CEBS GBA 2 Practice Exam Questions
Which of the following is (are) among the limitations of ordinary whole life insurance? I. Relatively high cost II. Limited flexibility III. No savings fund
A.) I only
For long term care (LTC) purposes, the Internal Revenue Code defines a chronically ill individual as one who has been certified by a licensed health care practitioner as unable to perform, without substantial assistance from another individual, at least how many activities of daily living (ADLs) for a period of at least how many days due to a loss of functional capacity? A.) One ADL, 90 days B.) Two ADLs, 90 days C.) Three ADLs, 90 days D.) Two ADLs, 60 days E.) Three ADLs, 60 days
B.) Two ADLs, 90 days
Mr. Smith is insured in his company's group life insurance plan. The plan is noncontributory and meets the requirements of Internal Revenue Code Section 79. How much group life insurance can be provided to Mr. Smith without him incurring a federal income tax liability on the value of his employer's contributions? A.) 0 B.) 25,000 C.) 50,000 D.) 100,000 E.) An unlimited amount
C.) 50,000
Which of the following statements regarding health expenditures and related research is correct? A.) In general, risk adjustment models have been able to predict about 80 percent of total claims. B.) Age and gender account for about 90 percent of explained variation in health care expenditures. C.) Medicare currently pays Medicare Advantage plans on the basis of the Centers for Medicare & Medicaid Services Hierarchical Condition Categories (CMS-HCC) model, which uses approximately 70 clinical conditions. D.) Health maintenance organizations (HMOs) that could predict health expenditures only five percentage points better than Medicare would not gain a significant amount of profit per enrollee. E.) Inpatient expenditures are more predictable than outpatient expenditures.
C.) Medicare currently pays Medicare Advantage plans on the basis of the Centers for Medicare & Medicaid Services Hierarchical Condition Categories (CMS-HCC) model, which uses approximately 70 clinical conditions.
Self-funded health care insurance plans are exempt from several key requirements in Affordable Care Act (ACA), Employee Retirement Income Security Act (ERISA), and state regulations. All the following are included in these exemptions EXCEPT: A.) The ACA exempts self-funded plans from essential health benefit (EHB) and community rating requirements that apply to insurers selling to small groups. B.) Self-funded plans are not subject to medical loss ratio requirements that apply to fully insured plans. C.) Self-funded plans are exempt from annual and lifetime caps on coverage. D.) Self-funded plans are exempt from state premium taxes. E.) ERISA effectively exempts these plans from state insurance laws, including mandated benefits, reserve requirements and consumers protections.
C.) Self-funded plans are exempt from annual and lifetime caps on coverage.
Which of the following statements regarding the Affordable Care Act (ACA) is (are) correct? I. The ACA puts a limit on the medical loss ratio for large and small groups. II. The ACA prohibits medical underwriting. III. The ACA should produce lower health premiums for men and for younger people relative to the premiums for the same coverage prior to the law.
D.) I and II only
Which of the following statements regarding insurer payments and consumer out-of-pocket payments for out-of-network providers is (are) correct? I. Out-of-network providers are not limited to an insurer fee schedule when setting price and often charge more than insurers are willing to reimburse. II. There is evidence that cost-sharing for using an out-of- network provider is decreasing. III. Some out-of-network providers will accept as full payments reimbursements made by insurers or they will negotiate with consumers on price.
D.) I and III only
Which of the following statements regarding the loading percentage for health insurance rates is (are) correct? I. The loading percentage is lower for group health insurance rates than it is for individual health insurance rates. II. The loading percentage is lower for small groups than for large groups. III. The Affordable Care Act imposes penalties on insurers if their loading fees are too high.
D.) I and III only
Which of the following statements regarding private health insurance exchanges and Small Business Health Options Program (SHOP) exchanges is correct? A.) A lot of evidence has been produced to show that private exchanges have been designed to make it easier for small business to self-insure. B.) The income tax incentives previously provided to small employers in the SHOP program have expired. C.) Recently states were given the option of making SHOP exchanges mandatory for all employers with fewer than 200 employees. D.) Private exchanges could affect SHOP exchanges by siphoning enrollment from them and thereby reducing revenue (administrative fees) critical to SHOPs' financial viability. E.) Unlike private exchanges, SHOP exchanges do not have the ability to offer small employers a number of plan choices.
D.) Private exchanges could affect SHOP exchanges by siphoning enrollment from them and thereby reducing revenue (administrative fees) critical to SHOPs' financial viability.
The Affordable Care Act included several risk and market stabilization programs. Which of the following is one of the programs that dealt with limiting insurer losses and gains beyond an allowable range? A.) Reinsurance program B.) Risk adjustment program C.) Medical loss ratio program D.) Risk corridor program E.) Bidding process program for qualified health plans
D.) Risk corridor program
All the following are included in the ten guiding principles in Medicare's current risk adjustment approach EXCEPT: A.) The measures should be based on large enough sample sizes that they yield accurate and stable predictions. B.) The health status-related measures should be clinically meaningful. This means they should face validity and be sufficiently clinically specific to make it difficult for plans to assign a beneficiary with a vaguely defined condition. C.) Transitivity must hold. If condition A results in a greater payment than condition B and if B is paid more than C, then A should be paid more than C. D.) Providers should not be penalized for reporting many conditions. E.) Discretionary diagnostic codes should be permitted.
E.) Discretionary diagnostic codes should be permitted.
