reimbursement based on the actual

costs of the Oriole member's hospitalization

Choice D: a specific negotiated amount for each day the

Oriole member is hospitalized

:B

Question 258

The owners of an MCO typically delegate authority for

governing the operation of the MCO by electing the MCO's

Choice A: quality management committee

Choice B: medical director

Choice C: board of directors

Choice D: chief executive officer

:C

Question 259

The paragraph below contains two pairs of terms enclosed in

parentheses. Determine which term in each pair correctly
completes the paragraph. Then select the choice
containing the two terms you have selected.

The Harbor Health Plan convened a litig

Choice A: a standing / ongoing

Choice B: a standing / specific

Choice C: an ad hoc / ongoing

Choice D: an ad hoc / specific

:D

Question 260

The participating physicians remain independent practitioners

who operate out of their own offices and can treat other
patients in addition to Kayak plan members. Kayak can
correctly be characterized as

Choice A: a closed-panel HMO

Choice B: an open-panel HMO

Choice C: a direct contract model HMO

Choice D: a dual choice HMO

:B

Question 261

The parties to the contractual relationship that provides

Castle's group health coverage to Knoll employees are

Choice A: Castle and Knoll only

Choice B: Knoll and all covered Knoll employees only

Choice C: Castle, Knoll, and all covered Knoll employees

Choice D: Castle and all covered Knoll employees only

:A

Question 262

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

Choice A: Polestar's relationship to Polaris: partnership

Type of board member: operations director

Choice B: Polestar's relationship to Polaris: partnership

Type of board member:outside director

Choice C: Polestar's relationship to Polaris: holding company

Type of board member: operations director

Choice D: Polestar's relationship to Polaris: holding company

Type of board member:outside director

:D

Question 263

The process of calculating the appropriate premium to charge

purchasers, given the degree of risk represented by the
individual or group, the expected costs to deliver medical
services, and the expected marketability and competitiveness
of the health plan

Choice A: financing

Choice B: rating

Choice C: underwriting

Choice D: budgeting

:B

Question 264

The process that Mr. Sybex used to identify and classify the
risk represented by the Koster Group so that Intuitive can
charge premiums that are adequate to cover its expected
costs is known as

Choice A: coinsurance

Choice B: plan funding

Choice C: underwriting

Choice D: pooling

:C

Question 265

The provision of mental health and chemical dependency

services is collectively known as behavioral healthcare. The
following statements are about behavioral healthcare. Select
the choice containing the correct statement.

Choice A: In most preferred provider organizations (PPOs) and

open access plans, plan members must receive a referral
before accessing behavioral healthcare services from a
specialist.

Choice B: To manage the delivery of behavioral healthcare

services, managed behavioral health organizations (MBHOs)
typically use alternative treatment levels and alternative
treatment methods rather than crisis intervention or
alternative treatment settings.

Choice C: Managed behavioral health organizations (MBHOs)

typically are prohibited from negotiating with network
providers for reduced fees in exchange for increased patient
volume.

Choice D: The treatment approaches for behavioral

healthcare most often include drug therapy, psychotherapy,
and counseling.

:B

Question 266

The provision of mental health and chemical dependency

services is collectively known as behavioral healthcare. The
following statements are about behavioral healthcare. Three of
these statements are true and one statement is false. Select
the choi
Choice A: Factors that have increased the demand for
behavioral healthcare services include increased stress on
individuals and families and the increasing availability of
behavioral healthcare services.

Choice B: To manage the delivery of behavioral healthcare

services, managed behavioral health organizations (MBHOs)
use only two basic strategies: alternative treatment levels and
crisis intervention.

Choice C: The treatment approaches for behavioral healthcare

most often include drug therapy, psychotherapy, and
counseling.

