NEW QUESTION 1

The feature that formed the foundation of Health Maintenance Act of 1973

• A. Federal Qualification Requirements
• B. Exemption from state laws
• C. All of the above

Answer: C

NEW QUESTION 2

The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.

• A. True
• B. False

Answer: B

NEW QUESTION 3

In order to cover some of the gap between FFS Medicare coverage and the actual cost of services, beneficiaries often rely on Medicare supplements. Which of the following statements about Medicare supplements is correct?

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

Answer: A

NEW QUESTION 4

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 answer 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
• B. healthcare services.
• C. To manage the delivery of behavioral healthcare services, managed behavioral health organizations (MBHOs) use only two basic strategies: alternative treatment levels and crisis intervention.
• D. The treatment approaches for behavioral healthcare most often include drug therapy, psychotherapy, and counseling.
• E. 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

Answer: B

NEW QUESTION 5

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

• A. Life Style of the people
• B. Concentration of physicians in highly populated areas.
• C. Advancement in information technology

Answer: B

NEW QUESTION 6

Which of the following is NOT a factor that is used by MCOs to determine which services will undergo utilization review?

• A. Cost per procedure
• B. Concurrent review
• C. Cost of review
• D. Access requirements

Answer: D

NEW QUESTION 7

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

• A. inability of a proposed insured to share with the insurer the financial risks of healthcare coverage
• 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
• C. inability of a proposed insured to provide sufficient evidence that proves he or she is an insurable risk
• 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

Answer: D

NEW QUESTION 8

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

• 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
• B. patients from requesting that restrictions be placed on the accessibility and use of protected health information
• C. transmission of individually identifiable health information for purposes other than treatment, payment, or healthcare operations without the individual's written authorization
• D. patients from accessing their medical records and requesting the amendment of incorrect or incomplete information

Answer: D

NEW QUESTION 9

More procedures or services may be fully covered within the PPO network than those out of network.

• A. True
• B. False

Answer: A

NEW QUESTION 10

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

• 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.
• B. Health plans are never allowed to medically underwrite individual market customers who are under age 65.
• 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.
• 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.

Answer: A

NEW QUESTION 11

One typical characteristic of an integrated delivery system (IDS) is that an IDS.

• A. Is more highly integrated structurally than it is operationally.
• B. Provides a full range of healthcare services, including physician services, hospital services, and ancillary services.
• C. Cannot negotiate directly with health plans, plan sponsors, or other healthcare purchasers.
• D. Performs a single business function, such as negotiating with health plans on behalf of all of the member providers.

Answer: B

NEW QUESTION 12

Maternity management programs are commonly included in?

• A. Screening Programs
• B. Health promotion Programs
• C. Immunization programs

Answer: C

NEW QUESTION 13

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 provide

• A. A and C only
• B. A, B, and C
• C. B and C only
• D. A and B only

Answer: A

NEW QUESTION 14

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

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

Answer: A

NEW QUESTION 15

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

• 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
• B. a fixed rate based on average expected use of hospital resources in a given geographical area for that DRG
• C. a retrospective reimbursement based on the actual costs of the Oriole member's hospitalization
• D. a specific negotiated amount for each day the Oriole member is hospitalized

Answer: B

NEW QUESTION 16

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

• A. $525
• B. $1,050
• C. $2,100
• D. $5,250

Answer: B

NEW QUESTION 17

Historically most HMOs have been

• A. Closed-access HMO
• B. Closed-panel HMO
• C. Open-access HMO
• D. Open-panel HMO

Answer: B

NEW QUESTION 18

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:

• A. State that D
• B. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges.
• C. 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.
• D. Give D
• E. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network.
• F. Specify that Badger can terminate this provider contract without providing a reason, but only if Badger gives D
• G. Aldridge at least 90-days' notice of its intent to terminate the contract.

Answer: C

NEW QUESTION 19

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

• A. A contract management system
• B. A credentialing system
• C. A legacy system
• D. An interoperable communication system

Answer: A

NEW QUESTION 20

Keith Murray is a 45 year old chartered accountant & is employed in Livingstone consultancy firm. He has been paying payroll taxes for the past 15 years. Which of the following statements is true regarding Medicare Part A entitlement?

• A. Keith shall be entitled to Part A benefits when he attains 65 years of age
• B. Keith’s wife shall be entitled to Part A benefits when she attains 65 years of age
• C. Keith’s wife shall be required to pay a monthly premium in order to receive Medicare Part A benefits
• D. Both a & b

Answer: D

NEW QUESTION 21

The scandent Health Group contracted with the Empire Corporation to provide behavioral healthcare services to.
Empire employees. As a condition of providing behavioral healthcare services, scandent required Empire to contract with scandent for basic medical services scandent's actions
constituted the type of antitrust violation known as a

• A. Horizontal group boycott
• B. Price-fixing agreement
• C. Horizontal division of markets
• D. Tying arrangement

Answer: D

NEW QUESTION 22

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

• A. CCC, AAA, BBB
• B. BBB, CCC, AAA
• C. BBB, AAA, CCC
• D. CCC, BBB, AAA

Answer: A

NEW QUESTION 23

According to the IRS, which of the following is not an allowable preventive care service?

• A. Smoking cessation programs.
• B. Periodic health examinations.
• C. Health club memberships.
• D. Immunizations for children and adults.

Answer: C

NEW QUESTION 24

From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence

• A. Health plans and their providers are obligated not to harm their members
• 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
• C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members
• 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

Answer: B

NEW QUESTION 25

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

• A. Under the terms of the Health Plan Network Adequacy Model Act, all health plans would be required to hold covered persons harmless against provider collections and provide continued coverage for uncompleted treatment in the event of plan insolvency
• B. The Health Carrier Grievance Procedure Model Act requires all health carriers to maintain a first-level grievance review, but it does not require any second-level review
• C. According to the Health Care Professional Credentialing Verification Model Act, a health plan must select all providers who meet the plan's credentialing criteria
• D. The Quality Assessment and Improvement Model Act exempts closed plans from
• E. implementing a quality improvement program.

Answer: A

NEW QUESTION 26

Several marketplace factors helped fuel the movement toward consumer choice. Which one of the following statements is NOT accurate with regard to these factors?

• A. After a period of relative stability, annual growth in private health spending per capita began to increase rapidly in 2002.
• B. During the height of the recent cost upswing, insurance premiums were increasing by more than 13% annually.
• C. Increased utilization was the largest factor contributing to the rise in premiums, accounting for 43% of the increase.
• D. Employer payers began seeking ways to control spiraling utilization rates and provide lower cost health coverage options.

Answer: A

NEW QUESTION 27

Integration of provider organizations is said to occur when

• A. Previously separate providers combine & come under common ownership or control.
• B. Two or more providers combine their business operations that they previously carried out separately.
• C. Both A & B
• D. None of the above

Answer: C

NEW QUESTION 28
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