Exam: 412757RR Group Medical Expense Benefits

1. Because Dr. Roberts participates in an IPA, what type of patients can she see?

A. Only Medicare and Medicaid patients

B. Any patient she wants to see

C. Only patients who have been assigned to her

D. HMO patients

2. HMOs and PPOs are examples of

A. point-of-service plans.

B. Medicaid.

C. the Blues.

D. managed care plans.

3. Julio wants data to compare the performance of three different managed care plans before he chooses one for his company. Which one of the following tools will be most effective for his employees?

A. National Committee for Quality Insurance

B. Joint Commission on Accreditation of Healthcare Organizations

C. Health Plan Employer Data and Information Set

D. Utilization Review Accreditation Commission

4. An employer wishes to be assured that employees aren’t seeking unneeded medical care. One approach to that objective is

A. MSAs.

B. self-management.

C. HIPC.

D. indemnity.

5. Bob is insured under a managed care plan. Under this plan, which one of the following tasks is he allowed to do?

A. Go to any doctor he wants

B. Avoid review requirements

C. Participate in a weight-control program

D. Go to any hospital he wants

6. Continental Company employs 22 people—14 males and 8 females. According to the Model Act, this company would be considered a/an _______ employer.

A. discriminatory

B. growing

C. small

D. well-balanced

7. Mary goes to the doctor and pays for her visit. When she gets home, she must fill out a form and submit it to the insurance company so she can be reimbursed. What type of insurance does she most likely have?

A. Indemnity

B. HMO

C. POS

D. The Blues

8. Suppose an employee’s 18-year-old son has group medical insurance as a dependent of the employee. Which one of the following reasons would cause the son to lose his insurance benefits?

A. The son graduates from high school.

B. The employee becomes divorced.

C. The son joins the Navy.

D. The son moves away to attend college.

9. A new mom delivered her healthy baby by cesarean section on Monday at 8 p.m. Her insurance company has told her doctor that if she goes home on Wednesday by 8 p.m., it will provide a visit by a nurse to the new mom’s home. Is the insurance company able to offer this benefit? Why or why not?

A. Yes, the insurance company may offer this as an option to staying in the hospital because hospital expenses are remarkably high.

B. No, the Newborns’ and Mothers’ Health Protection Act makes it mandatory that a new mom with a cesarean section remain in the hospital for a full 96 hours after delivery.

C. No, the Newborns’ and Mothers’ Health Protection Act doesn’t allow extra benefits for patients who don’t use the 96 hours of allowed recovery time in the hospital unless those who stay receive it as well.

D. Yes, the new mom is allowed to have a nurse come to her home because she didn’t use the full allowed amount of recovery time in the hospital.

10. According to a Supreme Court ruling in 1949, _______ now have a role in employee benefits.

A. unions

B. insurance companies

C. senior management

D. all employees

11. In most states, if a woman who’s covered by a managed care plan believes that she’s pregnant, she should first call her

A. obstetrician, because she doesn’t need preauthorization for care.

B. primary care physician, to make an appointment so that she can be referred to an obstetrician.

C. managed care plan, to get preauthorization for care.

D. employer, to get preauthorization for care.

12. A contributing factor to the rise in health care costs from the 1970s to the 1990s is

A. Medicaid.

B. Medicare.

C. AIDS.

D. SIDS.

13. When Blue Cross first began, it was in the business of providing coverage for

A. prescriptions.

B. hospitalization.

C. physician care for the elderly.

D. physician care for the financially needy.

14. Which one of the following types of review is conducted after a patient has already been treated for the purpose of determining if the treatment was appropriate?

A. Reactive

B. Retrospective

C. Concurrent

D. Prospective

15. In the 1990s, the major shift in health care was that most employees were now

A. covered by an indemnity plan.

B. responsible for paying for their own insurance.

C. covered under a traditional insurance plan.

D. covered under a managed care plan.

16. In the 1960s, the main cause of the dramatic rise in health care coverage was the

A. introduction of Medicare and Medicaid.

B. introduction of HMOs.

C. increase in employee benefits.

D. Depression.

17. Which accrediting organization would be most likely to post HMO and POS reports on the Internet?

A. NCQA

B. URAC

C. JCAHO

D. HEDIS

18. Bev has an HMO that allows her to see a specialist without going through her primary care physician. What type of HMO does Bev have?

A. Group-model

B. Closed-panel

C. Direct-access

D. Staff-model

19. The medical expense insurance-like organizations that eventually came to be called Blue Cross plans were initially run by

A. physicians.

B. employers.

C. charity organizations.

D. hospitals.

20. Company X must make sure that it provides HMO coverage as an option in its benefit-selection process. What act would require Company X to do this?

A. Financial Services Modernization Act

B. Health Insurance Portability and Accountability Act

C. Health Maintenance Organization Act

D. Americans with Disabilities Act