Question 1 Traditional HMOs and EPOs are similar in that both types of health plans pay benefits for

in-network services, but exclude benefits for out-of-network services. With respect to the types of laws that regulate these health plans, it is generally correct to say that, unlike the regulation of HMOs, EPOs are regulated by For 1 points Question 2 One characteristic of the accreditation process for health plans is that For 1 points Question 3 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. Retrospective review For 1 points Question 4 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 contributions to the development of EDI standards, but currently, the ONLY one that can create a standard which can be recognized as an official American standard is the For 1 points Question 5 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 services primarily to Quest plan members. The Pier HMO has contracted with three group practices of physicians and two specialty groups of physicians to provide healthcare services to Pier plan members. These physicians are not employees of Pier.

From the following answer choices, select the response that correctly indicates the types of HMO models illustrated by Quest and Pier. For 1 points Question 6 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 For 1 points Question 7 Jim Rowe is covered by a traditional indemnity health insurance plan that specifies a $500 deductible and includes a 20% coinsurance provision. When Mr. Rowe was hospitalized, he incurred $4,000 in medical expenses that were covered by his health plan. He incurred no other medical expenses during the calendar year. In this situation, the amount that the Mr. Rowe was obligated to pay was For 1 points Question 8 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 For 1 points Question 9 The Gable Health Plan 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 of the lower premium rates often available to large groups, is known as For 1 points Question 10 In order to set up and to contribute to a Health Savings Account (HSA), an individual must: For 1 points Question 11 The following statements are about the financing of an HMO's delivery of healthcare to its members. Select the answer choice containing the correct statement. For 1 points Question 12 The Helm Health Plan segmented the non-group market for its new healthcare product by using factors such as education level, gender, and household composition. The Amberly Health Plan segmented the non-group market for its products based on the approaches by which it sold its non-group products. From the following answer choices, select the response that correctly indicates the types of market segmentation used by Helm and Amberly. For 1 points Question 13 In response to the demand for assessing outcomes, accreditation organizations and other government and commercial organizations have developed performance measures. A performance measure is: A: a quantitative measure of the quality of care provided by a health plan or provider. B: used by consumers, payors, regulators, and others to compare the plan or provider to other plans or providers

For 1 points Question 14 The Madison Health Plan, a national health insurance plan, and a local hospital system that operates its own health plan network recently created a new and separate organization, the Pineapple Health Plan. Madison and the hospital system share ownership of Pineapple, as well as responsibility for Pineapple's operations. This transaction between Madison and the hospital system is an example of For 1 points Question 15 The statements below describe technology used by two health plans to respond to incoming telephone calls: The Morton Health Plan uses an automated system that answers telephone calls with recorded or synthesized speech and prompts the caller to respond to a menu of options by entering information through a touchtone keypad or by speaking into the phone. Each response takes the caller to the next appropriate menu until the caller receives the desired information from the system, hangs up, or selects the option to speak to a representative. The Autumn Health Plan uses a device that answers telephone calls with a recorded message and then routes calls to the appropriate department or unit at Autumn. If no representative in the appropriate unit is available, this device places the call in a queue to be answered when a representative becomes available. The following statements are about the technology used by Morton and Autumn. Select the answer choice containing the correct statement. For 1 points Question 16 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 For 1 points

Question 17 The data evaluation stage of UR typically consists of an administrative review and a medical review. It is correct to say that in a medical review For 1 points Question 18 One true statement about the Medicaid program in the United States is that For 1 points Question 19 Lunsford 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 Lunsford requires members to pay for in-network services is best defined as a For 1 points Question 20 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. For 1 points Question 21 The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander Health Plan with regard to the administration of a particular health plan product. This agreement complies with all of the provisions of the NAIC TPA Model Law. One of the Cleopatra Group's responsibilities under this agreement is to For 1 points