The vast majority of long-term care needs are met by: A.) Medicare B.) Medicaid C.) Individual health insurance policies D.) Long-term care insurance policies E.) Family members on an unpaid basis
E.) Family members on an unpaid basis
Which of the following statements regarding health care providers and out-of-network coverage is (are) correct? I. The Affordable Care Act's "Summary of Benefits and Coverage" is expected to make it easier for individuals to navigate the complex system of out-of-network coverage. II. Many plans allow out-of-network expenses to count toward an individual's out-of-pocket maximum. III. In some states insurers are required to report statistics related to driving distance to providers.
E.) I and III only
Disadvantages of group term life insurance for employees include which of the following? I. Coverage is rarely portable II. Only pure protection is provided III. Coverage is not guaranteed to be permanent
E.) I, II and III
The Affordable Care Act specifically refers to which of the following patient-centered medical home features or characteristics? I. Expanded access to health care II. Payments that recognize added value from additional components of patient-centered care III. Safe and high-quality care through evidence informed medicine
E.) I, II and III
Which of the following statements describe(s) the objectives of the risk and market stabilization programs in the Affordable Care Act? I. To redistribute funds from plans with lower-risk enrollees to plans with higher-risk enrollees. II. To provide payments to plans that enroll higher-cost individuals. III. To limit insurer losses and gains beyond an allowable range.
E.) I, II and III
Which of the following statements regarding different approaches by which to compensate physicians in managed care plans is (are) correct? I. Some managed care organizations may prefer to use arrangements that provide no direct link between quality or quantity of physician effort and compensation. II. Some managed care organizations preferring to provide a link between quantity of physician effort and compensation will use a fee-for-service arrangement. III. Some managed care organization will use a capitation arrangement to create incentives for physicians to provide visits and referrals that cost less than the capitated amount.
E.) I, II and III
Which of the following statements regarding the self-funding of health benefits by small firms are correct? I. Total costs in self-funded plans are lower relative to fully insured product options in large part because traditional insurance premiums include carrier marketing costs and profit margins—factors that are not applicable to self-funded plans. II. With a self-funded plan, a small employer can personalize a benefits package to reflect the needs of its workers. III. A shift to self-insurance may lead to adverse selection in the fully insured market for small groups.
E.) I, II and III
Which of the following statements regarding reimbursement methods for patient-centered medical homes (PCMHs) is correct? A.) The most popular approach, by far, is fee-for-service. B.) The most common approach is a capitation system. C.) Typically reimbursement is based on a pay-for-performance approach. D.) A negotiated, or modified, fee-for-service is the most common. E.) Nearly all approaches utilize a blend of pay-for-performance, monthly per-enrollee payments, and fee-for-service.
E.) Nearly all approaches utilize a blend of pay-for-performance, monthly per-enrollee payments, and fee-for-service.
All the following statements regarding the Diamond Project, cited as a case study in the readings, are correct EXCEPT: A.) The Diamond Project was built on Institute of Clinical Systems Improvement's years of experience. B.) Member groups developed considerable expertise in implementing the organizational changes necessary for major Quality Improvement. C.) Success was built on the high degree of trust and common mission between medical groups and health plan sponsors. D.) Success was built on several years of collectively trying to improve depression care by a number of other means. E.) Of the many successes of the Diamond Project, much of it has been with patients covered by Medical Assistance fee-for-service insurance.
E.) Of the many successes of the Diamond Project, much of it has been with patients covered by Medical Assistance fee-for-service insurance.
Which of the following has been a key focus of redesign and improvement efforts in healthcare? A.) Hospital care B.) Diagnostic/imaging services C.) Critical care D.) Orthopedic surgery E.) Primary care medicine
E.) Primary care medicine
Using private exchanges, employers have begun to implement the defined contribution model for medical benefits for which group of individuals? A.) All active full-time employees B.) Active full-time employees with dependent coverage C.) All part-time employees D.) Part-time employees with dependent coverage E.) Retirees and their eligible dependents
E.) Retirees and their eligible dependents
Long-term care insurance may cover all the following types of services EXCEPT: A.) Custodial care B.) Home health care C.) Hospice care D.) Assisted living care E.) Short-term hospital stays
E.) Short-term hospital stays
The major advantage of term insurance for the policyowner is the fact that: A.) A substantial amount of life insurance can be purchased for relatively modest premiums B.) It provides lifetime protection if the insured continues to pay the premiums C.) The premiums remain at the same level for the life of the insured D.) With a policy rider it can be used to provide retirement E.) Premiums are highly competitive especially for those at older ages
A.) A substantial amount of life insurance can be purchased for relatively modest premiums
A provision in some group life insurance plans that provides for the payment of all or part of the death benefit in the event of the insured's terminal illness is called: A.) Accelerated death benefits B.) Waiver of premiums C.) Maturity value benefits D.) Continuation-of-protection E.) Assignment
A.) Accelerated death benefits
Studies regarding hospital price negotiations in selective contracting include which of the following implications? I. Insurers and consumers generally should encourage the entry of new and additional capacity in the local health care market if the purpose is to reduce prices. II. The existence of numerous self-employed pediatricians is likely to hinder selective contracting efforts. III. If a local hospital market has idle capacity, it is likely that neighboring hospitals will tend to have healthy financial results.
A.) I only
Which of the following statements regarding health insurance rating systems is (are) correct? I. Both prospective and retrospective experience rating use an employer's experience to calculate the insurance rate. II. With prospective rating, the insured, not the insurer, bears the underwriting risk. III. If experience in the year 20X1 is used to determine the rate for the subsequent year, 20X2, this would be retrospective rating.
