HSA 312 Final Exam

HSA 312 Final Exam Who has final responsibility for all aspects of an independent HMO? - ✔✔board of directors Medical Directors typically have responsibility for: - ✔✔Utilization management Benefits determination for ...

HSA 312 Final Exam Who has final responsibility for all aspects of an independent HMO? - ✔✔board of directors Medical Directors typically have responsibility for: - ✔✔Utilization management Benefits determination for appeals Quality managment List at least four core operational competencies of a typical managed care information system - ✔✔Claims payment, Customer services, Benefit configuration & Provider enrollment What is the most common form of claims submission ? - ✔✔Electronic What are intermediaries in the employer-sponsored business called? - ✔✔Brokers and Consultants Beginning in 2014, what new distribution channel became available? - ✔✔state-level health insurance exchanges What is typically considered to be marketing functions? - ✔✔Typical marketing function types within a larger business might include performing market research, producing a marketing plan, and product development, as well as strategically overseeing advertising, promotion, distribution for sale, customer service and public relations ___ rates are high enough to generate sufficient revenue to cover all claims and other plan expenses and to yield an acceptable return on equity. - ✔✔adequate Dependent Coverage is extended to what age under the Affordable Care Act (ACA)? - ✔✔26 ____ rating entails the application of a standard rate to all groups within the community being underwritten - ✔✔Basic community What is considered a "life event" for insurance enrollment? - ✔✔marriage, retirement, loss of a loved one or birth of a new baby, and possibly an unexpected relocation What aspects of the claims capability must be "counted" or measured in order to allocate adequate resources and verify financial assumptions about an insured population? - ✔✔Inventory receipts & Timely filing limits, Turnaround time based on the date the MCO received the claim, & Claims lag as well as IBNR. Is a participating provider permitted to balance bill a member for any copayments, coinsurance, or deductibles that are applicable to a claim payment ? - ✔✔False Member services is responsible for what activities? - ✔✔Providing information to members, handling member grievances and complaints, and adjusting claims. What is the distinction between a member complaint and a grievance. - ✔✔A grievance is defined is a denial of a specific section of the contract.. A complaint is not a violation of the contract. Eg. You would file a grievance if your supervisor refused to pay time and a half for overtime worked Are appeal of coverage denial reviews a distinctly formal process governed by both state and federal laws? - ✔✔True _________ is a method of measuring the minimum amount of capital appropriate for an HMO or an insurer to support its overall business operations on the basis of its size and the degree of risk taken in each of five major categories of risk. - ✔✔Risk Based Capital IBNR stands for - ✔✔incurred but not reported Dual Eligible Special Needs Plans enroll individuals who are "dual eligible." Who are the "dual eligible"? - ✔✔Individuals who are eligible for Medicare and Medicaid. Is Medicare provided without cost to the Medicare beneficiary? If not what do they pay for? - ✔✔False Does the Affordable Care Act reduce enrollee cost sharing during the drug coverage gap? - ✔✔True Plans can receive bonus payments for high star quality ratings. The bonus payments can be used to: - ✔✔Provide additional benefits, reduce cost sharing, and reduce enrollee premiums MA plans must have a quality improvement program that measures performance under the program and that includes: - ✔✔Chronic Care Improvement programs (CCIP), Quality Improvement Projects (QIPs), and Health Information Systems Does CMS requires MA plans to have a quality improvement program to measure program performance? - ✔✔True Name 5 measures in the Medicare Quality Bonus Program (i.e. the "Stars" program) for Medicare Advantage plans? - ✔✔1. quality of care 2. customer service 3. cost reduction 4. managing chronic conditions 5. member satisfaction Are marketing and sales activities allowed for Medicare Advantage or managed Medicaid plans? - ✔✔False What certificate is the state-issued operating license for an HMO? - ✔✔Certificate of authority (COA) What formula has been adopted by NAIC to determine how much the capital requirements are for a particular managed care plan? - ✔✔Risk-Based Capital (RBC) Do State mandated benefits laws apply to self-funded employee benefits plans? - ✔✔False Define ERISA and ACA - ✔✔ERISA is a voluntary program designed for the benefit of employees ACA (Affordable Care Act)is a mandatory program, it is inevitable that a subset of employers will forego their pension plans in order to fund the mandated health plans or penalty taxes. Erisa and the ACA both require expedited review for benefits determination involving urgent medical care. Are EMR electronic transactions standardized? - ✔✔through HIPAA Name 4 federal laws affecting health insurance, health benefits plans, or HMOs - ✔✔1. ERISA - Employee Retirement Income Security Act 2. COBRA- Consolidated Omnibus Budget Reconciliation Act 3. HIPAA- Health Insurance Portability and Accountability Act 4. ACA- Affordable Care Act ACA - ✔✔Affordable Care Act ACO - ✔✔Accountable Care Organization AHRQ - ✔✔Agency for Healthcare Research and Quality HMO - ✔✔health maintenance organization MCO - ✔✔Managed Care Organization MA - ✔✔medical assistant POS - ✔✔Point of Service PPO - ✔✔preferred provider organization PCP - ✔✔primary care physician UM - ✔✔utilization management ABN - ✔✔Advanced Beneficiary Notice ASC - ✔✔ambulatory surgery center ANSI - ✔✔American National Standards Institute CON - ✔✔Certification of need COBRA - ✔✔Consolidated Omnibus Budget Reconciliation Act CMS - ✔✔Content Management System CAHPS - ✔✔Consumer Assessment of Healthcare Providers and Systems NCQA - ✔✔National Committee for Quality Assurance COB - ✔✔coordination of benefits EMR - ✔✔electronic medical record DME - ✔✔durable medical equipment EDI - ✔✔Electronic Data Interchange ERISA - ✔✔Employee Retirement Income Security Act EOB - ✔✔explanation of benefits HDHP - ✔✔High Deductible Health Plan HIE - ✔✔Health Information Exchange IDS - ✔✔Integrated Delivery System NPI - ✔✔National Provider Identifier OIG - ✔✔Office of Inspector General OCR - ✔✔Office of Civil Rights PHR - ✔✔Personal Health Record QHP - ✔✔Qualified Health Plan TPA - ✔✔Third Party Administrator TEFRA - ✔✔Tax Equity and Fiscal Responsibility Act QA - ✔✔Quality Assurance QM - ✔✔quality management URO - ✔✔utilization review organization VBP - ✔✔Value Based Purchasing