- (Topic 3)
The Hill Health Plan designed a set of benefits that it packaged in the form of a PPO product. Hill then established a pricing structure that allowed its product to compete in the small group market, and it developed advertising designed to inform potential

1. A. An indemnity wraparound plan
2. B. A self-funded plan
3. C. An aggregate stop-loss plan
4. D. A fully funded plan

Correct Answer: D

- (Topic 3)
In the CPT system, each service or procedure is identified by

1. A. Three-digit with decimal point
2. B. Three-digit
3. C. Five-digit with decimal point
4. D. Five-digit

Correct Answer: D

- (Topic 3)
The Mabry County Hospital negotiated a contract with Wellfolk HMO. Mabry negotiated the inclusion of a provision in the contract whereby Mabry agreed to capitated compensation from Wellfolk up to a specified total cost of providing medical services for an

1. A. quality assurance provision
2. B. performance-based financial provision
3. C. dual-choice provision
4. D. stop-loss provision

Correct Answer: D

- (Topic 1)
Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim

1. A. A, B, C, and D
2. B. A and C only
3. C. A, B, and D only
4. D. B, C, and D only

Correct Answer: A

- (Topic 3)
Which of the following statements is FALSE?

1. A. The license that HMOs get in each state is called ‘Certificate of Authority’
2. B. The HMO contracts directly with the individual physicians who provide the medical services to the HMO members in a variation of the IPA model called direct contract model HMO.
3. C. All medicare/mediclaim beneficiaries should comply with utilization management requirements set forth by HCFA
4. D. HMO’s usually impose high coinsurance or deductible requirements

Correct Answer: D