PHLT 313 EXAM 3 CERTIFICATION EVALUATION
2026 FULL QUESTIONS AND CORRECT
ANSWERS
◉ Managed care main goal.
Answer: Control costs while maintaining quality and access
◉ Why managed care is dominant in US.
Answer: It controls costs and has large buying power by enrolling
many people
◉ Large buying power managed care.
Answer: One organization can negotiate lower costs because it
covers many enrollees
◉ Managed Care Organization MCO.
Answer: An organization that manages health care financing,
insurance, delivery, and payment
◉ Four functions managed by MCO.
Answer: Financing, insurance, delivery, and payment
,◉ Utilization control.
Answer: Formal control over how health care services are used
◉ Three main provider payment methods.
Answer: Capitation, discounted fees, and salaries
◉ Capitation.
Answer: A fixed monthly payment per enrollee also called PMPM
◉ PMPM.
Answer: Per member per month payment under capitation
◉ Discounted fees.
Answer: A modified fee for service payment in which providers
accept reduced fees for higher patient volume
◉ Salaries.
Answer: Fixed payment to providers often combined with bonuses
for efficiency
◉ Accreditation purpose.
Answer: Sets standards to measure and compare performance
,◉ NCQA.
Answer: National Committee for Quality Assurance, an accrediting
body for managed care quality
◉ CMS role in managed care.
Answer: CMS rates Medicare Advantage Part C plans
◉ Early roots of managed care.
Answer: Railroad, mining, and lumber companies developed early
health arrangements for workers
◉ First private health insurance plan.
Answer: The Baylor University Hospital plan in 1929
◉ 1940s managed care development.
Answer: Large health plans began to emerge in the United States
◉ HMO Act of 1973.
Answer: A federal law that helped expand health maintenance
organizations
, ◉ 1980s managed care.
Answer: Growth was slow but health care costs kept rising
◉ After 1980s managed care.
Answer: Other forms of managed care plans were created
◉ Medicare Advantage Part C.
Answer: Managed care option within Medicare
◉ Medicare beneficiary choice.
Answer: Beneficiaries can choose Medicare Advantage or remain in
fee for service Medicare
◉ 2023 Medicare Advantage fact.
Answer: Over 51 percent of the Medicare population was enrolled in
Part C
◉ Medicaid and managed care.
Answer: More than 75 percent of Medicaid beneficiaries are enrolled
in managed care plans nationwide
◉ Managed care in the 1990s.
2026 FULL QUESTIONS AND CORRECT
ANSWERS
◉ Managed care main goal.
Answer: Control costs while maintaining quality and access
◉ Why managed care is dominant in US.
Answer: It controls costs and has large buying power by enrolling
many people
◉ Large buying power managed care.
Answer: One organization can negotiate lower costs because it
covers many enrollees
◉ Managed Care Organization MCO.
Answer: An organization that manages health care financing,
insurance, delivery, and payment
◉ Four functions managed by MCO.
Answer: Financing, insurance, delivery, and payment
,◉ Utilization control.
Answer: Formal control over how health care services are used
◉ Three main provider payment methods.
Answer: Capitation, discounted fees, and salaries
◉ Capitation.
Answer: A fixed monthly payment per enrollee also called PMPM
◉ PMPM.
Answer: Per member per month payment under capitation
◉ Discounted fees.
Answer: A modified fee for service payment in which providers
accept reduced fees for higher patient volume
◉ Salaries.
Answer: Fixed payment to providers often combined with bonuses
for efficiency
◉ Accreditation purpose.
Answer: Sets standards to measure and compare performance
,◉ NCQA.
Answer: National Committee for Quality Assurance, an accrediting
body for managed care quality
◉ CMS role in managed care.
Answer: CMS rates Medicare Advantage Part C plans
◉ Early roots of managed care.
Answer: Railroad, mining, and lumber companies developed early
health arrangements for workers
◉ First private health insurance plan.
Answer: The Baylor University Hospital plan in 1929
◉ 1940s managed care development.
Answer: Large health plans began to emerge in the United States
◉ HMO Act of 1973.
Answer: A federal law that helped expand health maintenance
organizations
, ◉ 1980s managed care.
Answer: Growth was slow but health care costs kept rising
◉ After 1980s managed care.
Answer: Other forms of managed care plans were created
◉ Medicare Advantage Part C.
Answer: Managed care option within Medicare
◉ Medicare beneficiary choice.
Answer: Beneficiaries can choose Medicare Advantage or remain in
fee for service Medicare
◉ 2023 Medicare Advantage fact.
Answer: Over 51 percent of the Medicare population was enrolled in
Part C
◉ Medicaid and managed care.
Answer: More than 75 percent of Medicaid beneficiaries are enrolled
in managed care plans nationwide
◉ Managed care in the 1990s.
