CLAHS - California Life, Accident and Health or Sickness Examination

Question 21: An HMO pays a contracted physician a fixed monthly amount for each member assigned, regardless of how often those members are seen. This payment method is known as which of the following?

Coinsurance

Usual, customary, and reasonable

Capitation

Indemnity reimbursement

Question 22: In an HMO that uses the gatekeeper concept, a subscriber who wants to see a specialist must generally do which of the following first?

Obtain a primary care physician referral

Pay the full annual deductible

Switch to an out-of-network provider

File a written appeal with the insurer

Question 23: Which of the following is the distinguishing emphasis of a health maintenance organization compared with traditional insurance?

Unlimited choice of any provider

Payment of fixed daily hospital income

Coverage only for named diseases

Preventive care to detect conditions early

Question 24: A subscriber suffers a medical emergency while traveling outside the HMO service area and is treated by a non-network provider. How does the HMO generally handle this?

It denies all out-of-area care

It reimburses the emergency care

It pays only after a specialist referral

It converts the member to a PPO

Question 25: A managed-care plan lets subscribers use providers outside its network, paying for that care at a reduced reimbursement level. This open-panel design identifies which plan type?

A health maintenance organization

An exclusive provider organization

A preferred provider organization

A dread disease plan

Question 26: Providers in a preferred provider organization agree to deliver services at pre-negotiated discounted fees in exchange for which of the following?

Access to the plan's pool of subscribers

A guaranteed capitation payment

Ownership of the plan

Exemption from all utilization review

Question 27: A managed-care plan covers care only when received from its own network, yet allows members to see specialists without a referral. This combination identifies which plan type?

A point-of-service plan

A health maintenance organization

A preferred provider organization

An exclusive provider organization

Question 28: A plan that operates like an HMO with a gatekeeper when used in network, but also allows out-of-network care at a reduced level, is best described as which of the following?

An accident-only plan

A traditional indemnity plan

A point-of-service plan

An exclusive provider organization

Question 29: Which of the following plans offers complete freedom of provider choice, requires no referral to see a specialist, and is NOT considered a managed-care plan?

A health maintenance organization

A traditional indemnity plan

A point-of-service plan

A preferred provider organization

Question 30: An indemnity plan pays a provider's full charge as long as it matches what other providers in the same area charge for the service. This payment method is known as which of the following?

Capitation

A benefit schedule

A corridor deductible

Usual, customary, and reasonable

Question 31: Approval that an insurer requires before a hospitalization or an expensive treatment takes place is a form of which type of utilization review?

Prospective review

Concurrent review

Retrospective review

Coordination of benefits

Question 32: Utilization review that monitors care while a patient is still hospitalized, to confirm the stay is on schedule, is known as which of the following?

Prospective review

Predetermination of benefits

Concurrent review

Retrospective review

Question 33: Utilization review conducted after a course of treatment is complete, to evaluate the outcome and identify improvements, is known as which of the following?

Prospective review

Concurrent review

Preauthorization

Retrospective review

Question 34: A health plan with lower premiums and a higher deductible, required before contributing to a health savings account, is known as which of the following?

A basic hospital plan

A high-deductible health plan

A flexible spending arrangement

A point-of-service plan

Question 35: A health savings account is often described as offering a triple tax advantage. Which of the following best states that advantage?

Deductible in, tax-deferred growth, tax-free medical use

Taxable in, taxable growth, tax-free out

No deduction, taxed growth, taxed withdrawals

Employer-only funding with no tax benefit

Question 36: Compared with a flexible spending arrangement, a health savings account differs because the health savings account does which of the following?

Forfeits unused funds each year

Is owned by the employer

Is individually owned and rolls over

Requires no health plan at all

Question 37: An individual contributing to a health savings account enrolls in Medicare. What is the effect on the health savings account?

The account is immediately forfeited

Contribution limits automatically double

The account converts to a spending arrangement

Contributions stop; the balance remains usable

Question 38: A health reimbursement arrangement is funded by which party?

The employer only

The employee through salary reduction

The insurer from premiums

The individual and the government jointly

Question 39: An employee funds an account through pre-tax salary reduction, and money left at year end is generally forfeited under a use-it-or-lose-it rule. This account is known as which of the following?

A health savings account

A health reimbursement arrangement

A flexible spending arrangement

A medical savings account

Question 40: Which tax-advantaged account was aimed at the self-employed and small employers, required a high-deductible plan, and has not accepted new enrollees for many years?

The flexible spending arrangement

The Archer medical savings account

The health reimbursement arrangement

The health savings account

CLAHS California Life, Accident and Health or Sickness Examination - Set 2 - Part 2

Question 21: An HMO pays a contracted physician a fixed monthly amount for each member assigned, regardless of how often those members are seen. This payment method is known as which of the following?

Question 22: In an HMO that uses the gatekeeper concept, a subscriber who wants to see a specialist must generally do which of the following first?

Question 23: Which of the following is the distinguishing emphasis of a health maintenance organization compared with traditional insurance?

Question 24: A subscriber suffers a medical emergency while traveling outside the HMO service area and is treated by a non-network provider. How does the HMO generally handle this?

Question 25: A managed-care plan lets subscribers use providers outside its network, paying for that care at a reduced reimbursement level. This open-panel design identifies which plan type?

Question 26: Providers in a preferred provider organization agree to deliver services at pre-negotiated discounted fees in exchange for which of the following?

Question 27: A managed-care plan covers care only when received from its own network, yet allows members to see specialists without a referral. This combination identifies which plan type?

Question 28: A plan that operates like an HMO with a gatekeeper when used in network, but also allows out-of-network care at a reduced level, is best described as which of the following?

Question 29: Which of the following plans offers complete freedom of provider choice, requires no referral to see a specialist, and is NOT considered a managed-care plan?

Question 30: An indemnity plan pays a provider's full charge as long as it matches what other providers in the same area charge for the service. This payment method is known as which of the following?

Question 31: Approval that an insurer requires before a hospitalization or an expensive treatment takes place is a form of which type of utilization review?

Question 32: Utilization review that monitors care while a patient is still hospitalized, to confirm the stay is on schedule, is known as which of the following?

Question 33: Utilization review conducted after a course of treatment is complete, to evaluate the outcome and identify improvements, is known as which of the following?

Question 34: A health plan with lower premiums and a higher deductible, required before contributing to a health savings account, is known as which of the following?

Question 35: A health savings account is often described as offering a triple tax advantage. Which of the following best states that advantage?

Question 36: Compared with a flexible spending arrangement, a health savings account differs because the health savings account does which of the following?

Question 37: An individual contributing to a health savings account enrolls in Medicare. What is the effect on the health savings account?

Question 38: A health reimbursement arrangement is funded by which party?

Question 39: An employee funds an account through pre-tax salary reduction, and money left at year end is generally forfeited under a use-it-or-lose-it rule. This account is known as which of the following?

Question 40: Which tax-advantaged account was aimed at the self-employed and small employers, required a high-deductible plan, and has not accepted new enrollees for many years?

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