NEW QUESTION 1

Which of the following statements about Family and Medical Leave Act (FMLA) is WRONG?

• A. Employers need to maintain the coverage of group health insurance during this period
• B. Employees can take upto 12 weeks of unpaid leave in a 36 month period
• C. Protects people faced with birth/adoption or seriously ill family members
• D. Employers that have > 50 employees need to comply

Answer: B

NEW QUESTION 2

What are the characteristics that the underwriter has to consider while determining the premium rate for health insurance coverage for a group?

• A. Level of benefits
• B. Geographic location
• C. Group size
• D. All the above

Answer: D

NEW QUESTION 3

One way in which health plans differ from traditional indemnity plans is that health plans typically

• A. provide less extensive benefits than those provided under traditional indemnity plans
• B. place a greater emphasis on preventive care than do traditional indemnity plans
• 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
• 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

Answer: B

NEW QUESTION 4

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

• A. providers who care for Medicaid recipients must accept Medicaid payment as payment in full for services rendered
• B. Medicaid requires recipients to pay deductibles, copayments, and coinsurance amounts for all services
• C. Medicaid is always the primary payer of benefits
• D. benefits offered by Medicaid programs are federally mandated and do not vary by state

Answer: A

NEW QUESTION 5

Which of the following statements is true?

• A. A declining economy can lead to lower healthcare costs as a result of an older population with greater healthcare needs.
• B. A larger patient population increases pressure on the health plan to offer larger panels.
• C. Provider networks are not affected by the federal and state laws that apply to health plans
• D. Network management standards established by independent accrediting organizations have no influence on health plan network design.

Answer: B

NEW QUESTION 6

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

• A. Receive compensation based on the volume and variety of medical services they perform for Hill plan members, whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services.
• B. 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.
• 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.
• D. Receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem charges.

Answer: C

NEW QUESTION 7

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 8

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

• A. 18 months, but his coverage under COBRA will cease if he obtains group health coverage through another employer.
• B. 18 months, even if he obtains group health coverage through another employer.
• C. 36 months, but his coverage under COBRA will cease if he obtains group health coverage through another employer.
• D. 36 months, even if he obtains group health coverage through another employer.

Answer: A

NEW QUESTION 9

Health plans use the following to determine the number of providers to add to a network:

• A. Staffing ratios
• B. Drive time
• C. Geographic availability
• D. All of the above

Answer: D

NEW QUESTION 10

Graff Scott is a member of the ABC Health Plan. Whenever she needs non-emergency medical care, sees Dr. Michael Chan, an internist. Ms. Scott cannot self-refer to a specialist, so she saw Dr. Michael Chan when she experienced headaches. Dr. Michael Chan referred her to Dr. Bruce Lee, a neurologist, who had hospitalized at the Polo Hospital for tests. ABC has contracts with Dr. Michael Chan, Dr. Lee, and Polo to provide medical services to its members. The following statements are about Polo's organized system of healthcare. Select the answer choice containing the correct statement

• A. Within Polo's system, M
• B. Scott received primary care from both D
• C. Michael Chan and D
• D. Lee
• E. Polo's system allows its members open access to all of Ultra's participating providers
• F. Polo's network of providers includes D
• G. Michael Chan and D
• H. Lee but not Polo Hospital
• I. Within Polo's system, D
• J. Michael Chan serves as a coordinator of care or gatekeeper for the medical services that M
• K. Scott receives

Answer: D

NEW QUESTION 11

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

• A. D
• B. High serves as the coordinator of care for the medical services that M
• C. Canton receives.
• D. Omega's network of providers includes D
• E. High, but not D
• F. Miller.
• G. Omega's system allows its members open access to all of Omega's participating providers.
• H. Omega used a financing arrangement known as a relative value scale (RVS) to compensate D
• I. Miller.

Answer: A

NEW QUESTION 12

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

• A. Consolidated medical group
• B. Integrated Delivery System
• C. Medical Foundation
• D. Both B & C

Answer: A

NEW QUESTION 13

System classifies hundreds of hospital services based on a number of criteria, such as primary and secondary diagnosis, surgical procedures, age, gender, and the presence of complications.

• A. Carve-out
• B. DRG
• C. Global capitation
• D. Partial capitation

Answer: B

NEW QUESTION 14

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

• A. channel segmentation
• B. geographic segmentation
• C. demographic segmentation
• D. product segmentation

Answer: C

NEW QUESTION 15

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

• A. A HDHPs have a higher deductible than other traditional insurance products such as HMOs & PPOs.
• B. HDHPs generally cost more than traditional heathcare coverage.
• C. Some HDHPs cover preventive care on a first-dollar coverage basis.
• D. All of the above

Answer: A

NEW QUESTION 16

One true statement regarding ethics and laws is that the values of a community are reflected in

• A. both ethics and laws, and both ethics and laws are enforceable in the court system
• B. both ethics and laws, but only laws are enforceable in the court system
• C. ethics only, but only laws are enforceable in the court system
• D. laws only, but both ethics and laws are enforceable in the court system

Answer: B

NEW QUESTION 17

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

• A. Requires self-funded employee benefit plans to pay premium taxes at the state level.
• 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.
• C. Contains strict reporting and disclosure requirements for all employee benefit plans except health plans.
• D. Requires that state insurance laws apply to all employee benefit plans except insured plans.

Answer: B

NEW QUESTION 18

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 19

Who will be covered by TRICARE PRIME by applying for enrollment

• A. Active duty military personnel
• B. Active duty Dependents
• C. Retires
• D. B and C

Answer: D

NEW QUESTION 20

Health savings accounts were created by which of the following laws:

• A. COBRA
• B. HIPAA
• C. Medicare Modernization Act
• D. None of the Above

Answer: C

NEW QUESTION 21

The following statements are about issues associated with marketing healthcare plans to
small groups and large groups. Select the answer choice that contains the correct statement.

• 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.
• 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.
• C. health plans typically treat an employer purchasing coalition as a small group for marketing purposes.
• D. Large groups rarely use self-funding to finance their healthcare plans.

Answer: B

NEW QUESTION 22

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

• A. emphasized compensating physicians based solely on the volume of medical services they provide
• B. exempted HMOs from all state licensure requirements
• C. established a process under which HMOs could elect to be federally qualified
• D. required federally qualified HMOs to relate premium levels to the health status of the individual enrollee or employer group

Answer: C

NEW QUESTION 23

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 answer choice containing the correct statement.

• A. Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.
• 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.
• 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.
• D. The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) me

Answer: B

NEW QUESTION 24

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

• A. Claims
• B. Bond
• C. ASO
• D. None of the above

Answer: C

NEW QUESTION 25

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

• A. 67
• B. 274
• C. 365
• D. 1,000

Answer: B

NEW QUESTION 26
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