HSM420
Managed Care & Health Insurance
4.0 Credits
Final Exam Review (Qns & Ans)
2025
©2025
, Multiple Choice Questions
1. Case Scenario:
A state legislature is reviewing a healthcare reform bill that would
alter Medicaid eligibility and reimbursement mechanisms.
Stakeholder lobbying is intense during the debate.
Question:
Which stakeholder is typically most influential in shaping Medicaid
policy outcomes through lobbying efforts?
Options:
A. Patient advocacy groups
B. Insurance companies
C. Provider associations
D. Pharmaceutical manufacturers
Correct ANS:
B. Insurance companies
Rationale:
Insurance companies have a significant financial stake in Medicaid
reimbursement and eligibility rules; they often invest in lobbying to
shape policies that directly affect their profitability and market
operations.
---
2. Case Scenario:
A health services management team is designing a new benefit
package for a managed care plan. They must balance cost
containment with an attractive array of services.
Question:
Which managed care strategy involves paying providers a fixed
amount per beneficiary regardless of services rendered?
Options:
A. Fee-for-service
B. Capitation
C. Bundled payments
D. Pay-for-performance
Correct ANS:
©2025
,B. Capitation
Rationale:
Capitation pays providers a set fee per enrollee over a specified
period. This method is intended to encourage efficient care delivery
and reduce unnecessary utilization while transferring some risk to
providers.
---
3. Case Scenario:
A patient enrolled in a managed care plan is required to obtain
services only from providers within the plan’s network, except in
emergencies.
Question:
Which type of health plan is described in this scenario?
Options:
A. Preferred Provider Organization (PPO)
B. Health Maintenance Organization (HMO)
C. Point of Service (POS) plan
D. Exclusive Provider Organization (EPO)
Correct ANS:
B. Health Maintenance Organization (HMO)
Rationale:
HMOs require beneficiaries to seek care within a defined network,
emphasizing primary care coordination, cost control, and
preventive services.
---
4. Case Scenario:
A research analyst studies how non-medical factors have come to
be regarded as matters of clinical importance through new policy
trends.
Question:
What term describes the process by which everyday life issues are
redefined as medical problems needing intervention?
Options:
A. Social construction
©2025
, B. Medicalization
C. Institutionalization
D. Pathologization
Correct ANS:
B. Medicalization
Rationale:
Medicalization is the process whereby non-medical issues—such
as natural aging or behavioral traits—are redefined and treated as
medical conditions, influencing both policy debates and insurance
coverage decisions.
---
5. Case Scenario:
A health plan introduces utilization management techniques to
ensure that the services provided to beneficiaries are both
necessary and cost-effective.
Question:
What is the principal objective of utilization management?
Options:
A. To increase patient volume
B. To control healthcare costs and prevent unnecessary care
C. To expand provider networks
D. To enhance patient satisfaction exclusively
Correct ANS:
B. To control healthcare costs and prevent unnecessary care
Rationale:
Utilization management is designed to evaluate and monitor the
use of healthcare services, ensuring that care is appropriate,
necessary, and cost-effective while maintaining quality.
---
6. Case Scenario:
A managed care organization is concerned about overutilization
due to moral hazard, where insured individuals may consume more
services than medically necessary.
Question:
©2025
Managed Care & Health Insurance
4.0 Credits
Final Exam Review (Qns & Ans)
2025
©2025
, Multiple Choice Questions
1. Case Scenario:
A state legislature is reviewing a healthcare reform bill that would
alter Medicaid eligibility and reimbursement mechanisms.
Stakeholder lobbying is intense during the debate.
Question:
Which stakeholder is typically most influential in shaping Medicaid
policy outcomes through lobbying efforts?
Options:
A. Patient advocacy groups
B. Insurance companies
C. Provider associations
D. Pharmaceutical manufacturers
Correct ANS:
B. Insurance companies
Rationale:
Insurance companies have a significant financial stake in Medicaid
reimbursement and eligibility rules; they often invest in lobbying to
shape policies that directly affect their profitability and market
operations.
---
2. Case Scenario:
A health services management team is designing a new benefit
package for a managed care plan. They must balance cost
containment with an attractive array of services.
Question:
Which managed care strategy involves paying providers a fixed
amount per beneficiary regardless of services rendered?
Options:
A. Fee-for-service
B. Capitation
C. Bundled payments
D. Pay-for-performance
Correct ANS:
©2025
,B. Capitation
Rationale:
Capitation pays providers a set fee per enrollee over a specified
period. This method is intended to encourage efficient care delivery
and reduce unnecessary utilization while transferring some risk to
providers.
---
3. Case Scenario:
A patient enrolled in a managed care plan is required to obtain
services only from providers within the plan’s network, except in
emergencies.
Question:
Which type of health plan is described in this scenario?
Options:
A. Preferred Provider Organization (PPO)
B. Health Maintenance Organization (HMO)
C. Point of Service (POS) plan
D. Exclusive Provider Organization (EPO)
Correct ANS:
B. Health Maintenance Organization (HMO)
Rationale:
HMOs require beneficiaries to seek care within a defined network,
emphasizing primary care coordination, cost control, and
preventive services.
---
4. Case Scenario:
A research analyst studies how non-medical factors have come to
be regarded as matters of clinical importance through new policy
trends.
Question:
What term describes the process by which everyday life issues are
redefined as medical problems needing intervention?
Options:
A. Social construction
©2025
, B. Medicalization
C. Institutionalization
D. Pathologization
Correct ANS:
B. Medicalization
Rationale:
Medicalization is the process whereby non-medical issues—such
as natural aging or behavioral traits—are redefined and treated as
medical conditions, influencing both policy debates and insurance
coverage decisions.
---
5. Case Scenario:
A health plan introduces utilization management techniques to
ensure that the services provided to beneficiaries are both
necessary and cost-effective.
Question:
What is the principal objective of utilization management?
Options:
A. To increase patient volume
B. To control healthcare costs and prevent unnecessary care
C. To expand provider networks
D. To enhance patient satisfaction exclusively
Correct ANS:
B. To control healthcare costs and prevent unnecessary care
Rationale:
Utilization management is designed to evaluate and monitor the
use of healthcare services, ensuring that care is appropriate,
necessary, and cost-effective while maintaining quality.
---
6. Case Scenario:
A managed care organization is concerned about overutilization
due to moral hazard, where insured individuals may consume more
services than medically necessary.
Question:
©2025