A.) I only
Which of the following statements regarding the amount of benefits provided in private long-term disability income (PLTDI) and Social Security Disability Income (SSDI) plans is (are) correct? I. Most PLTDI plans replace 60 percent of the insured's predisability income, and 60 percent generally exceeds what he would receive if he met the SSDI definition of disability and applied for and received Social Security disability benefits. II. High income workers often get more than 60 percent of their predisability income replaced by SSDI. III. SSDI benefits replace about 85 percent of lifetime predisability earnings for the average worker even if he does not receive the maximum family benefit.
A.) I only
Which of the following statements regarding the financing of workers' compensation programs is (are) correct? I. Workers' compensation programs are based on the principle that the cost of work-related accidents is a business expense. II. Employers can purchase workers' compensation insurance from a private carrier or state fund but no state allows this exposure to be self-insured. III. Most state workers' compensation programs rely heavily on the general taxing power of the state to finance workers' compensation.
A.) I only
Which of the following statements regarding the strategies that can be used to pursue quality improvement (QI) is (are) correct? I. One of the top strategies that has been identified is to delegate authority to the implementation planners. II. It is now believed that a universal implementation approach for the various practice settings is better than a tailored implementation approach for each practice setting. III. One of the best strategies is to focus on special projects using a team of volunteers.
A.) I only
Which of the following statements regarding the so-called "death spiral" in health insurance premiums is (are) correct? I. The fundamental cause of the "death spiral" is the great disparity between the size of large health insurance plans and the size of small health insurance plans. II. To counter problems arising from adverse selection, risk adjustment methods can be used to transfer funds from plans with below-average costs to plans with above-average costs. III. Several industry reports argue that risk adjustment is needed in the multicarrier exchange market, and there is strong evidence and detailed procedures for such adjustments.
A.) II only
A medical group is paid fee-for-service up to a withhold amount. The group is paid 75 percent at the time of service and the remaining 25 percent is paid if the managed care plan: A.) Is able to cover its overall claim costs. B.) Covers the physician salaries. C.) Anticipates providing less than two percent of out-of-network benefits in the next computation period. D.) Provides virtually 100% in-network benefits in the computation period. E.) Is efficient at recapturing capitation fees for late subscriber terminations.
A.) Is able to cover its overall claim costs.
The practice of hospitals paid based on billed charges by commercial insurers and allowable costs by Medicare ended primarily because: A.) Managed care plans introduced selective contracting into the market. B.) Hospitals started using more advanced technology. C.) Patients became less concerned about the cost of services. D.) Hospitals started to focus more on the quality of services. E.) Physicians gained a greater voice in the pricing of health care.
A.) Managed care plans introduced selective contracting into the market.
Which of the following entities have participated in the risk adjustment program of the Affordable Care Act? I. All qualified health plans offered outside the exchange II. Self-insured health plans offered on private exchanges III. Medicare Part D plans
A.) None
Which of the following statements regarding Small Business Health Options Program (SHOP) exchanges is correct? A.) SHOP exchanges are marketplaces that are essentially online portals which enable small employers to select from a range of fully insured plans and contribution arrangements for their employees. B.) Plans marketed on SHOP exchanges are exempt from all federal requirements for insurers. C.) SHOP exchanges require employees to contribute at least 50-75% of premium costs. D.) Employees who receive an employer offer of qualified health care coverage purchased on a SHOP exchange are eligible for federal subsidies. E.) SHOP exchanges are primarily targeted to employers with 50-100 employees.
A.) SHOP exchanges are marketplaces that are essentially online portals which enable small employers to select from a range of fully insured plans and contribution arrangements for their employees.
All the following statements regarding the services that third-party administrators (TPAs) provide to self-funded health plans are correct EXCEPT: A.) TPA services provided to self-funded plans are highly uniform among TPA firms. B.) TPAs handle a broad range of administrative services for self-funded plans. C.) Most TPAs will arrange access to provider (physician and hospital) networks, pharmacy benefits and review claims. D.) TPAs may also perform some of the customer services in lieu of brokers, such as enrolling employees and resolving customer disputes. E.) In many cases, TPAs are owned by large insurance companies that license out their physician network and help administer claims for self-funded groups.
A.) TPA services provided to self-funded plans are highly uniform among TPA firms.
In the calculation of health insurance rates, the pure premium is determined to be $1,300 and the loading percentage is 35 percent. All of the following statements regarding these figures are correct EXCEPT: A.) The gross premium must be $2,145. B.) The loss ratio is 65 percent. C.) The expense ratio is 35 percent. D.) The loading percentage is also known as the expense ratio. E.) The pure premium is the amount allocated for the expected losses.
A.) The gross premium must be $2,145.
All the following are reasons why insurance companies have been dissatisfied with the long term care (LTC) insurance product structure EXCEPT: A.) The use of unisex rates, which insurers would prefer, has been prohibited. B.) LTC insurers have been subject to reinvestment risk because interest rates have been low for so long and insurers have been forced to invest cash flows from expiring assets at rates lower than what they have assumed. C.) Insurers have been concerned that the Genetic Information Nondiscrimination Act (GINA) may prevent the use of genetic information for underwriting, but potential policyholders may have this personal information, thereby creating a situation for adverse selection. D.) Insurers have been concerned about the negative consequences when applying for rate increases. E.) Insurers find it difficult to objectively specify claim criteria due to the complexity of disability.
A.) The use of unisex rates, which insurers would prefer, has been prohibited.