Choice D: The development of alternative treatment options,

incorporation of community-based resources into the
healthcare system, and increased reliance on case
management have shifted the emphasis of managed
behavioral healthcare from meeting the service needs of

:B

Question 267

The Robust Health Plan sometimes uses prospective

experience rating to calculate the premiums for a group.
Under prospective experience rating, Robust most likely will:

Choice A: At the end of a rating period, the financial gains and

losses experienced by the group during that rating period and,
if the group's experience during the period is better than
expected, refund part of the group's premium in the form of an
experience rati

Choice B: Use Robust's average experience with all groups to

calculate this particular group's premium.

Choice C: Use the group's past experience to estimate the

group's expected experience for the next period.

Choice D: All of the above

:C
Question 268

The statements below describe technology used by two health

plans to respond to incoming telephone calls:

The Manor Health Plan uses an automated system that s

telephone calls with recorded or synthesized speech and
prompts the caller to respond t

Choice A: Manor's system is best described as an automated

call distributor (ACD).

Choice B: Both Manor's system and Squire's device are

applications of computer/telephone integration (CTI).

Choice C: Squire's device is best described as an interactive

voice response (IVR) system.

Choice D: All of these statements are correct.

:B

Question 269

The statements below describe technology used by two MCOs

to respond to incoming telephone calls:

The Morton MCO uses an automated system that s

telephone calls with recorded or synthesized speech and
prompts the caller to respond to a menu of opt

Choice A: Autumn's device is best described as an interactive

voice response (IVR) system.

Choice B: Both Morton's system and Autumn's device are

applications of computer/telephony integration (CTI).

Choice C: Morton's system is best described as an automatic

call distributor (ACD).

Choice D: Morton's system can be correctly characterized as

an expert system.

:B
Question 270

The Stateside Health Plan uses the following outcomes

measures to evaluate the quality of its diabetes disease
management program.

Measure A: Incidence of foot ulcers among long-term diabetes

patients

Measure B: Ability of long-term diabetes patients to m

Choice A: Measure A clinical status Measure B patient

perception

Choice B: Measure A clinical status Measure B functional

status

Choice C: Measure A functional status Measure B patient

perception

Choice D: Measure A functional status Measure B clinical

status

:B

Question 271

The Titanium Health Plan and a third-party administrator (TPA)

have entered into a TPA agreement with regard to the
administration of a particular health plan. This agreement
complies with all of the provisions of the NAIC TPA Model Law.
One of the TPA's

Choice A: Hold all funds it receives on behalf of Titanium in

trust.

Choice B: Assume full responsibility for ensuring that the

health plan is administered properly

Choice C: Obtain from the federal government a certificate of

authority designating the organization as a TPA.

Choice D: Assume full responsibility for determining the claim

payment procedures for the plan

:A

Question 272

The Venus Hospital provides medical care to paying patients,

as well as to people who either have no healthcare coverage
and cannot pay for the care by themselves or who receive
services at reduced rates because they are covered under
government sponsored

Choice A: antiselection

Choice B: cost shifting

Choice C: receivership

Choice D: underwriting

:B

Question 273

To achieve widespread use of electronic data interchange (EDI)

in the healthcare industry, all entities within the industry need
to agree on industry standards regarding the information
format and software to be used. Several organizations are
making cont

Choice A: Computer-based Patient Records Institute (CPRI)

Choice B: American National Standards Institute (ANSI)

Choice C: American Health Information Management

Association (AHIMA)

Choice D: American Medical Association (AMA)

:B

Question 274
To address the problems associated with multiple data
management systems, the Kayak Health Plan has begun to
use a data warehouse. One likely characteristic of Kayak's
data warehouse is that:

Choice A: It requires Kayak's individual databases to store

large amounts of data that are not needed for daily
operations.

Choice B: It contains data from internal sources only.

Choice C: It stores historical data rather than current data.

Choice D: The data in the warehouse are linked by a common

subject.

