Question Managed Health Explained for Students (Easy Guide)

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QUESTION 1 Managed Health Insurance plans: a. Are concerned about both the Financial and the Medical Risk associated with the use of medical services by the insured group. b. Include HMOs, Point of Service / POS plans, and Preferred Provider Organizations / PPOs. c. a., b., and e. only. d. Always require that plan members be assigned a Primary Care Provider who will serve as the medical services “gatekeeper” for those members and their families. e.Use medical management techniques such as Utilization Management to control and limit the use of personal health care goods and services. QUESTION 2 In a defined health insurance benefits plan, covered health services benefits are defined in detail, and with specific reference to the price of the service to be paid through premiums and cost sharing. This differs from a defined contributions plan, which uses very broad categories of benefits and focuses on the dollar limits of health plan payments for those broad service categories. True False QUESTION 3 In self-insured employer sponsored health plans, Third Party Administrators (TPAs) are hired by the employer to perform basic administration and network management functions for the employer. True False QUESTION 4 An Underinsured individual or family: a. May experience high deductibles and other out-of-pocket expenditures associated with their existing group health insurance. b. May find their group health insurance coverage to be too expensive to use because significant medical services are either not covered or have limited coverage (for example limits on the number of visits covered by the insurance plan, and/or the period of time over which services are covered. c. May avoid accessing necessary medical services even though they are insured. d. All of the above. QUESTION 5 Copayment is: a. Money that a member must pay before the plan begins to pay. b. A fixed amount of money that a member pays for each office visit or prescription. c. A percentage of the allowable charge that the member is responsible for paying. d. Not a type of cost-sharing. QUESTION 6 The two main sources of money (funds)from which a health plan’s providers are paid are the plan premiums and out-of-pocket expenditures (cost sharing) for which plan members are directly responsible. True False QUESTION 7 For self-insured employers, which of the following is FALSE? a. The do not have to pay State premium taxes. b. They do not share Financial or Medical Risk with the Third-Party Administrators which administer their plans. c. They are usually organized like Preferred Provider Organizations. d.They have a great deal of flexibility in designing the benefits coverage of their health plans. e. None of the above. QUESTION 8 The Federal McCarran-Ferguson Act, passed by Congress in 1945, prohibited the federal regulation of insurance companies. As a result, regulation of health insurance became the responsibility of the individual states. True False QUESTION 9 Which one (1) of the following was NOT a reason for the ongoing explosion in U.S. national health expenditures from the late 1960’s through the early 1990’s? a. The method by which Medicare paid providers (doctors and hospitals) was very generous and was largely defined by the preferences of the providers. b. The ongoing trend toward specialization and sub specialization of medical practice and medical education. c. The spread of Managed Health Insurance plans throughout the United States after the passage of the 1973 HMO Act. d. Medicare subsidies to hospitals through Medicare payments toward the costs of Post Graduate Training programs. e. Continuous technological progress in the medical treatment of illness and disease. QUESTION 10 Indemnity and Service group health insurance plans, rather than Managed Health insurance plans, were the type of employer-sponsored health insurance plans which covered most American workers from the late 1930’s through the mid 1980’s. True False QUESTION 11 Between 1930 and the mid 1970’s, employer-sponsored Indemnity and Service health insurance plans: a. Were only concerned with paying provider claims and minimizing financial risk for the insured group. b. Did not require employee/insurance plan member cost-sharing such as deductibles and co-insurance. c. Offered increasingly comprehensive benefits, including major medical insurance benefits. d. Showed interest in neither the health of whole populations, nor in plan member use of preventive health care services. e. a., c., and d. QUESTION 12 Company X offers its employees two health insurance plans created and managed by Aetna, the health insurance company. Some board members have suggested that Company X should reduce its subsidy for 65% of the member health insurance premiums for each of these plans to 55%, leaving the members to pay a higher portion of