Evolution of Health Plans and Managed Care Models

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Chap
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Question
A health plan can best be defined as an organization that

The earliest versions of health plans appeared in
Which is not an early form of health plan?
Which is a provision of the HMO Act of 1973?
For an HMO, which was not an advantage of federal qualification?
The HMO Act of 1973
In the 1990s HMOs
Janine can go to any doctor she chooses, but if she goes to one not
in her plans network, she has to pay a larger share of the cost.
Janine is covered by
Jacob must pay $2,000 in healthcare expenses each year before he

receives benefits from his health plan, but he can use money from a
tax-advantaged savings account. Jacob has
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What are the roles of the state and federal governments in regulating
health plans?
Have government health coverage programs been a significant factor
in the evolution of health plans?
Which is not a cause of higher healthcare spending?
Under the fee-for-service approach, healthcare providers have a
financial incentive to provide
Which is not typical of managed care?
Which will probably have the lowest premium?
In relation to health plans, over the years the definition of quality
Which is not an accrediting organization?
Why is it useful in studying health plans to learn about indemnity
insurance?
Andy is covered by his employers group health insurance policy. Who
is the policyholder of this policy?
Who pays the premiums of an employer-sponsored group policy?
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What happens in adverse selection?

Which employee group is most likely to have a higher-than-average
loss rate?
Which employee group presents a high risk of adverse selection?
In traditional indemnity health insurance, insureds
In traditional indemnity health insurance, how are providers
compensated?
Owen pays 20 percent of the cost of healthcare services covered by
his policy. This describes
Which is not common in traditional indemnity health insurance?
Coordination of benefits is designed to
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Increasing cost-sharing
Cost containment helps hold down health insurance premiums
primarily by
Coverage of preventive care is
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In this course health plan is defined as any entity that
What is the trend in health plan products?

Members do not have to select how to receive services until they use
them. This describes a
A health savings account is combined with a high-deductible health
plan. This describes a
Which of these health plan types uses managed care techniques and
concepts the most?
What goals do all health plans share?
Organizations that finance or reimburse the cost of healthcare
services are known as
How are the roles of the key players in health plans evolving?
Compared to indemnity insurance. health plan benefit packages are
typically
Mandated benefits are imposed
Carla pays a flat $10 fee to her doctor for an office visit, regardless of
the cost of the services she receives. This is
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Jacob pays 20 percent of the cost of a hospital stay. This is

Dan pays the first $ 1,000 of his healthcare expenses each year. after
which his health plan begins paying benefits. This is
In creating a provider network, health plans generally seek to ensure
member access by
Primary care physicians are typically involved in
If a health plan has a network. members
Compared to indemnity insurance. health plans generally require
______ out-of pocket expense by members.
Managing the use of healthcare services so that patients receive
necessary, appropriate, and high-quality care in a cost-effective way
is
Which does not focus on individuals with special needs or certain
medical conditions?
Which is a quality management technique?
In traditional indemnity health insurance, the main

provider compensation method is
Under fee-for-service, providers have incentives to
Under fee-for-service, who bears financial risk?
Under capitation. provider compensation is based on
Teresa, a doctor, is paid by a health plan by capitation.
One month she delivers very few services to plan
members, the next month she delivers about the
projected amount, and the third month she delivers
well over the projected amount. Teresa is paid
Capitated physicians have incentives
Which statement about capitation is true?
Currently, capitation accounts for what portion of
physician compensation?
Under a fee schedule, a provider receives
Under a fee schedule or discounted fee-for-service, if a
providers normal fee is more than the amount allowed
by the heafth plan
A health plan assigns a certain value to a service and
muftiplies this value by a negotiated dollar figure to
yield the payment amount. This describes
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A member is hospitalized, her case is classified based

on several factors, and the hospital is paid an amount
based on that classification. This describes
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A hospital is paid a set amount for each day a plan

member is in the hospital. This is
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A group of providers is paid a single amount for all the

care related to a surgery, both in the hospital and for
three months afterward. This is
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A plan holds back a percentage of PCPs monthly

capitation payments. At the end of the year, some of
this money is paid to the PCPs, but some is used to pay
for higher- than-projected referrals. This is an example
of
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A plan pays money into a pool to cover hospitalization.

At the end of the year, if there is money left over in the
pool, some is given to PCPs, but if there is not enough
money, PCPs must cover some of the cost. This is an
example of
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If a doctor meets certain performance targets related

to quality of care and patient satisfaction, she receives
a bonus. This is an example of
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Which compensation arrangement involves the most

risk for providers?
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Which compensation arrangement involves the least

risk for a hospital?
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1 An HMO
2 The HMO Act of 1973
3 HMOs are
4 Which is not a key characteristic of an HMO?
Which is an employer most likely to consider in

5 selecting an HMO?
6 A person enrolls in an HMO
7 HMOs were traditionally marketed to
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8 HMOs provide
Compared to other heafth plan types, in HMOs member

9 cost-sharing tends to be
10 HMOs typically provide
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11 An HMO provides medical care to its members by

12 The delivery of healthcare is primarily
In building and maintaining an HMO network, the

13 location of a healthcare provider is primarily a factor in
To see a specialist, must an HMO member obtain a

14 referral from her PCP?
15 Do HMOs cover out-of-network services?
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5
16 How are HMOs usually paid for providing healthcare?

17 Which are most common in HMOs?
Which is not a common HMO compensation

18 arrangement for physicians?
A physician is compensated by an HMO by capitation,

but once her total costs have reached a certain level,
additional costs are reimbursed by discounted FFS. This
19 describes a
Which utilization management technique is used

20 primarily for physicians?
In the area of quality management. HMOs are subject

21 to
1 Which statement best describes an open-panel HMO?
2 Which is true about a closed-panel HMO?
3 In an open-access HMO, members
4 Which is true about closed-access HMOs?
An HMO pays a doctor for his services based on a fee

5 schedule. This is an example of
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An HMO pays a doctor a certain amount per member

per month to provide care needed by HMO members.
6 This describes
In which compensation method do physicians assume

7 risk?
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8 A mixed model HMO is one that

9 The current trend is toward
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10 In an IPA model HMO, physicians are usually
In which HMO model does each doctor manage her own

11 office?
12 How are IPA physicians most commonly compensated?
13 Which is a disadvantage of the IPA model HMO?
14 In a staff model HMO, physicians are normally
In which HMO model do doctors normally work in a

15 central facility owned and operated by the HMO?
How do staff model HMOs normally compensate

16 physicians?
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17 Which is not an advantage of a staff model HMO?

18 The HMO contracts with a single group practice. This des
19 In a group model HMO, physicians are
20 What is the most common compensation system in a g
21 An HMO contracts with six group practices. This is an ex
22 The trend in network model HMOs is toward
23 The most common HMO model today is the
24 Which HMO model normally has a closed panel?
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PPOs, EPOs, and POS products are
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PPO members receive

Which statement is true about a PPO?
What portion of U.S. employees is covered by PPOs?
A majority of PPOs are owned by
Which statement is true about PPOs?
PPOs most commonly compensate physicians by means of
Providers contracting with PPOs
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About what percentage of US. Adults experience some sort of

behavioral health disorder during any year?
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Douglas is in a substance abuse program. He spends most of his

time in a facility but goes out during the day to attend school. What
level of behavioral healthcare is this?
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EPOs are generally like PPOs except that

A POS product offers
How is a POS product like an HMO?
How many employees are covered by POS products?
ABC health plan has no provider network and reimburses providers
on a fee-for service basis, but it conducts precertification and
utilization review. ABC can best be described as a
Historically, managed care plans
Which is not generally considered a specialty healthcare service?
A health plan transfers to another organization some (but not all) of
the activities involved in delivering and managing behavioral
healthcare. This is a
In a mature health plan market, compensation for a comprehensive
carve-out is typically by
State laws
Managed dental care accounts for what portion of all dental
coverage?
Managed dental care is
Plan members must, with a few exceptions, see a network dentist.
This describes
HMOs usually compensate dentists by means of
Which is typical of a dental HMO?
PPOs commonly compensate dentists by means of
Which are typical of a dental PPO?
Andre does not have to choose a dentist or network during an annual
open enrollment-he can decide when he needs care. He has
Which dental plan type typically has the smallest network?
Which dental plan type typically costs the least?
Lilly receives 10 hours of therapy a week at a psychologists office,

but she is not confined to a facility. What level of behavioral
healthcare is this?
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Which is least common in health plans today?
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Do pharmacy benefits management (PBM) plans concern

themselves with quality of care?
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A PBM notifies a doctor that he is prescribing a certain drug much

more frequently than his peers and educates him on its use and
alternatives to it. This is an example of
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Repeated late refills indicate that Phil is not taking his low blood
pressure medication as often as he should. This is an example of
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Patrices plan covers any drug her doctor prescribes, but she pays a
higher copayment for drugs not on the plans formulary. This is
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A PBM requires physicians to obtain certification of medical necessity

before prescribing a drug. This is
A pharmaceutical card is not generally used in
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Which sentence best summarizes the requirements of federal mental

health parity legislation for medium and large health plans?
Which statement is true about federal mental health parity laws?
How many health plans use pharmacy benefits management (PBM)
plans?
A PBM provides all pharmacy services to an employee group in

exchange for a fixed dollar amount per employee per month. This is
What are the recent trends in healthcare spending?
Beginning in the late 1990s there was a shift
The consumer choice philosophy is based on giving consumers
What are the two main components of a consumer-directed health

plan?
Which is the oldest type of personal healthcare account?
Who can contribute to an FSA?
Which is not a feature of FSAs that has limited their popularity?
Who can contribute to an HRA
Which is a feature of an HRA?
Which account offers annual rollover, full portability, and tax-free
investment growth?
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To be eligible for an HSA, a person must be covered by

According to studies, switching to a CDHP brings cost-savings
According to studies, the cost-savings of CDHPs come mostly from
What is the trend in CDHP enrollment?
Which is not an element of consumer-directed health plans?
Most CDHPs are based on
Compared to traditional health coverage, the premiums of highdeductible health plans are generally
An FSA
How popular are FSAs?
Which statement is true about FSAs?
Which statement is true about HRAs?
What portion of workers is covered by an HRA?
An HSA offers
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To be eligible for an HSA, a person must be covered by
A qualified HDHP must have
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Which may a qualified HDHP exclude from an annual deductible?
Who can contribute to an HSA?
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An HSA accountholder cannot use account funds tax-free to pay for

Which premiums cannot be paid tax-free with HSA funds?
Can a person use HSA funds to pay non-medical expenses?
Can a person 65 or older use HSA funds to pay non-medical
expenses?
What is the impact of healthcare reform on CDHPs?