Out-of-network health care accounts for approximately what percentage of total covered health insurance expenses? A.) 3 B.) 10 C.) 20 D.) 25 E.) 30
B.) 10
All of the following statements regarding legal protection from out-of-network medical bills incurred unknowingly by patients are correct EXCEPT: A.) Very few states extend balance billing protection to health plan enrollees from out-of-network providers. B.) A patient-plaintiff facing surprise medical bills from out-of-network providers is likely to prevail in a breach-of-fiduciary-duty claim against the hospital. C.) The doctrine of unconscionability permits courts to void a contract if no sensible person would accept and no honest person would offer such a contract. D.) Courts have been reluctant to find hospital admission contracts for those receiving out-of-network care billed at chargemaster rates as unenforceable. E.) Addressing the problem of involuntary balance billing at the state level has the benefit of allowing citizen preferences to have a more direct role in policy.
B.) A patient-plaintiff facing surprise medical bills from out-of-network providers is likely to prevail in a breach-of-fiduciary-duty claim against the hospital.
All of the following are factors a stop-loss insurer might consider when underwriting a health care policy for an employer EXCEPT: A.) Previous health care experience and anticipated trends going forward for the employer B.) Anonymized medical surveys of existing policies' covered employees C.) The employer's preferred physician network D.) The geographic location of the employer E.) The third-party administrator selected by the employer
B.) Anonymized medical surveys of existing policies' covered employees
The Health and Medicine Division (formerly known as Institute of Medicine) promulgated six goals following the two landmark reports that identified widespread quality problems within the U.S. healthcare system. All the following are included among these six goals EXCEPT: A.) Equity B.) Convertibility C.) Timeliness D.) Effectiveness E.) Patient centeredness
B.) Convertibility
What reasons are given for the Silver plan being a popular choice among all the Affordable Care Act (ACA) health plans? A.) The Silver plan has the greatest actuarial value of all the plans. B.) Cost-sharing subsidies to lower out-of-pocket costs are available only to people who select the Silver plan. C.) The Silver plan has the greatest benefits, even more than the Gold and Platinum plans. D.) The Silver plan has the lowest out-of-pocket costs of any plan even before any subsidies. E.) Many people select the Silver plan because they are not eligible for the Gold or Platinum plans.
B.) Cost-sharing subsidies to lower out-of-pocket costs are available only to people who select the Silver plan.
All of the following are reasons cited for consumers being reluctant to purchase long-term care (LTC) insurance EXCEPT: A.) Rate increases announced by insurers and the negative publicity that follow such announcements erode public trust in LTC insurance companies. B.) Fears of not being able to change carriers due to the underwriting practice of not accepting policyholders with an existing five-plus-years policy in force with another carrier. C.) The onerous process required to receive benefits. D.) The cost is considered too expensive. E.) The fact that many elderly disabled individuals are unable to satisfy the requirements to be eligible for LTC benefits.
B.) Fears of not being able to change carriers due to the underwriting practice of not accepting policyholders with an existing five-plus-years policy in force with another carrier.
"Desktop medicine" is a fully integrated approach using information technology whose primary goal is to: A.) Recruit prospective health plan subscribers B.) Help track patients through their plan of care C.) Encourage patient self-diagnosis using the Internet D.) Gather health status metrics for large patient populations E.) Expedite health provider use of technology
B.) Help track patients through their plan of care
Which of the following statements regarding patient-centered medical homes (PCMHs) is (are) correct? I. PCMHs institute a team approach to patient care. II. The medical home model emphasizes patient involvement through shared decision making. III. The PCMH model requires a greater number of visits with physicians than traditional health care delivery methods.
B.) I and II only
Reinsurance is especially important in self-funded health insurance plans. Which of the following statements regarding stop-loss reinsurance for these plans is (are) correct? I. "Lasering" is the process of excluding selected high-cost employees from reinsurance coverage. II. The stop-loss reinsurance contract is almost always limited to one year. III. Stop-loss reinsurance for self-funded health plans is currently regulated almost exclusively at the federal level.
B.) II only
Which of the following statements regarding low-cost, retail health care clinics is (are) correct? I. While low-cost, retail health clinics offered the promise of lowering the cost of health care, actual experience has been negative and the number of these clinics has been declining. II. This approach requires the onsite, day-to-day management of a physician. III. These clinics can offer a range of medical services from basic triage and prevention to management of chronic conditions like diabetes and heart disease.
B.) III only
All the following statements regarding salary continuation programs are correct EXCEPT: A.) One advantage of a salary continuation program is that it may encourage employees to conserve their sick days for extended disability protection. B.) Insurance companies that provide this type of coverage often provide expertise in state regulatory requirements. C.) These programs are not deemed to be Employee Retirement Income Security Act (ERISA) plans and therefore are not subject to ERISA reporting and disclosure requirements and fiduciary standards. D.) Employers subject to Statement 112 of the Financial Accounting Standards Board (FAS 112) (or ASC 712) need to annually estimate the accrued liability for these benefits, put aside (reserve) funds for it and report it on their financial statements. E.) The burden of making determinations regarding disability criteria and duration of disability of these programs typically rests on the employer.
B.) Insurance companies that provide this type of coverage often provide expertise in state regulatory requirements.
Reference pricing used by some managed care health plans: A.) Is an example of center-of-excellence pricing. B.) Is one method of giving subscribers an incentive to use lower-cost but quality providers. C.) Can only be used in a capitation system. D.) Is a model that has not been used in practice. E.) Is designed to attract healthier individuals into the plan. .