their premium. Which one of the two major philosophies of health insurance do you think has influenced these board members to call for this reduction in premium subsidies? a. Social Justice philosophy. b. Consumer Directed Health / Market philosophy. QUESTION 13 Moral Hazard is a concept used to guide the design of health insurance plans and other types of insurance plans. A principal belief associated with this concept is that if insurance is too generous (maximizes coverage of payment of benefits, while minimizing the financial contribution insurance plan members make to the plan, for instance through premiums or out -of -pocket expenditures)), that insurance will encourage plan members to engage in risky behavior. In the case of health insurance that would mean purchase of unnecessary or ineffective medical care. True False QUESTION 14 Under the Affordable Care Act of 2010, members of a health insurance plan offered through an ACA State Marketplace / Exchange may receive premium reductions through premium tax credits, and in some cases may receive subsidies to help the plan members pay their out-of-pocket expenditures. Which one of the two major philosophies of health insurance do you think influenced the inclusion of these subsidies in the design of the ACA Marketplaces / Exchanges? a. Social Justice philosophy. b. Consumer Directed Health / Market philosophy. QUESTION 15 The managed care backlash of the late 1990’s resulted in: a. A reduction in HMO membership b. Fewer health plan members being required to choose a Primary Care Physician or team of providers c. Improvements in quality of care d. Reduced administrative costs e. All the above f. a & b only QUESTION 16 Key common characteristics of PPOs do NOT include which one of the following: a. Limited provider panels b. Discounted payment rates c. More consumer choice of providers d. Utilization management e. Payment to providers of medical services is limited only to contracted in-network providers of care. QUESTION 17 Federally qualified Consumer Directed Health Plans assume that it should be the role of group health insurance plan members to take significant responsibility in shopping around for low-cost, high quality elective medical services. True False QUESTION 18 The consolidation and integration of hospitals and health systems over the past 20 years has usually resulted in the following in the regions where they operate: a. Lower costs b. No change in costs c. Higher costs QUESTION 19 The National Practitioner Data Base includes information on licensure actions taken in each State by the respective State medical boards and boards of dentistry. True False QUESTION 20 Credentialing of professional staff such as physicians may be performed by a. HMOs b. PPOs c. CVOs (Credentials Verification Organizations) d. Hospitals e. All the above. QUESTION 21 State network access (network adequacy) standards for the provider networks of health insurance plans are most likely to focus on: a. The drive times to any contracted provider in a plan’s service area b. In urban areas, the time in which any physician in a defined geographic area may be reached by bus or subway c. The number of general hospitals in the provider network d. Minimum standards for the numbers of Primary Care and Specialty Physicians in each zip code, borough, or other defined geographic area e. a., b.,and d. QUESTION 22 Vertically integrated delivery systems (VIDS): a. Contain groups of many different kinds of providers (For example: hospitals and physicians) b. Are expected to facilitate patient transitions from hospital care to post-acute care (For instance: rehabilitation facilities) c. Are expected to support the provision of Primary Care through such organizations such as Patient Centered Medical Homes d. Were initially formed to give providers more power in payment negotiations with insurance plans. e. All the above. QUESTION 23 If provider networks are too narrow in size, composition, and/or geographic availability of providers, they may force plan enrollees to spend large amounts of money out-of-pocket to seek care from more accessible out-of-network providers: True False QUESTION 24 The basic ways that HMOs (Health Maintenance Organizations) may pay for PCP (Primary Care Practitioner) services are: a. Capitation b. APGs (Ambulatory Payment Groups) c. Fee-for-service d. Both a and c e. a, b, and c QUESTION 25 Between 2000 and 2010, Blue Cross / Blue Shield health insurance plans and commercial health insurance plans (e.g. Aetna) made it almost impossible for people who sought individual health insurance contracts (self-employed people, unemployed people) to obtain health insurance. This policy hurt which group of individuals the hardest? People over the age of 50. People With Families People With Preexisting Medical Conditions People Who have been unemployed for more that 6 months

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