Question 1 of 75
Which way of accessing behavioral healthcare services used to be common but no longer is?
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Direct access.
Question 2 of 75
Each patient has a strong, ongoing relationship with a personal physician who is responsible for providing or
coordinating her care. This is the core principle of
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a medical foundation.
Question 3 of 75
In traditional indemnity health insurance, how are healthcare providers paid by the insurer?
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Capitation.
Negotiated rates.
Salary.
Fee-for-service.
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Question 4 of 75
In the health plan market, large employers
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Question 5 of 75
Under which compensation arrangement do providers assume the greatest financial risk?
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Discounted fee-for-service.
Capitation.
Question 6 of 75
A history of an individuals health and his encounters with the healthcare system that is owned by the individual is
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Question 7 of 75
What happens when adverse selection occurs?
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People more likely to need healthcare are more likely to obtain health coverage.
People less likely to need healthcare are more likely to obtain health coverage.
People who have health coverage are more likely to use healthcare services.
Physicians who provide inferior care are more likely to join a health plan network.
Question 8 of 75
Which statement about health plan claims processing is true?
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A plan must pay benefits for a medically necessary service even if authorization was not obtained.
A plan must process and investigate claims within timeframes set by regulation.
A plan may not deny a claim because it was submitted too long after the service was provided.
A health plan identifies another plan with high immunization rates among children and adopts its practices in this
area. This is an example of
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provider profiling.
peer review.
benchmarking.
Question 10 of 75
A health plans utilization review staff want to know how long a certain member can be expected to remain in the
hospital. They are most likely to use
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experience-based criteria.
length-of-stay guidelines.
utilization guidelines.
site-appropriateness listings.
Question 11 of 75
For what type of group is community rating least commonly used?
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Small groups.
Medium-size groups.
Employer groups.
Large groups.
Question 12 of 75
Which HMO model has high facility costs but greatest control of care management and quality?
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Network model.
Group model.
IPA model.
Staff model.
Question 13 of 75
Who regulates HMOs?
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Both the federal government and the states heavily regulate HMOs.
HMOs are regulated by the states but not the federal government.
Neither the federal government nor the states substantially regulate HMOs.
HMOs are regulated under the federal HMO Act but not state laws.
Question 14 of 75
Which of these is a provision of the Affordable Care Act of 2010 (ACA) (healthcare reform)?
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Most people will have to have health coverage or pay a tax penalty.
Question 15 of 75
The two main components typical of a consumer-directed health plan (CDHP) are
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Question 16 of 75
In which HMO model is each physician an independent practitioner with her own office?
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Group model.
Network model.
IPA model.
Staff model.
Question 17 of 75
In establishing and maintaining provider networks, health plans generally try to ensure member access to care by
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Question 18 of 75
Which type of dental plan has the least choice of providers but generally costs the least?
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POS.
Indemnity.
PPO.
HMO.
Question 19 of 75
Whether a health plan has an open panel or a closed panel depends on whether
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Question 20 of 75
Which is a common position in a health plan but is not common in other types of companies?
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Question 21 of 75
Which statement about trends in health plan products is correct?
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Fewer types of plans are being offered, and the distinctions between them are becoming blurred.
Fewer types of plans are being offered, and the distinctions between them are becoming sharper.
More types of plans are being offered, and the distinctions between them are becoming sharper.
More types of plans are being offered, and the distinctions between them are becoming blurred.
Question 22 of 75
What category of low-income people are not currently covered by Medicaid but will be covered under healthcare
reform?
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Pregnant women.
Childless adults.
Elderly people.
Disabled people.
Question 23 of 75
Managed dental care accounts for
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Question 24 of 75
Which statement about raising capital is correct?
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Mutual companies find it easier than stock companies, and not-for-profit plans find it easier than for-profit plans.
Stock companies find it easier than mutual companies, and for-profit plans find it easier than not-for-profit plans.
Stock companies find it easier than mutual companies, and not-for-profit plans find it easier than for-profit plans.
Mutual companies find it easier than stock companies, and for-profit plans find it easier than not-for-profit plans.
Question 25 of 75
What population is eligible for health coverage from TRICARE?
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Active and retired members of the military and their spouses and dependents.