B.) Is one method of giving subscribers an incentive to use lower-cost but quality providers
The health insurance rating system in which insurers place policyholders into groups according to their loss producing characteristics is known as: A.) Calibrated rating B.) Manual rating C.) Durational rating D.) General liability rating E.) Objective rating
B.) Manual rating
According to the RAND Health Insurance Experiment, which variable has the greatest power in explaining health expenditures? A.) Welfare eligibility B.) Prior utilization C.) Physical health (based on self-reported measures) D.) General health (based on self-reported measures) E.) Mental health (based on self-reported measures)
B.) Prior utilization
Developed countries other than the U.S. spend a much lower proportion of their gross domestic product on health care and enjoy better quality than the U.S. does. It is widely believed by policy makers that one major reason for this phenomenon is because: A.) The medical educational programs are better in the other countries. B.) The health care systems in such countries are built on a strong primary care base. C.) Other countries use much better technology than the U.S. does. D.) The U.S. has not made quality healthcare a high priority. E.) Other countries have healthier populations.
B.) The health care systems in such countries are built on a strong primary care base.
All the following are major requirements of a qualified long-term care (LTC) policy EXCEPT: A.) The policy must only provide coverage for qualified LTC services. B.) The policy must provide a cash surrender value or other money that can be paid, assigned, or pledged as collateral for a loan. C.) The policy must be guaranteed renewable. D.) The policy must provide that all policyholder dividends and premium refunds be applied against future premiums or to increase benefits. E.) The policy must provide certain consumer protection provisions.
B.) The policy must provide a cash surrender value or other money that can be paid, assigned, or pledged as collateral for a loan.
The Affordable Care Act defines a Patient Centered Medical Home (PCMH) as a model of care that has six core features. All of the following are included in this list of core features EXCEPT: A.) The safe and high-quality care through evidence-informed medicine. B.) The rare use of personal physicians. C.) A whole person orientation. D.) The appropriate use of health information technology. E.) A payment that recognizes added value from additional components of patient-centered care.
B.) The rare use of personal physicians.
All the following statements regarding private health insurance exchanges are correct EXCEPT: A.) In private exchanges, the exchange vendor can be relied on to help explain exchanges to each employee, rather than have employers try to do it on their own. B.) The technology deployed by most private exchanges renders telephone hotlines and face-to- face customer service redundant. C.) Private exchanges typically provide extensive software to aid consumers in decision support. D.) The more advanced software of private exchanges allows side-by-side comparisons as the employee adjusts particular characteristics. E.) Exchange websites can include pop-up information to explain facets of the benefits as the employee is looking at a particular item, such as the drug coverage in a health plan.
B.) The technology deployed by most private exchanges renders telephone hotlines and face-to- face customer service redundant.
The Age Discrimination in Employment Act (ADEA), as amended and clarified, stipulates all the following for group term life insurance benefits for active employees after age 65 EXCEPT: A.) An employer may be able to make greater reductions in benefits on the basis of its own demonstrably higher cost experience. B.) An employer may reduce coverage each year starting at age 65 by 8 to 9 percent of the declining balance of the life insurance benefit. C.) An employer generally may terminate life insurance coverage for active employees at age 70 while continuing to provide coverages for younger employees. D.) An employer may make a one-time reduction in life insurance benefits at age 65 from 35 to 40 percent and maintain this until retirement. E.) An employer may use a "benefit-by-benefit" analysis to ascertain if a reduction in older workers' benefits is permissible. .
C.) An employer generally may terminate life insurance coverage for active employees at age 70 while continuing to provide coverages for younger employees.
All of the following statements concerning the concept of a free market are correct EXCEPT: A.) One of its basic assumptions is that consumers are rational and will make informed decisions about value, quality, and price. B.) One of its premises is that producers meeting consumer demands will be rewarded with market share and profit. C.) Consumer choices must be limited for a free market to empower consumers, regulate producers and operate efficiently. D.) Certain economists and sociologists have challenged the basic assumptions underlying the concept of free market. E.) The theory of bounded rationality casts doubt on the concept.
C.) Consumer choices must be limited for a free market to empower consumers, regulate producers and operate efficiently.
Objective risk for health insurers is most closely related to which of the following concepts? A.) Expense ratios B.) Carve out coverage such as prescription drug benefits C.) Dispersion (which is often measured by standard deviation) D.) Investment underwriting E.) Subjective risk
C.) Dispersion (which is often measured by standard deviation)
Until now, the biggest source of cost savings with private health insurance exchanges has been: A.) Transition to the defined contribution approach B.) Increased use of technology C.) Employees choosing less generous plans D.) Better health education of employees E.) Elimination or reduction in administrative waste
C.) Employees choosing less generous plans
What is the waiting period for Social Security Disability Income (SSDI) benefits? A.) One month B.) Three consecutive months C.) Five consecutive months D.) Six consecutive months E.) Twelve consecutive months
C.) Five consecutive months
All the following are advantages cited for noncontributory financing of group-term life insurance EXCEPT: A.) Greater control of plan by employer B.) Economy of installation C.) Greater employee interest D.) Simplicity of administration E.) Coverage of all eligible employees
C.) Greater employee interest
All the following statements regarding patient-centered medical homes are correct EXCEPT: A.) One critical component of this model of health delivery is electronic health record systems. B.) This model has been used for a long time as a coordinated care model for children (pediatrics). C.) Growth of PCMHs in recent years has been powered by the steady growth of consumer-driven health plans. D.) PCMHs rely heavily on medical technology. E.) Tracking patient engagement and satisfaction plays a significant role in PCMH assessments by payers and the public.
C.) Growth of PCMHs in recent years has been powered by the steady growth of consumer-driven health plans.
In which of the following ways does the U.S. health care market not function like a "normal" market? I. The health care market has significant asymmetry in information between consumers, providers and insurers. II. Moral hazard is a problem because the marginal cost of covered care is zero, causing some to overconsume medical care. III. Doctors are initially chosen from websites providing physician reviews rather than from recommendations by friends or relatives.
