CEBS - GBA 1 & 2 PRACTICE PRACTICE
EXAMINATION 2026 QUESTIONS WITH
ANSWERS GRADED A+
◍ Discuss the need for a significant amount of time and financial resources in
order to transform medical practices from traditional care delivery platforms
to PCMHs (Mod 9.5).
Answer: For demonstration projects, medical practices need to be aware of
true resource needs for transformation; many healthcare providers believe
that both meaningful use of fed/state funding is inadequate. There are
limited data regarding the direct/indirect costs of PCMH implementation.
Therefore, one many look to traditional practice data for integration of
health information technology.According to study of implementation in
TX-based practices (traditional primary care not PCMH), estimated first
year cost of system implementation was $162,000 for 5 physician practice,
with $85,000 in maintenance. Maintenance costs are significant financial
burden and include hardware replacement, software upgrades, as well as
ongoing training and support for end users through external contractors or
IT professionals. Given additional challenges in medical home
transformation, these figures likely underestimate needs of PCMHs.
◍ How do NCQA requirements for PCMH align with the criteria for PCMH as
specified in Sec 3502 of ACA? (Mod 9.2).
Answer: The NCQA recognition criteria for status as a PCMH are aligned
with the PCMH definition in ACA. In Sec 3502 of ACA, a PCMH is
defined as a model of care with six core features, including the use of
personal physicians, "a whole person orientation; coordinated and integrated
care; safe and high-quality care through evidence-informed medicine;
appropriate use of health information technology and continuous quality
, improvements; expanded access to care; and payment that recognizes added
value from additional components of patient-centered care.
◍ What stipulation does ACA make regarding the relationship in health
insurance premium between an aged insured and a younger insured? (Mod
2.6).
Answer: ACA requires premiums for oldest insured to be no more than 3X
that of youngest insured.
◍ What are broader implications of the findings outlined in the study between
prices and plan behavior? (Mod 4.1).
Answer: -Insurers and consumers generally should encourage entry of new
and additional capacity in local health care market as means of reducing
prices.-If managed care plan has relatively small network of providers, it is
likely to be able to negotiate lower prices in exchange for higher volume to
providers with contracts. In contrast, a managed care plan with a large
network relative to subscriber based less able to negotiate cost.-If local
hospital market has idle capacity, many if not all local hospitals will incur
losses until one or more facility close.-Certificate of need laws have real
potential to keep hospital prices high by keeping new competitors and/or
additional capacity out of the market.-The merger of several pediatric
groups in a market will likely result in higher prices charged to managed
care plans.
◍ Describe the services a broker might provide to small firms seeking health
care insurance (Mod 7.3).
Answer: A broker consults with an ER to determine what approach to
insurance is best (self-funded, FI, or combination). If ER decides to
self-fund, broker works as an agent on behalf of the ER to secure contracts
with a TPA (3rd party admin) and stop-loss insurers. After an ER establishes
a self-funded plan, broker may perform other services for the ER, such as
enrolling EEs and resolving customer claims.
◍ List several recent initiatives in the US that purport (to claim, often falsely)
to use market forces to increase efficiency in the healthcare system. (Mod
, 1.1).
Answer: 1) Employers are offering more HDHPs with some as high as
$10,000. These plans, often paired with HSAs, are coupled with the idea of
transparency, or making more info available to consumer on cost and
quality. Idea is that consumers will have more skin in game and be prudent
purchasers of care with their own money.2) ACA is creating marketplaces
that employ a form of managed competition where standardized health plans
compete on cost and quality.3) Public Medicaid and Medicare programs are
moving towards requiring or making choices available for managed care
products that structure care within provider networks.
◍ a) Do ACA demonstration projects, existing guidelines and the standards
promoted by recognition bodies provide enough impetus for encouraging
adoption of PCMHs on a national scale? b) What areas seem to need
improvement in order to achieve potential offered by PCMHs? (Mod 9.6).
