Practice Questions Flashcards by Patrick Bross

Which of the following statements regarding the Affordable Care Act (ACA) is (are) correct?

Employer plans must cover dependent children up to the age of 26, but only if they are not married.
Limits on maximum lifetime benefits must be eliminated.
Cadillac plans must be eliminated by 2015.

I only

II only

III only

I and II only

I, II and III

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Which of the following statements regarding the Affordable Care Act (ACA) is correct?

The ACA requires that employers with 30 or more employees must provide health insurance for their employees or pay a penalty.
If a large employer does not provide health coverage and has one or more employees who receive a premium tax credit, the fine is $1,000 per employee.
Large employers cannot have grandfathered plans; this status can be held only by small employers.
The medical loss ratio for large employers must be no more than 80%.
The “play-or-pay” mandate is likely to have almost no effect on large employers.

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Under the Affordable Care Act (ACA), a health insurer can use all the following to classify premium rates EXCEPT:

Age
Gender
Geographic location
Family composition
Tobacco use

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The Affordable Care Act limits premiums for the oldest insured in relationship to the premiums for the youngest insured. Specifically, premiums for the oldest cannot be more than how many times the premiums for the youngest?

A. 1.4
B. 1.8
C. 2.0
D. 3.0
E. 3.5

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Which of the following statements regarding self-insured health plans is (are) correct?

Self-insurance is the same as prospective experience rating.
A reason to use self-insurance is the desire to avoid premium taxes and other state insurance regulations.
Self-insurance is not used in firms with fewer than 5,000 workers.

I only

II only

III only

I and II only

II and III only

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All the following statements regarding the loading percentage and loss ratios used in calculations of health insurance premiums are correct EXCEPT:

The loading percentage is lower for group coverage than it is for individual coverage.
The loading percentage varies according to firm size.
The Affordable Care Act requires that the medical loss ratio for small groups must be no less than 80%.
The loading percentage is the markup an insurer charges to cover its objective risk, profit and costs of marketing and administering the benefits.
The gross premium is the pure premium divided by the loading percentage.

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Which of the following was created by the Affordable Care Act primarily to mitigate any incentives for plans to attract healthier individuals?

Risk adjustment program
Medical loss ratio
Reinsurance program
Risk corridors program
Qualified health plans’ target amount

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Which of the following statements describe(s) the impact of the Balanced Budget Act of 1997 on Medicare Advantage plans?

It phased in a new risk adjustment methodology that computed average expenditures by county.
It necessitated the requirement of Medicare HMOs and other providers to furnish encounter data to the Centers for Medicare & Medicaid Services.
It made it possible for Medicare to pay more for “sicker” patients.

I only

II only

III only

I and II only

II and III only

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All of the following statements regarding findings from the RAND Health Insurance Experiment are correct EXCEPT:

Inpatient expenditures are more predictable than outpatient expenditures.
Age, gender, location and welfare status account for a relatively small percentage of explained variation in health care expenditures.
Operationally self-reported health status is likely to frustrate Medicare efforts to increase its percentage of explained variation in health care expenditures.
HMOs that can predict expenditures one percentage point better than Medicare can gain a not-insignificant amount of profit per enrollee.
HMOs would need to finance costly collection data efforts to explain variation in health care expenditures to a more accurate degree than Medicare.

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Which of the following statements is correct regarding price negotiations between hospitals and managed care organizations?

A managed care organization in general is not able to negotiate lower prices when there are too many hospitals in the local market.
A managed care organization can drive prices down when the hospital has failed to attract patients covered by one of the managed care’s plans.
A managed care organization can negotiate lower prices if the hospital is already covering its fixed costs and the lower prices can cover its marginal costs.
A managed care organization is likely to advocate certificate-of-need laws since they have been found to reduce hospital prices.
A managed care organization has no bargaining power when the local hospital market is pursuing a medical arms race strategy.

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In the pre-managed care period, hospitals primarily competed by exceeding in which of the following areas?

I. Services
II. Quality
III. Amenities

I only

II only

III only

II and III only

I, II and III

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All of the following statements regarding managed care’s impact on the physician market are correct EXCEPT:

Managed care’s impact on the physician market is markedly different from that on the hospital marketplace.
Managed care plans have paid lower fees for procedures when there is greater managed care penetration in the metropolitan market.
Managed care plans have paid lower fees when there are more physicians per capita in the metropolitan area.
HMOs have been able to negotiate lower fees than were PPOs at their peak of popularity, presumably because the HMOs have had smaller networks of physician providers and used more aggressive selective contracting tactics.
Managed care leads to fewer self-employed physicians.