:D

Question 275

To determine fee reimbursements to be paid to physicians, the

Triangle Health Plan assigns a weighted value to each medical
procedure or service and multiplies the weighted value by a
money multiplier. Triangle and the providers negotiate the
value of the

Choice A: Diagnosis-related group (DRG) system

Choice B: Relative value scale (RVS)

Choice C: Partial capitation arrangement

Choice D: Capped fee system

:B

Question 276

To determine fee reimbursements to be paid to physicians, the

Triangle Health Plan assigns a weighted value to each medical
procedure or service and multiplies the weighted value by a
money multiplier. Triangle and the providers negotiate the
value of the
Choice A: diagnosis-related group (DRG) system

Choice B: relative value scale (RVS)

Choice C: partial capitation arrangement

Choice D: capped fee system

:B

Question 277

To set up and contribute to an HSA, an individual must:

Choice A: Be covered by a high-deductible health plan that

meets federal requirements.

Choice B: Not have other health insurance.

Choice C: Not be enrolled in Medicare.

Choice D: All of the above.

:D

Question 278

Traditional Medicare includes two parts: Medicare Part A and

Medicare Part B. With regard to the ways these parts differ
from each other, it is correct to say that Medicare Part A

Choice A: provides benefits for physicians' professional

services, whereas Medicare Part B provides basic
hospitalization insurance

Choice B: is financed through premiums paid by covered

persons and from the federal government's general tax
revenues, whereas Medicare Part B is funded primarily through
a payroll tax imposed on employers and workers

Choice C: provides 100% coverage for eligible medical

expenses, whereas Medicare Part B includes annual deductible
and coinsurance provisions

Choice D: is provided automatically to most eligible persons,

whereas Medicare Part B is a voluntary program

:D

Question 279

Two MCOs in a single service area divided purchasers into two

groups and agreed to each market their products to only one
purchaser group. This information indicates that these two
MCOs violated antitrust requirements because they engaged
in an activity k

Choice A: horizontal group boycott

Choice B: horizontal division of markets

Choice C: a tying arrangement

Choice D: price fixing

:B

Question 280

Types of alternative care centers include urgent care centers,

observation care units, and stepdown units. One difference
between the costs associated with alternative care centers is
that, compared to the cost of:

Choice A: Facilities, equipment, and staffing in hospital

emergency departments (EDs), the cost of facilities,
equipment, and staffing in observation care units is generally
lower

Choice B: Care delivered in urgent care centers, the cost of

care delivered in hospital emergency departments (EDs) is
generally lower.

Choice C: Care in step-down units, the cost of acute inpatient

care is generally lower.

Choice D: Primary care in a physician's office, the cost of care

delivered in urgent care centers is generally lower.
:A

Question 281

Using a code for a procedure or diagnosis that is more

complex than the actual procedure or diagnosis and that
results in igher reimbursement to the provider is called
______________.

Choice A: Coding error

Choice B: Overcharging

Choice C: Upcoding

Choice D: Unbundling

:C

Question 282

Utilization data can be transmitted to the health plan

manually, by telephone, or electronically. Compared to other
methods of data transmittal, manual transmittal is generally

Choice A: less cumbersome and labor intensive

Choice B: faster and more accurate

Choice C: more acceptable to physicians

Choice D: subject to greater scrutiny by regulatory bodies

:C

Question 283

Wellborne HMO provides health-related information to its plan

members through an Internet Web site. Laura Knight, a
Wellborne plan member, visited Wellborne's Web site to gather
uptodate information about the risks and benefits of various
treatment option
Choice A: shared decision making

Choice B: self-care

Choice C: preventive care

Choice D: triage

:A

Question 284

When determining physicians' fee reimbursements, the

Blossom Managed Healthcare Group assigns a weighted value
to each medical procedure or service and multiplies the
weighted value by a money multiplier, as shown below:

Weighted value for service Money

Choice A: discounted fee-for-service system

Choice B: global capitation arrangement

Choice C: withhold arrangement

Choice D: relative value scale (RVS)