Answer: a) Not yet - future adoption rests on response to demonstration
projects and the nature of amendments made by recognition bodies like
NCQA. Changes may be needed to further the right level of adoption and to
ensure comparability, as well as to promote more rigorous standard for
governance and implementation consistency; policy should be amended in
terms of funding, timeline, practice setup.b) Three main areas for
improvement:1: funding methodology - critical to maintain ongoing
funding/financial support for long term transformation into PCMH. 2:
expected timeline for transformation - many political/healthcare leaders
want immediate results for medical home projects, but must have realistic
expectations. After 2-3 yrs, many PCMHs can accurately assess progress
made for patient populations, whereas some could take longer. Full
transformation is a long and challenging process for team development, tech
implementation and financial stability. Underlying challenge is the need to
do more in managing neglected functions related to chronic care - involves
reorganization and teamwork to manage time and resources. 3: variation in
reimbursement methods and medical home setups - could make comparisons
difficult; policymakers want practices to participate, but they also need to
, measure improvement to determine if PCMH is worth pursuing on a larger
scale. More stringent requirements (esp from NCQA) would lead to better
comparability of outcomes. Criteria could be ranked on order of importance,
allocating more points for transformative steps deemed most important (Ex:
if evidence based guidelines, health info tech and improvements in patient
access are 3 most important initial components, these 3 should command
greater weight in assessment or simply be required for tier-1 recognition.
◍ The typical LTC legacy product is flawed for several reasons and has
produced an imbalance of risk and flexibility for both the carrier and the
consumer. List the reasons this is the case (Mod 11.4).
Answer: a) Typical LTC product was designed to satisfy multiple
constituents (health code, insurance code) at the unintended expense of
consumer.b) Legacy products build up level premium equity and require the
PH to lose it if he or she exits the policy.c) Legacy products are supported
by investor capital, whereas the typical whole life contract does not rely
solely on investor capital.d) The legacy LTC carrier bears tremendous risk
by attempting to project and match assets to liabilities for time horizons of
up to 40 years.e) Legacy carriers have made 40 year assumptions with
respect to morbidity.
◍ Discuss the unexpected out of pocket expenses that individuals may incur
for a hospital stay (Mod 5.5).
Answer: Involuntary use of "other hospital-based providers" such as
anesthesiologists, radiologists, etc is a growing problem. Typically hospital
based providers do not inform patients they are out of network before
delivering care. For some specialties, patients may not even come into
contact with the out of network provider. While a hospital may be in
network, providers treating patients at that hospital may not be in network;
this means that, though a patient may check before a routine surgery to
ensure a hospital is in network, during surgery they may receive services
from an out of network assistant surgeon or anesthesiologist, which would
be impossible to refuse. The patient may not discover they are out of
network until they are billed for the service.
EXAMINATION 2026 QUESTIONS WITH
ANSWERS GRADED A+
◍ Discuss the need for a significant amount of time and financial resources in
order to transform medical practices from traditional care delivery platforms
to PCMHs (Mod 9.5).
Answer: For demonstration projects, medical practices need to be aware of
true resource needs for transformation; many healthcare providers believe
that both meaningful use of fed/state funding is inadequate. There are
limited data regarding the direct/indirect costs of PCMH implementation.
Therefore, one many look to traditional practice data for integration of
health information technology.According to study of implementation in
TX-based practices (traditional primary care not PCMH), estimated first
year cost of system implementation was $162,000 for 5 physician practice,
with $85,000 in maintenance. Maintenance costs are significant financial
burden and include hardware replacement, software upgrades, as well as
ongoing training and support for end users through external contractors or
IT professionals. Given additional challenges in medical home
transformation, these figures likely underestimate needs of PCMHs.
◍ How do NCQA requirements for PCMH align with the criteria for PCMH as
specified in Sec 3502 of ACA? (Mod 9.2).
Answer: The NCQA recognition criteria for status as a PCMH are aligned
with the PCMH definition in ACA. In Sec 3502 of ACA, a PCMH is
defined as a model of care with six core features, including the use of
personal physicians, "a whole person orientation; coordinated and integrated
care; safe and high-quality care through evidence-informed medicine;
appropriate use of health information technology and continuous quality
, improvements; expanded access to care; and payment that recognizes added
value from additional components of patient-centered care.
◍ What stipulation does ACA make regarding the relationship in health
insurance premium between an aged insured and a younger insured? (Mod
2.6).
Answer: ACA requires premiums for oldest insured to be no more than 3X
that of youngest insured.
◍ What are broader implications of the findings outlined in the study between
prices and plan behavior? (Mod 4.1).
Answer: -Insurers and consumers generally should encourage entry of new
and additional capacity in local health care market as means of reducing
prices.-If managed care plan has relatively small network of providers, it is
likely to be able to negotiate lower prices in exchange for higher volume to
providers with contracts. In contrast, a managed care plan with a large
network relative to subscriber based less able to negotiate cost.-If local
hospital market has idle capacity, many if not all local hospitals will incur
losses until one or more facility close.-Certificate of need laws have real
potential to keep hospital prices high by keeping new competitors and/or
additional capacity out of the market.-The merger of several pediatric
groups in a market will likely result in higher prices charged to managed
care plans.
