MANAGED CARE FINAL REVIEW QUESTIONS AND ANSWERS
Which of the following certificate is the state -issued operating license for an HMO? - CORRECT
ANSWER✅✅Certificate of authority (COA)
All the states require PPOs to be accredited. - CORRECT 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 ? - CORRECT ANSWER✅✅Risk-Based Capital (RBC)
Which of the following are not required to be licensed by states ? - CORRECT ANSWER✅✅Benefits
consultants
States regulate all employer sponsored health benefits plans - CORRECT ANSWER✅✅False
State mandated benefits laws apply to self - funded employee benefits plans - CORRECT
ANSWER✅✅False
Erisa and the ACA both require expedited review for benefits determination involving urgent medical
care - CORRECT ANSWER✅✅True
Which of the following electronic transactions does HIPAA not standardized? - CORRECT
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 . - CORRECT ANSWER✅✅False
Which of the following is not a federal law affecting health insurance, health benefits plans , or HMOs -
CORRECT ANSWER✅✅CSNY
Managed health care was developed as a way to provide affordable, comprehensive, prepaid health
care services to - CORRECT 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 - CORRECT ANSWER✅✅Medicare and Medicaid
The Amendment of the HMO act of 1973 allowed federally qualified HMOs to permit members to -
CORRECT ANSWER✅✅Occasionally use non -HMO physicians and be partially reimbursed
Hedis was developed by the - CORRECT 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 - CORRECT
ANSWER✅✅Quality assessment and performance improvement ( QAPI)
The primary care provider is responsible for - CORRECT 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. - CORRECT ANSWER✅✅Laws
Many states have enacted legislation requiring a(n) _____ to review health care provided by managed
care organization - CORRECT 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 ____ - CORRECT
ANSWER✅✅Standards
NCQA reviews managed care plans and develops reports card to - CORRECT 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 - CORRECT ANSWER✅✅Utilization management
Which of the following certificate is the state -issued operating license for an HMO? - CORRECT
ANSWER✅✅Certificate of authority (COA)
All the states require PPOs to be accredited. - CORRECT 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 ? - CORRECT ANSWER✅✅Risk-Based Capital (RBC)
Which of the following are not required to be licensed by states ? - CORRECT ANSWER✅✅Benefits
consultants
States regulate all employer sponsored health benefits plans - CORRECT ANSWER✅✅False
State mandated benefits laws apply to self - funded employee benefits plans - CORRECT
ANSWER✅✅False
Erisa and the ACA both require expedited review for benefits determination involving urgent medical
care - CORRECT ANSWER✅✅True
Which of the following electronic transactions does HIPAA not standardized? - CORRECT
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 . - CORRECT ANSWER✅✅False
Which of the following is not a federal law affecting health insurance, health benefits plans , or HMOs -
CORRECT ANSWER✅✅CSNY
Managed health care was developed as a way to provide affordable, comprehensive, prepaid health
care services to - CORRECT 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 - CORRECT ANSWER✅✅Medicare and Medicaid
The Amendment of the HMO act of 1973 allowed federally qualified HMOs to permit members to -
CORRECT ANSWER✅✅Occasionally use non -HMO physicians and be partially reimbursed
Hedis was developed by the - CORRECT 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 - CORRECT
ANSWER✅✅Quality assessment and performance improvement ( QAPI)
The primary care provider is responsible for - CORRECT 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. - CORRECT ANSWER✅✅Laws
Many states have enacted legislation requiring a(n) _____ to review health care provided by managed
care organization - CORRECT 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 ____ - CORRECT
ANSWER✅✅Standards
NCQA reviews managed care plans and develops reports card to - CORRECT 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 - CORRECT ANSWER✅✅Utilization management
