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NEW QUESTION 1
Since its inception, Medicare has undergone a number of changes because of legal and regulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to

  • A. expand Medicare benefits by mandating coverage for certain preventive services
  • B. reduce the number of organizations that can deliver covered services
  • C. encourage growth of managed Medicare programs in all markets
  • D. increase the number of “zero premium” plans available to Medicare beneficiaries

Answer: A

NEW QUESTION 2
A health plan's preventive care initiatives may be classified into three main categories: primary prevention, secondary prevention, and tertiary prevention. Secondary prevention refers to activities designed to

  • A. develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare
  • B. educate and motivate members to prevent illness through their lifestyle choices
  • C. prevent the occurrence of illness or injury
  • D. detect a medical condition in its early stages and prevent or at least delay disease progression and complications

Answer: D

NEW QUESTION 3
Performance variance can be classified as either common cause variance or special cause variance. The following statement(s) can correctly be made about special cause variance:
* 1. Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance
* 2. Special cause variance is typically more difficult to detect and correct than is common cause variance

  • A. Both 1 and 2
  • B. 1 only
  • C. 2 only
  • D. Neither 1 nor 2

Answer: B

NEW QUESTION 4
Recent laws and regulations have established new requirements for Medicaid eligibility. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 affected Medicaid eligibility by

  • A. severing the link between Medicaid and public assistance
  • B. eliminating the need for applications for Medicaid and public assistance
  • C. allowing states to provide healthcare benefits to groups outside the traditional Medicaid population
  • D. providing supplemental funding for dual eligibles in the form of five-year block grants

Answer: A

NEW QUESTION 5
In most health plans, the formulary system is developed and managed by a P&T committee. The P&T committee is responsible for

  • A. evaluating and selecting drugs for inclusion in the formulary
  • B. overseeing the manufacture, distribution, and marketing of prescription drugs
  • C. certifying the medical necessity of expensive, potentially toxic, or nonformulary drugs
  • D. all of the above

Answer: A

NEW QUESTION 6
In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be

  • A. achievable within a specified timeframe
  • B. defined in terms of multiple results
  • C. expressed in subjective, qualitative terms
  • D. all of the above

Answer: A

NEW QUESTION 7
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
The Millway Health Plan received a 15% reduction in the price of a particular pharmaceutical based on the volume of the drug Millway purchased from the manufacturer. This reduction in price is an example of a (rebate / price discount) and (is / is not) dependent on actual provider prescribing patterns.

  • A. rebate / is
  • B. rebate / is not
  • C. price discount / is
  • D. price discount / is not

Answer: D

NEW QUESTION 8
Determine whether the following statement is true or false:
Immunization programs are a direct means of reducing health plan members’ needs for healthcare services and are typically cost-effective.

  • A. True
  • B. False

Answer: A

NEW QUESTION 9
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the terms or phrases that you have chosen.
Due to competitive pressures and consumer demand, many health plans now offer direct access or open access products. Under a direct access product, a member is (required / not required) to select a primary care provider (PCP), and is (required / not required) to obtain a referral from a PCP or the health plan before visiting a network specialist.

  • A. required / required
  • B. required / not required
  • C. not required / required
  • D. not required / not required

Answer: B

NEW QUESTION 10
The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.

  • A. A patient who has been transferred to a hospitalist for management of inpatient care usually continues to receive care from the hospitalist after discharge.
  • B. Hospitalists are used primarily to manage care for obstetric, pediatric, and oncology patients.
  • C. In order to serve as a hospitalist, a physician must have a background in critical care medicine.
  • D. Hospitalists typically spend at least one-quarter of their time in a hospital setting.

Answer: D

NEW QUESTION 11
The following statements are about health plans’ use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement.

  • A. One advantage of EDI over manual data management systems is improved data integrity.
  • B. EDI may use the Internet as the communication link between the participating parties.
  • C. EDI involves back-and-forth exchanges of information concerning individual transactions.
  • D. The data format for EDI is agreed upon by the sending and receiving parties.

Answer: C

NEW QUESTION 12
Outcomes management is a tool that health plans use to maximize all the results
associated with healthcare processes. The following statement(s) can correctly be made about outcomes management:
* 1. The goal of outcomes management is to identify and implement treatments that are cost- effective and deliver the greatest value
* 2. Outcomes management introduces performance as a critical factor in the assessment and improvement of outcomes

  • A. Both 1 and 2
  • B. 1 only
  • C. 2 only
  • D. Neither 1 nor 2

Answer: A

NEW QUESTION 13
When conducting performance assessment, a health pln may classify the key processes associated with its services into the following categories: high-risk, high-volume, problem- prone, and high-cost.
The following statements are about this classification of processes. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  • A. In some instances, relatively inexpensive processes can qualify as high-cost processes.
  • B. Each process must be classified into a single category.
  • C. High-risk processes most often involve medical interventions or treatment plans for acute illnesses or case management processes for complex conditions.
  • D. Administrative processes such as scheduling appointments are examples of high- volume processes.

Answer: B

NEW QUESTION 14
Many health plans use HRA to target their preventive care programs to the healthcare needs of their members. With regard to HRA, it is correct to say that

  • A. Health plans rarely delegate HRA activities to external entities
  • B. Health plans typically focus their HRA efforts on newly enrolled members
  • C. HRA focuses on clinical data for an entire population and does not include demographic information that might identify individual members
  • D. HRA is generally a reliable predictor of medical resource utilization

Answer: B

NEW QUESTION 15
The Medicaid population can be divided into subgroups based on their relative size and the costs of providing benefits. From the answer choices below, select the response that correctly identifies the subgroups that represent the largest percentages of the total Medicaid population and of total Medicaid expenditures. Largest % of Medicaid Population- Largest % of Medicaid Expenditures-

  • A. Largest % of Medicaid Population-dual eligibles Largest % of Medicaid Expenditures- children and low-income adults
  • B. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for MedicareLargest % of Medicaid Expenditures-dual eligibles
  • C. Largest % of Medicaid Population-children and low-income adults Largest % of Medicaid Expenditures-chronically ill or disabled individuals not eligible for Medicare
  • D. Largest % of Medicaid Population-chronically ill or disabled individuals not eligible for Medicare Largest % of Medicaid Expenditures-children and low-income adults

Answer: C

NEW QUESTION 16
The following statements are about the use of provider profiling for pharmacy benefits. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  • A. Health plans typically use provider profiles to improve the quality of care associated with the use of prescription drugs.
  • B. Provider profiles identify prescribing patterns that fall outside normal ranges.
  • C. Health plans can motivate providers to change their prescribing patterns by sharing profile information with plan members and the general public.
  • D. Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.

Answer: D

NEW QUESTION 17
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