Managed Care Final Review Exam
Questions And Complete Answers
Which of the following certificate is the state -issued operating license for an HMO? -
answer Certificate of authority (COA)
All the states require PPOs to be accredited. - answer False
Which of the following formulas has been adopted by NAIC to determine how much the
capital requirements are for a particular managed care plan ? - answer Risk-Based
Capital (RBC)
Which of the following are not required to be licensed by states ? - answer Benefits
consultants
States regulate all employer sponsored health benefits plans - answer False
State mandated benefits laws apply to self - funded employee benefits plans - answer
False
Erisa and the ACA both require expedited review for benefits determination involving
urgent medical care - answer True
Which of the following electronic transactions does HIPAA not standardized? - answer
Electronic medical records
Under the ACA , the federal government is now responsible for regulating health
insurance premiums rates in the small group market , not the states . - answer False
Which of the following is not a federal law affecting health insurance, health benefits
plans , or HMOs - answer CSNY
Managed health care was developed as a way to provide affordable, comprehensive,
prepaid health care services to - answer Enrollees
The health maintenance organization (HMO) assistance act of 1973 authorized grants
and loans to develop HMOs under private sponsorship. It defines a federally qualified
HMO as being certified to provide health care services to _____enrollees - answer
Medicare and Medicaid
The Amendment of the HMO act of 1973 allowed federally qualified HMOs to permit
members to - answer Occasionally use non -HMO physicians and be partially
reimbursed
Hedis was developed by the - answer National committee for quality Assurance ( NCQA)
, Which of the program results from the BBA of 1997 and requires that quality assurance
activities are performed to improve the functioning of Medicare advantage (Part C)
organization - answer Quality assessment and performance improvement ( QAPI)
The primary care provider is responsible for - answer Supervising and coordinating
health care services to enrollees
Managed care plans that are federally qualified and those that must comply with state
quality review mandates , or ____ are required to establish quality assurance programs.
- answer Laws
Many states have enacted legislation requiring a(n) _____ to review health care provided
by managed care organization - answer External quality review organization
Medicare establishes the quality improvement system for managed care (QISMC) to
ensure the accountability of managed care plans in terms of objectives, measurable
____ - answer Standards
NCQA reviews managed care plans and develops reports card to - answer Allow health
care consumers to make informed decisions when selecting a plan
Which is a method of controlling health care costs and quality of care by reviewing the
appropriateness and necessity of care provided to patients prior to the administration of
care or after care has been provided - answer Utilization management
Which is a review that grants prior approval for reimbursement of a health care services
- answer Preauthorization
Which is a review for medical necessity of inpatient care to the patient admission -
answer Pre-admission certification
Which involves the development of patient care plans for the coordination and provision
of care for complicated cases in a cost -effective manner - answer Case management
Medicare and many states prohibits managed care contracts from containing ___which
prevent providers from discussing all treatment options with patients , whether or not
the plan would provide reimbursement for services - answer Gag clauses
In markets with high levels of managed care penetration, hospitals are usually paid
using a sliding scale discount in charges method - answer False
The following term refers to an all - inclusive rate paid by the HMO for both institutional
and professional services - answer Bundled payment
The same methodology used to pay a hospital for inpatient care is usually also use to
pay for outpatient care - answer False
Which of the following forms of hospital payment contain no elements of risk sharing by
the hospital - answer Sliding scale FFS
Questions And Complete Answers
Which of the following certificate is the state -issued operating license for an HMO? -
answer Certificate of authority (COA)
All the states require PPOs to be accredited. - answer False
Which of the following formulas has been adopted by NAIC to determine how much the
capital requirements are for a particular managed care plan ? - answer Risk-Based
Capital (RBC)
Which of the following are not required to be licensed by states ? - answer Benefits
consultants
States regulate all employer sponsored health benefits plans - answer False
State mandated benefits laws apply to self - funded employee benefits plans - answer
False
Erisa and the ACA both require expedited review for benefits determination involving
urgent medical care - answer True
Which of the following electronic transactions does HIPAA not standardized? - answer
Electronic medical records
Under the ACA , the federal government is now responsible for regulating health
insurance premiums rates in the small group market , not the states . - answer False
Which of the following is not a federal law affecting health insurance, health benefits
plans , or HMOs - answer CSNY
Managed health care was developed as a way to provide affordable, comprehensive,
prepaid health care services to - answer Enrollees
The health maintenance organization (HMO) assistance act of 1973 authorized grants
and loans to develop HMOs under private sponsorship. It defines a federally qualified
HMO as being certified to provide health care services to _____enrollees - answer
Medicare and Medicaid
The Amendment of the HMO act of 1973 allowed federally qualified HMOs to permit
members to - answer Occasionally use non -HMO physicians and be partially
reimbursed
Hedis was developed by the - answer National committee for quality Assurance ( NCQA)
, Which of the program results from the BBA of 1997 and requires that quality assurance
activities are performed to improve the functioning of Medicare advantage (Part C)
organization - answer Quality assessment and performance improvement ( QAPI)
The primary care provider is responsible for - answer Supervising and coordinating
health care services to enrollees
Managed care plans that are federally qualified and those that must comply with state
quality review mandates , or ____ are required to establish quality assurance programs.
- answer Laws
Many states have enacted legislation requiring a(n) _____ to review health care provided
by managed care organization - answer External quality review organization
Medicare establishes the quality improvement system for managed care (QISMC) to
ensure the accountability of managed care plans in terms of objectives, measurable
____ - answer Standards
NCQA reviews managed care plans and develops reports card to - answer Allow health
care consumers to make informed decisions when selecting a plan
Which is a method of controlling health care costs and quality of care by reviewing the
appropriateness and necessity of care provided to patients prior to the administration of
care or after care has been provided - answer Utilization management
Which is a review that grants prior approval for reimbursement of a health care services
- answer Preauthorization
Which is a review for medical necessity of inpatient care to the patient admission -
answer Pre-admission certification
Which involves the development of patient care plans for the coordination and provision
of care for complicated cases in a cost -effective manner - answer Case management
Medicare and many states prohibits managed care contracts from containing ___which
prevent providers from discussing all treatment options with patients , whether or not
the plan would provide reimbursement for services - answer Gag clauses
In markets with high levels of managed care penetration, hospitals are usually paid
using a sliding scale discount in charges method - answer False
The following term refers to an all - inclusive rate paid by the HMO for both institutional
and professional services - answer Bundled payment
The same methodology used to pay a hospital for inpatient care is usually also use to
pay for outpatient care - answer False
Which of the following forms of hospital payment contain no elements of risk sharing by
the hospital - answer Sliding scale FFS