Which provision of healthcare reform may stimulate growth in
CDHPs?
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Two independent organizations are joined into one entity under

common ownership and control. This is an example of
An example of partial structural integration is
A number of physicians join together and combine their billing and
collections operations. This is an example of
Which physician-hospital model is the least integrated?
For a physician, what is a disadvantage of provider integration?
For purchasers and consumers, what is not a potential advantage of
provider integ ration?
Which physician-only model is the least integrated?
What does an IPA generally do for its member physicians?
What is the structure of most IPAs?
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If an IPA spends more than $80,000 a year providing care to a single

individual, an insurance company covers any amount over $80,000.
This is called
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What is the main difference between a group practice without walls

(GPWW) and an independent practice association (IPA)?
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The main purpose of a management services organization (MSO) is

to
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How does a physician practice management (PPM) company differ

from a regular MSO?
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What is the primary purpose of a physician-hospital

organization (PHO)?
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When a physician-hospital organization (PHO) is

formed, physician practices
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A hospital allows any of its admitting physicians to join

its PHO. This is an example of
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An integrated delivery system (IDS) may or may not be

highly integrated
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Which physician-only model is the most integrated?
What is the purpose of a medical foundation?
For a health plan, the main advantage of contracting

with an at-risk provider organization is that the plan
does not have to
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If a provider organization assumes insurance risk, is it

regulated as an insurance company or HMO?
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A healthcare delivery model based on each patient

having a personal physician who is responsible for
providing or coordinating her care on a ongoing basis is
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The Affordable Care Act seeks to
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What distinguishes a corporation from other

organizations?
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Company A exists for the purpose of owning other

companies, and it owns company B among others.
Company A is
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Which statement is true about a for-profit heafth plan

compared to a not-for-profit plan?
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Which statement is true about tax exemption of not-forprofit health plans?

Who owns a mutual insurance company?
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A health plans day-to-day operations are typically the

responsibility of
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Which position is likely to increase in importance in the

coming years?
Who is responsible for advertising?
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Which position is typically found in health plans but not

in corporations in other industries?
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Who is responsible for preventing misconduct in a

health plan?
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A permanent committee to advise a health plan on

compensation is an example of a
Which is not true about a patient-centered medical

home (PCMH)?
What statement is true about mutual and stock

insurance companies?
Most health plans are
The ultimate source of authority in a heafth plan is
Which statement about a health plans board of
directors is true?
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Which committees primary responsibility is reviewing

cases of poor quality healthcare?
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Which committee administers a health plans drug

formulary?
A heafth plan determines that it will not cover an
experimental therapy requested by Sharon. If Sharon
appeals this decision, which committee will likely
review the case?
Market maturity refers tthe
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Where is it most difficult tdevelop a comprehensive

network?
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Health plans that offer more than one type of plan

typically have
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In market analysis, what is considered in regard

tproviders?
Which are generally most receptive thealth plans?
Network adequacy refers twhether

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Which type of law might require a health plan tinclude

a particular doctor in its network?
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Open panel or closed panel refers twhether a

health plans
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Devin is a neurologist who mostly provides outpatient

care in his office. He is likely to be categorized by a
network as a
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Which plan types need fewer providers per 1,000

members?
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A health plan is developing a network, and it is

believed that the most important consideration of
potential members is accessibility. The plan will likely
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What is the purpose of credentialing?
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In credentialing, dhealth plans verify information

submitted by providers?
The information that a health plan can obtain from the
National Practitioner Data Bank (NPDB) about a
provider primarily relates to
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A provider agrees taccept a health plans compensation

as payment in full and not talsbill plan members. What
contract provision does this describe?
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A party that breaches a contract is given a certain

amount of time tremedy the problem and avoid
termination of the contract. What contract provision
does this describe?
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Can a health plan terminate its contract with a provider

when there has been nproblem with the providers
performance?
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A provider already in a health plans network is

evaluated by another provider in the same specialty.
This describes
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Medical management can be divided into three broad

categories, which are
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Managing the use of medical services sthat plan

members receive necessary and appropriate care in a
cost-effective manner is
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A health plan conducts a health risk assessment (HRA)

tdetermine a persons likelihood of developing certain
illnesses. The purpose is to
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A health plan program seeks tdetermine if a member

has a health condition even if he has nsymptoms. This
is
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A program supports health plan members whwant tstop

smoking, lose weigh, eat better, and exercise more.
This is a
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A program teaches health plan members how ttreat

minor illnesses and distinguish them from serious
conditions. This is a
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Colleen can access data about different drugs and

healthcare providers on her health plans website. This
is an example of
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Telephone triage programs are typically staffed by
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Clarks doctor gives him information about the

treatment options available thim, and Clark makes the
final decision. This is an example of
While Gloria is being treated for an illness, her health
plan conducts an evaluation of whether the services
she is receiving are necessary, appropriate, and costeffective. This is an example of
Wilson is assigned a healthcare professional

whassesses his needs, designs a plan of care, and
coordinates and monitors the services he receives. This
describes
Case management is used for
Case managers are most commonly
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Which statement is true about disease management

programs?
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A doctor treating a patient with diabetes refers

tguidelines for this condition in making decisions about
the most appropriate course of action. This describes
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If both prospective and retrospective review are

possible, which is generally preferable?
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Precertification (prior authorization) is most commonly

used for
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The average number of days a patient with certain

characteristics stays in a hospital. This describes
Which type of UM program focuses on populations

instead of individuals?
Disease management focuses on
Jill, a pediatrician, is considering prescribing a certain

drug for Eric. She asks herself, Is there research that
indicates that if Eric takes this drug he will likely get
better quickerthan if he did not? Jill is
Laurie has diabetes. She wants tstay well and is willing
tchange her lifestyle, but sometimes she doesnt follow
instructions about diet because she doesnt
understand. The problem here is
Utilization review
Utilization review focuses primarily on whether a
healthcare service is
The purpose of utilization review is to

UR staff decide what treatments
UR programs use clinical practice guidelines to
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Which form of UR is most likely tdiscover billing errors

and fraud?
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In order To receive a larger payment, a doctor

improperly and deliberately bills two procedures
separately instead of together. This is
Subjecting all healthcare services to UR is
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When are experience-based criteria usually used?

Testing needed before an inpatient treatment should be
performed
For which is concurrent review not commonly used?
Prior authorization is a feature of
Retrospective review most commonly
For which type of care is a health plan member most

likely need a referral or authorization?
Which service is least likely To require authorization?
Emergency department use
Is emergency department care subject to utilization
review?
Do health plans cover urgent care centers?
Bill has chest pains and is awaiting test results. He
doesnt need any treatment at this time, but he needs
to be monitored. What is probably the best care setting
for him?
Jack has had surgery. He doesnt need full hospital care
anymore, but he does need 24-hour nursing care under
the supervision of a doctor. What is probably the best
care setting for him?
Health plans generally pay for home health care for
Do health plans pay for hospice care?

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Which UR data transmittal method has the most

problems with accuracy?
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Which UR data transmittal method is the fastest and

least labor-intensive?
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Which UR data transmittal method is the most

regulated?
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In the UR process, administrative review focuses on

whether a proposed service is
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In the UR process, administrative review is performed

by
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Whcan deny an authorization based on medical

necessity and appropriateness?
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May UR staff recommend a different treatment for a

member?
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Which statement is not true?
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The wrong medication is prescribed for a patient,

causing an adverse event. This is an error of
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Which problem is being addressed by national

databases?
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A health plans network has a certain number of

primary care physicians. This is
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The percentage of health plan members whhave

received a medical checkup in the past twyears is
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The two main components of quality management are

The twmain categories of health plan quality are
Carol has a question about her health coverage, but
she tries all day and is unable treach her health plan by
phone. This is an issue of
Medical errors
Consumer perceptions of healthcare quality
Five years after treatment, 80 percent of cancer

patients are still alive. This is
The trend in quality measures is toward greater use of
What is the relationship of structure, processes, and
outcomes?
The average claim processing time is a
The main disadvantage of structure measures is that
A certain percentage of patients are able treturn twork
twyears after a stroke. This is a
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Which is not a disadvantage of outcomes measures?

Which generally presents the most problems?
Which statement about quality improvement is true?

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A hospital identifies another hospital with high cancer

survival rates and adopts its practices. This is
A health plan analyzes data from different
gynecologists and notices that one of them performs a
certain procedure much more often than the rest. This
is
A panel of pediatricians evaluates the appropriateness
and timeliness of the care provided by another
pediatrician in a particular case. This is an example of
Which is most likely tbe controversial among providers?
Which statement is not true about health plans
internal standards?
NCQA accredits
Nationally, NCQA accreditation covers
The NCQA accreditation process
What form does NCQA accreditation take?
URAC accredits
The URAC accreditation process
HEDIS is designed primarily tbe used by purchasers
and consumers tcompare
Quality Compass is
The Agency for Healthcare Research and Quality
(AHRQ) is
The Affordable Care Act
What will the Affordable Care Act dwith regard

tMedicare Advantage plans?
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Theterm marketing mix refersto
A health plans potential customers include

Which is a market research technique?
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How is marketing in health plans different from

marketing in many other industries?
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Will the Affordable Care Act (ACA) affect product

development?
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Developing multiple product lines helps a health plan

compete among
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What is the difference between advertising and

publicity?
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345
18
346
18
10
347
348
18
18
11
12
349
18
13
Whcommonly works with individuals rather than

groups?
350
18
14
Which direct marketing method is commonly used

today?
351
18
15
Dividing a market into smaller groups of customers is

called
352
18
16
Medicare beneficiaries are generally considered part of

the
353
18
17
A health plan decides tcompete in the small group

market instead of the large group market by offering a
basic and inexpensive product. This is an example of
354
18
18
355
18
19
Which is not a common distribution channel in the

individual market?
356
18
20
The Affordable Care Act (ACA) will affect the marketing

of all health plans, but it will have the greatest impact
on the
357
18
21
358
18
22
The term promotion mix is commonly used trefer to

Which distribution channel is made up of health plan
employees?
Whare generally compensated by the buyer of a health
plan, not by the seller?
Whare considered trepresent the health plan?
Whsells the products of only one company?
Whis not a member of the regular group market?
Which is not true under the ACA?

Which is not a common distribution method in the
senior market?
359
18
23
People eligible for Medicare
The group market is made up mostly of
360
18
24
361
18
25
362
18
26
363
18
27
364
19
365
19
Which statement best describes adverse selection

(antiselection)?
366
19
367
368
19
19
4
5
In health underwriting, what are the most important

risk factors for individuals?
Which will be prohibited by PPACA?
Which will be prohibited by PPACA?
369
19
370
19
371
19
372
19
373
19
10
A health plan sets premiums for classes of members

based on age, family composition, and geography, but
not experience. This is an example of
374
19
11
A health plan sets premiums for a group based on the

plans average experience with all groups rather than
that particular group. This describes
375
19
12
376
19
13
377
19
14
378
19
15
379
19
16
Small businesses choosing a health plan usually focus

strongly on
Which is true of small employers?
Which is true of large employers?
Underwriting involves
In renewal underwriting of a group, what are the

twmain factors?
In rating, what are the main considerations?
Setting premiums based on the expected costs of
providing benefits tthe community as a whole rather
than tany subgroup is called
Community rating is least likely tbe used for
A health plan uses a groups past experience testimate

its expected experience, and if actual experience is
different, the plan absorbs the gains or losses. This
describes
Which will PPACA dregarding rating as of 2014?
An MCOs income statement
The major categories of an MCOs balance sheet are
State insurance regulators are primarily concerned with
an H MOs
380
19
17
381
19
18
382
19
19
383
19
20
A variance is the difference between

An insurance company is financially responsible for
paying healthcare benefits tthe employees of High
Plateau Company. High Plateaus health plan is
Big River Corporation takes responsibility for paying
healthcare benefits tits employees, but if total claims
rise above $10 million in a year, an insurer pays any
claims above this level. This is an example of
A third-party administrator generally

An information management system incorporates
membership data and provider reimbursement
arrangements and analyzes transactions according
tcontract rules. This describes a
384
20
385
20
A health plan has an automated system tfacilitate the

processing of requests for authorization of payment.
What kind of information management system is this?
386
20
An information management system identifies

physicians whtend tprovide fewer services than the
norm in certain situations. This is an example of
387
20
388
20
A health plans members can gthe plans website

tcheck on the status of their claims. What kind of
information management system is this?
389
20
Which statement about the quality of health plan data

is not true?
390
20
391
20
392
20
The use of an MRI machine is expensive, sa health plan

needs tefficiently coordinate utilization by providers.
What type of information management system
addresses this need?
The data used by health plans is

Which aspect of information management in health
plans is most strongly addressed by government
regulation?
In health plans, information management is
Which term encompasses all types of electronic

business functions?
393
20
10
394
20
11
395
20
12
A security device designed tblock unauthorized access

ta private network is
396
20
13
397
20
14
A computer network is accessible only the employees

of a health plan. This is an
The main threat ta health plans network is
398
20
15
How does electronic data interchange (EDI) differ from

e-business?
399
20
16
Which generally results in more accurate data, manual

processes or EDI?
400
20
17
The focus of business intelligence and decision support

systems is to
401
20
18
The main problem that a data warehouse is designed

taddress is
402
20
19
403
20
20
Medical information for an individual designed tbe used

at the site of care is
404
20
21
The main advantage of health information networks

(HINs) and health information exchange (HIE) isthat
providerstreating a patient
405
20
22
406
407
20
20
23
24
408
20
25
409
20
26
410
21
In traditional indemnity health insurance, which is most

common?
411
21
when is an encounter report submitted instead of a

claim?
412
21
health plan claims processing is similar tthat of

traditional insurance for
413
21
About what portion of a typical health plans claims are

processed electronically?
Which statement best describes health plans and the

Internet?
The main disadvantage of data warehouses is
How does an HIE (such as a RHIO) differ from an HIN?

