Question 1

Dr. Julia Phram is a cardiologist under contract to Holcomb HMO, Inc., a typical closed-panel plan. The following statements are about this situation. Select the answer choice containing the correct statement.

Accepted Answer

The answer of Dr. Julia Phram is a cardiologist under...

Question 2

Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

Accepted Answer

The answer of Before the Hill Health Maintenance Organization (HMO)...

Question 3

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:

Accepted Answer

Typically, brokers are considered to be an agent of the buyer rather than an agent of the health plan or insurer. This means that they work on behalf of their clients (buyers), and not the insurance company, and are responsible for finding the best plan to meet their clients' needs. However, some states do require brokers to be licensed, and brokers may represent multiple health plans or insurers instead of just one. Brokers are also typically compensated through commissions based on the number of policies they sell.

Question 4

Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

Accepted Answer

The statement that Hill had to meet the state's licensing requirements and financial standards establishes that the state had specific requirements for HMOs operating within it. The fact that Hill had to have an initial net worth of at least $1.5 million indicates that financial standards were one of these requirements.

Question 5

Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:

Accepted Answer

The due process clause in a provider contract typically gives the provider the right to appeal decisions, such as termination with cause, ensuring fairness and a chance to contest the decision.

Question 6

During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, former broken ankle, and high blood pressure. Which of these conditions apply?

Accepted Answer

The answer of During an open enrollment period in 1997,...

Question 7

Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health dictate that staff be onsite at all times. What is needed for this type of care?

Accepted Answer

The answer of Because many patients with behavioral health disorders...

Question 8

Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a 30% coinsurance provision for all healthcare obtained outside the plan's network of providers. In 1998, Ms. Martin became ill while she was on vacation, was hospitalized, and incurred $2,000 for healthcare that she obtained outside her plan's network, but that is covered by the plan. Ms. Martin incurred no other out-of-network expenses during 1998. Of the $2,000 in covered out-of-network expenses that Ms. Martin incurred, she is responsible for paying a total of:

Accepted Answer

Since Ms. Martin's plan includes a $300 deductible, she is responsible for paying that amount first. This leaves $1,700 ($2,000 - $300) in covered expenses remaining. However, because these expenses were obtained outside the plan's network, Ms. Martin is responsible for paying 30% of the remaining $1,700, or $510. Therefore, the total amount Ms. Martin is responsible for paying is $300 + $510 = $810.

Question 9

Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to

Accepted Answer

Primary care physicians (PCPs) typically receive capitation payments, which are fixed monthly amounts per member, while specialists often receive compensation based on discounted fee-for-service arrangements.

Question 10

Before an HMO contracts with a physician, the HMO first verifies the physician's credentials. Upon becoming part of the HMO's organized system of healthcare, the physician is typically subject to

Accepted Answer

The answer of Before an HMO contracts with a physician,...

Question 11

By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an HMO provides comprehensive care include:

Accepted Answer

An HMO provides comprehensive care by coordinating care across a variety of benefits, emphasizing preventive care by covering many preventive services either in full or with a small copayment, and offering its members access to wellness programs.

Question 12

As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members: -Brad Van Note, age 28, is taking many different, costly medications for

Accepted Answer

The answer of As part of its utilization management (UM)...

Question 13

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

Accepted Answer

The primary plan pays its benefits first, and the secondary plan may cover remaining costs up to 100% of the total expenses. If Bart's total expenses are $550, and the primary plan covers $380, the secondary plan would cover the remaining $170, resulting in a total of $550 covered.

Question 14

Col. Martin Avery, on active duty in the U.S. Army, is eligible to receive healthcare benefits under one of the three TRICARE health plan options. If Col Avery elects to participate in TRICARE Prime, he will be:

Accepted Answer

Col. Avery will be assigned to a primary care manager who is responsible for coordinating all his care if he elects to participate in TRICARE Prime.

Question 15

Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included:

Accepted Answer

All of the factors listed contributed to increased demand for behavioral healthcare services. Increased stress on individuals and families can lead to a greater need for mental health support. The increased availability of behavioral healthcare services means that more individuals have access to services that they may have previously been unable to obtain. Greater awareness and acceptance of behavioral healthcare issues means that individuals are more likely to seek treatment and feel comfortable talking about their struggles.

Question 16

By definition, a health plan's network refers to the:

Accepted Answer

A health plan's network refers to the group of physicians, hospitals, and other medical care providers with whom the plan has contracted to deliver medical services to its members. Option A is incorrect as it refers to the stakeholders involved in healthcare consumption, which is not necessarily the network itself. Option B may be a factor in determining the effectiveness of the network, but it is not the definition of a network. Option D is a vague statement and does not accurately describe the network.

Question 17

Bill Clinton is a member of Lewinsky's PBM plan which has a three-tier copayment structure. Bill fell ill and his doctor prescribed him AAA, a brand-name drug which was included in the Lewinsky's formulary; BBB, a non-formulary drug; and CCC, a generic drug.  In which order, from most preferred to least, is the preferred drug of choice for this coverage?

Accepted Answer

Generic drugs (CCC) are usually the most preferred due to lower costs, followed by brand-name drugs on the formulary (AAA), and lastly non-formulary drugs (BBB).

Question 18

By definition, the marketing process of defining a certain place or market niche for a product relative to competitors and their products and then using the marketing mix to attract certain market segments is known as:

Accepted Answer

The marketing process of defining a certain place or market niche for a product relative to competitors and their products is called positioning. This involves creating a unique image and value proposition for the product that sets it apart from competitors in the minds of the target market. The marketing mix refers to the various tactics and strategies that are used to implement the positioning, such as product features, pricing, distribution, and promotion. Branding is a related concept that involves creating a distinctive name, design, and image for a product or company. Database marketing involves using data to target and personalize marketing messages to specific customer segments. Personal selling refers to the use of salespeople to communicate with and persuade potential customers to buy the product.

Question 19

Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of:

Accepted Answer

The answer of Consumer-directed health plans are not a new...

Question 20

Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Dr. Ware's provider contract with Riverside contains a typical no-balance billing provision. One purpose of this provision is to:

Accepted Answer

A no-balance billing provision in a provider contract prevents the provider from billing plan members for additional amounts beyond what the MCO pays for medical services. This ensures that plan members are not surprised by unexpected bills, and it also helps control healthcare costs by setting a clear and consistent payment amount for medical services. This provision does not necessarily prevent the provider from collecting coinsurance, copayment, or deductibles from plan members, as these are typically part of the member's responsibility under the terms of the plan. However, the provider cannot bill the member for any additional amounts beyond what the MCO pays.

Exam 3: Health Plan Finance and Risk Management

Dr. Julia Phram is a cardiologist under contract to Holcomb HMO, Inc., a typical closed-panel plan. The following statements are about this situation. Select the answer choice containing the correct statement.

Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

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:

Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:

Before the Leo Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to

Before an HMO contracts with a physician, the HMO first verifies the physician's credentials. Upon becoming part of the HMO's organized system of healthcare, the physician is typically subject to

By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an HMO provides comprehensive care include:

As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members: -Brad Van Note, age 28, is taking many different, costly medications for

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

Col. Martin Avery, on active duty in the U.S. Army, is eligible to receive healthcare benefits under one of the three TRICARE health plan options. If Col Avery elects to participate in TRICARE Prime, he will be:

Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included:

By definition, a health plan's network refers to the:

By definition, the marketing process of defining a certain place or market niche for a product relative to competitors and their products and then using the marketing mix to attract certain market segments is known as:

Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of: