From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence

A. Health plans and their providers are obligated not to harm their members

B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group

C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members

D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives

Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example

A. Encounter reports

B. Diagnostic codes

C. Durational ratings

D. Edits

Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl

A. Low or stable costs.

B. Appropriate, rather than inappropriate, utilization rates.

C. A benefit that cannot be easily defined.

D. Defined patient population.

A health plan may use one of several types of community rating methods to set premiums for a health plan. The following statements are about community rating. Select the answer choice containing the correct statement.

A. Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.

B. Under standard (pure) community rating, a health plan charges all employers or other group sponsors the same dollar amount for a given level of medical benefits or health plan, without adjusting for factors such as age, gender, or experience.

C. In using the adjusted community rating (ACR) method, a health plan must consider the actual experience of a group in developing premium rates for that group.

D. The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) me

Patrick Flaherty's employer has contracted to receive healthcare for its employees from the Abundant Healthcare System. Mr. Flaherty visits his primary care physician (PCP), who sends him to have some blood tests. The PCP then refers Mr. Flaherty to a special

A. an integrated delivery system (IDS)

B. a Management Services Organization (MSO)

C. a Physician Practice Management (PPM) company

D. a physician-hospital organization (PHO)

Paul Gilbert has been covered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began a new job and immediately enrolled in his new company's group health plan, which has a

A. Can exclude coverage for treatment of Mr. Gilbert's angina for one year, because HIPAA does not impact a group health plan's pre-existing condition provision.

B. Can exclude coverage for treatment of Mr. Gilbert's angina for one year, because Mr. Gilbert did not have at least 36 months of creditable coverage under his previous health plan.

C. Can exclude coverage for treatment of Mr. Gilbert's angina for three months, because that is the length of time he received treatment for this medical condition prior to his enrollment in the new health plan.

D. Cannot exclude his angina as a pre-existing condition, because the one-year preexisting condition provision is offset by at least one year of continuous coverage under his previous health plan.

High deductible health plans (HDHP) are characterized by all of the following features except

A. A HDHPs have a higher deductible than other traditional insurance products such as HMOs and PPOs.

B. HDHPs generally cost more than traditional heathcare coverage.

C. Some HDHPs cover preventive care on a first-dollar coverage basis.

D. All of the above

The following statement(s) can correctly be made about the characteristics of reports that should be provided to managers for use in managing a healthcare delivery system:

A. Users typically need access to all the raw data used to generate reports

B. Info

C. Both A and B

D. A only

E. B only

F. Neither A nor B

FSA is funded by

A. Employers

B. Employee

C. A and B

Which of the following is NOT a preventive care initiative often used by health plans?

A. Screening for high blood pressure

B. Maternity management programs

C. Vaccines

D. Physical therapy