Which is owned by the individual?
Personal health records are available from
How does the electronic medical record differ from the
personal health record?
An example of an insourcing-outsourcing hybrid is
414
21
Which statement is true about electronic claims

processing?
415
21
A health plan employee whdeals with claims that have

been paid incorrectly is a claims
416
21
417
21
418
21
419
21
10
420
21
11
421
21
12
422
21
13
A claims examiners responsibilities generally include

Under which type of provider compensation
arrangement is the most claims information needed?
Which standardized claim form is used by physicians?
What is the standard code set for diagnoses?
A claim triggers an edit. Usually, the claim will be
In which situation is it not uncommon for a health plan
tmake a partial payment on a claim?
Which statement is true about claims processing?

423
21
14
424
21
15
425
21
16
426
22
427
22
428
22
Which means of distributing information thealth plan

members is declining?
429
22
Jeff calls his health plans toll-free number and is able,

by following prompts and without talking ta person,
tchange his PCP. This is an example of
430
22
In health plan member services, when are paper

documents sent by mail?
431
22
Which statement about health plan communication

with members is true?
432
22
Why must a health plan adequately deal with

complaints?
433
22
Coordination of benefits may apply when

Most claim investigations
The primary focus of the NAIC Unfair Claims Settlement
Practices Act is
Health plans member education focuses on
Health plans member education is directed to
A health plans complaint resolution procedures (CRPs)
434
22
Who generally conducts a health plans level twappeal

of a member complaint?
435
22
10
What happens if a health plan member does not win a

level twappeal?
436
22
11
What are the twmain ways of measuring member

satisfaction with a health plan?
437
22
12
What populations dhealth plan member satisfaction

surveys target?
438
22
13
Who conducts member satisfaction surveys
439
22
14
440
22
15
Which is likely tdecrease the number of employees

needed for adequate member services staffing?
441
22
16
Which statement about member service

representatives is true?
442
22
17
Which statement about member services technology is

not true?
443
22
18
The amount of time required tcomplete a transaction

requested by a member is
444
22
19
Which is a measure of both quality and costeffectiveness?
445
22
20
Which is considered a measure of cost-effectiveness

rather than quality?
446
23
447
23
448
23
449
23
Which statement about the structure of health plan

member services is true?
The medical laboratories in a community get together

and decide how much they will all charge health plans
for various tests. This is probably a case of
A physician group refuses to provide certain specialty
services to a heafth plan unless the plan agrees to
contract with the group for all the services the group
offers. This may be a case of
Which is an important provision of the Financial
Services Modernization Act?
ERISA applies to
450
23
Under ERISA, what are the roles of the federal and

state governments in regulating employer-sponsored
health plans?
451
23
Under ERISA, an individual challenging a coverage

decision by an employer-sponsored health plan
452
23
If an employee is laid off, under COBRA she has the

right to continue her employer-sponsored health
coverage
453
23
Bill is covered under his wife Lones employersponsored health plan. What rights does Bill have
under COBRA to continue this coverage?
454
23
455
23
10
Noah has been laid off and is continuing his employer

health coverage under COBRA. Who pays?
What is the impact of the HMO Act of 1973?

456
23
11
Under ADEA, an employer sponsoring health coverage
457
23
12
458
23
13
459
23
14
460
23
15
Under HIPAA, guaranteed individual issue of health

insurance generally applies to persons who
461
23
16
Which is not a provision of HIPAA for group health

plans?
462
23
17
463
23
18
464
24
Under FMLA, an employee who is ill or needs to care for

a family member has the right to l2 weeksof
Which is not one of the main goals of HIPAA?
HIPAA applies to
HIPAAs administrative simplification standards apply to
Which is not true under HIPAA privacy and security

standards?
Which of these is a component of healthcare reform?
465
24
When will the new healthcare financing system become

operational?
466
24
With some exceptions, individuals whdnot have health

coverage will
467
24
468
24
Large employers are
Small employers are

469
24
470
24
471
24
472
25
473
25
State financial standards for HMOs are intended

primarily to
474
25
If a health plan risks becoming insolvent, what can an

insurance commissioner do?
475
25
The primary goal of receivership of a health plan is to
476
25
State regulators review the description of an H MOs

service area and the list of network providers. The
regulators are concerned with
477
25
478
25
479
25
States generally regulate

Which plan type is often not governed by a states
regular insurance code?
Have states enacted laws tregulate PPOs
480
25
An HMwith a point-of-service (P05) option
481
25
10
Which statement best describes states regulation of

utilization review organizations?
482
25
11
Which statement best describes states regulation of

third-party administrators?
483
25
12
Which is not required by NAICs Heafth Care

Professional Credentialing Verification Model Act?
Tax credits will be available thelp people pay for

Under the new requirements for health insurance
plans, which of these will be permitted?
Under the new requirements for health insurance
plans, which cannot be considered in setting
premiums?
At which level of government is most heafth plan
regulation?
484
25
13
485
26
486
26
487
26
488
26
489
26
490
26
491
26
492
26
493
26
494
26
10
495
26
11
496
26
12
497
26
13
498
26
14
499
26
15
500
26
16
501
26
17
502
26
18
503
26
19
504
26
20
Which statement is true about the NAICs Privacy of

Consumer Financial and Health Information Model
Regulation?
Original Medicare consists of
The main purpose of Medicare Part C (Medicare
Advantage) is
Medicare Part D prescription drug coverage is
Medicare Part A beneficiaries whgintthe hospital
Medicare Part A skilled nursing facility and home heafth
care benefits are paid
Medicare Part A is available tpersons 65 and older,
For a disabled person tqualify for Medicare, her
disability
Medicare Part A is funded primarily by
Does Medicare Part B cover services provided by
dentists, podiatrists, optometrists, and chiropractors?
Medicare Part B charges
For Medicare Part B
For Medicare Part B
How does Medicare enrollment work?
Tim decides not tenroll in Medicare Part B when he first
becomes eligible, even though he has nemployersponsored health coverage. Can he enroll later?
Medicare Advantage is
Medicare Advantage (MA) plans provide
Medicare Part D prescription drug coverage is offered
by
Which statement is correct about MA plans?
Medicare Part D prescription drug coverage is provided
Medicare Part D prescription drug plans (PDPs)
505
26
21
Which statement is correct?
In a typical Medicare Part D PDP, after the PDP and the
beneficiary have together paid a certain total amount
for drugs, the beneficiary pays
506
26
22
507
26
23
Clarice decides not tenroll in Medicare Part D when she

first becomes eligible, even though she has nemployersponsored drug coverage. Can she enroll later?
508
26
24
509
26
25
What is the recent trend in Medicare heatth plan

enrollment?
Managed care was introduced intMedicare by
510
26
26
What is the main aspect of Medicare managed care

that the MMA of 2003 changed?
511
26
27
What is the main impact of heafthcare reform on

Medicare Advantage?
512
26
28
513
26
29
514
26
30
515
26
31
516
27
517
27
A Medigap policy is available tthose enrolled in

Which of these is covered by some Medigap policies?
Medigap policies
Can an insurer deny Medigap coverage tan eligible
Medicare beneficiary or charge him a higher-thanstandard premium?
Medicaid eligibility and coverage
Currently, Medicaid is available

518
27
3
Under PPACA, Medicaid will be available
519
27
If a healthcare service is covered by both Medicare and

Medicaid, whpays?
520
27
The primary purpose of CHIP is tprovide health

coverage tchildren who
521
27
Alex, Logan, Kaitlyn and are all 14-years-old. Whmay

be eligible for CHIP?
522
27
States have the option of offering CHIP coverage

tpregnant women,
523
27
Under CHIP
Over the years the importance of managed care in

Medicaid has
524
27
525
27
10
Currently, what portion of Medicaid recipients are in

managed care?
526
27
11
Which is currently a rule governing Medicaid managed

care?
527
27
12
Which is not a challenge generally faced by health

plans serving the Medicaid population?
528
27
13
529
27
14
530
27
15
531
27
16
532
27
17
533
27
18
534
27
19
535
27
20
536
27
21
537
27
22
538
27
23
539
27
24
What portion of CHIP enrollees are in managed care?

States can offer premium assistance instead of health
coverage to
Under FEHB, health coverage is provided by
FEHB health plans include
FEHB health plans
TRICARE serves
TRICARE coverage takes the form of
Whpays a premium for TRICARE?
What is workers compensation?

Workers compensation pays benefits tcover
Which is a feature of workers compensation?
An employee is eligible for workers compensation

benefits
Option1
Integrates the delivery and financing of healthcare and seeks to
manage healthcare costs, access, and quality.
1954
Preferred provider Organization.
All employers had to sponsor an HMO for their employees.
The HMO might be eligible f federal loans and grants to expand its
service area.
was a failure in promoting the growth of HMOs.
were popular because they held down costs, but people objected to
the lack of provider choice.
a traditional health maintenance organization.
a point-of-service plan.
The states regulate health insurance, and the federal government
plays only a minor role.
No, because these programs do not cover very many people.