Question 26 of 75
What does the Affordable Care Act do with regard to healthcare quality?
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It provides quality incentives for Medicare Advantages plans but does not otherwise address quality.
It focuses on cost and does not address quality in any major way.
It sets minimal standards for federal programs but does not address quality in the private sector.
It provides quality incentives for Medicare Advantages plans and includes a variety of other quality improvement
provisions.
Why has the popularity of flexible spending accounts (FSAs) been limited?
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Question 28 of 75
What is the main purpose of the Childrens Health Insurance Program (CHIP)?
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To provide health coverage to children unable to obtain private-sector insurance because of their medical history
or a preexisting condition.
To help pay the health insurance deductibles, coinsurance, and copayments of families with moderate incomes.
To provide financial relief to families who have incurred very large medical expenses for children.
To provide health coverage to children whose families cannot afford private-sector insurance but do not qualify
for Medicaid
SS
Question 29 of 75
Government regulation has the greatest impact on which aspect of health plan data?
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Usability.
Quality.
Volume.
Question 30 of 75
Internal quality standards for health plans are
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Question 31 of 75
Who owns a mutual insurance company?
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A non-profit organization.
Question 32 of 75
Which of these is an example of adverse selection (anti-selection)?
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An employer is located in a large city, where healthcare costs are considerably higher than the national average.
An employer is engaged in a hazardous business, and its employees are more likely than average to be injured
or become ill.
A higher percentage of unhealthy employees enroll in an employers health plan compared to healthy
employees.
A very high percentage of the employees who are eligible for an employers health plan choose to enroll in it.
Question 33 of 75
A health plan projects the cost of providing benefits to a group based partly on the plans rate manual and partly on
the groups experience. This describes
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pooling.
manual rating.
experience rating.
blended rating.
Question 35 of 75
How does electronic data interchange (EDI) differ from e-business?
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EDI is the transfer of batches of data, not back-and-forth exchanges of information about a transaction.
EDI requires considerable human involvement, for instance for data entry.
Question 36 of 75
Which physician-only provider organization is the most integrated?
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Question 37 of 75
Which statement best summarizes the use of the Internet by health plans?
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Few health plan transactions are suitable for being conducted online, but plans do offer information on their
websites.
Health plans have been in the forefront compared to other industries and conduct a wide range of transactions
online.
Few health plan transactions are suitable for being conducted online, so plans have only a small web presence.
Health plans have historically lagged behind compared to other industries but now conduct many transactions
online.
Question 39 of 75
Which type of physician-hospital provider organization is the least integrated?
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Question 40 of 75
In which HMO model are physicians salaried employees working in HMO facilities?
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Network model.
IPA model.
Staff model.
Group model.
SQuestion
41 of 75
Which health plan types generally require a referral from a primary care physician to see a specialist?
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PPOs.
Traditional HMOs.
Question 42 of 75
What is the measurement of how long it takes a health plan member services representative to complete a
transaction requested by a member?
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Wait time.
Turn-around time.
First contact resolution rate.
Call abandonment rate.
Question 43 of 75
In the United States, indemnity health insurance
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has always been and continues to be the predominant form of health coverage.
has historically represented a minority of health coverage but has steadily grown in popularity over the past few
decades.
used to be the predominant form of health coverage but no longer is.
Question 44 of 75
Which of these is a method used in market research?
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Focus groups.
Positioning.
Database marketing.
Branding.
SQuestion
45 of 75
Medicare Part D
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Question 46 of 75
FeelGood Health Plan has a program that educates and supports members who are trying to lose weight, exercise
more, and/or stop smoking. This is a
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self-care program.
wellness program.
Question 47 of 75
What kind of risk does an HMO assume or share?
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Question 48 of 75
Which of these is a feature of a health reimbursement arrangement (HRA)?
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Full portability.
Question 49 of 75
Excelsior Health Plan gives its members information about how to treat minor illnesses and injuries and how to
distinguish them from serious medical conditions. This is
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a self-care program.
shared decision-making.
a wellness program.
disease management.
Question 50 of 75
Most regulation of health plans
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has been at the federal level but after the Affordable Care Act (ACA) will be at the state level.
has been at the state level but after the Affordable Care Act (ACA) will be at the federal level.
