Chapter21:OperationalFinance and Budgeting
1.___ is the primary revenuesource for HMOs.
A.Investments
B.Equityfinancing
C.Withholds
D.Premiumrevenue
2.___ rating entailsthe application of a standard rate to all groups within thecommunity being underwritten.
A.Experiencerating
B.Basic communityrating
C.Adjusted communityrating
D.None of theabove
3.___ develops a group rate onthe basis of a group’s actual experience.
A.Experiencerating
B.Basic communityrating
C.Adjusted communityrating
D.None of theabove
4.Medical expenses of an MCO maybe incurred on a:
A.Capitatedbasis
B.Feeschedule
C.Per diemarrangement
D.All of theabove
5.___ is a method of measuringthe minimum amount of capital appropriate for an MCO to support itsoverall business operations on the basis of its size and the degreeof risk taken into account each of the five major categories ofrisk.
A.ABCanalysis
B.RBC
C.Paretoanalysis
D.None of theabove
6. TheSarbanes Oxley Act of 2002 created which of thefollowing
A.Securities and ExchangeCommission
B.Institute of InternalAuditors
C.Public Company AccountingOversight Board
D.NAIC
Chapter 22:Underwriting and Rating Functions
1.?___ involves gatheringinformation about applicants or groups of applicants to determinean adequate, competitive, and equitable rate at which to insurethem.
A.?Adjusting
B.?Underwriting
C.?Rating
D.?Noneof the above
2.?___ involves calculatingthe premium to be charged for a specific individual or group on thebasis of information gathered during the ___process.
A.?Rating,Underwriting
B.?Underwriting,Rating
C.?Rating,Adjusting
D.?Noneof the above
3.?Thebest data source for any health plan is ___ because it implicitlyrecognizes all the plan-specific characteristics.
A.?Underwriting
B.?Actuarialconsulting firms’ data
C.?Experience
D.?Allof the above
4.?___ rates are high enoughto generate sufficient revenue to cover all claims and other planexpenses and to yield an acceptable return onequity.
A.?Equitable
B.?Adequate
C.?Competitive
D.?Noneof the above
5.?_ rates will approximate anygiven group’s costs without an unreasonable amount ofcross-subsidization across groups.
A.?Equitable
B.?Adequate
C.?Competitive
D.?Noneof the above
6. Why is historicalpersistency an important factor to consider whenunderwriting?
A.There aresignificant fixed costs to write a new group
B.Groups that changecarriers often are cheaper to underwrite
C.Multi-yearrelationships with groups may be required bylaw
D.None of theabove
7. Applicants/groups with poorcredit histories may be required to do which of thefollowing?
A.Produce some formof collateral
B.Produce a letter ofcredit
C.Pay premiums inadvance of the coverage period
D.Any of theabove
Chapter 23:Information Systems and EDI for Managed CareOrganizations
1.?True or false? MCO relygreatly on information systems to reduce costs and improveservice.
2.?True or false? Claimsprocessing is the primary differentiator between health plans inthe marketplace.
3.?True or false? The mostcommon form of claims submission is electronic.
4.?True or false? Thelargest opportunity to improve healthcare utilization, quality, andcost is through proactive and intensive medical and case managementleverage medical management software.
Chapter 24:Health Plans and Medicare
1.Which type of MA plan isexperiencing an increase in availability and enrollment due tobroad waivers from CMS?
A.Medical savings accountplan.
B.Health Maintenance Organizationplan.
C.Private fee-for-serviceplan.
D.Group retireeplan.
2.Dual Eligible Special NeedsPlans enroll individuals who are “dual eligible.” Who are the “dualeligible”?
A.Individuals who are eligiblefor Medicare and have Long-Term care insurance
B.Individuals who are eligiblefor Medicare and Medicaid
C.Individuals who are eligiblefor Medicare and are institutionalized
D.Individuals who are eligiblefor Medicare and have a severe or disabling chroniccondition
3.Plans can receive bonuspayments for high star quality ratings. The bonus payments can beused to:
A.Provide additionalbenefits
B.Reduce costsharing
C.Reduce enrolleepremiums
D.All of theabove
4. If aplan’s bid to CMS exceeds the benchmark, the plan must chargeenrollees the difference in the form of:
A.A monthlypremium
B.Higherdeductibles
C.Reducedservices
D.Highercopayments
5.MA plans must have a qualityimprovement program that measures performance under the program andincludes:
A.Chronic Care ImprovementPrograms (CCIP)
B.Quality Improvement Projects(QIPs)
C.Health InformationSystems
D.All of theabove
6.Which of the following is mostlikely to cause the rise of Medicare enrollment in MAplans overthe next few decades?
A.The Affordable CareAct
B.Baby Boomer interest in stayingin managed care when becoming eligible forMedicare
C.Politicians encouragingMedicare beneficiaries to choose MA over FFS
D.Increased marketing by MA plansto raise awareness of MA