C.) I and II only
Which of the following are key assumptions that were proven to be incorrect for long-term care (LTC) policies sold from when first introduced in the 1980s to the 1990s? I. Morbidity experience was higher than expected II. Lapse rates turned out to be higher than expected III. Higher-than-expected margins were needed to account for adverse selection
C.) I and III only
Which of the following statements regarding self-insured health plans is (are) correct? I. Self-insured health plans want to be exempt from state insurance regulation. II. Relatively few, less than 20 percent, of workers are in some type of self-insured preferred provider organization (PPO) health plans. III. A third-party administrator (TPA) may be used when an employer wants to have a self-insured plan but does not want the burden of administering the plan.
C.) I and III only
Which of the following statements regarding the advantages of private health exchanges is (are) correct? I. They provide more health insurance options to employees. II. They have provided substantial administrative cost savings. III. They can relieve the employer of having to choose one or two plans for an entire workforce.
C.) I and III only
Which of the following statements regarding the methodology used by the Affordable Care Act's risk adjustment program is (are) correct? I. The risk adjustment program transfers funds from plans with lower-risk enrollees to plans with higher-risk enrollees. II. Individual risk scores based on an individual's age and sex are specifically prohibited. III. If an enrollee is receiving subsidies to reduce his or her cost sharing, an induced utilization factor is applied to account for induced demand.
C.) I and III only
Which of the following statements regarding the size of price concessions managed care plans can negotiate with hospitals is (are) correct? I. Virtually no managed care plans pay full billed II. Discounts rarely exceed 40 percent. III. There apparently is no direct relationship between the size of the discount and the actual price of hospital services.
C.) I and III only
How did the Affordable Care Act change Medicare? I. The law provides strong incentives for health care providers to return to traditional fee-for-service compensation. II. The law mandates that consumers choose the most cost- effective plan for them. III. The law expanded Medicare's wellness and prevention benefits.
C.) III only
Studies concerning employees' willingness to change health plans when faced with changes in out-of-pocket premiums show that not all employees have the same degree of price sensitivity. Which of the following groups of employees are less likely to change plans for a given increase in the out-of-pocket premium? I. Enrollees of point-of-service (POS) plans II. Enrollees of health maintenance organization (HMO) plans III. Employees with chronic health conditions
C.) III only
A small employer has a self-funded health plan with reinsurance coverage. Which of the following statements regarding this type of reinsurance is correct? A.) Aggregate stop-loss reinsurance limits the dollar amount of coverage on each employee's health care costs. B.) Reinsurers often help small employers revise their health plans. C.) Lower "attachment points" decrease the employer's financial risk. D.) Federal law requires stop-loss insurers to provide policyholders an advance notice of at least 90 days before cancelling a policy. E.) Specific stop-loss coverage reinsurance limits the dollar amount of health care costs for an entire employee population over a period of time.
C.) Lower "attachment points" decrease the employer's financial risk.
Which of the following statements regarding recognition as a patient-centered medical home (PCMH) is correct? A.) The only organization that can officially recognize a PCMH is the Federally Qualified Health Center Demonstration. B.) The only organization that can officially recognize a PCMH is the National Committee for Quality Assurance (NCQA). C.) No single organization is responsible for recognizing PCMHs. D.) The main organization that recognizes PCMHs is the Joint Commission and the Accreditation Commission for Health Care. E.) A PCMH can be recognized only by the state in which it is domiciled.
C.) No single organization is responsible for recognizing PCMHs.
Which of the following statements best describes the Affordable Care Act (ACA) approach to the problem of involuntary out-of-network emergency health care? A.) Higher copayments and coinsurance for out-of-network emergency room care is permitted but limited and balance billing is prohibited. B.) Higher copayments and coinsurance for out-of-network emergency room care is allowed, but only for certain specific types of care; balance billing is not allowed. C.) Plans cannot impose higher copayments or coinsurance for out-of-network emergency room care and balance billing is still allowed within certain parameters; these requirements do not apply to grandfathered plans. D.) Plans cannot impose higher copayments or coinsurance for out-of-network emergency room care and balance billing is not allowed; no plans are grandfathered. E.) The ACA has yet to address this issue but new guidance is expected.
C.) Plans cannot impose higher copayments or coinsurance for out-of-network emergency room care and balance billing is still allowed within certain parameters; these requirements do not apply to grandfathered plans.
All of the following are criteria utilized by the National Committee For Quality Assurance (NCQA) in awarding a "Distinction in Patient Experience Reporting" to medical homes EXCEPT: A.) Access to care B.) Shared decision making C.) Provider personality ratings D.) Self-management support E.) Coordination of care
C.) Provider personality ratings
All the following statements regarding self-insured health plans are correct EXCEPT: A.) Self-insurance may not be a wise choice for group plans with low credibility factors. B.) The Affordable Care Act unintentionally has made self-funding more attractive to small employers. C.) The concept of objective risk leads one to anticipate that employers with fewer covered lives prefer self-insurance. D.) Self-insurance dominates the large group health market. E.) Self-insured plans have the option of adjudicating their claims in-house.
C.) The concept of objective risk leads one to anticipate that employers with fewer covered lives prefer self-insurance.
What is the provision in the Part D Medicare law that gives a significant benefit to pharmaceutical companies? A.) The law allows only pharmaceutical companies registered with a specified trade association to market drugs under Part D and virtually all pharmaceutical companies are so registered B.) The law guarantees a certain profit margin to all pharmaceutical companies that sell drugs under Part D. C.) The law prohibits the government from using its purchasing power to negotiate widespread discounts with drug plans. D.) The law gives all U.S. pharmaceutical companies special income tax benefits for an extended period of time. E.) The law prohibits the widespread dissemination of information regarding specified drugs.
