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Krishnas questions for AHM250

Question 1 of 75
Which way of accessing behavioral healthcare services used to be common but no longer is?
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Employee assistance program (EAP).

Direct access.

Centralized telephone referral system.

Primary care provider (PCP) referral.

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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an integrated delivery system.

a medical foundation.

an accountable care organization (ACO).

a patient-centered medical home (PCMH).

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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tend to change health plans more frequently than small plans.


tend to focus almost solely on price.
are often self-funded.
usually offer employees only one health plan.

Question 5 of 75

Under which compensation arrangement do providers assume the greatest financial risk?
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Discounted fee-for-service.

Capitation.

Diagnosis-related groups (DRGs).

Resource-Based Relative Value Scale (RBRVS).

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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The electronic medical record (EMR).

The personal health record (PHR).

The electronic health record (EHR).

The computer-based patient record (CPR).

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.

Electronic claims processing can handle only simple claim decisions.

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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clinical practice guidelines.

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.

Medicare will be available to anyone 50 or older.

All health plans will have to be structured like an HMO.

All employers will have to sponsor a health insurance plan.

Question 15 of 75
The two main components typical of a consumer-directed health plan (CDHP) are
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an individual high-deductible health plan and an employer-sponsored catastrophic plan.

an employer-sponsored high-deductible health plan and an individual supplemental insurance policy.

a high-deductible health plan and a tax-advantaged personal healthcare account.

a tax-advantaged personal healthcare account and enrollment in a health maintenance organization.

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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considering the number, type, and location of providers needed.

imposing no barriers or disincentives on the use of out-of-network care.

recruiting as many providers of all types as they can.

accepting all providers who meet minimal standards.

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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members can receive care from non-network providers.

providers can provide care to non-plan members.

members can receive care from a specialist without a referral.

members pay higher cost-sharing for non-network providers.

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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Chief medical officer.

Chief financial officer.

Chief operations officer.

Chief information officer.

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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about half of dental coverage and is stable.

a large majority of dental coverage but is declining.

a large majority of dental coverage and is growing.

a minority of dental coverage but is growing.

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 members of the military only.

Active and retired members of the military and their spouses and dependents.

Active and retired members of the military.

Active 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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The limited types of healthcare expenses on which funds can be spent.

The tax penalty on funds withdrawn before age 65.

The use it or lose it rule and the lack of portability.

The prohibition on employee contributions.

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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Security and privacy.

Usability.

Quality.

Volume.

Question 30 of 75
Internal quality standards for health plans are
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based on industry benchmarks and usually apply to administrative services.


developed by the health plan itself and usually apply to administrative services.
based on industry benchmarks and usually apply to healthcare services.
developed by the health plan itself and usually apply to healthcare services.

Question 31 of 75
Who owns a mutual insurance company?
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The companys stockholders.

The companys policyholders.

A non-profit organization.

The companys board of directors

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.

EDI is an internal operation, not a transaction between two organizations.

EDI does not require a standardized data format.

Question 36 of 75
Which physician-only provider organization is the most integrated?
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The group practice without walls (GPWW).

The independent practice association (IPA).

The management services organization (MSO).

The consolidated medical group.

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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The integrated delivery system (IDS).

The physician-hospital organization (PHO).

The medical foundation.

Accountable care organization (ACO).

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.

Traditional HMOs and POS products.

HMOs and PPOs.

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 and continues to represent a minority of health coverage.

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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charges a premium and has substantial cost-sharing.

charges a premium but has only nominal cost-sharing.

does not charge a premium but has substantial cost-sharing.

does not charge a premium and has only nominal cost-sharing.

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.

decision support program.

wellness program.

value-based care program.

Question 47 of 75
What kind of risk does an HMO assume or share?

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Both financial and delivery risks.

Neither financial nor delivery risks.

Delivery risks only, not financial risks.

Financial risks only, not delivery risks.

Question 48 of 75
Which of these is a feature of a health reimbursement arrangement (HRA)?
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Only employer contributions.

Pretax employee contributions.

Investment growth of account funds.

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.

has been and continues to be at the federal level.

has been and continues to be at the state 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.

drug utilization review.

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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an IPA model HMO.

a mixed model HMO.

a network model HMO.

a group model HMO.

Question 54 of 75
What coverage do Medicare Advantage plans provide?
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The coverage of one of the standard Medigap plans.

Medicare Part A and Part B coverage only.

Medicare Part A and Part B coverage only, but without cost-sharing.

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.

PPOs and POS products.

Managed indemnity plans.

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, an employee, or a self-employed person.

An employer or an employee.

An employer, an employee, a self-employed person, or a family member on behalf of an eligible person.

Question 57 of 75
What is the main problem a data warehouse is intended to solve?
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Data in multiple databases.

Large amounts of data.

Inaccurate data.

Security and privacy requirements.

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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Copayments of $10 to $50, but no deductibles, coinsurance, or annual limits.

An annual deductible, coinsurance, and an annual maximum benefit.

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

What is the main source of the cost-savings of consumer-directed health plans?


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Consumers making cost-effective healthcare choices.

Employers receiving favorable tax-treatment.

Employers shifting costs to consumers.

Consumers receiving less healthcare.

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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Somewhat over half.

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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HMOs and PPOs.

Traditional HMOs and EPOs.

HMOs and POS products.

Traditional HMOs and indemnity plans.

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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per diem payments.

diagnosis-related groups (DRGs).

episode-based payments.

a relative-value scale (RVS).

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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Diagnosis-related groups (DRGs).

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.

A younger population because of immigration.

Consumer-directed health plans.

New drugs and technology.

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.

compensation amounts and methods are attractive to a large number of providers.

Question 72 of 75
Who can receive Medicare coverage?
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People 65 or older and younger people with low incomes.

People 65 or older only.

People 65 or older and younger people with severe, long-term disabilities or a few diseases.

People 65 or older and younger people with disabilities.

Question 73 of 75
When a health plan compensates a provider by capitation, which generally occurs?
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The provider submits encounter reports to the plan.

The member submits encounter reports to the plan.

The provider submits claims to the plan.

The member submits claims to the plan.

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.

choose from a large number of health plans and plan types.

are all enrolled in the same fee-for-service group plan.

are all enrolled in the PPO for their state or region.S

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.

pay for performance.S