A younger population because of immigration.
more services.
Fee-for-service compensation.
A preferred provider organization.
has become broader.
NCQA
Most health coverage today is indemnity insurance.
Andy.
Employees may pay allot part, but they do so through the employer.
People who need healthcare enroll in greater numbers than average

people.
A group made up mostly of women.
Company B has a very large employee group.
must go to a network provider.
Fee-for-service.
coinsurance.
Coinsurance.
prevent a person from having more than one health insurance policy.
helps hold down healthcare expenditures through insured incentives.
reducing payments to healthcare providers.
cost-effective in the long run and so has been adopted by insurers.

uses certain concepts or techniques to manage the cost, access, and
quality of healthcare.
More types are being offered, and the distinctions between them are
becoming more pronounced.
consumer directed health plan (CDHP).
point-of-service (POS) product.
Health maintenance organization (HMO).
Quality and accessibility.
providers.
Roles are becoming clearer and mutually exclusive.
more extensive and encourage the use of preventive care.
both by states and the federal government and apply to all form of
health insurance.
a copayment.
coinsurance.
coinsurance.
considering number, type, and location of providers.
prevention, treatment of routine conditions, and care coordination.
either. depending on the plan design.
less
utilization management.
Case management.
Credentialing.
fee-for-service.
provide unnecessary care.
The insurer.
the number of services performed.
less than the standard amount for the first month and
more for the third month.
to provide more services.
It cannot be used if members are allowed to receive
non-network care.
About half.
his normal fee minus a percentage discount.
she can bill the member for the balance.
Discounted FF5.
per diem payments.

episode-based payments.
an episode-based payment.
pay for performance.
a withhold.
a risk pool.
Fee schedules.
Fee-for-service.
assumes or shares both financial and delivery risks.
was instrumental in the initial growth of HMOs.
subject only to state, not federal regulation.
The importance of primary care providers.
Access.
most commonly through an employer, but sometimes
individually.
small groups, but they now serve large groups as well.
comprehensive medical benefits but not special

services such as dental and vision care, mental health
care, and prescription drugs.
low.
only limited preventive care and charge significant
cost-sharing for it.
employing providers.
local.
access.
Always.
Traditionally they did not, but almost all HMOs now do
at no extra cost.
Based on the amount of services delivered.
Copayments.
DRGs.
stop.loss provision.
Discharge reviews.
no significant regulation.
Any physician who meets the HMOs standards has a

right to join its network.
Physicians are employees of the HMO or members of a
contracted group.
need a referral from their PCPs to see specialists.
Nearly all HMOs have closed access.
discounted fee-for-service.
capitation.
Fee-for-service.
combines features of different HMO models.
mixed model HMOs.
contracted with the HMO.
staff model.
Capitation for PCPs and discounted fee-for-service or
RBRVS for specialists.
Members have a limited choice of physicians.
employees of a group practice contracted with the
HMO.
Network model.
Capitation.
Low facility costs.
an IPA model HMO.
employees (or employee/owners) of the group practice.
The HMO compensates the group practice by capitation, a
network model HMO.
a mix of capitation and discounted fee-for-service.
staff model.
Staff model.
At the tightly managed end of the managed care continuum.

Lower benefits for non-network care.
Providers must participate in utilization review and quality
management.
A majority.
Employers.
PPOs generally assume risk.
Discounted fees.
Do not assume risk.
a referral from a PCP is needed to go out of the network

The same coverage of non-network care as network care.
PCPs coordinate referrals to specialists.
A small but stable minority.
Point-of-service plan.
Focused on supplemental coverage (dental, behavioral, and drugs).
Hospital care.
Comprehensive carve-out arrangement.

discounted fee-for-service,
Do not usually address carve-outs.
A majority.
Remaining stable.
An HMO.
Discounted fee-for-service.
An annual maximum benefit.
Capitation.
Annual deductible and annual maximum benefit, but no copayments
or coinsurance.
An HMO.
PPO
POS plan.
25 percent.
Intensive outpatient care
Outpatient care.
Members must get a referral from their primary care provider to

access behavioral healthcare.
It requires all plans to provide some behavioral healthcare coverage,
but not necessarily equivalent to medical coverage.
Cost-sharing for behavioral healthcare cannot be greater than for
medical care.
About half.
No, this is the responsibility of the health plan.
Drug utilization review.
Formulary management.
A copayment formulary.

Electronic processing of claims.
Capitation.
Annual increases were high in the 1980s, lower in the mid-1990s,
then high again since then.
To less restrictive forms of managed care in response to consumer
demand.
More decision-making power and more responsibility for costs.
A high-deductible health plan and a tax-advantaged personal

healthcare account.
The HRA, introduced in the 1980s.
Only employers may contribute.
A lack of portability.
Self-employed individuals only.
Tax-free employee contributions.
HRA.
Any high deductible health plan.

Initially but probably not in the long run.
Consumers making cost-effective healthcare choices.
Rapid growth, expected to continue.
Higher premiums for coverage.
a health maintenance organization (HMO).
about the same.

may be coupled with an employer health plan or may be stand-alone.
Only a minority of workers have access to them, but a large majority
of those participate.
If an employee leaves an employer, he recerves the balance of his
FSA.
Accounts belong to the employee and are fully portable.
About a third.
annual rollover, tax-free investment growth of account funds, and
limited portability.
any employer-sponsored health plan or a qualified individual HDHP.
a deductible of at least a certain amount and total out of-pocket
expenses no greater than a certain level.
In-network care.
An employer or an employee.
his HDHP premium.
Medicare Advantage.
Yes, she may, but she must pay income tax and a tax penalty.
Yes, she may; she must pay income tax but not a tax penalty.
Probably modest-some rules will change, and HDHPs may be
affected, depending on how regulations are written.
Medical loss ration requirement.
operational integration.
a joint venture.
complete structural integration.

The medical foundation.
A loss of professional autonomy.
Lower costs resulting from greater effkiency
The consolidated medical group.
Contracts with health plans and handles administrative functions.
Physicians are employees of the IPA, and the IPA contracts with the
health plan.
a limited liability PA.

A GPWW handles business operations for members, but an IPA does
not.
integrate clinical services provided by physicians.
It purchases physicians buildings and equipment and leases them
back to them.
The consolidated medical group.
Integrating business functions.

are replaced by one centralized PHO medical center.
a closed PHO.
operationally.
To go a step beyond an integrated delivery system by

fully integrating clinical functions.
develop a provider network.
No.
a patient-centered medical home (PCMH).

promote accountable care organizations (ACOs) and
patient-centered medical homes (PCMHs).
The personal physician coordinates a patients care not
only in her office but in other settings such as hospitals.
It issues stock.
a holding company and a subsidiary of Company B.

It pays less in taxes.
Tax exempt plans pay premium taxes but not income
tax.
Its stockholders.
Most insurers are stock companies.
mutual companies.
the CEO.
The board appoints the CEO.
key senior managers reporting to the CEO.
Chief financial officer.
Chief marketing officer.
Chief information officer.
Chief medical officer.
standing committee.
Appeals review committee.

Utilization management committee.
Medical advisory committee.

degree of urbanization of a market.
Provider number, types, locations, utilization, costs,
referral patterns, and relationships.
Medium-size employers.
Very large metropolitan areas.
either separate networks or nested networks.
the number, types, and locations of providers are

adequate tmeet member needs.
Any willing provider.
members can see non-network providers.
specialist.
Highly managed and small plans.
focus on provider selection criteria.

Selecting the most qualified providers, meeting
accreditation standards, and minimizing legal risks.
They generally do, before offering them a contract.
malpractice, licensure, and adverse actions.
Nbalance billing provision.
Hold harmless provision.

Yes, provided it can show that it has good economic
reasons for doing so.
peer review.
care management, case management, and quality
management.
help her reduce her risk and thereby improve outcomes
and reduce cost.
a screening program.
wellness program.
screening program.
value-based healthcare.
nonprofessional personnel with access tprofessionals.
a self-care program.
disease management.
case management.
high-risk and high-cost cases.
physicians.
Case management.
acute diseases.
They encourage doctors ttry a variety of treatments
instead of following one standard for all.
utilization review.
engaging in evidence-based healthcare.
a lack of motivation.
is always conducted before treatment is provided.
the lowest cost available in the area.
ensure correct payment of benefits and promote quality

and cost-effective care.
a patient must receive.
reduce unnecessary and ineffective practice variation.
Retrospective review.
hospital admissions.
site-appropriateness listings.
For stays in hospitals and other facilities.

before admission tthe hospital.
A specialist visit.
prospective, concurrent, and retrospective review.
analyzes data timprove utilization.
Retrospective review.
unbundling.
desirable, but not possible.
Primary care.
A high cost service.
can increase or decrease health plan costs.
Some plans require retrospective review and
authorization.
Some do, and some dnot.
Observation care unit.
A subacute care facility or hospital step-down unit.

those recovering from an acute injury or illness, but not
those with chronic conditions.
Most dfor all those with a terminal illness.

Telephone.
Telephone.
Telephone.
cost-effective.
either, depending on the plan.
A physician, nurse, or nonclinical employee.
No, they may only approve or deny proposed services.
Once a PCP has referred a patient ta specialist, the
specialist can generally provide whatever treatment
and as many visits as she sees fit.
quality assessment and quality improvement.
service quality and healthcare quality.
healthcare quality.
are both a patient safety issue and a cost issue.
omission.
Lack of communication among healthcare providers.
are important because they reflect valid concerns and
affect purchaser decisions.
an outcomes measure.
a process measure.
process measures.
Structure and processes produce outcomes.
process measure of healthcare quality.
their link toutcomes is generally not proven by
research.
clinical outcomes measure.
Comparing different providers is problematic.

Clinical data.
After actions are taken timprove quality, measurement

and analysis of outcomes is repeated and ongoing.
provider profiling.
peer review.
clinical practice guidelines.

Clinical practice guidelines.
They are typically applied thealthcare services.
Health plans of various types.
about half of health plan members.
consists of an offsite review of data.
A plan earns one of five accreditation levels.
health plans and health networks.
consists of an offsite review of plan policies and
procedures.
the quality of different health plans.
a national database of performance and accreditation
information.
a research branch of the Department of Health and
Human Services.
addresses healthcare quality only in federal programs.
It will maintain current payment levels tMA plans
overall but give bonuses and higher rebates tplans that
meet quality criteria.
agents, brokers, and direct marketing.

individuals, including employees and Medicare
beneficiaries.
Positioning.
Research is not very important.
No, state laws will continue tgovern this area.
small employers, but it makes marketing more
complicated.
Advertising uses the mass media, publicity is personal
contact.
personal selling and direct marketing.
Brokers.
Brokers.
Brokers.
A captive agent.
Employee benefits consultants.
Telemarketing.
positioning.
group market.
positioning.
Joanne recently lost her job and her group health plan.
Agents.
individual market.
The individual market will be eliminated, and everyone
will have group coverage.
Direct marketing.
may receive health and/or drug coverage through

private-sector health plans.
associations.
price.
Only one health plan is usually offered.
They tend tchoose very basic and inexpensive
products.
determining the premium tcharge for a risk.
Those more likely tneed healthcare are more likely
tobtain health coverage.
Health status and occupation, but not usually age or
gender.
Waiting periods.
Annual and lifetime benefit limits.
Group size and participation.
Marketability and competitiveness.
manual rating.
large groups.
community rating by class (CRC).
manual rating.
retrospective experience rating.

Prohibit the use of experience in rating any group.
summarizes its revenue and expense activity during a
specified period.
capital and surplus.
liabilities and reserves.
expected and actual revenues and expenses.
a self-funded plan.
aggregate stop-loss coverage.

administers benefits and is financially responsible for
paying claims.
quality management system.
Claim processing.
contract management.
Provider profiling.
Member services.
The information supplied by codes is often not
complete.
often in different databases but in compatible formats.
Security and privacy.

somewhat automated.
E-business.
Health plans have historically lagged behind other
industries but are now handling many transactions
online.
digital tagging.
internet.
members.
It does not require a standardized data format.
They are about equal in this regard.
help managers make decisions in specific cases.
inaccuracy of data.
the complexity and cost of implementing them.
an electronic medical record.
receive guidance on the best course of treatment for

her.
An HIN includes only physician information, while an
HIE includes data from other sources.
The personal health record (PHR).
the federal government.
The EHR is not subject tprivacy and security
regulations.
a data warehouse.
Claims are submitted by the provider.
When the provider is compensated by capitation or
salary.
hospitals but not healthcare professionals.
30 t40 percent.
It is promoted by federal legislation.

examiner.
converting paper documents intelectronic files.
Capitation.
CMS-1500.
ICD.
examined furthered.
Authorization was not obtained.
If a required authorization was not obtained but the
service was medically necessary, the health plan is
obligated tpay.
a required authorization or referral was not obtained.
are complicated and time-consuming.
promoting the electronic transmission and processing
of claims.
general health information, including wellness and
prevention.
members with certain characteristics.
Websites,
IVR.
Usually only when required by regulations for important
notifications.
Email is not generally used because of the strict
regulatory requirements.
Tcomply with regulations only-since only a tiny minority
of members complain, they dnot have a significant
impact on overall satisfaction.
are generally up tthe plan and not subject tregulation
or accreditation requirements.
The appeals committee.
Her case is automatically referred tarbitration.