Question 22 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 her health plan. She incurred no other medical expenses during the calendar year. With regard to the $3,000 of medical expenses, the amount that the insurer was obligated to pay was For 1 points Question 23 The Clover Group is a for-profit health plan 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 indicates that Clover can correctly be characterized as a For 1 points Question 24 Which of the following job descriptions best match the job of a telephone triage staff member? For 1 points Question 25 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. This type of capitation arrangement is known as a For 1 points Question 26 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 has a one-year pre-existing condition provision. According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996,

the new health plan For 1 points Question 27 A ____________is 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. For 1 points Question 28 The Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) renamed the Medicare + Choice program to Medicare Advantage and expanding the existing private health plan product options available to Medicare beneficiaries. The MMA product options include: For 1 points Question 29 From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence For 1 points Question 30 As part of its maintenance and management of its provider network, the Crescent Health Plan has taken the following actions: Action 1: Crescent includes in each participating provider's contract a provision that requires the periodic evaluation of the provider's performance by other network providers who practice within the same medical specialty and within the same geographic area. Action 2: Because participating providers must operate within the parameters of Crescent's health plan products, Crescent provides training in its utilization review, authorization, and information management systems. From the following answer choices, select the response that correctly identifies these two aspects of Crescent's management of its provider network.

For 1 points Question 31 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 For 1 points Question 32 The Ketcham Health Plan offers a typical preferred provider organization (PPO benefit plan). This information indicates that, in administering this PPO benefit plan, Ketcham most likely For 1 points Question 33 For this question, select the answer 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 health plans nationwide. Performance measures for Quality Compass are drawn from _____A_____, and a health plan's submission of performance and accreditation information is _____B_____. For 1 points Question 34 One of the clinical services provided by pharmacy benefit management companies (PBMs) focuses on compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to expected patterns within select drug categories. The PBM then targets aberrant prescribers for educational intervention. This service provided by PBMs is, by definition, known as For 1 points

Question 35 The following statements are about the non-group market for health plan products in the United States. Select the answer choice containing the correct statement. For 1 points Question 36 In addition to the credentialing activities that a 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 performed during both credentialing and recredentialing. One activity that is performed ONLY during the credentialing process is the For 1 points Question 37 The Shipper Group is a provider network that combines multiple independent physician practices under one umbrella organization. Although member physicians in the Shipper Group own the organization, they maintain their practices independently at multiple locations. However, Shipper provides centralized business operations, including medical record keeping, billing, and appointment scheduling for its providers. This information indicates that the Shipper Group most likely is a type of physician-only integrated model known as: For 1 points Question 38 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 administrative data. B. Most providers organize their EMRs by type of treatment rather than around an individual plan member. For 1 points

Question 39 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, then the PBM will share in the cost overrun. On the other hand, if the cost per employee per month is less than the target, the PBM shares in the savings. This type of contractual arrangement is known as a For 1 points Question 40 When the Libra Health Plan wanted to improve its service quality, Libra's managers first identified a competitor with extremely high service quality. Libra's managers then analyzed the competitor's practices and implemented those practices in Libra's organization. This information indicates that Libra attempted to improve its service quality by using a practice known as For 1 points Question 41 Dan Santori is covered under his employer's group health plan, which must comply with the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. Mr. Santori is terminating his employment and will have no other health coverage after his termination. He has elected to continue his coverage under his employer's group health plan after his termination. According to COBRA requirements, Mr. Santori can continue his coverage For 1 points Question 42 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 For 1 points Question 43 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. The Beret HMO markets extensively to small groups. If the lowest monthly rate that Beret charges a small group is $90, then, according to this model law, the highest rate Beret can charge a small group, given the same set of medical benefits, is For 1 points Question 44 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 answer choice containing the two words that you have chosen. Many pharmacy benefit management (PBM) plans perform generic and therapeutic substitutions of prescribed drugs in certain situations. (Generic / Therapeutic) substitution is the dispensing of a different chemical entity within the same drug class, and this type of substitution (never / always) requires physician approval before it can be performed by the PBM plan. For 1 points Question 45 State A has laws patterned after the NAIC HMO Model Act. If the commissioner of insurance for State A puts an HMO under administrative supervision, then this action most likely For 1 points Question 46 What is an advantage of a for-profit health plan? For 1 points Question 47 Two health plans 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 health plans violated antitrust requirements because they engaged in an activity known as

For 1 points Question 48 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 For 1 points Question 49 Many health plans are now integrating disease management into their medical management programs. One typical characteristic of disease management is that it For 1 points Question 50 The administrative standards described under Title II of HIPAA include privacy standards to control the use and disclosure of health information. In general, these privacy statements prohibit: For 1 points Question 51 In claims administration terminology, a claims investigation is correctly defined as the process of For 1 points Question 52 Integration of provider organizations has certain disadvantages to providers and to other healthcare participants. Which of the following is one of those disadvantages? For 1 points

