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Answers to Test Your Knowledge Question
from the
Course On-line Study Guide

Section 1 - Answers

1. Health maintenance organization (HMO) is a network or organization that provides health/medical insurance coverage for a monthly or annual fee. An HMO is made up of a group of medical insurance providers that limit coverage to medical care provided through doctors and other providers who are under contract with the HMO. Page 4 and 5.

2. Health Maintenance Organization (HMO) Plans, Preferred Provider Organization (PPO) Plans,
Private Fee-for-Service (PFFS) Plans and Special Needs Plans (SNPs). Page 5.

3. Preferred Provider Organizations (PPO). A Medicare Advantage PPO plan*, or a Preferred Provider Organization plan, is available through a private insurance company contracted with Medicare to provide and coordinate benefits for beneficiaries. Each PPO plan has its own network of doctors and hospitals. Individuals enrolled in a Medicare Advantage PPO plan are allowed to use out-of-network providers for Medicare covered services, but usually for a higher cost. Page 5.

4. Managed Care Organizations. Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services. Page 7.

5. The providers in the health insurance plan's network are called “network providers” or “in-network providers. Page 8.

6. Worker’s Compensation Managed Care Arrangement. Page 8 in course manual and page 10 in online study guide.

7. Tricare. page 9.


Section 2 - Answers

1. Utilization management. Page 15 in course manual and page 12 in online study guide.

2. Utilization management or Utilization Review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Page 12.

3. Prospective Assessment, Concurrent Assessment and Retrospective Assessment. Page 12.


4. Healthcare Effectiveness Data and Information Set (HEDIS). Page 12.

5. Yes, HEDIS is performed retrospectively.


Section 3 - Answers

1. The Privacy Rule - Ensure the confidentiality, integrity, and availability of all e-PHI they create, receive, maintain, or transmit. The Security Rule- Identify and protect against reasonably anticipated threats to the security or integrity of the information. The Breach Notification Rule - Protect against reasonably anticipated, impermissible uses or disclosures; and. Ensure compliance by their workforce. Page 16.

2. Telemedicine refers to the practice of caring for patients remotely when the provider and patient are not physically present with each other. Modern technology has enabled doctors to consult patients by using HIPAA compliant video-conferencing tools. Page 15.

3. Medical health informatics. Page 15 in course manual and page 24 in online study guide.


4. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. Page 17.

5. Health Care Reform Bill - The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”). Page 18.

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