Member satisfaction surveys and performance
measures.
Members whhave recently received services and all
members.
Plan employees or outside companies.

It is very uncommon for a single member services
representative thandle many types of needs through
different communication channels.
Representatives with broad responsibilities.

They are subject thigh stress and burn-out, sretention is
a concern.
IVR systems and websites can only provide information,
not handle transactions.
turn-around time.
First contact resolution rate.
Error rate.
bid-rigging.
a horizontal group boycott.

The protection of personal financial information.
no health plans (only retirement plans).
Self-funded plans are regulated only by the federal

government, and fully insured plans are regulated only
by the state.
must sue in state court and may receive punitive
damages.
for up to three months.
He has no rights.
Noah and his employer each continue paying the
portion they paid when he was employed.
HMOs that wish to be federally qualified must meet the

standards, and almost all HMOs do.
may not decline to offer health coverage to older
employees nor change them more.
paid leave, including health coverage.

Increasing the availability and continuity of healthcare.
the individual market only.
have certain specified chronic health conditions.

They must provide mental health coverage.
healthcare providers only.
Health plans may not use healthcare information for
their own treatment, payment, or operations without
obtaining the individuals consent.
The expansion of Medicare eligibility tpeople as young
as 55.
Most of the major components become operational in

2011, but some provisions ginteffect later.
have tpay an income tax penalty.
required tsponsor health coverage.
required tsponsor health coverage or pay fees.

premiums only.
Lifetime benefit limits.
Smoking.
At the federal level.
protect consumers from the risk of plan insolvency.
Intervene in the plans operations, but not take over its
management or liquidate it.
return the plan tnormal operation.
network adequacy.
PPOs but not HMOs or EPOs.
EPO.
Most have.
may be regulated under either, depending on the state.
Most states license them, require certification, and
regulate them tsome extent.
Most states have a few minimal requirements but dnot
require a certificate of authority.
Providers must be allowed treview and correct
credentialing information.
It addresses disclosure of nonpublic personal health

information.
Part A and Part B (hospital and medical coverage).
tprovide Medicare coverage through private-sector
heafth plans.
provided automatically tMedicare beneficiaries at
nextra cost.
must make a daily copayment beginning the first day.
indefinitely tthose whneed personal care because of a
chronic physical impairment.
but those whdid not pay intthe Medicare system pay a
premium.
may be partial but must be long-term.
premiums.
Nservices are covered.

coinsurance and copayments but ndeductible.
only those whdid not pay intthe Medicare system pay a
premium.
everyone pays an amount based on their income.
All people have tsign up for Medicare when they
become eligible.
Yes, he can, and he will pay the standard premium.

an afternative tMedicare Part B.
Part A and Part B coverage only.
all MA plans.
Premiums differ, but cost-sharing payments are the
same for all plans.
directly by Medicare, by PDPs, and by MA plans.
must all provide a minimal level of benefits.
All PDPs have the same deductible and coinsurance or

copayment amounts.
all costs.
Yes, she can, but she will pay a higher premium.

It was rising, but since the MMA in 2003 it has been
steadily declining.
BBA in 1997.
Types of plans available.
Drug benefits.
both Medicare Part A and Part B.
Vision care and eyeglasses.
all provide a different benefit package.
It cannot dthis if he enrolls when he first becomes
eligible or otherwise qualifies for guaranteed issue, but
otherwise it can.
vary somewhat from state tstate, within federal
guidelines.
all people with income below a certain level.

primarily tlow-income children, pregnant women,
elderly and disabled people, and a few parents.
Each pays 50 percent.
are unable tobtain private health Insurance because of
their medical history or a preexisting condition.
Kaitlyn is eligible for Medicaid.
but most dnot.
copayments and premiums can be charged within
limits.
remained about the same.

A large majority.
A health plan serving Medicaid recipients must alshave
a substantial number of non-Medicaid members.
Medicaid recipients often have limited access
ttransportation.
About half.
CHIP enrollees only, not Medicaid recipients.
the federal government.
a variety of plan types.
must offer at least a minimal benefit package.
active and retired members of uniformed services.

HMcoverage only.
Most participants except for active duty service
members.
Insurance that some employers and/or employees may
purchase tcover work-related injuries and illnesses.
both medical expenses and lost income.
Ncoverage of non-work-related injuries and illnesses.
whether or not the employer is at fault for her injury or
illness, and if the employer is at fault, she can alssue it
for damages.
Option2
Maintains a network of affiliated healthcare providers and
limits coverage to services rendered by those providers.
1910
Individual practice association.
All HMOs had to meet certain federal standards.
The HMO did not have to meet certain requirements that
applied to other health plans.
played a minor role in the early growth of HMOs.
were not popular because they were expensive and did not
oiler a wide choice of providers.
a preferred provider organization.
a consumer-directed health plan.

The states regulate health insurance, but the federal
government also passes laws affecting it.
Yes, because these programs have increasingly relied on
health plans to provide coverage.
Expensive new technology.
only appropriate services.
A consumer-directed health plan.
has remained more or less the same.
URAC.
Some features of todays health plans are inherited from
indemnity insurance or designed to address its problems.
Both Andy and the employer.

Employees pay premiums directly to the insurer.
An unexpectedly high percentage of employees choose to

enroll.
A group located in a rural area.
Company C is located in a large metropolitan area.
can go to any provider they choose.
Salary.
a deductible.
Deductible.
divide healthcare costs equally between two health
insurance policies covering the same person.
shifts costs from insurer to insured.
shifting healthcare costs to insured.
not cost-effective but popular among insured and so has
been adopted by insurers.
maintains a network, either exclusive or nonexclusive.
Fewer types are being offered, and the distinctions
between them are becoming blurred.
point-of -service (POS) product.
consumer directed health plan (CDHP).
Preferred provider- organization (PPO).
Cost-effectiveness and profitability.
payors.
Roles are overlapping and becoming less distinct.
more extensive but do not cover preventive care.
only the federal government and apply only to managed
care.
coinsurance.
a copayment.
a copayment.
accepting all providers who meet certain minimal
standards.
preventive care and the treatment of routine illnesses and
injuries.
can receive care only from network providers.
more
quality management.
Demand management.
Utilization review.
capitation.
not provide needed care.
The insurers and the providers.
the number of members cared for.
the same amount each month.

not provide unnecessary services and promote
prevention and wellness.
It is used only for PCPs. not specialists or
hospitals.
A small minority.
no more than a listed amount.
she can bill her normal amount provided it is
not more than the UCR amount.
RVS.
a relative-value scale (RVS).

capitat ion.
a per diem payment.
withhold.

Capitation.
Per diem.
assumes or shares financial risks only, not
delivery risks.
moved all HMOs from state to federal
regulatory jurisdiction.
heavily regulated at both the federal and state
levels.
Loose relationships with providers.
Prevention and weliness.
only through an employer, not individually.
large groups, but they now serve large and
small groups and individuals.
comprehensive medical benefits and usually

special services such as dental and vision care,
mental health care, and prescription drugs.
high.
extensive preventive care but charge
significant cost-sharing for it.
contracting with independent providers.
national.
contractual relationships.
Usually.
No, this is a defining characteristic of an HMO.
By means of a fixed monthly premium.
Deductibles.
Fee-for-service.
risk pool.
Risk pools.
strict state and federal regulation.
Any physician who meets the HMOs standards
is eligible to join its network, but the HMO is
not obligated to contract with anyone.
Most HMOs today have a closed panel.
receive benefits only for care from network
providers.
In the past most HMOs had closed access, but
this is no longer true.
capitation.
discounted fee-for-service.
allows affiliated physicians to contract with
other health plans.
group model HMOs.
contracted with the PA, which contracts with
the HMO.
IPA model.
Regular fee-for-service for both PCPS and
specialists.
The cost of building and maintaining facilities
is high.
employees of the HMO.
Staff model.
Tight control of care management and quality.
a group model HMO.
The HMO compensates the group practice by capi
group model HMO.
discounted fee-for-service only.
group model.
Group model.
At the unmanaged end of the managed care continuum.

No benefits for non-network care.
Providers receive their full normal fees for services.
A significant minority, about 10 percent.
Insurance companies.
PPOs are normally highly centralized organizations.
Salary.
May or may not assume risk.
There is no coverage of out-of-network care.

Reduced coverage of non-network care.
Members cannot go out of network.
A small but growing minority.
Managed indemnity plan.

Focused on standard medical care (physician and hospital
services).
Chiropractics.
Standard carve-out arrangement.

Capitation.
Tend to encourage carve-outs.
A minority.
Declining.
A PPO.
Capitation.
An annual deductible.
Copayments but no deductible, coinsurance, or annual
maximum benefit.
A PPO.
HMO
PPO
8 percent.
Partial hospitalization.
Intensive outpatient care.
Members can access behavioral healthcare directly.

It requires plans that provide behavioral healthcare
coverage to provide coverage equivalent to medical
coverage.
The rules apply only to the treatment of mental disorders,
not substance abuse.
Only a few.
A little, but they are focused on cost control.
Physician profiling.
An open formulary.
Therapeutic substitution.
Prior authorization.
A risk-sharing contract.
The annual rate of increase has been rising steadily since
the 1980s.
To more restrictive forms of managed care in response to
rising costs.
More responsibility for costs.
A tax-advantaged personal healthcare account and access
to a public healthcare benefit program such as Medicare or
Medicaid.
The FSA, introduced in the 1990s.
Most commonly only employees contribute, but employers
are allowed to.
Low limits on contributions.
Employees only.
Full portability.
HSA.
An employer-sponsored health insurance plan.

In the long run, but usually not initially.
Employers shifting costs to consumers.
Slow but steady growth, expected to increase.
Core contribution by employer.
an individual heafth insurance policy.
higher.
must be coupled with some type of employer-sponsored
health plan.
Only a minority of workers have access to them, and most
of those do not participate.
Employees can make contributions with pretax dollars.
To be eligible, an employee must be covered by an HDHP.
Only a few percent.
full portability, annual rollover, and tax-free investment
growth of account funds.
a qualified HDHP only, not other broad health coverage or
Medicare.
a deductible of at least a certain amount and copayment
amounts and coinsurance percentages below certain
levels.
Preventive care.
An employer, an employee, or a self-employed person.

copayments for his HDHP.
COBRA continuation coverage.
Yes, she may. and the withdrawal is usually tax-free.
Yes, she may, but she must pay income tax and a tax
penalty.
Major-FSAs and HRAs will be eliminated, and HDHPs will
have to be redesigned.
The tax on high-value health plans.
business integration.
an acquisition.
partial operational integration.

The integrated delivery system (IDS).
A decrease in business expertise.
Easier access to care.
The independent practice association (IPA).
Handles billing, claims, and other administrative functions.
Physicians contract with the IPA, and the PA contracts with
the health plan.
a messenger model IPA.

