NEW QUESTION 1

For this question, if answer choices (A) through C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Understanding the level of health plan penetration in a particular market can help a health plan determine which products are most appropriate for that market. Indicators of a mature health plan market include

• A. Areduction in the rate of growth in health plan premium levels
• B. Areduction in the level of outcomes management and improvement
• C. An increase in the rate of inpatient hospital utilization
• D. All of the above

Answer: A

NEW QUESTION 2

There are several approaches to providing Medicaid health plan. One such approach involves the use of organizations who contract with the state’s Medicaid agency to provide primary care as well as administrative services. These organizations are known as

• A. Enrollment brokers
• B. Primary care case managers (PCCMs)
• C. Certified medical assistants (CMAs)
• D. Prepaid health plans (PHPs)

Answer: B

NEW QUESTION 3

After HIPAA was enacted, Congress amended the law to include the Mental Health Parity Act (MHPA) of 1996, a federal requirement relating to mental health benefits. One true statement about the MHPA is that it

• A. requires all health plans to provide coverage for mental health services
• B. requires health plans to carve out mental/behavioral healthcare from other services provided by the plans
• C. allows health plans to require patients receiving mental health services to pay higher copayments than patients seeking treatment for physical illnesses
• D. prohibits health plans that offer mental health benefits from applying more restrictive limits on coverage for mental illness than on coverage for physical illness

Answer: D

NEW QUESTION 4

CMS Medicare+Choice regulations include a provision that allows health plans to deny benefits for any services the health plan objects to on moral or religious grounds. The provision that exempts health plans from providing such services is known as

• A. a conscience protection exception
• B. a hold harmless clause
• C. a medical necessity determination
• D. an intermediate sanction

Answer: A

NEW QUESTION 5

The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

• A. Typically, health plans are required to pay completed claims within 10 days of submission.
• B. Health plans typically are prohibited from examining the financial soundness of a self- funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.
• C. Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for- service (FFS) basis.
• D. Health plans require all providers to agree to an exclusive provider contract.

Answer: C

NEW QUESTION 6

Decide whether the following statement is true or false:
The organizational structure of a health plan’s network management function often depends on the size and geographic scope of the health plan. With respect to the size of a health plan, it is correct to say that smaller health plans typically have less integration and more specialization of roles than do larger health plans.

• A. True
• B. False

Answer: B

NEW QUESTION 7

The Walnut Health Plan provides a number of specialty services for its members. Walnut offers coverage of alternative healthcare, including coverage of treatment methods such as homeopathy and naturopathy. Walnut also offers home healthcare services, and it contracts with home healthcare providers on a non-risk basis to the health plan. The following statements are about the specialty services offered by Walnut. Select the answer choice containing the correct statement:

• A. Homeopathy treats diseases by using small doses of substances which, in healthy people, are capable of producing symptoms like those of the disease being treated.
• B. Naturopathy is an approach to healthcare that uses electronic monitoring devices to teach a patient to develop conscious control of involuntary bodily functions, such as heart rate.
• C. Under a non-risk contract, Walnut most likely transfers the responsibility for arranging home healthcare to the home healthcare provider organizations.
• D. Federal law allows Walnut to contract with a home healthcare provider organization only if the provider organization has received accreditation by the Utilization Review Accreditation Commission (URAC).

Answer: A

NEW QUESTION 8

The Brice Health Plan submitted to Clarity Health Services a letter of intent indicating Brice’s desire to delegate its demand management function to Clarity. One true statement about this letter of intent is that it

• A. creates a legally binding relationship between Brice and Clarity
• B. most likely contains a confidentiality clause committing Brice and Clarity to maintain theconfidentiality of documents reviewed and exchanged in the process
• C. prohibits Clarity from performing similar delegation activities for other health plans
• D. most likely contains a detailed description of the functions that Brice will delegate to Clarity

Answer: B

NEW QUESTION 9

The Zephyr Health Plan identifies members for whom subacute care might be an appropriate treatment option. The following individuals are members of Zephyr:
Selena Tovar, an oncology patient who requires radiation oncology services, chemotherapy, and rehabilitation.
Dwight Borg, who is in excellent health except that he currently has sinusitis.
Timothy O'Shea, who is beginning his recovery from brain injuries caused by a stroke. Subacute care most likely could be an appropriate option for:

• A. M
• B. Tovar, M
• C. Borg, and M
• D. O'Shea
• E. M
• F. Tovar and M
• G. O'Shea only
• H. M
• I. O'Shea only
• J. M
• K. Borg only

Answer: B

NEW QUESTION 10

The actual number of providers included in a provider network can be based on staffing ratios. One true statement about staffing ratios is that, typically:

• A. A small health plan needs fewer physicians per 1,000 than does a large plan.
• B. A closely managed health plan requires fewer providers than does a loosely managedplan.
• C. Physician-to-enrollee ratios can be used directly only by network-within-a-network model HMOs.
• D. Medicare products require fewer providers than do employer-sponsored plans of the same size.

Answer: B

NEW QUESTION 11

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
The following statement(s) can correctly be made about Gardenia’s establishment of the PPO and the staff model HMO in its new market:
* 1. When establishing its PPO network, Gardenia most likely initiated outcomes measurement tools and developed collaborative process improvement relationships with providers.
* 2. To avoid high overhead expenses in the early stages of market evelopment, Gardenia’s HMO most likely contracted with specialists and ancillary providers until the plan’s membership grew to a sufficient level to justify employing these specialists.

• A. Both 1 and 2
• B. Neither 1 nor 2
• C. 1 Only
• D. 2 Only

Answer: D

NEW QUESTION 12

Dr. Janet Dubois is a radiologist who practices exclusively at the Rightway Healthcare Center. This information indicates that Dr. Dubois is employed by Rightway as

• A. An academic practitioner
• B. An independent practitioner
• C. Anetwork manager
• D. Ahospital-based specialist

Answer: D

NEW QUESTION 13

The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):

• A. Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.
• B. Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.
• C. Both A and B
• D. A only
• E. B only
• F. Neither A nor B

Answer: A

NEW QUESTION 14

Since 1981, states have had the option to experiment with new approaches to their Medicaid programs under the “freedom of choice” waivers. Under one such waiver, a Section 1915(b) waiver, states are allowed to

• A. Give Medicaid recipients complete freedom in choosing healthcare providers
• B. Give Medicaid recipients the option to choose not to enroll in a healthcare plan
• C. Mandate certain categories of Medicaid recipients to enroll in health plans
• D. Establish demonstration projects to test new approaches for delivering care to Medicaid recipients

Answer: C

NEW QUESTION 15

The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.

• A. While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule.
• B. In general, the ideal negotiating style for provider contracting is a collaborative approach.
• C. Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.
• D. The actual signing of the provider contract typically takes place after negotiations are completed.

Answer: C

NEW QUESTION 16

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
One statement that can correctly be made about Gardenia’s two-level POS product is that

• A. members who self-refer without first seeing their PCPs will receive no benefits
• B. both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow
• C. members will pay higher coinsurance or copayments if they first see their PCPs each time
• D. the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

Answer: D

NEW QUESTION 17

Most health plan contracts provide an outline of the criteria that a healthcare service must meet in order to be considered “medically necessary.” Typically, in order for a healthcare service to be considered medically necessary, the service provided by a physician or other healthcare provider to identify and treat a member’s illness or injury must be

• A. Consistent with the symptoms of diagnosis
• B. Furnished in the least intensive type of medical care setting required by the member’s condition
• C. In compliance with the standards of good medical practice
• D. All of the above

Answer: D

NEW QUESTION 18

The provider contract that Dr. Nick Mancini has with the Utopia Health Plan includes a clause that requires Utopia to reimburse Dr. Mancini on a fee-for-service (FFS) basis until 100 Utopia members have selected him as their primary care provider (PCP). At that time, Utopia will begin reimbursing him under a capitated arrangement. This clause in Dr. Mancini's provider contract is known as:

• A. an antidisparagement clause
• B. a low-enrollment guarantee clause
• C. a retroactive enrollment changes clause
• D. an eligibility guarantee clause

Answer: B

NEW QUESTION 19
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