HSA4109 FINAL EXAM QUESTIONS WITH
CORRECT ANSWERS
Once a claim is captured, the enrollment status is checked and the member is covered,
what is the next step for processing the claim? - ANSWER determining what to pay
Plans can receive bonus payments for high star quality ratings. The bonus payments
can be used to: - ANSWER (All)
Reduce cost sharing
Provide additional benefits
Reduce enrollee premiums
Dual Eligible Special Needs Plans enroll individuals who are "dual eligible." Who are the
"dual eligible"? - ANSWER Individuals who are eligible for Medicare and Medicaid
Which of the following is not a measure in the Medicare Quality Bonus Program (i.e. the
"Stars" program) for Medicare Advantage plans: - ANSWER Reducing costs
The "donut hole" characteristic of the "defined standard" benefit refers to: - ANSWER a
coverage gap that appears at a certain point, and when an enrollee who has no
low-income subsidy is responsible for 100 percent of the cost of drugs
Network adequacy is typically measured based on which of the following factors? -
ANSWER (all)
the location of a physician's office or inpatient facility in relation to the enrollee,
the ratio of healthcare provides to enrollees,
waiting times for appointments
Member services is responsible for all of the following activities, except: - ANSWER
, Adjudicating claims
States have passed these laws requiring MCOs to accept any healthcare provider who
is willing to accept the terms and conditions of the network. These laws are known as? -
ANSWER AWP
When the MCO and enrollee are unable to resolve the appeal then what must take
place? - ANSWER External review
MA plans must have a quality improvement program that measures performance under
the program and that includes: - ANSWER (all)
Quality Improvement Projects (QIPs)
Chronic Care Improvement Programs (CCIP)
Health Information Systems
T/F The ACA requires health insurers to community rate all business. - ANSWER False
T/F The most common form of claims submission is electronic. - ANSWER True
T/F For clean claims, basic benefits administration is almost always auto-adjudicated
meaning the process is fully automated. - ANSWER True
T/F CMS requires MA plans to have a quality improvement program to measure program
performance. - ANSWER True
T/F ERISA and the ACA both require expedited review for benefits determinations
involving urgent medical care. - ANSWER True
T/F Most, but not all, MCOs have a board of directors. - ANSWER True
CORRECT ANSWERS
Once a claim is captured, the enrollment status is checked and the member is covered,
what is the next step for processing the claim? - ANSWER determining what to pay
Plans can receive bonus payments for high star quality ratings. The bonus payments
can be used to: - ANSWER (All)
Reduce cost sharing
Provide additional benefits
Reduce enrollee premiums
Dual Eligible Special Needs Plans enroll individuals who are "dual eligible." Who are the
"dual eligible"? - ANSWER Individuals who are eligible for Medicare and Medicaid
Which of the following is not a measure in the Medicare Quality Bonus Program (i.e. the
"Stars" program) for Medicare Advantage plans: - ANSWER Reducing costs
The "donut hole" characteristic of the "defined standard" benefit refers to: - ANSWER a
coverage gap that appears at a certain point, and when an enrollee who has no
low-income subsidy is responsible for 100 percent of the cost of drugs
Network adequacy is typically measured based on which of the following factors? -
ANSWER (all)
the location of a physician's office or inpatient facility in relation to the enrollee,
the ratio of healthcare provides to enrollees,
waiting times for appointments
Member services is responsible for all of the following activities, except: - ANSWER
, Adjudicating claims
States have passed these laws requiring MCOs to accept any healthcare provider who
is willing to accept the terms and conditions of the network. These laws are known as? -
ANSWER AWP
When the MCO and enrollee are unable to resolve the appeal then what must take
place? - ANSWER External review
MA plans must have a quality improvement program that measures performance under
the program and that includes: - ANSWER (all)
Quality Improvement Projects (QIPs)
Chronic Care Improvement Programs (CCIP)
Health Information Systems
T/F The ACA requires health insurers to community rate all business. - ANSWER False
T/F The most common form of claims submission is electronic. - ANSWER True
T/F For clean claims, basic benefits administration is almost always auto-adjudicated
meaning the process is fully automated. - ANSWER True
T/F CMS requires MA plans to have a quality improvement program to measure program
performance. - ANSWER True
T/F ERISA and the ACA both require expedited review for benefits determinations
involving urgent medical care. - ANSWER True
T/F Most, but not all, MCOs have a board of directors. - ANSWER True