In an IPA physicians maintain their own independent
practices, but in a GPWW they do not.
negotiate contracts with health plans for physicians.
It purchases physicians entire practices.
The independent practice association (IPA).
Contracting with health plans and marketing.

become branches of the PHO owned and
operated by it.
an open PHO.
clinically.
To go a step beyond an integrated delivery

system by assuming insurance risk.
comply with state HMO laws.
Yes.
an accountable care organization (ACO).

limit accountable care organizations (ACOs)
and patient-centered medical homes.
Provider compensation is by pure capitation.

It is a legal entity separate from its owners.
holding company and the parent company of
Company B.
It is better able to raise capital.
Tax exempt plans pay no income or premium
taxes.
Its policyholders.
Mutual companies find it easier to raise capital
than stock companies.
corporations.
the board of directors
Only not-for-profit plans have a board.
the board of directors.
Chief marketing officer.
Chief operations officer.
Network management director.
Chief compliance officer.
ad hoc committee.
Peer review committee.

Pharmacy and therapeutics committee.
Appeals review committee.

economic growth rate of a market.
Provider number, types, and locations.
Large employers.
Rural areas.
one network.
the premiums and cost-containment strategies
are sufficient tmake the network financially
sustainable.
Mandated benefits.
providers can see non-plan members.
primary care provider.

Highly managed and large plans.
create a large, very inclusive specialist panel.

Selecting the most qualified providers and
meeting accreditation standards.
They generally dnot unless the information
gives rise tquestions or concerns.
personal finances and net worth.
Cure provision.
Due process clause.

Yes, if the state permits termination without
cause and this is allow by the contract.
recredentialing.
utilization management, case management,
and disease management.
quality management.
decide whether taccept or decline her
application.
a wellness program.
decision support program.
wellness program.
web-based decision support tools.

nurses directed by physicians and supported
by nonprofessional personnel.
shared decision-making.
concurrent utilization review.
disease management.
high-risk cases.
nurses.
Self-care.
geriatric diseases.
They focus on individual episodes of medical
care.
clinical practice guidelines.
conducting case management.
a lack of health literacy.

is always conducted after treatment is
provided.
delivered by a network or non-network
provider.
ensure correct payment of benefits.

a doctor can provide.
eliminate all practice variation.
Prospective review.
specialist office visits.
length-of-stay guidelines.
In determining the best care setting.

after admission tthe hospital but at least one
day before treatment.
A long hospital stay.
prospective review and sometimes concurrent
review.
reviews a particular case for appropriateness
of services.
Prospective review.
a billing error.
neither possible nor desirable.
Nonprimary care.
A service with a high authorization denial rate.
generally decreases health plan costs.
No, this is prohibited by nearly all states.
No,theydnot.
Subacute care facility.
Home healthcare.
all those who need it, regardless of the reason.
Most dfor those whhave six months or less
tlive and whforegcertain medical treatment.
Electronic.
Manual.
Electronic.
medically appropriate.
nonclinical employees.
A physician or nurse.
Yes, but only when consensus is reached with
the treating physician.
For inpatient hospital care, authorizations
generally include services related tthe main
procedure approved.
quality assessment and quality reassessment.
medical quality and customer satisfaction.
service quality.
are the responsibility of providers, not health
plans.
commission.
Lack of coordination among parties concerned
with medical errors.
should be considered provided they dnot
conflict with objective measures.
a process measure.
a structure measure.
outcomes measures.
Structure produces outcomes, but processes
are independent.
outcomes measure of service quality.
they are difficult and expensive tcalculate.
clinical process measure.
Outcomes are not directly related tquality.

Customer satisfaction data.
It is not generally necessary or desirable for a
health plan tpublicize its quality improvement
efforts outside the plan.
benchmarking.
benchmarking.
provider profiling.
Benchmarking.
They are usually based on the plans past
performance.
PPOs only.
a minority of health plan members.
includes both an onsite visit and offsite data
review.
A plan is either accredited or not, with nother
evaluation given.
health plans, health networks, and functional
areas within organizations.
includes both an onsite visit and offsite policy
and procedure review.
the extensiveness of different health networks.
an onsite evaluation program for hospitals and
clinics.
a division of CMS concerned with quality in
Medicare Advantage plans.
does not address healthcare quality in any
major way.
It will lower payments tMA plans overall but
give bonuses and higher rebates tplans that
meet quality criteria.
publicity, advertising, and sales.

employers, associations, employees, Medicare
and Medicaid beneficiaries, and other
individuals.
Focus groups.
Markets are generally local.
Yes, but only by requiring a minimal benefit
package.
large employers, and it makes marketing
simpler.
Advertising focuses on a product, publicity on
an organization.
advertising, publicity, personal selling, and
sales promotion.
Agents.
A broker.
Brokers.
Door-to-door selling.
branding.
non-group market.
market segmentation.
Susans employer does not sponsor a group
health plan.
Direct marketing.
large group market.

Individuals will buy coverage through
government-sponsored exchanges.
Door-to-door selling.
dnot need private-sector health plans.

multi-employer groups.
quality.
Self-funding is common.
They tend tchange health plans more
frequently than small plans.
identifying and assessing risks.
Those less likely tneed healthcare are more
likely tobtain health coverage.
Age1 health status, and sometimes
occupation, but not gender.
Preexisting condition exclusions.
Annual enrollment periods.
Experience and participation.
Risk and expected healthcare costs.
pooling.
small groups.
standard community rating.
experience rating.
prospective experience rating.

Require pure community rating for all health
plans.
shows its financial status on a specified date.
assets, liabilities, and capital.
revenues and profit.
assets and the sum of liabilities and capital.
a fully funded plan.
individual stop-loss coverage.

administers benefits and is financially
responsible for paying claims above a certain
level.
utilization management system.
Utilization management.
provider profiling.
Quality management.
The use of codes largely eliminates problems
of accuracy.
generally in one database and in the same
format.
Qualityof data.
almost entirely automated.
I-business.
Health plans have adopted information
technology for internal operations, but few
transactions are suitable for being conducted
online.
encryption.
extranet.
hackers.
It is the transfer of batches of data, not
exchanges about a transaction.
Manual.
replace physicians in making clinical decisions.
data in multiple databases.
their incompatibility with decision support
systems.
a decision support system.
have access tall of her medical records and

health information.
An HIN shares information within a health plan
network, while an HIE shares it across
healthcare entities.
The electronic health record (EHR).
health plans and other organizations.
c The EHR adds information from providers.
cloud computing.
Claims are submitted by the insured.
When the provider is not in a plans network.
healthcare professionals but not hospitals.
80 t90 percent.
It can handle only simple claims.

adjustor.
explaining claim decisions tmembers and
providers.
Salary.
UB-04.
CPT.
automatically paid.
The service is not considered medically
necessary.
If a provider bills more than six months after
delivering a service, a plan is not required
tpay.
a person is treated by more than one provider.
involve suspected fraud.
protecting the privacy of members health
information.
either administrative matters or health or both.
both.
Letters and newsletters sent by mail.
CTI (ACD or IVR).

For a variety of notifications and routine
transactions.
Members can not only obtain information from
websites but alssometimes perform
transactions.
Tmaintain member satisfaction and avoid bad
publicity-there are nregulatory requirements.
are generally subject tstate and federal
regulation and accreditation requirements.
The medical director.

She has nfurther recourse and must accept the
decision.
Member satisfaction surveys and complaint
monitoring.
Members whhave recently received services.

Plan employees or outside companies, but
some accrediting bodies and purchasers
require outside companies.
In large, complex health plans, several
departments rather than a single department
handle member services.
The use of CTl.

Their initial training typically takes only a few
days, but frequent ongoing training is needed.
With new technologies, somewhat complex
matters can be handled online.
first contact resolution rate.
Call abandonment rate.
Call abandonment rate.
a horizontal allocation.
horizontal allocation.
The break-up of large health insurance
companies.
employer- and union-sponsored health plans.
An employer health plan is regulated by the

federal government, but any insurer involved
is regulated by the state.
must sue in federal court and may not receive
punitive damages.
indefinitely, until she has access to coverage
from a new employer.
He has rights if Lones employment is
terminated.
Noah pays the full cost of coverage, and the
employer may charge him a certain amount for
administrative costs.
HMOs that wish to be federally qualified must
meet the standards, and while qualification is
less important today, many HMOs are
qualified.
may decline to offer heafth coverage to older
employees.
unpaid leave, including health coverage.

Expanding Medicaid eligibility.
the individual and group markets.
have lost group coverage and are not currently
eligible for it.
They may not discriminate based on
individuals health status.
health plans, healthcare providers, and
healthcare clearinghouses.
Patients are allowed to access their medical

records.
The requirement that all large employers
sponsor a health insurance plan.
Most of the major components become

operational in 2014, but some provisions
ginteffect later.
be enrolled in a government program.
required tsponsor health coverage or pay fees.
not required tsponsor health coverage but may
be eligible for a tax credit if they do.
both premiums and cost-sharing payments.
Annual benefit limits.
Health.
Formerly at the state level, but after ACA at
the federal level.
ensure that costs and premiums remain low.
Intervene in the plans operations or take over
its management, but not liquidate it.
convert the plan ta state program.
financial responsibility.
HMOs, PPOs, and EPOs.
ppo.
Only a few have.
is regulated under HMlaws.
Most regulate them tsome extent, but only a
few license them or require certification.
Most states dnot regulate them tany significant
extent.
Providers must be given access twritten
credentialing procedures.
It focuses primarily on financial, not heafth

information.
Parts A, B, and C, but not Part D (prescription
drug coverage).
tsupplement original Medicare by paying
benefits for health care services it does not
cover.
made available tMedicare beneficiaries at an
extra cost.
must pay a large deductible before Medicare
pays any benefits.
indefinitely tthose whneed supervision
because of a cognitive disorder.
and none pays a premium.
must be total and long-term.
general government revenues.
Most services are covered.

ndeductible, coinsurance, or copayments, but
a premium.
none pays a premium.
most people pay a standard premium, but
those with high incomes pay more.
Most people have tsign up for Medicare when
they become eligible.
Yes, he can, but he may have tpay a higher

premium.
an afternative toriginal Medicare.
Part A and Part B coverage and usually other
benefits.
most but not all MA plans.
Premiums and cost-sharing payments differ
from plan tplan.
directy by Medicare.
must all provide the same benefit package.
All PDPs have the same deductible, but

coinsurance and copayment amounts vary.
all costs until catastrophic coverage is
triggered.
No,shecannot.
It was declining, but since the MMA in 2003 it
has been steadily rising.
TEFRA in 1982.
Operations of plans.
Funding.
either Medicare Part A or Part B, or both.
Health care received outside the United States.
must provide one of a few standard benefit
packages.
Yes, it can dthis whenever it sees fit.

are the same in all states.
only tlow-income children and a few pregnant
women.
all people with income below a certain level.

