Deck 2: Understanding Managed Care: Insurance Plans

Question 1

The type of managed care plan in which members can only obtain care from providers within the network is the:

A)health maintenance organization (HMO).
B)preferred provider organization (PPO).
C)point-of-service (POS).
D)indemnity.

Answer 1

health maintenance organization (HMO).

Question 2

Terms used to refer to fees in an insurance contract include all of the following EXCEPT:

A)customary.
B)ordinary.
C)reasonable.
D)usual.

Answer 2

ordinary.

Question 3

As government program healthcare costs increased, federal and state governments:

A)increased premiums.
B)increased taxes.
C)increased deductibles.
D)decreased benefits.

Answer 3

increased taxes.

Question 4

The purpose of a withhold program is to:

A)encourage providers to use cost-effective methods.
B)reward physicians for ordering extensive tests.
C)discourage preventive care.
D)promote the use of specialty physicians.

Question 5

To determine the amount due from a patient, it is necessary to know the:

A)billed amount.
B)allowed amount.
C)adjusted amount.
D)diagnostic code.

Question 6

Managed care systems ensure the delivery of high-quality care while managing costs through:

A)provider networks and discounted fees for services.
B)provider networks and regular premium increases.
C)prohibiting the use of out-of-network providers.
D)discounted fees for services and mandatory high deductibles across all health plans.

Question 7

The major types of managed care plans are:

A)health maintenance organization (HMO) and preferred provider organization (PPO).
B)preferred provider organization (PPO), point-of-service (POS), and indemnity.
C)health maintenance organization (HMO), preferred provider organization (PPO), and point-of-service (POS).
D)health maintenance organization (HMO) and point-of-service (POS).

Question 8

The percentage of the provider's fees that the patient has to pay is known as:

A)copayment.
B)coinsurance.
C)deductible.
D)stoploss.

Question 9

In a managed care organization (MCO), a primary care physician (PCP) is typically any of the following EXCEPT:

A)general practitioner.
B)family practitioner.
C)dermatologist.
D)internist.

Question 10

The goals of managed care include all of the following EXCEPT:

A)medical care that is medically necessary and appropriate based on the patient's condition and diagnosis.
B)medical care rendered by the most appropriate provider.
C)medical care rendered in the most appropriate setting.
D)medical care rendered in the most profitable setting.

Question 11

Utilization guidelines are used to:

A)determine if services are medically necessary.
B)provide physician offices with more paperwork.
C)determine if the provider is in the network.
D)determine if an employee is covered under the plan.

Question 12

The subscriber in a health maintenance organization (HMO) can also be called a(n):

A)employer or policyholder.
B)policyholder or member.
C)member or provider.
D)patient or carrier.

Question 13

Which of the following plan types does not use a network of providers?

A)Indemnity plan
B)PPO plan
C)HMO plan
D)EPO plan

Question 14

To avoid the higher costs of healthcare, employers:

A)hired younger employees.
B)refused to extend health insurance to employees.
C)increased employee premium contributions.
D)decreased the number of health plans available to employees.

Question 15

During the first half of the 20th century, most doctors were paid directly by:

A)preferred provider organizations (PPOs).
B)health maintenance organizations (HMOs).
C)government programs.
D)individuals.

Question 16

The fixed dollar amount a member pays at each office visit or hospital encounter is the:

A)copayment.
B)coinsurance.
C)deductible.
D)premium.

Question 17

The most restrictive type of managed care plan is the:

A)exclusive provider organization (EPO).
B)health maintenance organization (HMO).
C)individual practice association (IPA).
D)preferred provider organization (PPO).

Question 18

The HMO Act of 1973 used federal funds for the purpose of:

A)promoting health maintenance organizations (HMOs).
B)increasing restrictions on HMOs.
C)developing new managed care corporations.
D)establishing a regulatory board for HMOs.

Question 19

The duties of a primary care physician (PCP) in a health maintenance organization (HMO) include:

A)acting as a gatekeeper to services.
B)coordinating patient care.
C)referring patients to specialists.
D)all of the above.

Question 20

Primary care physicians (PCPs) in a health maintenance organization (HMO) can include:

A)family practice, general practice, internal medicine, and OB/GYN.
B)family practice and general practice only.
C)family practice, general practice, and internal medicine only.
D)family practice, general practice, and OB/GYN only.

Question 21

An exclusive provider organization (EPO) is similar to a preferred provider organization (PPO) because they both have:

A)a limited provider network.
B)gatekeepers.
C)payment by capitation.
D)flexible benefit design.

Question 22

Which of the following is true of self-insured plans?

A)They are regulated by the Employee Retirement Income Security Act (ERISA).
B)They use third-party administrators.
C)They assume the financial risk of providing benefits for employees or members.
D)They do not abide by state insurance regulations.

Question 23

In comparing group and individual insurance, group insurance provides:

A)fewer benefits and lower costs.
B)fewer benefits and higher costs.
C)better benefits and higher costs.
D)better benefits and lower costs.