◍ Describe the services a broker might provide to small firms seeking health
care insurance (Mod 7.3).
Answer: A broker consults with an ER to determine what approach to
insurance is best (self-funded, FI, or combination). If ER decides to
self-fund, broker works as an agent on behalf of the ER to secure contracts
with a TPA (3rd party admin) and stop-loss insurers. After an ER establishes
a self-funded plan, broker may perform other services for the ER, such as
enrolling EEs and resolving customer claims.
◍ List several recent initiatives in the US that purport (to claim, often falsely)
to use market forces to increase efficiency in the healthcare system. (Mod
, 1.1).
Answer: 1) Employers are offering more HDHPs with some as high as
$10,000. These plans, often paired with HSAs, are coupled with the idea of
transparency, or making more info available to consumer on cost and
quality. Idea is that consumers will have more skin in game and be prudent
purchasers of care with their own money.2) ACA is creating marketplaces
that employ a form of managed competition where standardized health plans
compete on cost and quality.3) Public Medicaid and Medicare programs are
moving towards requiring or making choices available for managed care
products that structure care within provider networks.
◍ a) Do ACA demonstration projects, existing guidelines and the standards
promoted by recognition bodies provide enough impetus for encouraging
adoption of PCMHs on a national scale? b) What areas seem to need
improvement in order to achieve potential offered by PCMHs? (Mod 9.6).
Answer: a) Not yet - future adoption rests on response to demonstration
projects and the nature of amendments made by recognition bodies like
NCQA. Changes may be needed to further the right level of adoption and to
ensure comparability, as well as to promote more rigorous standard for
governance and implementation consistency; policy should be amended in
terms of funding, timeline, practice setup.b) Three main areas for
improvement:1: funding methodology - critical to maintain ongoing
funding/financial support for long term transformation into PCMH. 2:
expected timeline for transformation - many political/healthcare leaders
want immediate results for medical home projects, but must have realistic
expectations. After 2-3 yrs, many PCMHs can accurately assess progress
made for patient populations, whereas some could take longer. Full
transformation is a long and challenging process for team development, tech
implementation and financial stability. Underlying challenge is the need to
do more in managing neglected functions related to chronic care - involves
reorganization and teamwork to manage time and resources. 3: variation in
reimbursement methods and medical home setups - could make comparisons
difficult; policymakers want practices to participate, but they also need to
, measure improvement to determine if PCMH is worth pursuing on a larger
scale. More stringent requirements (esp from NCQA) would lead to better
comparability of outcomes. Criteria could be ranked on order of importance,
allocating more points for transformative steps deemed most important (Ex:
if evidence based guidelines, health info tech and improvements in patient
access are 3 most important initial components, these 3 should command
greater weight in assessment or simply be required for tier-1 recognition.
◍ The typical LTC legacy product is flawed for several reasons and has
produced an imbalance of risk and flexibility for both the carrier and the
consumer. List the reasons this is the case (Mod 11.4).
Answer: a) Typical LTC product was designed to satisfy multiple
constituents (health code, insurance code) at the unintended expense of
consumer.b) Legacy products build up level premium equity and require the
PH to lose it if he or she exits the policy.c) Legacy products are supported
by investor capital, whereas the typical whole life contract does not rely
solely on investor capital.d) The legacy LTC carrier bears tremendous risk
by attempting to project and match assets to liabilities for time horizons of
up to 40 years.e) Legacy carriers have made 40 year assumptions with
respect to morbidity.
◍ Discuss the unexpected out of pocket expenses that individuals may incur
for a hospital stay (Mod 5.5).
Answer: Involuntary use of "other hospital-based providers" such as
anesthesiologists, radiologists, etc is a growing problem. Typically hospital
based providers do not inform patients they are out of network before
delivering care. For some specialties, patients may not even come into
contact with the out of network provider. While a hospital may be in
network, providers treating patients at that hospital may not be in network;
this means that, though a patient may check before a routine surgery to
ensure a hospital is in network, during surgery they may receive services
from an out of network assistant surgeon or anesthesiologist, which would
be impossible to refuse. The patient may not discover they are out of
network until they are billed for the service.