:D

Question 285

When determining the premium rates it will charge a

particular group, the Blue Jay Health Plan used a rating
method known as community rating by class (CRC). Under this
rating method, Blue Jay

Choice A: was allowed to use no more than four rating classes

when determining how much to charge the group for health
coverage

Choice B: was required to make the average premium in each

class no more than 105% of the average premium for any
other class

Choice C: divided its members into rating classes based on

demographic factors, experience, or industry characteristics,
and then charged each member in a rating class the same
premium

Choice D: charged all employers or other group sponsors the

same dollar amount for a given level of medical benefits,
without adjustments for age, gender, industry, or experience

:C

Question 286

When determining the rates it will charge a small group, the

Eagle HMO, a federally qualified HMO, divides its members
into classes or groups based on demographic factors such as
geography, family composition, and age. Eagle then charges
all members of a

Choice A: Retrospective experienced rating.

Choice B: Adjusted community rating (ACR).

Choice C: Pure community rating.

Choice D: Standard community rating.

:B

Question 287

When the Knoll Company purchased group health coverage

from the Castle Health Maintenance Organization (HMO), the
agreement between the two parties specified that the plan
would be a typical fully funded plan. Because Knoll had been
covered under a previo

Choice A: Castle is responsible for paying for all incurred

covered benefits

Choice B: Knoll is solely responsible for guaranteeing claim

payments

Choice C: Knoll makes no premium payments to Castle

Choice D: Castle has no responsibilities for administering the
health plan

:A

Question 288

When the Knoll Company purchased group health coverage

from the Castle Health Maintenance Organization (HMO), the
agreement between the two parties specified that the plan
would be a typical fully funded plan. Because Knoll had been
covered under a previo

Choice A: 230

Choice B: 270

Choice C: 220

Choice D: 180

:C

Question 289

Which is an advantage of a for-profit health plan?

Choice A: Flexibility in raising capital

Choice B: Double taxation

Choice C: Exemption from paying federal income taxes.

Choice D: None of the above.

:A

Question 290

Which of the choices below contains the four tools used by

marketers that make up the 'promotion mix?'

Choice A: Advertising, personal selling, sales promotion, and

publicity.

Choice B: Advertising, price, sales promotion, and publicity.

Choice C: Admissions, personal selling, sales promotion, and

publicity.

Choice D: Advertising, personal selling, sales promotion, and

privacy.

:A

Question 291

Which of the following best describes an organization that is

owned by a hospital or group of investors and provides
management and administrative support services to individual
physicians or small group practices?

Choice A: Independent Practice Association (IPA).

Choice B: Group Practice Without Walls (GPWW)

Choice C: Management Services Organization (MSO).

Choice D: Consolidated Medical Group.

:C

Question 292

Which of the following is CORRECT?

Choice A: Electronic transmittal of authorization is subject to

the same regulatory requirements as other methods of
transmittal

Choice B: Telephone transmittal increases data entry errors.

Choice C: Medical review is conducted before administrative

review.

Choice D: Prospective review, concurent review and

retrospective review are types of utilization review
:D

Question 293

Which of the following is NOT a factor that is used by MCOs to

determine which services will undergo utilization review.

Choice A: Cost per procedure

Choice B: Concurrent review

Choice C: Cost of review

Choice D: Access requirements

:D

Question 294

Which of the following is NOT a preventive care initiative often

used by health plans?

Choice A: Screening for high blood pressure

Choice B: Maternity management programs

Choice C: Vaccines

Choice D: Physical therapy

:D

Question 295

Which of the following is NOT a reason for conducting

utilization reviews?

Choice A: Improve the quality and cost effectiveness of

patient care

Choice B: Reduce unnecessry practice variations

Choice C: Make appropriate authorization decisions

Choice D: Accommodate special equirements of inpatient care

Question 296

Which of the following is WRONG?

