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AHIP AHM-250 - Healthcare Management: An Introduction

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Total 367 questions

Natalie Chan is a member of the Ultra Health Plan, a health plan. Whenever she needs nonemergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Cr

A.

Within Ultra's system, Ms. Chan received primary care from both Dr. Craig and Dr. Lee

B.

Ultra's system allows its members open access to all of Ultra's participating providers.

C.

Within Ultra's system, Dr. Craig serves as a coordinator of care or gatekeeper for the medical services that Ms. Chan receives.

D.

Ultra's network of providers includes Dr. Craig and Dr. Lee but not Arrow Hospital

Khalyn Drury's employer includes managed dental care in its employee benefits package. During open enrollment, Ms. Drury enrolled in the dental plan, which provides dental services to its members in exchange for a prepayment (the premium). Dental services

A.

dental preferred provider organization (PPO)

B.

traditional fee-for-service (FFS) dental plan

C.

plan with a dental point of service (POS) option

D.

dental health maintenance organization (DHMO)

Ronald Canton is a member of the Omega MCO. He receives his nonemergency medical care from Dr. Kristen High, an internist. When Mr. Canton needed to visit a cardiologist about his irregular heartbeat, he first had to obtain a referral from Dr. High to see

A.

Dr. High serves as the coordinator of care for the medical services that Mr. Canton receives.

B.

Omega's network of providers includes Dr. High, but not Dr. Miller.

C.

Omega's system allows its members open access to all of Omega's participating providers.

D.

Omega used a financing arrangement known as a relative value scale (RVS) to compensate Dr. Miller.

One of the most influential pieces of legislation in the advancement of managed care within the United States was the HMO Act of 1973. One provision of the HMO Act of 1973 was that it

A.

emphasized compensating physicians based solely on the volume of medical services they provide

B.

exempted HMOs from all state licensure requirements

C.

established a process under which HMOs could elect to be federally qualified

D.

required federally qualified HMOs to relate premium levels to the health status of the individual enrollee or employer group

One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. One of the provisions of the Act was that it

A.

exempted HMOs from all state licensure requirements.

B.

required all employers that offered healthcare coverage to their employees to offer only one type of federally qualified HMO.

C.

eliminated funding that supported the planning and start-up phases of new HMOs.

D.

established a process by which HMOs could obtain federal qualification

Some states mandate that an independent enrollment broker or benefits counselor contractor selected by the state must manage enrollment of the eligible Medicaid population into managed care. In other states a health plan can engage independent brokers and

A.

Many states have regulations that prohibit health plans from using door-to-door and/or telephone solicitation to market health plan products to the Medicaid population.

B.

Health plans are never allowed to medically underwrite individual market customers who are under age 65.

C.

To promote a health plan product to the individual market, health plans typically use captive agents who give sales presentations to potential customers, rather than using promotion tools such as direct mail, telemarketing, or advertising.

D.

Health plans typically are allowed to medically underwrite all individual market customers who are covered by Medicare and can refuse to cover such customers.

Most contracts between health plans and providers contain a provision which forbids providers from seeking compensation from patients if the health plan fails to compensate the provider because of insolvency or for any other reason. Such a provision is kn

A.

due process provision

B.

cure provision

C.

hold-harmless provision

D.

risk-sharing provision

______________ HMOs can't medically underwrite any group – incl small groups.

A.

State

B.

Not-for-profit

C.

For-profit

D.

Federally qualified

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.

Are not required to be licensed by the states in which they market health plans

B.

Are compensated on a salary basis

C.

Represent only one health plan or insurer

D.

Are considered to be an agent of the buyer rather than an agent of the health plan or Insurer

Emily Brown works for Integral Health Plan and represents the company as a board member for the board of directors. Which best describes Emily's position?

A.

Community Representative

B.

Inside Director

C.

Outside Director

D.

None of these