Question 24

A point-of-service (POS) plan allows members to:

A)choose a health maintenance organization (HMO) or preferred provider organization (PPO) option each time they seek care.
B)receive medical care from any in-network or non-network provider.
C)do both a and b.
D)do neither a nor b.

Question 25

Features of a preferred provider organization (PPO) includes which of the following?

A)It contracts with healthcare providers to form a network.
B)It offers members financial incentives to use network providers.
C)A PCP arranges, provides, coordinates, and authorizes all aspects of a member's healthcare.
D)It employs salaried physicians who treat members in facilities it owns and operates.

Question 26

Which of the following is a characteristic of a preferred provider organization (PPO)?

A)It includes a contracted network of providers.
B)Members select a primary care physician (PCP) as a gatekeeper.
C)The plan is more restrictive than a health maintenance organization (HMO).
D)Members must obtain referrals to see a specialist.

Question 27

By accepting lower payments from MCOs, physicians are forced to see more patients each day in order to:

A)deliver MCO-required preventive care.
B)minimize malpractice suits.
C)enroll more members in the health plan.
D)maintain their income due to lower payments.

Question 28

Health maintenance organization (HMO) plans add a point-of-service (POS) option to:

A)lower the cost of the plan.
B)lower the benefits of the plan.
C)provide physicians with more choice.
D)provide members with more choice.

Question 29

Incentives for preferred provider organization (PPO) members to use network providers include:

A)lower out-of-pocket costs.
B)reduced benefits.
C)higher out-of-pocket costs.
D)ability to obtain care more quickly.

Question 30

Disadvantages of managed care include all of the following EXCEPT:

A)it includes disease management programs based on recent research.
B)it creates an increased administrative burden.
C)it may require physicians to carry additional malpractice insurance.
D)it restricts physicians' latitude in caring for patients.

Question 31

Group insurance is issued to an employer to provide coverage for:

A)employees only.
B)employees and spouses only.
C)employees and children only.
D)employees and all their dependents.

Question 32

The type of health maintenance organization (HMO) plan that involves contracting with individual physicians to create a healthcare delivery system is a(n):

A)group model.
B)individual practice association (IPA) model.
C)network model.
D)staff model.

Question 33

All of the following are types of health maintenance organizations (HMOs) EXCEPT the:

A)group model.
B)preferred provider model.
C)individual practice association.
D)open access model.

Question 34

The type of health maintenance organization (HMO) that contracts with more than one community-based multispecialty group to provide wider geographical coverage is a(n):

A)group model.
B)individual practice association (IPA) model.
C)network model.
D)staff model.

Question 35

Which of the following is true of an exclusive provider organization (EPO)?

A)It is regulated under insurance statutes.
B)It is regulated under federal and state health maintenance organization (HMO) regulations.
C)Premiums are lower than with a health maintenance organization (HMO).
D)Premiums are higher than with a preferred provider organization (PPO).

Question 36

The type of health maintenance organization (HMO) plan that employs salaried physicians who treat members in facilities owned and operated by the HMO is a(n):

A)group model.
B)individual practice association (IPA) model.
C)network model.
D)staff model.

Question 37

Physicians in an individual practice association (IPA) health maintenance organization (HMO):

A)are typically capitated.
B)see both members and nonmembers of the HMO.
C)must act as primary care physicians (PCPs).
D)contract only with managed care organizations (MCOs).

Question 38

A characteristic of a staff model health maintenance organization (HMO) is that it:

A)contracts with a multispecialty physician group.
B)is a decentralized healthcare delivery system.
C)employs salaried physicians.
D)agrees to contractual discounts with physicians.

Question 39

Advantages of managed care include all of the following EXCEPT:

A)hospitals and physicians provide services more efficiently.
B)providers strive to improve the quality of their care.
C)physicians run the risk of adverse selection by enrollees.
D)data is collected and analyzed to measure health outcomes.

Question 40

Physician-hospital organizations (PHOs) may include:

A)nursing homes.
B)laboratories.
C)surgery centers.
D)all of the above.

Question 41

Because of managed care, providers have been required to revamp the way they operate their businesses and methods of patient care.

Question 42

If a physician has ordered surgery for a patient, a managed care organization (MCO) case manager may disallow an inpatient stay if the MCO guidelines designate the procedure as best suited for outpatient care.

Question 43

The type of policy that would provide coverage for custodial care in a nursing home is:

A)short-term health insurance.
B)long-term care insurance.
C)Medicare.
D)supplemental insurance.

Question 44

An insurance identification card usually includes all of the following information EXCEPT:

A)name of the insurance policy or health plan.
B)name of the subscriber.
C)detailed benefit information.
D)insurance policy number.

Question 45

Which of the following is true of COBRA insurance?

