In a self-funded health plan for a commercial company, which entity bears the risk for the medical costs: A. Health Plan B. Federal Government C. Member D. The company purchasing the insurance
In a self-funded health plan for a commercial company, which entity bears the risk for the medical costs:
A. Health Plan
B. Federal Government
C. Member
D. The company purchasing the insurance
2. Under the essential benefits of the affordable care act, which benefit requires no cost sharing for the member (i.e., first dollar coverage):
A. Emergency services
B. Maternity services
C. Laboratory services
D. Preventive and wellness services
3. Language in provider contracts that automatically renew the agreement for additional term(s) would be found under which of the following contract clauses in a managed care agreement:
A. For cause termination
B. Indemnification
C. Evergreen
D. Utilization management
4. Payment by a health plan to a provider in a fee for service arrangement represents what to a provider:
A. Cost
B. Revenue
C. Investment
D. Reimbursement
5. Which of the following is not true of a self-funded plan:
A. Health plan bears the risk for the medical cost
B. Not regulated by the state
C. Pays no premium taxes
D. Employer bears the risk for the medical cost
6. Elements that frequently change are included in the main body of a managed care contract:
A. True
B. False
7. Which of the following is not a true statement:
A. In a risked based agreement, the provider shares a portion of the risk for medical cost
B. In a non-risked based agreement, provider shares no risk for medical cost
C. In a capitated arrangement, all of the risk is on the health plan
D. In a value-based payment arrangement, the payment is impacted by both cost and quality
9. The ability of a member to receive care from a contracted provider on a reasonable basis refers to:
A. Network adequacy
B. Preferred provider network
C. Non discrimination
D. Affordable care act
10. Which of the following physician payment types represents a non risk-based payment to the physician:
A. Fee
B. Case rate
C. Discount off billed charges
D. All of the above
11. Which of the following is true as you proceed on the managed care continuum from Closed Panel HMOs to indemnity plans:
A. New elements of management and control are introduced
B. Utilization management decreases
C. Administrative costs increase
D. Medical cost decreases
13. Health plans look at capitation as a good way to control medical cost
A. True
B. False
14. Implementation of managed care to control cost resulted in which of the following:
A. PCP roles decrease
B. Delay and/or denial of payment to provider claims
C. Direct access to specialists
D. All of the above
E. None of the above
15. Which of the following is true in a PPO plan:
A. No contract exists between the provider and the health plan
B. Providers cannot balance bill the patient if the health plan doesn’t pay full billed charges
C. Member has no out of network benefits
D. Members must choose a PCP
16. Multi-hospital systems have market power, meaning the have the power to negotiate higher payment rates with health plans:
A. True
B. False
17. Single rate payment covering the hospital portion of an inpatient hospital stay is:
A. DRG payment
B. Bundled payment
C. Fee schedule payment
D. Relative value scale payment
19. Which of the following is considered a specialty hospital:
A. Children's hospital
B. Acute care hospital
C. Community hospital
D. Rural hospital
20. Reimbursement means being made whole for the actual cost of out-of-pocket expenses:
A. True
B. False
21. What was the name of the managed Medicare program before the name was changed to Medicare Advantage under the Medicare Modernization Act of 2003:
A. It was always named Medicare Advantage
B. Medicare for All
C. Medicare + Choice
D. Medicare Fee For Service
22. What is the name of the contract clause in a managed care contract that prohibits members from being billed by providers, regardless of whether the payor makes payment to the provider:
A. Non discrimination
B. Coordination of benefits
C. Hold harmless
D. Other party liability
23. Which of the following type of medical benefit plans contains out of network benefits, but still requires the member to choose a PCP:
A. Indemnity
B. HMO
C. POS
D. PPO
24. The Fee for service methodology mis-aligns incentives of health plans and providers:
A. True
B. False
25. A payment rate where a higher per day payment is made for the early days of a stay is referred to as what payment type:
A. Fee schedule
B. Case rate
C. Percent of Medicare allowable
D. Stepped per diem
26. Which of the following is not true in a benefit plan design where hospitals are tiered into tier 1 and tier 2 network providers:
A. Members have less cost sharing when they use a tier 1 hospital
B. Members are considered out of network if they use a tier 2 hospital
C. Tiering is based on cost and clinical quality outcomes
D. Costs can be controlled by incenting members to choose tier 1 hospitals
27. Contract language in a managed care agreement can have a significant impact on the amount of revenue a provider will yield under an agreement
A. True
B. False
*if you answer all my questions I will send you $20 through paypal or venmo or whatever you have. Thank you!!
Trending now
This is a popular solution!
Step by step
Solved in 2 steps