Choice A: Computer Based Patient Records Institute (CPRI)

deveoped the standards for digital imaging of xrays.

Choice B: HL7 developers focuses on interchange of Clinical

Health Data

Choice C: ANSI, a voluntary national standards organization,

creates a consensus based process by which fair and equitable
standards can be developed and serves as a legitmizer of
standards.

Choice D: American Health Information Management

Association focuses on EDI standards for exchange of clinical
data

Question 297

Which of the following is(are) CORRECT?

(A) Staff model HMOs can achieve maximum economies of

scale but are heavily capital intensive.

(B) Staff model HMOs are closed panel.

(C ) Staff model HMOs operate out of ambulatory care

facilities.

Choice A: A & B

Choice B: None of the listed options

Choice C: B & C

Choice D: All of the listed options

Question 298
Which of the following job descriptions best match the job of a
telephone triage staff member?

Choice A: Check patient vitals, write prescriptions, administer

drugs.

Choice B: Greet patients at the door, collect insurance

information, schedule appointments, collect payments.

Choice C: Determine urgency of the condition, notify

emergency department, schedule appointments, authorize
referrals, provide self-care information.

Choice D: None of the above.

Question 299

Which of the following people would be considered part of the

individual market segment?

Choice A: John is eligible for Medicare.

Choice B: Julie has coverage through an employer group.

Choice C: James works for an employer that does not offer

health coverage.

Choice D: Jenny is eligible for Medicaid.

Question 300

Which of the following statements about EPO & HMO models is

FALSE?

Choice A: In-network visit is allowed only on PCP's referral in

HMO model.

Choice B: Out-of-network visit is not allowed in HMO model.

Choice C: Out-of-network visit is not allowed in EPO model.

Choice D: In-network visit is allowed only on PCP's referral in

EPO model.
Question 301

Which of the following statements about Family and Medical

Leave Act (FMLA) is WRONG?

Choice A: Employers need to maintain the coverage of group

health insurance during this period

Choice B: Employees can take upto 12 weeks of unpaid leave

in a 36 month perio

Choice C: Protects people faced with birth/adoption or

seriously ill family members

Choice D: Employers that have > 50 employees need to

comply

Question 302

Which of the following statements about the Title VII of the

Civil Rights Act is WRONG?

Choice A: Employers with more than 15 employees engaged

in interstate commerce need to comply

Choice B: Pregnancy Discrimination Act (an amendment to

this act) requires health plans to provide coverage during
childbirth and related medical conditions on the same basis as
they provide coverage for other medical conditions

Choice C: Allows HMOs to set different policies for people from

different races, religions, sex or national origin to safeguard
their interests.

Choice D: Protects all employees

Question 303

Which of the following statements is FALSE?

Choice A: The license that HMOs get in each state is called

Certificate of Authority
Choice B: The HMO contracts directly with the individual
physicians who provide the medical services to the HMO
members in a variation of the IPA model called direct contract
model HMO.

Choice C: All medicare/mediclaim beneficiaries should comply

with utilization management requirements set forth by HCFA

Choice D: HMOs usually impose high coinsurance or

deductible requirements

Question 304

Which of the following statements is NOT a requirement for a

service to be deemed a 'medically necessary service?'

Choice A: Furnished in the least intensive type of medical care

setting required by the member's condition.

Choice B: Solely for the convenience of the member.

Choice C: In accordance with the standards of good medical

practice.

Choice D: Consisitent with the symptoms of the member's

condition.

Question 305

Which of the following statements is true?

Choice A: A declining economy can lead to lower healthcare

costs as a result of an older population with greater healthcare
needs.

Choice B: A larger patient population increases pressure on

the health plan to offer larger panels.

Choice C: Provider networks are not affected by the federal

and state laws that apply to health plans

Choice D: Network management standards established by

independent accrediting organizations have no influence on
health plan network design.