Question 53 Ed Murray 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. Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim for answers to the following questions: Question A Was the treatment provided medically appropriate and/or medically necessary? Question B Was a preauthorization or referral required for the service or treatment? Question C Does the member have other healthcare coverage? Question D Was the provider a participant in the plan's network of providers? With respect to the claims decision process, prior to approving a claim, Mr. Murray should obtain satisfactory answers to questions For 1 points Question 54 Dr. Milton Ware, a physician in the Riverside Health Plan'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 nobalance billing provision. One purpose of this provision is to For 1 points Question 55 The Oriole Health Plan 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 For 1 points Question 56 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 For 1 points

Question 57 The owners of a health plan typically delegate authority for governing the operation of the health plan by electing the health plan's For 1 points Question 58 The set of benefits a health plan designs and packages for sale to the employer in the form of an HMO plan represents which of these elements in the marketing mix? For 1 points Question 59 Identify which of the following types of consumer-directed health plans (CDHPs) allow individuals the ability to both roll over unspent funds from year to year as well as offer portability of the funds, allowing individuals to take funds with them when they retire or change jobs: For 1 points Question 60 The following statements are about the National Association of Insurance Commissioners (NAIC) HMO Model Act. Three of these statements are true and one statement is false. Select the answer choice containing the FALSE statement. For 1 points Question 61 Bart Vereen is insured by both a PPO, which is his primary plan, and an HMO. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of benefits provision. Mr. Vereen incurred $800 of medical expenses from a specialist and assigned benefits to the specialist, who filed claims with both plans. The PPO paid a total benefit amount of $420 and notified the HMO of this payment. If the HMO had been Mr. Vereen's primary plan, it would have paid a benefit amount of $550. According to these plans' COB provisions, the total amount that the HMO owed on these medical expenses was

For 1 points Question 62 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 financially responsible for paying plan expenses, including claims made by group plan members. With regard to this situation, it is correct to say that For 1 points Question 63 State laws define the specific requirements that an HMO must satisfy. According to the laws of most states, an HMO typically must For 1 points Question 64 In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of anti-selection. Anti-selection can correctly be defined as the For 1 points Question 65 One way that health plans 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 health plan may use the amount retained to offset or pay for any cost overruns for referral or hospital services, and any remaining funds may then be distributed to the providers. Health plans that use this risk-sharing method are said to be using For 1 points Question 66 Which of the choices below contains the four tools used by marketers that make up the 'promotion mix?'

For 1 points Question 67 The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the CORRECT response: For 1 points Question 68 If the Heptagon Group is a typical employment-model integrated delivery system (IDS), then Heptagon most likely For 1 points Question 69 The following statements are about accreditation in health plans. Select the answer choice that contains the correct statement For 1 points Question 70 The group market includes groups that enter into contracts with health plans in order to provide healthcare coverage for the individual members of the group. State insurance laws define the types of groups eligible for group insurance coverage. In most states, eligible groups include employer-employee groups, For 1 points Question 71 As part of its utilization management (UM) system, the Poplar Health Plan 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 a chronic medical condition. Craig Albrecht, age 50, is recovering from third-degree burns and has

incurred over $200,000 in medical expenses to treat his condition. Leslie Cromartie, age 30, has terminal pancreatic cancer. If Poplar uses criteria similar to those used by most health plans in identifying medical conditions which are appropriate for case management, then Poplar most likely will conclude that case management could be appropriate for the medical conditions presented by For 1 points Question 72 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 that, unlike traditional group healthcare, a workers' compensation program For 1 points Question 73 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 move around and perform household tasks without assistance. From the answer choices below, select the response that correctly identifies the type of healthcare outcome addressed by each measure. For 1 points Question 74 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 traditionally separate components of the financial services industry. B. The GLB Act requires all financial institutions to notify customers of any sharing of non-public personal information with nonaffiliated third parties. For 1 points

Question 75 The following programs are part of the Alcove Health Plan'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 correct to say that Alcove's For 1 points