#1
Which of the following is a key characteristic of an HMO (Health Maintenance Organization) in managed care?
Requires a primary care physician (PCP)
ExplanationEmphasizes centralized care through designated primary providers.
#2
What role does utilization management play in managed care?
Reviewing and managing the appropriate use of healthcare services
ExplanationEnsures resources are used effectively and efficiently.
#3
What is the primary focus of a gatekeeper in the context of managed care?
Controlling access to specialty care and healthcare services
ExplanationDirects patient access to ensure cost-effective care.
#4
Which federal program provides health coverage for low-income individuals and families, and is jointly funded by federal and state governments in the United States?
Medicaid
ExplanationOffers healthcare access to economically disadvantaged groups.
#5
What is the primary function of a Pharmacy Benefit Manager (PBM) in managed care?
Manage prescription drug benefits
ExplanationAdministers and optimizes medication benefits.
#6
In a PPO (Preferred Provider Organization), what is a significant feature that distinguishes it from other managed care models?
Flexibility to see out-of-network providers
ExplanationOffers greater provider choice, including out-of-network services.
#7
What is the primary goal of case management in managed care?
Coordinate and optimize healthcare services for cost-effective outcomes
ExplanationFocuses on efficient utilization of resources to improve care efficiency.
#8
Which of the following is a characteristic of a Health Savings Account (HSA) in the context of managed care?
Contributions are tax-deductible
ExplanationAllows tax benefits for savings used for healthcare expenses.
#9
What is the primary focus of disease management programs in managed care?
Management of chronic conditions for improved outcomes
ExplanationTargets long-term conditions to enhance patient well-being.
#10
Which regulatory body oversees and enforces compliance with the Affordable Care Act (ACA) in the United States?
Centers for Medicare & Medicaid Services (CMS)
ExplanationResponsible for ensuring ACA adherence.
#11
Which type of managed care model is characterized by both HMO and PPO features, allowing members to choose between in-network and out-of-network providers?
Point of Service (POS)
ExplanationCombines elements of HMO and PPO, offering flexibility in provider selection.
#12
In the context of managed care, what is the term for a fixed amount paid by the patient for covered services at the time of service?
Copayment
ExplanationA predetermined fee paid directly by the patient for each service.
#13
In managed care, what is the primary purpose of a formulary?
To list preferred medications and control costs
ExplanationGuides medication choices to manage expenses and quality.
#14
Which financial arrangement involves a fixed monthly payment per enrollee, regardless of the services provided, and is commonly used in HMOs?
Capitation
ExplanationProviders receive a set fee per patient, irrespective of services.
#15
What is the term for a healthcare delivery system that integrates the financing and delivery of appropriate healthcare services to covered individuals?
Managed care
ExplanationCoordinates funding and provision for efficient care.