C.) The law prohibits the government from using its purchasing power to negotiate widespread discounts with drug plans.
As quality improvement (QI) has been implemented in health care, the approach has evolved over time with certain lessons learned and various improvements made. All the following statements involving this evolutionary process are correct EXCEPT: A.) When QI was first imported from other industries into medical care, it usually adopted an approach of creating specific projects managed by special QI teams that applied. B.) A revised model of QI was greatly simplified and instead of many steps, the model proposed that QI teams first answer three basic questions. C.) QI teams need a solid understanding and application of systems thinking, measurement, variation, and change management. D.) A modification of the QI process involved the focus on macrosystems. E.) One step recognizes that QI effort must be incorporated into the normal management of the primary care organization rather than being conducted as special projects using ad hoc teams of volunteers.
D.) A modification of the QI process involved the focus on macrosystems.
All of the following are underwriting methods used in health insurance EXCEPT: A.) Adjusted community rating B.) Retrospective experience rating C.) Community rating by class D.) Administrative rating E.) Prospective experience rating
D.) Administrative rating
To become eligible for Social Security Disability Insurance benefits, a worker must meet all the following requirements EXCEPT: A.) File a claim for disability insurance benefits B.) Meet the definition of disability set forth in the Social Security Act C.) Be insured for disability under the Social Security Act D.) Be at least 30 years old E.) Not have attained normal retirement age
D.) Be at least 30 years old
All the following statements regarding the usual and customary rate (UCR) used in health insurer reimbursement practices are correct EXCEPT: A.) An investigation by one large state alleged conflict of interest between a major insurer and the entity responsible for managing the database used to calculate UCR. B.) An independent, nonprofit company has been established to manage the database for computing UCR. C.) More and more insurers are abandoning the traditional UCR pay formulas. D.) Changes involving the UCR have greatly decreased the amount of balance billing. E.) The use of the Medicare rate has increased recently.
D.) Changes involving the UCR have greatly decreased the amount of balance billing.
Using out-of-network health providers is often difficult and/or unavoidable for consumers. All the following statements regarding issues related to in- and out-of-network care are correct EXCEPT: A.) Often the amount the insurer will reimburse for out-of-network care and the amount the consumer will pay are not transparent to the consumer. B.) Consumers may find themselves unknowingly relying on inadequate or outdated directories to determine provider network participation. C.) Some specialties have noticeably lower provider participation (in-network) rates. D.) Excess charges for out-of-network hospital-based providers (e.g., anesthesiologists) that are not chosen by the consumer are the responsibility of the hospital if it fails to notify consumers of the providers' out-of-network status. E.) Out-of-network coverage may need to be accessed if an appropriate in-network provider is not available within a reasonable distance from a consumer's home.
D.) Excess charges for out-of-network hospital-based providers (e.g., anesthesiologists) that are not chosen by the consumer are the responsibility of the hospital if it fails to notify consumers of the providers' out-of-network status.
Which of the following is (are) recommendations that have been made to address certain issues including adverse selection related to Small Business Health Options Program (SHOP) exchanges? I. The premium subsidies that have been made available to firms that purchase SHOP plans should be increased. II. SHOP exchanges should invest in technology and operations to make the process of purchasing a plan as simple and easy as possible. III. SHOP exchanges should dissuade small firms from continuing their relationships with traditional brokers once they have signed on with an exchange.
D.) I and II only
Which of the following statements describe(s) the federal income tax treatment of qualified long-term care (LTC) insurance premiums? I. If an individual who is not self-employed pays qualified LTC insurance premiums, the premiums are not deductible under any circumstances. II. If an S corporation, partnership, or LLC pays qualified premiums for an employee who is also an owner of the business, the premium is considered compensation. III. If a Subchapter C corporation pays for qualified LTC insurance premiums for an employee, officer, or owner, the amount is 100 percent deductible to the business as a business expense, and the premium is not considered compensation to the employee, officer, or owner.
D.) II and III only
Which of the following statements regarding the condition of the delivery of health care is (are) correct? I. Studies show that regions in the U.S. with higher numbers of subspecialists have lower costs (attributable to lower malpractice costs) and better health outcomes. II. Studies show only incremental improvements in health care disparities among different segments of the U.S. population. III. Most primary care practices are financially insecure.
D.) II and III only
A life insurance policy in which the insurance provides lifetime protection, the premiums are level, but they are paid only for a certain period is referred to as: A.) Endowment insurance B.) Term to age 65 C.) Straight life D.) Limited payment life E.) Variable life
D.) Limited payment life
After extensive study and research, certain conclusions can be drawn regarding the various approaches to achieve quality improvements in health care. All the following statements concerning these conclusions are correct EXCEPT: A.) Performance measures, incentives and penalties focused on health plans are not likely to be very successful in bringing about effective and extensive quality improvement. B.) External bodies have limited ability to foster the redesign of care unless there is a change in the payment system. C.) Physicians and care delivery organizations must take a leading role in any serious improvement in care and costs. D.) Payment systems have little impact on quality improvements. E.) Basing physician payments on the volume of services provided neither incentivizes significant changes in care approach nor covers the costs of making such changes.
D.) Payment systems have little impact on quality improvements.
Studies of physician markets show all the following regarding the employment and compensation of physicians in managed care plans EXCEPT: A.) Health maintenance organizations (HMOs) were able to negotiate lower fees than were preferred provider organizations (PPOs). B.) Managed care plans paid lower fees when there were more physicians per capita in the metropolitan area. C.) Managed care plans paid lower fees for procedures when there was greater managed care penetration in the area. D.) Studies show that the use of the capitation method of compensation has been increasing for many years. E.) Managed care leads to somewhat fewer self-employed physicians.
