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Question 1:
______________ HMOs can\’t medically underwrite any group ?incl small groups.
A. State
B. Not-for-profit
C. For-profit
D. Federally qualified
Correct Answer: B
Question 2:
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
A. coordinating care across a variety of benefits
B. emphasizing preventive care by covering many preventive services either in full or with a small copayment
C. offering its members access to wellness programs
D. All of the above
Correct Answer: D
Question 3:
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
A. Notify customers of any sharing of non-public personal financial information with nonaffiliated third parties.
B. Prohibit customers from having the opportunity to \’opt-out\’ of sharing non-public personal financial information.
C. Disclose to affiliates, but not to third parties, their privacy policies regarding the sharing of nonpublic personal financial information.
D. Agree not to disclose personally identifiable financial information or personally identifiable health information.
Correct Answer: A
Question 4:
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
A. are exempt from review by the Internal Revenue Service (IRS)
B. are organized as stock companies for greater flexibility in raising capital
C. rely on income from operations for the large cash outlays needed to fund long-term projects and expansion
D. engage in lobbying or political activities in order to maintain their tax-exempt status
Correct Answer: C
Question 5:
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
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
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
C. prevent Dr. Ware from seeking compensation from patients if Riverside fails to compensate him because of the MCO\’s insolvency
D. prevent Dr. Ware from billing a Riverside member for medical services that are not included in Riverside\’s plan
Correct Answer: B
Question 6:
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
A. random change
B. structural change
C. haphazard change
D. reactive change
Correct Answer: D
Question 7:
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
D. If these settings are ranked in order of the cost of providing c
A. A, B, C
B. A, C, B
C. B, C, A
D. C, A, B
Correct Answer: B
Question 8:
Historically most HMOs have been
A. Closed-access HMO
B. Closed-panel HMO
C. Open-access HMO
D. Open-panel HMO
Correct Answer: B
Question 9:
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 example
A. Encounter reports
B. Diagnostic codes
C. Durational ratings
D. Edits
Correct Answer: D
Question 10:
Amendments to the HMO act 1973 do not permit federally qualified HMO\’s to use
A. Retrospective experience rating
B. Adjusted community rating
C. Community rating by class
D. Community rating
Correct Answer: A
Question 11:
Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included
A. increased stress on individuals and families
B. increased availability of behavioral healthcare services
C. greater awareness and acceptance of behavioral healthcare issues
D. all of the above
Correct Answer: D
Question 12:
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 plan\’s network of providers. In 1998, Ms. Martin became ill while she was on vacation,
A. $300
B. $510
C. $600
D. $810
Correct Answer: D
Question 13:
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
Correct Answer: D
Question 14:
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
A. verification of a network provider\’s medical education and residency
B. performance of site inspections in a provider\’s facilities
C. review of information from a provider\’s quality improvement activities
D. verification of a provider\’s licensure and certification
Correct Answer: A
Question 15:
During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a group\’s geographic location, the size and gender mix of the group, and the level of participation in the grou
A. Healthcare costs are typically higher in rural areas than in large urban areas.
B. The morbidity rate for males is higher than the morbidity rate for females.
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.
D. All of the above
Correct Answer: C
