NEW QUESTION 1

Under the compensation arrangement that the Falcon Health Plan has with some of its providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held back. This way of motivating providers to control costs while providing high-quality, appropriate care is known as a:

• A. Risk pool arrangement
• B. Withhold arrangement
• C. Cost-shifting arrangement
• D. Bonus pool arrangement

Answer: B

NEW QUESTION 2

The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

• A. The standard fees of indemnity health insurance plans, adjusted by region
• B. The Medicare fee schedules used by other health plans, adjusted by region
• C. Whichever amount is higher, the billed charge or the DFFS amount
• D. Whichever amount is lower, the billed charge or the DFFS amount

Answer: D

NEW QUESTION 3

The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

• A. The NCQA requires a health plan to conduct all delegation oversight functions rather than delegating the responsibility for oversight to another entity.
• B. Credentialing and UM activities are the most frequently delegated functions, whereas delegation is less common for quality management (QM) and preventive health services.
• C. One reason that a health plan may choose to delegate a function is because the health plan's staff seeks external expertise for the delegated activity.
• D. When the health plan delegates authority for a function, it transfers the power to conduct the function on a day-to-day basis, as well as the ultimate accountability for the function.

Answer: D

NEW QUESTION 4

Health plan contract negotiations with an integrated delivery system (IDS) or a hospital are usually lengthier and more complex than negotiations with a single-specialty provider.

• A. True
• B. False

Answer: A

NEW QUESTION 5

If a third party is responsible for injuries to a plan member of the Hope Health Plan, then Hope has a contractual right to file a claim for the resulting healthcare costs against the third party. This contractual right to recovery from the third party is known as

• A. Subrogation
• B. Partial capitation
• C. Coordination of benefits
• D. Aremedy provision

Answer: A

NEW QUESTION 6

One true statement about the Employee Retirement Income Security Act of 1974 (ERISA) is that:

• A. ERISA applies to all issuers of health insurance products, such as HMOs
• B. pension plans and employee welfare plans are exempt from any regulation under ERISA
• C. ERISA requires self-funded plans to comply with all state mandates affecting health insurance companies and health plans
• D. the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans

Answer: D

NEW QUESTION 7

Medicaid is a joint federal and state program that provides healthcare coverage for low- income, medically needy, and disabled individuals. Under the terms of this joint sponsorship, the

• A. Federal government is responsible for making all claim payments
• B. Federal government is responsible for determining the basic benefits that must be provided to eligible Medicaid beneficiaries
• C. State governments are responsible for setting minimum standards regarding eligibility, benefit coverage, and provider participation and reimbursement
• D. State governments are responsible for establishing overall regulation of the Medicaid program

Answer: B

NEW QUESTION 8

If a member of the Green Health Plan reasonably believes that a provider in Green's provider network was acting as Green's employee or agent while providing negligent care, then the member may have cause to bring action against the health plan. This legal concept is known as vicarious liability. Steps that Green can take to reduce its exposure to vicarious liability claims include:

• A. Placing restrictions on provider-member communication involving treatment decisions.
• B. Implementing risk management and quality assurance programs for its provider network.
• C. Including in its provider agreements and marketing and membership literature a statement that members of the Green provider network are not independent contractors.
• D. All of the above.

Answer: B

NEW QUESTION 9

Health plans can often reduce workers’ compensation costs by incorporating 24-hour coverage into their workers’ compensations programs. Twenty-four-hour coverage reduces costs by

• A. Maximizing the effects of cost shifting
• B. Eliminating the need for utilization management
• C. Requiring members to use separate points of entry for job-related and non-job related services
• D. Combining administrative services for workers’ compensation and non-workers’ compensation healthcare and disability coverage

Answer: D

NEW QUESTION 10

The Aegean Health Plan delegated its utilization management (UM) program to the Silhouette IPA. Silhouette, in turn, transferred authority for case management to Brandon Health Services. In this situation, Brandon is best described as the

• A. delegator, and Aegean is ultimately responsible for Brandon’s performance
• B. delegator, and Silhouette is ultimately responsible for Brandon’s performance
• C. subdelegate, and Aegean is ultimately responsible for Brandon’s performance
• D. subdelegate, and Silhouette is ultimately responsible for Brandon’s performance

Answer: C

NEW QUESTION 11

A health plan has several options for delivering pharmacy services to its subscribers. Each option has potential advantages to a health plan. An advantage to a health plan of using:

• A. performance-based open networks is that they tend to increase participation in the pharmacy network.
• B. closed networks is that they improve the health plan's ability to set standards and implement cost-control programs for pharmacy services.
• C. customized networks is that they typically are inexpensive to operate.
• D. open networks is that they tend to improve the health plan's ability to control pharmaceutical costs.

Answer: B

NEW QUESTION 12

The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to

• A. Hold plan members responsible for unreimbursed charges or unpaid claims
• B. Allow providers to develop their own standards of care
• C. Adhere to specified disclosure requirements related to provider contract termination
• D. File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)

Answer: C

NEW QUESTION 13

The provider contract that Dr. Lorena Chau has with the Fiesta Health Plan includes an evergreen clause. The purpose of this clause is to:

• A. Allow Fiesta to change or amend the contract without D
• B. Chau's approval as long as the modifications are made in order to comply with new legal and regulatory requirements
• C. Prohibit D
• D. Chau from encouraging her patients to switch from Fiesta to another health plan
• E. Prohibit D
• F. Chau from encouraging her patients to switch from Fiesta to another health plan
• G. Assure that D
• H. Chau provides Fiesta members with healthcare services in a timely manner appropriate to the member's medical condition

Answer: C

NEW QUESTION 14

Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

• A. $42,857
• B. $56,700
• C. $272,160
• D. $680,400

Answer: C

NEW QUESTION 15

As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must

• A. Allow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider
• B. Base a provider’s participation in the network, reimbursement, and indemnification levels on the provider’s license or certification
• C. Define its service area according to community patterns of care
• D. Require enrollees to obtain prior authorization for all emergency or urgently needed services

Answer: C

NEW QUESTION 16

The following statements are about waivers and the Medicaid program. Select the answer choice containing the correct statement:

• A. The Balanced Budget Act (BBA) of 1997 eliminated the need for states to make formal applications for waivers.
• B. Section 1115 waivers allow states to bypass the Medicaid program's usual requirement of giving recipients complete freedom of choice in selecting providers.
• C. Title XVIII waivers allow states to mandate certain categories of Medicaid recipients to enroll in health plan plans.
• D. Section 1915(b) waivers allow states to establish demonstration projects in order to test new approaches to benefits and services provided by Medicaid.

Answer: A

NEW QUESTION 17

Member satisfaction surveys help an health plan determine whether its providers are consistently delivering services to plan members in a manner that lives up to member expectations. Member satisfaction surveys allow the health plan to gather information about

• A. Amember’s reaction to services received during a specific encounter
• B. The reactions of specific subsets of the health plan’s membership
• C. Members’ positive and negative experience with the plan’s services
• D. All of the above

Answer: D

NEW QUESTION 18

The following statements are about the specialist component of a provider panel. Select the answer choice containing the correct statement.

• A. Ideally, a health plan should have every specialist category represented on its provider panel with appropriate geographic distribution.
• B. Most specialist contracts do not ensure the provider’s adherence to UM policies set up by the health plan.
• C. No-balance-billing clauses are not desirable in health plan contracts with specialists.
• D. In geographic regions where there is a shortage of PCPs, a health plan is not permitted to contract with specialists to perform primary care services, even for patients with chronic conditions.

Answer: A

NEW QUESTION 19
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