Deck 2: Understanding Managed Care: Insurance Plans

Question 1

The HMO Act of 1973 used federal funds to:

A) promote health maintenance organizations (HMOs).
B) increase restrictions on (HMOs).
C) develope new managed care corporations.
D) establish a regulatory board for (HMOs).

Answer 1

promote health maintenance organizations (HMOs).

Question 2

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

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

Answer 2

coinsurance.

Question 3

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.

Answer 3

encourage providers to use cost-effective methods.

Question 4

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 5

All the following are true regarding HMOs EXCEPT:

A) regulated by federal and state law.
B) encourage preventative health services.
C) the least restrictive type of care plan.
D) require a referral for specialist services.

Question 6

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 7

Utilization guidelines are used to:

A) determine if services are medically necessary.
B) determine if care is provided by the most appropriate provider.
C) determine if the provider is in the network.
D) determine if an employee is covered under the plan.

Question 8

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 9

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 10

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

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

Question 11

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 12

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

A) general practitioner.
B) family practitioner.
C) dermatologist.
D) internal medicine doctor.

Question 13

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 14

Which is true regarding health reimbursement arrangements (HRAs)?

A) unused reimbursements cannot be accessed.
B) participation ends upon termination of employment.
C) expenses must have incurred during the coverage period.
D) the funds cannot be used for dental and vision care.

Question 15

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 16

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 17

Beginning in 2014, employers with 50 or more workers who do not offer coverage will be fined what amount for each employee?

A) $250.
B) $500.
C) $1,000.
D) $2,000.

Question 18

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 19

Before managed care most doctors were paid directly by:

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

Question 20

As the costs of government healthcare programs increased, federal and state governments:

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

Question 21

How long does a physician have to give a written notice before closing the practice to members of a MCO plan?

A) 30-60 days.
B) 60-90 days.
C) 3-6 months.
D) 6-12 months.

Question 22

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 23

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) a flexible benefit design.

Question 24

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 25

All the following are true regarding the Affordable Care Act EXCEPT:

A) It is also known as Obamacare.
B) It cannot deny coverage due to a pre-existing condition.
C) It offers five different types of government plans.
D) It requires people to prove citizenship before receiving services.

Question 26

Physician-hospital organizations (PHOs) may include:

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

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.

Question 28

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 29

Features of a preferred provider organization (PPO) include which of the following? (Select all that apply)

A) It contracts with healthcare providers to form a network.
B) It offers members financial incentives to use network providers.
C) It usually rewards providers for managing the cost of care.
D) It employs salaried physicians who treat members in facilities it owns and operates.

Question 30

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 unfavorable evaluations by enrollees.
D) Data is collected and analyzed to measure health outcomes.

Question 31

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 32

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 33

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 34

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 35

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 provider choice.

Question 36

When compared to 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 37

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.
E) all of the above.

Question 38

All of the following are government plans under the Affordable Care Act EXCEPT:

A) catastrophic.
B) silver.
C) bronze.
D) titanium.

Question 39

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 40

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 41

Which is true regarding a flexible spending account (FSA)?

A) The money deducted is subject to taxes.
B) The money can be withdrawn without penalty.
C) Funds are lost when the plan year is over.
D) It is used exclusively as a managed care plan.

Question 42

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 43

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 44

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 45

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

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

Question 46

The Patient Protection and Affordable Care Act requires that all individuals have health insurance beginning in:

A) 2012
B) 2013
C) 2014
D) 2015

Question 47

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) major medical insurance.
D) special risk insurance.

Question 48

HIPAA was created in 1999.

Question 49

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

Question 50

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 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.
E) all of the above.

Question 53

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

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

Question 54

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 55

Consolidated Omnibus Reconciliation Act (COBRA) insurance is available to former employees of businesses that have a minimum of:

A) 5 employees.
B) 20 employees.
C) 50 employees.
D) 100 employees.

Question 56

Insurance information obtained by the medical office specialist:

A) should be kept in the medical record.
B) updated on a regular basis.
C) verified with the insurance company.
D) all of the above.

Question 57

At what age can an individual withdraw money from a health savings account (HSA) without penalty?

A) 18
B) 21
C) 65
D) 72

Question 58

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 59

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

Question 60

In 2011, what percentage of all U.S. citizens of working age experienced a gap in medical health insurance coverage?

A) 13%
B) 26%
C) 38%
D) 49%

Question 61

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

Question 62

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

Question 63

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 64

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

Question 65

An integrated delivery system (IDS) is a network of healthcare organizations under a parent holding company.

Question 66

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

Question 67

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

Question 68

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 69

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

Question 70

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

Question 71

Medical healthcare coverage cost in 2012 averaged $6,000 per employee.

Question 72

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

Question 73

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

Question 74

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 75

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 76

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

Question 77

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 78

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

Question 79

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

Question 80

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.