The paragraph below contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the paragraph. Then select the answer choice containing the two terms you have selected.
The Harbor Health Plan convened a litigation
Which of the following features differentiates a 'Clinic without walls1 from a consolidated medical group?
The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential
In order to be more effective, changes to structure and processes must be carefully
The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the highest and lowest rates that a health plan charges small groups, to a particular ratio.
According to the Model Act, for example, if the lowest rate an HMO charges a small group for a given set of medical benefits is $40, then the maximum rate the HMO can charge for the same set of benefits is
Which of the following is NOT a reason for conducting utilization reviews?
What are the characteristics that the underwriter has to consider while determining the premium rate for health insurance coverage for a group?
The NAIC adopted the HMO Model Act in order to provide a system of ongoing regulatory monitoring of HMOs. All of the following statements are correct about the HMO Model Act EXCEPT that it:
Wellborne HMO provides health-related information to its plan members through an Internet Web site. Laura Knight, a Wellborne plan member, visited Wellborne's Web site to gather uptodate information about the risks and benefits of various treatment option
The following types of CDHPs allow federal tax advantages including the ability to roll funds from one year to the next:
Exclusive provider organizations (EPO) is similar and operates like a PPO in administration, structure but however in an EPO an out-of-network care is
To set up and contribute to an HSA, an individual must:
The following statements apply to health reimbursement arrangements. Select the answer choice that contains the correct statement.
Two MCOs in a single service area divided purchasers into two groups and agreed to each market their products to only one purchaser group. This information indicates that these two MCOs violated antitrust requirements because they engaged in an activity k
Keith Murray is a 45 year old chartered accountant & is employed in Livingstone consultancy firm. He has been paying payroll taxes for the past 15 years. Which of the following statements is true regarding Medicare Part A entitlement?
The Oriole MCO uses a typical diagnosis-related groups (DRGs) payment method to reimburse the Isle Hospital for its treatment of Oriole members. Under the DRG payment method, whenever an Oriole member is hospitalized at Isle, Oriole pays Isle
Which of the following statements about the Title VII of the Civil Rights Act is WRONG?
The process that Mr. Sybex used to identify and classify the risk represented by the Koster Group so that Intuitive can charge premiums that are adequate to cover its expected costs is known as
When determining the premium rates it will charge a particular group, the Blue Jay Health Plan used a rating method known as community rating by class (CRC). Under this rating method, Blue Jay
Managed behavioral health organizations (MBHOs) use several strategies to manage the delivery of behavioral healthcare services. The following statements are about these strategies.
Select the answer choice that contains the correct statement.
Several marketplace factors helped fuel the movement toward consumer choice. Which one of the following statements is NOT accurate with regard to these factors?
The following sentence contains an incomplete statement with two missing words. Select the answer choice that contains the words that correctly fill in the missing blanks.
At its core, consumer choice involves empowering healthcare consumers to play a __
The following programs are part of the Alcove MCO's utilization management (UM) program:
With regard to the UM programs, it is most likely cor
The following programs are typically included in TRICARE medical management efforts:
The following statement can be correctly made about Medicare Advantage eligibility:
Many HMOs are compensated for the delivery of healthcare to members under a prepaid care arrangement. Under a prepaid care arrangement, a plan member typically pays a
The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.
The Courtland PPO maintains computerized records that include clinical, demographic, and administrative data about individual plan members. The data in these records is available to plan providers, ancillary service departments, pharmacies, and others inv
The administrative simplification standards described under Title II of HIPAA include privacy standards to control the use and disclosure of health information. In general, these privacy standards prohibit
One ethical principle in health plans is the principle of non-malfeasance, which holds that health plans and their providers:
Specialty services that have certain characteristics generally are good candidates for managed care approaches. These characteristics generally include that the specialty service should have
John Kerry's employer has contracted to receive healthcare for its employees from the Democratic Healthcare System. Mr. Kerry visits his PCP, who sends him to have some blood tests. The PCP then refers Mr. Kerry to a specialist who hospitalizes him for on
One true statement regarding ethics and laws is that the values of a community are reflected in
One way in which health plans differ from traditional indemnity plans is that health plans typically
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing i
Some providers use electronic medical records (EMRs) to document their patients' care in an electronic form. The following statement(s) can correctly be made about EMRs:
The application of health plan principles to workers' compensation insurance programs has presented some unique challenges because of the differences between health plan for traditional group healthcare and workers' compensation. One key difference is that
PBM plans operate under several types of contractual arrangements. Under one contractual arrangement, the PBM plan and the employer agree on a target cost per employee per month. If the actual cost per employee per month is greater than the target cost, t
Bart Vereen is insured by both a traditional indemnity health insurance plan, which is his primary plan, and a managed care plan. Both plans have a typical coordination of benefits (COB) provision, but neither plan has a nonduplication of benefits provision
By definition, a health plan's network refers to the
Al Marak, a member of the Frazier Health Plan, has asked for a typical Level One appeal of a decision that Frazier made regarding Mr. Marak's coverage. One true statement about this Level One appeal is that
Identify the CORRECT statement(s):
(A) Smaller the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.
(B) Gender of the group's participants has no effect on the likelihood of loss.
In health plan terminology, demand management, as used by health plans, can best be described as
Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokers
A public employer, such as a municipality or county government would be considered which of the following?
Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organizations typically
In response to the demand for a method of assessing outcomes, accrediting organizations and other government and commercial groups have developed quantitative measures of quality that consumers, purchasers, regulators, and others can use to compare health
During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a group’s geographic location, the size and gender mix of the group, and the level of participation in the grou
In the paragraph below, a sentence contains two pairs of words enclosed in parentheses. Determine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you have chosen. Many pharmacy benefit
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
From the following choices, choose the definition that best matches the term Screening
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
In large health plans, management functions such as provider recruiting, credentialing, contracting, provider service, and performance management for providers are typically the responsibility of the
For providers, integration occurs when two or more previously separate providers combine under common ownership or control, or when two or more providers combine business operations that they previously carried out separately and independently. Such provi
Health plans require utilization review for all services administered by its participating physicians.