Medicare.
have serious illnesses and large medical
expenses.
Logan is covered by his fathers employers
health plan.
and all do.
premiums and copayments cannot be charged.
decreased.
About half.
Health plans serving Medicaid recipients must
meet certain requirements related tquality and
enrollee protection.
Most people in Medicaid managed care are
elderly or disabled.
A minority.
Medicaid waiver populations only.
one health plan in each locality.
managed care plans such as PPOs and HMOs
only.
may offer any benefit package.
active members of the uniformed services
only.
fee-for-service insurance only.
All participants.
State programs that require employers
tprovide benefits for work-related injuries and
illnesses.
medical expenses only.
Annual and lifetime maximums.
only if the employer is at fault for her injury or
illness, and if so, she can alssue the employer
for damages.
Option3
Answera
Provides coverage I or healthcare expenses and

is sponsored by an employer for its employees. A
1973 B
Prepaid group practice.
A
Federally qualified HMOs were exempted from
some state laws.
In the marketing of the HMO, federal

qualification served as a stamp of approval.
played a major role in the early growth of HMOs. C

were popular because they held down costs and
offered a wide choice of providers.
A
traditional indemnity insurance.
a specialty carve-out plan.
The federal government takes the primary role

in regulating and legislating in this area.
No, because health plans are not involved in

these programs in any major way.
The aging of the Baby Boomers.
as few services as possible.

Preventive healthcare.
A traditional indemnity insurance policy.
A
A
B
has become narrower.

HEDIS.
A
C
Todays health plans differ from traditional

indemnity insurance only in detail.
The employer.
The employer always pays the premium.
Many insureds do not pay their premiums and

let their policies lapse.
A group made up mostly of men.
In Company A a small percentage of employees

enroll.
C
can go to a non network provider but pay higher
cost-sharing if they do.
B
Capitation.
a copayment.
Copayment.
prevent duplication of benefits when a person is

covered by more than one health insurance
policies.
C
both.
reducing unnecessary healthcare services.
not cost-effective and so has been phased out

by insurers.
pays healthcare benefits, either on a fee-forservice or capitation basis.
More types are being offered, and the

distinctions between them are becoming
blurred.
preferred provider organization (PPO).
preferred provider organization (PPO).
Point-of-service (POS) product.
Accessibility, cost-effectiveness, and quality.
purchasers.
The number of players and roles is growing.
less extensive but encourage the use of

preventive care.
only by states and apply only to indemnity

insurance.
a deductible.
a deductible.
a deductible.
recruiting as many providers as they can.
preventive care only.
pay more for care from non-network providers.
about the same
case management.
Disease management.
Case management.
B
A
salary.
focus on prevention and wellness.

The providers.
A
A
the cost of services performed.
the same amount for the first two months but

more for the third month.
not provide unnecessary services.
It may be used for both primary and secondary

care.
C
A majority.
his normal fee.
B
B
she must accept the plans amount as payment

in full.
C
DRGs.
diagnosis-related groups (DRGs).
per diem payments.
a diagnosis-related group (DRG) payment.
a risk pool.
a risk pool.
a withhold.
DRG.
does not assume or share either financial or

delivery risks.
requires all HMOs to be federally qualified.
regulated under the federal HMO Act but not

state laws.
An emphasis on prevention and wellness.
Physician turnover.
most commonly individually, without employer

involvement.
individuals, but they now serve small groups as

well.
B
limited medical benefits and not special

services such as dental and vision care, mental
health care, and prescription drugs.
B
average.
extensive preventive care and charge little or no

cost-sharing foi it.
C
contracting with and/or employing providers.
regional.
C
A
credentialing.
Never.
Traditionally they did not, but some HMOs now

do at a higher cost.
By capitation.
Coinsurance.
B
A
Capitation.
withhold.
Referral management.
a few state regulations.
Any physician who is an employee of the HMO

or a member of a group practice contracted with
the HMO is eligible to join its network.
B
Typically, physicians can see patients who are
not members of the HMO.
receive lower benefits for non-network care.
In the past closed access was not common, but

it has become more so.
B
fee-for-service.
fee-for-service.
Capitation.
contracts with more than one group practice.

staff model HMOs.
A
A
group model.
Salaries for PCPs and discounted fee-for-service

for specialists.
A
The HMO has limited control of care
management and quality.
IPA model.
Salary.
Economies of scale because of centralization.

A
a network model HMO.
B
A
The HMO compensates the group practice by discou
A
mixed model HMO.
A
capitation only.
A
IPA model.
C
IPA model.
A
In the middle of the managed care continuum, between
tightly managed and unmanaged.
The same benefits for non-network care as for network care. A

Members must generally obtain a referral from their PCP to
A
see a specialist.
About a third.
Physician hospital groups.
A
B
PPOs usually cover some specialty services.
Capitation.
A
B
Usually assume risk.
Providers are paid by salary or capitation.
No coverage of non-network care.
Members pay higher cost-sharing out of

network.
A small but declining minority.
Traditional indemnity plan.
Included both standard medical care and

supplemental coverage.
Home healthcare.
Partial carve-out arrangement.
Fee-for-service.
May restrict carve-outs.
B
C
About half.
Growing.
A
C
A POS plan.
Fee-for-service.
Copayments.
A
B
C
Fee-for-service.
Annual deductible, coinsurance, and annual

maximum benefit.
POS plan.
POS plan.
HMO.
B
C
2 percent.
Acute care.
Acute care.
Members call a behavioral healthcare referral

system, which refers them to a provider.
It requires all plans to provide behavioral

healthcare coverage equivalent to medical
coverage.
Health plans must cover out-of-network

behavioral healthcare.
A large majority.
Yes, safe and effective drug use is a major

concern, along with cost.
Formulary management.
Physician profiling.
A closed formulary.
Prior authorization.
Eligibility and copayment information.
C
B
A fee-for-service arrangement.
Annual increases were high in the 1980s but

have been lower since the mid 1990s.
Back to indemnity insurance in response to

consumer dissatisfaction.
More decision-making power.
An employer-sponsored high-deductible health

plan and an individual supplemental insurance
policy.
The FSA, introduced in the 1970s.
Usually only employers contribute, but certain

employees are allowed to.
The use it or lose it rule.

Employers only.
Annual rollover (at employer option).
B
C
C
FSA.
A qualified high-deductible health plan.
Initially and probably in the long run as well.
Consumers receiving fewer healthcares.
Rapid growth, expected to level off.
Greater accountability for health plans and

providers.
high-deductible health plan.
A
C
lower.
must be coupled with an HDHP.
Most workers have access to them, but only a

minority participates.
Account balances are rolled over from year to

year and earn interest.
An employer may offer annual rollover of funds. C

About half.
B
annual rollover and full portability, but not taxfree investment growth of account funds.
a qualified HDHP or Medicare, or as a dependent

on someone else's coverage.
B
a deductible of at least a certain amount.
Prescription drugs.
An employer, an employee, a self-employed

person, or a family member on behalf of an
eligible person.
prescription drugs.
Medigap insurance.
No,she may not.
Yes, she may, and the withdrawal is tax-free.
Very minor-only a few rules and requirements

will change.
Minimum actuarial value.
structural integration.
a merger.
C
A
partial clinical integration.
The physician-hospital organization (PHO).
A weaker negotiating position.
Lower costs resulting from a stronger

negotiating position.
The group practice without walls (GPWW).
Negotiates contracts with health plans.
Physicians contract directly with the health plan,

but the IPA negotiates the contract.
B
stop-loss insurance.
A GPWW negotiates contracts for members, but

an IPA does not.
A
provide management and administrative
services to physicians.
It provides services for a fee but does not

purchase anything.
The management services organization (MSO).
Integrating clinical functions.
continue to be owned and operated by the

physicians.
a specialist PHO.
structurally.
To set up something similar to an integrated

delivery system in states that do not allow
corporations to buy physician practices.
handle quality and utilization management.
It depends on the state and how the

organization operates.
a consolidated medical practice.
replace accountable care organizations (ACOs)

with patient-centered medical homes.
Technology plays an important role.
It is a for-profit organization.
a sister corporation of Company B.
It is subject to more regulation.
All not-for-profit plans are tax-exempt.

A non-profit organization.
A
B
Many companies have mutualized in recent

years.
not-for-profit entities.
A
B
the owners.
The board is usually made up solely of top

executives of the plan.
the CEO.
Chief information officer.

Chief financial officer.
C
A
special committee.
Ethics committee.
level of health plan activity in a market.
B
C
Provider number and types.
Small employers.
Urban areas.
separate networks only.
the contractual arrangements, policies, and

procedures meet the standards of laws,
regulations, and credentialing organizations.
Network adequacy.
members pay more for non-network providers.
ancillary service provider.
Loosely managed and large plans.
create a large, very inclusive primary care

panel.
Selecting the most qualified providers.
They generally dnot unless a problem arises

after the provider is part of the network.
education, training, and experience.
Hold harmless provision.
Cure provision.
No, this is prohibited in all states.
verification.
utilization management, clinical practice

management, and quality management.
clinical practice management.
set her premium based of the amount of

healthcare she is likely tneed.
an immunization program.
self-care program.
self-care program.
shared decision making.
physicians supported by nonprofessional

personnel.
utilization review.
shared decision-making.
utilization review.
high-risk, high-cost, and/or chronic cases.
social workers.
A
C
B
Disease management.
chronic diseases.
C
C
They are typically an outreach and support

program for plan members with certain
diseases.
evidence-based healthcare.
referring tclinical practice guidelines.
a lack of information.
may be conducted before, during, or after

treatment.
medically necessary and appropriate.
ensure correct payment of benefits, promote

quality and cost-effective care, and collect data
for utilization management and other purposes. C
a health plan will pay for.
C
make information available and encourage
practice variation.
Both.
routine laboratory tests.
experience-based criteria.
When research-based utilization guidelines are

not available.
after admission tthe hospital.
A course of chemotherapy.
prospective review only.
seeks tdirect treatment and care settings.
Concurrent review.
upcoding.
possible, but not desirable.
A
B
Dental and vision care.
A frequently performed service.

generally increases health plan costs.
C
A
Some plans require prospective review and

precertification.
Yes, they do.
A
A
Urgent care center.
An observation care unit.
those with chronic physical impairments but not

a cognitive disorders.
A
They generally dnot, but government programs
do.
B
Manual.
Electronic.
Manual.
covered.
clinical professionals.
A physician only.
Yes, they may direct the treating physician

tperform certain treatments.
An authorization may cover one specialist visit

or multiple visits.
quality planning and quality improvement.
physician quality and facility quality.
provider quality.
are not common and sare not a major concern.
execution.
Lack of verification of individual analysis of test

results.
B
are not valid or reliable and should not be a
factor in health plan decisions.
a process measure.
structure measures.
Processes and outcomes determine structure.

process measure of service quality.
A
C
they have nrelation toutcomes.
functional outcomes measure.
Data can be difficult and costly tobtain.

Financial data.
B
A
While accrediting bodies require a health plan

thave a quality management program, they
dnot require much documentation of it.
peer review.
provider profiling.
peer review.
Provider profiling.
They are typically applied tadministrative

services.
HMOs only.
most health plan members.
A
A
C
consists of an onsite visit.
A plan is given a numerical score, with nother

evaluation given.
health plans.
consists of an onsite visit.
the cost of different health plans.
a quality awareness program for health plan

executives.
a research consortium of medical schools and

universities.
includes a variety of healthcare quality

improvement provisions.
It will increase payments tMA plans overall but

eliminate bonuses and higher rebates for plans
that meet quality criteria.
B
product, price, promotion, and distribution.
employers, associations, and government

programs.
Direct response marketing.
B
B
There is little regulation.
Yes, in relation tbenefit packages, cost-sharing,

and other matters.
C
large employers, but it makes marketing more
complicated.
Advertising is paid for, publicity is not.
advertising, branding, and publicity.
Internal salesforce.