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In health insurance underwriting, the loading fee refers to:

The difference between the final premium rates and the initial proposed rates
The amount the policyholder pays above the expected claim costs
The policyholder’s added premiums for carved-out benefits such as prescription drugs and mental health care benefits
The difference between the rates published by a self-insured employer and the equivalent rates provided by the insurer
The insurer’s fee for each claim loaded into its adjudication system

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Which of the following statements regarding the Affordable Care Act’s provisions for the reimbursement of out-of-network emergency care is (are) correct?

If the amount that Medicare would have paid is lower than that of other methods stipulated in the law, then the Medicare rate is not to be used.
Insurers are not permitted to consider their negotiated rates with in-network providers when determining the benefits for out-of-network providers.
Balance billing by out-of-network providers is no longer allowed by ACA.

I only

II only

III only

I and II only

II and III only

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All the following are factors typically cited as impacting the network adequacy of a managed care plan EXCEPT:

Geography
Form of employer contribution
Insurer reimbursement policies
Absolute number of providers
Level of provider competition

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It has become increasingly apparent in health care settings that successful quality improvement (QI) in primary care medicine needs to be:

Championed by recent hires and new change agents who bring a fresh perspective to the organization.
Implemented by external consultants who specialize in QI techniques.
Conducted as special projects using ad hoc teams of volunteers.
Incorporated into the normal management of the primary care organization.
Decided by health care consumers who make their opinions known to health care practitioners through patient focus groups.

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To improve quality within health care organizations, which of the following items must be present?

An understanding of the factors affecting the ability to improve quality.
Knowledge of the most effective strategies to institute organizational and process change.
Appreciation for which approaches are culturally acceptable within the organization.

I only

I and II only

I and III only

II and III only

I, II and III

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All of the following factors have been cited as hastening the evolution of primary practice medicine from largely solo doctor practices to both small single-specialty groups and ever-larger medical groups EXCEPT:

Technological changes in medicine
Changing physician attitudes about work
Creating negotiating power with traditional fee-for-service providers
Elevated consumer expectations
Heightened purchaser expectations

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When assessments made by different surveyors or survey teams are consistent with one another, it can be said that there is:

Intra-rater reliability
Survey validity
Inter-rater reliability
Deemed consensus
Process validity

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Which of the following statements concerning accreditation is (are) correct?

Accreditation was initially conceived and developed as a method to foster quality improvement initiatives.
Accreditation is used on a limited but pivotal basis in health care industries.
Accreditation is primarily applicable to public health and social insurance programs within the United States.

None

I only

II only

I and II only

I and III only

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All of the following are commonly addressed and legitimate areas contained within accreditation standards for health care organizations EXCEPT:

Infrastructure
Staff ethnic diversity goals
Organizational elements
Service levels
Continuum of patient care issues

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Regarding surveys of patient satisfaction and engagement, the National Committee for Quality Assurance (NCQA):

Is not yet convinced such measures are viable
Is polling health care stakeholders on the potential usefulness of these measures
Has standards for how these measures should be documented and reported
Will propose guidelines for use of these tools within the next three years
Leaves methodologies for survey documentation and reporting to be prescribed by governmental regulatory authorities

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Which of the following statements concerning patient-centered medical homes (PCMHs) is (are) correct?

To build long-term relationships with patients, PCMH practices must focus on access and patient involvement in care, including steps toward self- management of diseases.
Many PCMH practices adopt an open-access system allowing for a certain number of same-day appointments.
A PCMH practice typically has a principal physician or nurse practitioner in charge of a patient’s care playing a gatekeeper role to access specialist care.

III only

I and II only

I and III only

II and III only

I, II and III

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All of the following statements concerning patient-centered medical homes (PCMHs) is (are) correct EXCEPT:

The National Committee for Quality Assurance (NCQA) conducts audits for The Joint Commission, which is the sole body authorized to award recognition as a PCMH to medical practices.
To be recognized as a PCMH, a medical practice must possess a few basic features that distinguish it from a traditional care delivery model.
A medical practice seeking recognition as a PCMH applies to be recognized as such.
The process to be recognized as a PCMH is much like an accreditation process.
Some states have standards for medical practices seeking recognition as a PCMH.