A)It is available to former employees of businesses that employ 100 or more workers.
B)It is available to former employees of businesses that employ 50 or more workers.
C)It is available to former employees of businesses that employ 20 or more workers.
D)It is available to former employees of businesses that employ 5 or more workers.

Question 46

Which type of statement signed by the patient authorizes his or her insurance company to send payments directly to the provider?

A)Assignment of benefits
B)Authorization to release protected health information
C)Advance directive
D)Beneficiary designation

Question 47

Managed care is a method of controlling healthcare costs and the delivery of care.

Question 48

Which of the following is true of managed care contracts with providers?

A)They are irrevocable by the provider.
B)They are irrevocable by the managed care organization (MCO).
C)They are usually 1-year contracts.
D)Providers must provide a 1-year notice to cancel the contract.

Question 49

A physician who coordinates a patient's care and refers patients to specialists is a(n):

A)preferred provider physician (PPP).
B)referring gatekeeper.
C)primary care physician (PCP).
D)primary physician coordinator (PPC).

Question 50

In 2011, the new health care reform law required insurers to offer dependent coverage for adult children up to age ___ to be included on parents' coverage.

A)26
B)21
C)18
D)24

Question 51

Providers who contract with managed care organizations (MCOs) must provide care according to the MCO's policies and guidelines in order to:

A)increase revenue.
B)increase patient load.
C)be listed in the provider directory.
D)be paid for services provided.

Question 52

Examples
of individuals who would qualify for COBRA include:

A)employees who are laid off from their jobs.
B)employees who quit their jobs.
C)children of covered employees who are no longer full-time students.
D)divorced ex-spouses of covered employees.

Question 53

The type of insurance that provides coverage for a designated period of time is:

A)medical insurance.
B)special risk.
C)short-term health insurance.
D)long-term care.

Question 54

All health insurance contracts define medical necessity in the same way.

Question 55

In a managed care organization (MCO) contract, the provider will bill the patient the difference between the standard fee and the contractual or discount amount.

Question 56

The majority of payments received in a medical facility come from insurance carriers.

Question 57

The type of insurance coverage that pays a per diem for each day a patient is in the hospital is:

A)hospital.
B)hospital indemnity.
C)medical.
D)major medical.

Question 58

The first example of a managed care plan is the Kaiser plan for shipyards and steel mill employees in 1942.

Question 59

Insurance information obtained by the medical office specialist is:

A)stored in the patient's medical record.
B)stored separately from clinical information.
C)updated on a regular basis.
D)verified via phone with the insurance company.

Question 60

The type of insurance coverage that provides protection against a specific type of accident or illness is:

A)outpatient.
B)major medical.
C)special risk.
D)catastrophic health insurance.

Question 61

An individual or facility providing medical care is called the __________ .

Question 62

Point-of-service (POS) plans require members to select a primary care physician (PCP).

Question 63

The restrictions in a health maintenance organization (HMO) reduce members' premium costs.

Question 64

Managed care is a system that controls the __________ and __________ of health services to members.

Question 65

Point-of-service (POS) plans are becoming more popular because they offer more flexibility and freedom of choice than do standard health maintenance organizations (HMOs).

Question 66

Primary care physicians (PCPs) are sometimes referred to as gatekeepers because patients with HMO plans must obtain referrals from them to see specialists.

Question 67

Traditional insurance plans tend to cover more preventive services than health maintenance organizations (HMOs).

Question 68

A managed care organization (MCO) collects data on care delivery, such as identifying the percentage of children in a health maintenance organization (HMO) who have been immunized.

Question 69

A goal of managed care is for the patient to receive care in the most appropriate and most restrictive setting.

Question 70

Preferred provider organization (PPO) members typically do not have to obtain a referral to see a specialist.

Question 71

A(n) __________ medical condition is a diagnosis for which the insured has previously been treated and that may not be covered under the terms of some insurance plans.

Question 72

It is possible for a health maintenance organization (HMO) member to receive care from a non-network provider or facility in an emergency situation.

Question 73

When a provider agrees to receive payment directly from the patient's insurance carrier, it is accepting __________ .

Question 74

The amount that insured individuals have to pay out of pocket before insurance begins paying is called the __________ .

Question 75

A(n) __________ model health maintenance organization (HMO) contracts with more than one community-based multispecialty group to provide wider geographical coverage.

Question 76

If a member in a health maintenance organization (HMO) sees a specialist without a referral from his or her PCP, the HMO will not pay for the service.

Question 77

A point-of-service (POS) plan allows members to choose a health maintenance organization (HMO) or preferred provider organization (PPO) once a year at open enrollment.

Question 78

A primary care physician (PCP) in a health maintenance organization (HMO) can be an OB/GYN.

Question 79

Written approval from a managed care plan or insurer before a patient is admitted to a hospital or receives a particular treatment is known as __________ .

Question 80

Preferred provider organization (PPO) members pay less out of pocket for medical services from a contracted provider than from a non-network provider.