D.) Studies show that the use of the capitation method of compensation has been increasing for many years.
Which of the following measures of cost is generally used by analysts when they are examining the impact of insurance premiums on employees' choice of health insurance plans? A.) The loading percentage B.) The total gross premium C.) The insurer's profit D.) The employee's out-of-pocket price E.) The expected future gross premium
D.) The employee's out-of-pocket price
All the following could be the beneficiary of an employer-sponsored group term life insurance contract EXCEPT: A.) The employee's estate B.) The employee's children C.) A charity D.) The employer E.) The employee's former spouse
D.) The employer
A study examined the elements that affect health insurer price negotiations in selective contracting with hospitals. The study concluded that insurers are able to obtain lower prices in all the following situations EXCEPT: A.) When there are more hospitals in the local market. B.) When the insurer had a larger share of the hospital's book of business. C.) When the hospital had little bargaining power. D.) When the insurer is small, i.e., has assets lower than a certain amount. E.) When the hospital had a lower occupancy rate.
D.) When the insurer is small, i.e., has assets lower than a certain amount.
Which of the following is the approximate percentage of the U.S. population covered in the specified U.S. healthcare scheme? A.) 40% through private individual insurance B.) 25% through employer-sponsored group insurance C.) 25% through the Medicaid program D.) 20% through the Federal Employees Health Benefits (FEHB) program E.) 15% through the Medicare program
E.) 15% through the Medicare program
All the following statements regarding the definition and features of a "private health exchange" are correct EXCEPT: A.) In general, private health exchanges involve web portals through which employees can shop for health insurance. B.) Private health exchanges often include advanced decision making tools, such as benefit calculators. C.) These exchanges are really a shopping experience. D.) There is a lack of consensus on the defining characteristics of private health exchanges. E.) An exchange operator statutorily cannot vary plan offerings across geographic regions.
E.) An exchange operator statutorily cannot vary plan offerings across geographic regions.
In the patient-centered medical home (PCMH) model, which of the following statements regarding primary care visits is (are) correct? I. The first contact person during such visits might be a generalist, a specialist, or a nurse practitioner. II. Some medical homes use secure messaging through electronic health records for real-time specialist consultation during primary care visits. III. In many practices, it is common to have daily team "huddles" to preview cases.
E.) I, II and III
Research has shown which of the following statements regarding managed health care to be correct? I. While the prevailing public view is that managed health care results in lower quality, little evidence exists on this issue in part because of the difficulty in measuring quality. II. Favorable selection of patients does contribute to the overall lower claims experience that managed care plans enjoy over indemnity plans. III. Managed care plans can provide actual cost savings because of their ability to selectively contract with providers.
E.) I, II and III
All the following statements regarding healthcare quality improvement collaboratives (QICs) are correct EXCEPT: A.) QICs are one of the more promising ways to help clinics and medical groups to improve their quality. B.) The most well-known QICs are those short-term ones that have been run for specific topics by the Institute for Healthcare Improvement (IHI). C.) QICs are very expensive for participants and tend to attract mainly large care delivery organizations or those paid for by the government. D.) Enough separate QICs have been implemented in the U.S. that they now have their own national association, the Network for Regional Healthcare Improvement. E.) The conclusion, in a systematic review of the evidence of the value of QICs, was that QICs indeed provide significant value that can be predicted with much certainty.
E.) The conclusion, in a systematic review of the evidence of the value of QICs, was that QICs indeed provide significant value that can be predicted with much certainty.
Which of the following statements best describes the financial liability of self-insured plans administered through private health exchanges? A.) The plans can completely cap their financial liabilities by using these exchanges. B.) Using these exchanges, the plans can completely cap their financial liabilities by offering plans with a fixed credit that is not indexed to the rate of general inflation. C.) The plans can shift some of their financial liabilities to the private exchange vendor. D.) The plans can cap most of their financial liabilities by participating in a risk pool established by the exchange vendor. E.) The plans cannot, in general, completely cap their financial liabilities regardless of the delivery vendor they select.
E.) The plans cannot, in general, completely cap their financial liabilities regardless of the delivery vendor they select.
All the following statements regarding benefits under private long-term disability income (PLTDI) plans are correct EXCEPT: A.) Some of these plans offer lifetime benefits. B.) Many of these policies pay benefits up to age 65 or the individual's retirement age. C.) Some of these plans pay benefits for a set number of years (sometimes as few as two or five). D.) It is not uncommon for benefit periods arising from mental health conditions to be significantly shorter than for those arising from physical conditions. E.) These plans can have no restrictions on coverage for preexisting conditions.
E.) These plans can have no restrictions on coverage for preexisting conditions.
All the following statements regarding Medicare Advantage (Medicare Part C) plans are correct EXCEPT: A.) These plans give recipients the option to enroll in a health plan with a narrower network of hospitals and providers than that of Medicare Parts A and B, but with less out-of-pocket costs. B.) These plans are likely to include their own prescription drug coverage. C.) These plans are voluntary and beneficiaries always have the option of going back to the traditional program. D.) These plans are often chosen because of lower cost and greater care coordination. E.) These plans have minimal state variation.
E.) These plans have minimal state variation.
The definition of disability for Social Security Disability Insurance benefits requires the impairment to be expected to result in death or to last for a continuous period of at least how many months? A.) Three B.) Four C.) Five D.) Six E.) Twelve
E.) Twelve