Question 51 of 75
A computer program discovers that, based on repeated early refills, a plan member seems to be taking more of a
pain reliever than he should. This is an example of
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physician profiling.
formulary management.
prior authorization.
Question 52 of 75
What are the trends in healthcare quality?
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The definition of quality has become narrower, and employers have taken a more active role in seeking quality.
The definition of quality has become broader, and employers have taken a more active role in seeking quality.
The definition of quality has become narrower, and employers have taken a less active role in seeking quality.
The definition of quality has become broader, and employers have taken a less active role in seeking quality.
Question 53 of 75
An HMO contracts with eight group practices. This is an example of
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Question 54 of 75
What coverage do Medicare Advantage plans provide?
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Medicare Part A and Part B coverage, other benefits, and usually drug benefits.
Question 55 of 75
Which health plan types provide coverage of non-network care, but with higher cost-sharing?
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EPOs.
Traditional HMOs.
Question 56 of 75
Who can make a contribution to a health savings account (HSA)?
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An employer only.
An employer or an employee.
Question 57 of 75
What is the main problem a data warehouse is intended to solve?
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Inaccurate data.
Question 58 of 75
What portion of participants in Medicaid and the Childrens Health Insurance Program (CHIP) are in managed care?
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About half.
A large majority.
A small minority.
About a third.S
Question 59 of 75
What cost-sharing structure is most common in a dental PPO?
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Coinsurance ranging from 20 to 50 percent based on the service, but no deductibles or annual maximums.
An annual maximum ranging from $1,000 to $2,500, but no deductible, coinsurance, or copayments.
Question 60 of 75
Question 61 of 75
Most HMO models may have an open or closed panel. Which HMO model normally has a closed panel?
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Group model.
IPA model.
Network model.
Staff model.
Question 62 of 75
What portion of health plans contract with pharmacy benefits management (PBM) plans?
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A large majority.
About a third.
A small minority.
Question 64 of 75
Which health plan types do not normally pay benefits for out-of-network care?
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Question 63 of 75
Dan has multiple medical conditions. A nurse is assigned to him to assess his needs, design a plan of care, and
coordinate and monitor the services he receives. This describes
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value-based healthcare.
utilization review.
case management.
disease management.
Question 65 of 75
A health plan pays a hospital a certain amount for a hospitalization, according to the classification of the case based
on diagnosis, procedures, and other factors. This describes
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episode-based payments.
Question 66 of 75
A certain percentage of the members of a health plan have received a cholesterol screening. What kind of quality
measure is this?
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Process measure.
Outcomes measure.
Structure measure.
Perception measure.
Question 67 of 75
Under the Affordable Care Act (ACA) (healthcare reform), which may a health plan not consider in setting a persons
premiums?
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Locality.
Health.
Age.
Smoking.
Question 68 of 75
Which is a common HMO compensation arrangement for hospitals but not physicians?
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Discounted fee-for-service.
Fee-for-service.
Capitation.
Question 69 of 75
The percentage of stroke patients who are able to walk and speak normally after two years is
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a process measure.
a perception measure.
an outcomes measure.
a structure measure.
Question 70 of 75
Which is an important factor driving increased healthcare spending?
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Defensive medicine.
Question 71 of 75
In health plans the term network adequacy is usually used to indicate whether
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the number, types, and locations of providers are sufficient to meet member needs.
contract provisions, policies, and procedures comply with laws, regulations, and the standards of accrediting
organizations.
premiums and cost-sharing are sufficient for financial viability.
Question 72 of 75
Who can receive Medicare coverage?
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People 65 or older and younger people with severe, long-term disabilities or a few diseases.
Question 73 of 75
When a health plan compensates a provider by capitation, which generally occurs?
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Question 74 of 75
Under the Federal Employees Health Benefits (FEHB) program, employees
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choose from one HMO, one PPO, and one fee-for-service plan in their state or region.
Question 75 of 75
At the end of the year, if there is more than enough money in a pool to cover specialty care, a health plans primary
care providers (PCPs) receive some of the excess. If there is not enough money to cover costs, they must make up
some of the deficit. This is an example of
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a risk pool.
a withhold.
capitation.