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Under the “market facilitator” model, a state’s exchange would accept: * Some health plans that meet minimum quality standards * Some health plans that offer broad geographical coverage and meet minimum quality standards * Most health plans that are chartered in the state * All health plans that meet the federal minimum requirements for qualified health plans * All health plans that meet minimum quality standards of the state’s medical licensing board

If a national insurer participates in multiple state exchanges, it is required to offer which of the following plans in every exchange in which it participates? * Gold plan * Silver plan * Bronze plan III only I and II only I and III only II and III only I, II and III

All of the following information may be used by insurers participating in state exchanges to set health plan premiums EXCEPT: * Age * Geographic area * Preexisting health conditions * Family composition * Tobacco use

The small group market as it pertains to employer group health plans typically refers to groups whose employee census is less than: * A. 1,000 * B. 500 * C. 250 * D. 100 * E. 50

A health plan is said to be portable if it allows an individual to move from one employer’s plan to another employer’s plan without having to satisfy which of the following requirements? * Completion of the federal I-9 form upon hiring * Waiting periods for access to coverage * Preexisting condition waiting periods II only III only I and II only II and III only I, II and III

All of the following are typical reasons small employers cite for offering health insurance to their employees EXCEPT: * It is the right thing to do. * The owner needs coverage. * It increases turnover. * Employees expect the offering of health coverage. * Competitors offer employer-sponsored health coverage.

Which of the following statements regarding the Medicare supplementary medical insurance (Part B) program is correct? * Eligible individuals may purchase Part B coverage even if they do not purchase Part A. * Premiums for Part B coverage are the same for every individual, regardless of income. * There are no deductibles for Part B coverage although many benefits require a sizable copay. * Part B benefits are provided through the Hospital Insurance (HI) trust fund. * Part B coverage is mandatory for anyone who purchases Part A coverage.

Which of the following is (are) covered by Medicare Part A? * Inpatient hospital care * Outpatient hospital services * Home health visits I only I and II only I and III only II and III only I, II and III

All the following are basic types of Medicare Advantage plans EXCEPT: * A health maintenance organization (HMO) that typically has a closed panel of providers but may have a point-of-service option. * A special needs plan (SNP) designed for those who may live in a nursing home, are dually eligible for Medicaid or have specific chronic or disabling conditions. * A certified self-insurance plan (CSI) that has met all the conditions required to become certified under the Affordable Care Act. * A preferred provider organization (PPO) that typically allows enrollees to use nonplan providers for an extra copay. * A Medicare medical savings account (MSA), similar to a health savings account (HSA), in which the beneficiary has a high deductible and an HMO, PPO or private fee-for-service (PFFS) plan, together with an account into which Medicare deposits money.

Assume a retired person is covered by Medicare and an employer-sponsored health plan. Also assume the following: * Total bill $10,000 Under Medicare only: * Patient would pay $2,000 (in deductible and copay) * Medicare would pay the remainder, $8,000 Under the employer plan only: * Patient would pay $3,000 (in deductible and copay) * Employer plan would pay the remainder, $7,000 How much would the employer plan pay if the “carve-out” method of coordination is used? * $10,000 * $ 8,000 * $ 7,000 * $ 1,000 * 0

Which of the following statements regarding employer-sponsored retiree health coverage is (are) correct? * State and local governments and firms with union members are more likely to have employer-sponsored retiree health coverage than other types of organizations. * The percentage of large organizations that offer employer-sponsored retiree health coverage has been increasing during the last decade. * Employers that offer retiree health coverage are increasing retiree premium contributions and copayments. I only II only I and II only I and III only II and III only

All the following statements regarding Medigap policies are correct EXCEPT: * At present, individuals can purchase only one of four plans authorized by the Omnibus Budget Reconciliation Act of 1990. * The coverage in most Medigap policies is not extensive. * All Medigap plans cover the Part A and Part B copayments. * All plans must provide 365 days of lifetime hospital care once one exhausts the Medicare lifetime reserve days. * The plans seldom provide coverage for services not already provided by Medicare.

Practice Questions Flashcards

(36 cards)