Agents.
An independent agent.
C
C
A
Agents.
Direct mail.
market segmentation.
individual market.
direct marketing.
Daniel is self-employed.
Brokers.
Medicare market.
Individuals enrolling in a health plan will nlonger

undergmedical underwriting.
A
Meetings.
may receive drug (but not health) coverage

through private-sector health plans.
employers.
A
C
service.
Customization of a product is common.
A
A
They often use employee benefits consultants.

managing incoming and outgoing funds.
C
B
Those with health coverage are more likely tuse

healthcare services.
A
Age and gender, and sometimes health status
or occupation.
Minimum participation requirements.
Coinsurance.
C
B
A
Group size and new members.
Risk and expected costs balanced by

marketability and competitiveness.
community rating.
employer groups.
C
A
adjusted community rating (ACR).
blended rating.
pooling.
Limit premium differentials based on risk

factors.
documents its capital and surplus on a specified

date.
A
revenues and expenses.
statutory solvency.
total revenues and total expenses.
a self-insured plan.
specific stop-loss coverage.
administers benefits only.
contract management system.
Finances.
credentialing.
Enterprise scheduling.
The entering of codes often results in

inaccuracy.
often in different databases and in incompatible

formats.
C
Usability of data.
almost entirely unautomated.
A
A
E-commerce.
Health plans can offer information on their

websites, but conducting transactions online is
generally not feasible.
a firewall.
intranet.
employees.
C
C
It requires considerable human involvement.
EDI.
give managers a big picture, strategic view of

an organization.
a very high volume of data.
their lack of historical data.
a data warehouse.
can find out what services are and are not

covered by her health plan.
An HIN is available only tproviders, while an HIE

is accessible by the general public.
B
The electronic medical record (EMR).
A
physicians.
B
The PHR is usually in paper format.
an intranet.
Encounter reports but not claims are submitted

by the provider.
A
When the provider is compensated by fee-forservice.
hospitals and most (but not all) healthcare

professionals.
50 t60 percent.
It can handle only claims submitted

electronically.
reviewer.
reviewing and adjudicating claims not processed

electronically.
C
CPT
HCPCS.
A
A
automatically denied.
The service is not covered under the members

benefit package.
A
A health plan has nmedical malpractice liability
for actions by its providers.
B
a person is covered by more than one health
plan.
are short and simple.
C
C
ensuring that insurers handle claims fairly and

promptly.
administrative matters such as benefits, costsharing, and authorization.

all members.
B
B
Email.
ACD.
Tanswer routine questions and requests.
Email has almost entirely replaced regular mail B

Tcomply with regulations, maintain member
satisfaction, avoid bad publicity, and reduce
appeals.
are subject taccreditation requirements but not

usually regulation.
B
An outside third party.
She may have the right tappeal ta government

agency or an external review organization.
Performance measures and complaint

monitoring.
Members whhave recently received services, all

members, and former members.
C
Outside companies only, as required by
regulation and accrediting bodies.
Among plan types, small PPOs are least likely

thave a dedicated member services
department.
A complex benefit structure.
Their training is almost always on the job and

rarely involves formal instruction.
CTI systems can provide information for

performance management.
wait time.
Error rate.
Average time per contact.
price-fixing.
a tying arrangement.
The establishment of standards for provider

networks.
all health plans.
An employer health plan is regulated by the

federal government, and any insurer involved is
also regulated by the federal government.
B
may sue in federal court, giving them the
opportunity to obtain punitive damages.
for up to 18 months.
He has rights if Lones employment is

terminated, she dies, or they are divorced.
Noah pays the full cost of coverage, but the

employer pays all administrative costs.
All HMOs must meet the standards of the Act.
may not decline to offer health coverage to

older employees but may charge them more.
unpaid leave, not including health coverage.
Protecting healthcare information.

the group market only.
B
B
have been without coverage for at least one

year.
They must have guaranteed renewability.
health plans only.
Patients are allowed to request that restrictions

be placed on the accessibility and use of
protected health information.
A
The requirement that most people have health
coverage or pay a tax penalty.
Most of the major components become

operational in 2014, but some provisions
ginteffect earlier or later.
havetpay fines.
encouraged but not required tsponsor health

coverage.
not required tsponsor health coverage.
cost-sharing payments only.
Premiums based on age.
Age.
At the state level.

protect providers from unfair compensation
systems.
Intervene in the plans operations, take over its
management, or liquidate it.
terminate and liquidate the plan.
B
A
C
A
quality assurance.
HMOs but not PPOs or EPOs.
HMO.
All have.
is regulated under insurance laws.
Only a few states license them, require
certification, or regulate them.
A
B
C
A
A
Most states have various requirements including

a certificate of authority.
C
If a provider meets a plans credentialing
criteria, she must be contracted by the plan.
It preempts any existing state laws related

tmedical records or the privacy of health or
insurance information.
Part A (hospital coverage) only.
A
A
tprovide prescription drug coverage tMedicare

beneficiaries.
made available tMedicare beneficiaries at

nextra cost.
pay nothing out of their own pockets unless

they stay more than 60 days.
for a limited time tthose recovering from an

illness or injury.
but all pay a premium.

must be total and short-term.
Medicare payroll taxes.
A
B
C
Only limited services are covered, and only

when restrictive conditions are met.
an annual deductible and coinsurance for most

items.
everyone pays a premium.

everyone pays the same amount.
Most people are automatically enrolled in
Medicare when they become eligible.
C
B
C
B
No, he cannot.
a supplement toriginal Medicare.
coverage that may be more or less extensive
than Part A and Part B.
nMA plans.
Premiums and cost-sharing payments are the
same for all plans.
B
B
B
B
by private-sector prescription drug plans (PDPs) C

and MA plans.
may provide any benefit package they wish.
PDPs may have different deductibles (or

ndeductible), and coinsurance and copayment
amounts vary.
B
a percentage of costs.
Yes, she can, and she will pay the same

premium.
B
It has been steadily rising over the past decade.
MMA in 2003.
B
Benefits provided by plans.
Plan design.
Medicare Part A and B or Medicare Advantage.
Dental care and dentures.
all provide the same benefit package.
A
B
A
B
B
A
No, it cannot dthis under any circumstances.

vary widely from state To state.
primarily tlow-income children, pregnant

women, elderly and disabled people. and a few
parents.
C
only tlow-income children and a few pregnant
women.
Medicaid.
cannot afford private insurance but dnot qualify

for Medicaid.
C
Alexs familys income is about twice the FPL.
and most do.
premiums but not copayments can be charged. A
increased.
A substantial minority.
A state may not enroll a Medicaid recipient in

managed care without her consent.
There is a great deal of movement in and out of

Medicaid.
B
A majority.
both Medicaid and CHIP recipients, although it

may be voluntary.
a large number of health plans that employees

choose from.
traditional fee-for-service insurance only.

must all offer the same benefit package.
A
A
active and retired members of the uniformed

services and their spouses and dependent
children.
fee-for-service insurance or HMcoverage.
C
C
Only retirees.
A federal program that provides benefits for

work-related injuries and illnesses.
lost income only.
B
A
Deductibles and copayments.
whether or not the employer is at fault for her

injury or illness, but even if the employer is at
fault, she cannot sue it for damages.
Which is noWhich is noHigher pre Core contriGreater accA

Higher pre Most CDHPs
a health man individuhigh-deduct
C
Core contriCompared about
to
the higher.
lower.
C
Greater accAn FSA
may be coumust be comust be coA
A
How populaOnly a mino
Only a mino
Most worker
B
Which stat If an emploEmployeesAccount
c
balB
Most CDHPs
Which stat Accounts be
To be eligi An employer
C
a health mWhat portioAbout a thiOnly a few About half.B
an individuAn HSA off annual roll full portab annual roll B
high-deductible health plan.
C
Compared to traditional health coverage, the premiums of high-deductible healt

about the same.
higher.
lower.
C
An FSA
may be coupled with an employer health plan or may be stand-alone.
must be coupled with some type of employer-sponsored health plan.
must be coupled with an HDHP.
A
How popular are FSAs?

Only a minority of workers have access to them, but a large majority of those pa
Only a minority of workers have access to them, and most of those do not partic
Most workers have access to them, but only a minority participates.
B
Which statement is true about FSAs?
If an employee leaves an employer, he recerves the balance of his FSA.
Employees can make contributions with pretax dollars.
Account balances are rolled over from year to year and earn interest.
B
Which statement is true about HRAs?
Accounts belong to the employee and are fully portable.
To be eligible, an employee must be covered by an HDHP.
An employer may offer annual rollover of funds.
C
What portion of workers is covered by an HRA?
About a third.
Only a few percent.
About half.
B
An HSA offers
annual rollover, tax-free investment growth of account funds, and limited portab
full portability, annual rollover, and tax-free investment growth of account funds
annual rollover and full portability, but not tax-free investment growth of accoun
B
of high-deductible health plans are generally
e stand-alone.
d health plan.
arge majority of those participate.

ost of those do not participate.
participates.
ance of his FSA.
earn interest.
unds, and limited portability.

growth of account funds.
stment growth of account funds.
8
9
5
10
11

Evolution of Health Plans and Managed Care Models

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Evolution of Health Plans and Managed Care Models

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Number

A health plan can best be defined as an organization that

For an HMO, which was not an advantage of federal qualification?

The HMO Act of 1973

In the 1990s HMOs

Jacob must pay $2,000 in healthcare expenses each year before he

What happens in adverse selection?

Coordination of benefits is designed to

Coverage of preventive care is

In this course health plan is defined as any entity that

What is the trend in health plan products?

Jacob pays 20 percent of the cost of a hospital stay. This is

In traditional indemnity health insurance, the main

A member is hospitalized, her case is classified based

A hospital is paid a set amount for each day a plan

A group of providers is paid a single amount for all the

A plan holds back a percentage of PCPs monthly

A plan pays money into a pool to cover hospitalization.

If a doctor meets certain performance targets related

Which compensation arrangement involves the most

Which compensation arrangement involves the least

2 The HMO Act of 1973

4 Which is not a key characteristic of an HMO?

Which is an employer most likely to consider in

6 A person enrolls in an HMO

7 HMOs were traditionally marketed to

Compared to other heafth plan types, in HMOs member

10 HMOs typically provide

11 An HMO provides medical care to its members by

In building and maintaining an HMO network, the

To see a specialist, must an HMO member obtain a

15 Do HMOs cover out-of-network services?

16 How are HMOs usually paid for providing healthcare?

Which is not a common HMO compensation

A physician is compensated by an HMO by capitation,

Which utilization management technique is used

In the area of quality management. HMOs are subject

1 Which statement best describes an open-panel HMO?

2 Which is true about a closed-panel HMO?

3 In an open-access HMO, members

4 Which is true about closed-access HMOs?

An HMO pays a doctor for his services based on a fee

An HMO pays a doctor a certain amount per member

In which compensation method do physicians assume

8 A mixed model HMO is one that

10 In an IPA model HMO, physicians are usually

In which HMO model does each doctor manage her own

12 How are IPA physicians most commonly compensated?

13 Which is a disadvantage of the IPA model HMO?

14 In a staff model HMO, physicians are normally

In which HMO model do doctors normally work in a

How do staff model HMOs normally compensate

17 Which is not an advantage of a staff model HMO?

PPO members receive

Providers contracting with PPOs

About what percentage of US. Adults experience some sort of

Douglas is in a substance abuse program. He spends most of his

EPOs are generally like PPOs except that

Lilly receives 10 hours of therapy a week at a psychologists office,

Do pharmacy benefits management (PBM) plans concern

A PBM notifies a doctor that he is prescribing a certain drug much

A PBM requires physicians to obtain certification of medical necessity