NEW QUESTION 1

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 2

With regard to the compensation of dental care providers in a managed dental care system, it is correct to state that, typically:

• A. dental PPOs compensate dentists on a capitated basis
• B. group model dental HMOs (DHMOs) compensate general dental practitioners on a salaried basis
• C. independent practice association (IPA)-model dental HMOs (DHMOs) capitate general dental practitioners
• D. staff model dental HMOs (DHMOs) compensate dentists on an FFS basis

Answer: C

NEW QUESTION 3

Dr. Sarah Carmichael is one of several network providers who serve on one of the Apex Health Plan’s organizational committees. The committee reviews cases against providers identified through complaints and grievances or through clinical monitoring activities. If needed, the committee formulates, approves, and monitors corrective action plans for providers. Although Apex administrators and other employees also serve on the committee, only participating providers have voting rights. The committee that Dr. Carmichael serves on is a

• A. Utilization management committee
• B. Peer review committee
• C. Medical advisory committee
• D. Credentialing committee

Answer: B

NEW QUESTION 4

The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.
Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn’s PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn’s dermatology services fund for the first quarter was $15,000. During the quarter, Autumn’s PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
Autumn’s method of reimbursing specialty providers can best be described as a

• A. Disease-specific arrangement
• B. Contact capitation arrangement
• C. Risk adjustment arrangement
• D. Withhold arrangement

Answer: B

NEW QUESTION 5

In 1996, the NAIC adopted a standard for health plan coverage of emergency services. This standard is based on a concept known as the:

• A. Due process standard
• B. Subrogation standard
• C. Corrective action standard
• D. Prudent layperson standard

Answer: D

NEW QUESTION 6

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 7

The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
The comparative method of evaluation that Azure uses to identify and implement the practices that lead to the best outcomes is known as

• A. Case mix analysis
• B. Outcomes research
• C. Benchmarking
• D. Provider profiling

Answer: C

NEW QUESTION 8

The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

• A. Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles.
• B. It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover.
• C. An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers.
• D. In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities.

Answer: A

NEW QUESTION 9

Edward Patillo has established a Medicare+Choice medical savings account (MSA). This MSA will allow Mr. Patillo to:

• A. Carry over any money remaining in his MSA at the end of the benefit year to the next benefit year
• B. Make withdrawals at any time from the MSA, but only for medical expenses
• C. Obtain payment at 100% of the Medicare allowable payment for all Medicare-covered services he receives, without having to pay any deductibles or out-of-pocket expenses
• D. Make withdrawals from the MSA to meet qualified medical expenses that are not paid by his high-deductible health insurance policy, but these withdrawals are taxed as income to M
• E. Patillo

Answer: A

NEW QUESTION 10

State Medicaid agencies can contract with health plans through open contracting or selective contracting. One advantage of selective contracting is that it

• A. Allows enrollees to choose from among a greater variety of health plans
• B. Reduces the competition among health plans
• C. Increases the ability of new, local plans to participate in Medicaid programs
• D. Encourages the development of products that offer enhanced benefits and more effective approaches to health plans

Answer: D

NEW QUESTION 11

The Ventnor Health Plan requires the physicians in its provider network to be board certified. Ventnor has received requests to become a part of the network from the following specialists:
Cheryl Stovall, who is currently in the process of completing a residency in her field ofspecialization.
Thomas Kalil, who has completed a residency in his field of specialization and has passed a qualifying examination in that field within two years of completing his residency.
Roger Todd, who has completed a residency in his field of specialization but has not passed a qualifying examination in that field.
Ventnor's requirement of board certification is met by:

• A. Cheryl Stovall, Thomas Kalil, and Roger Todd.
• B. Thomas Kalil and Roger Todd only.
• C. Thomas Kalil only.
• D. None of these individuals.

Answer: C

NEW QUESTION 12

Factors that are likely to indicate increased health plan market maturity include:

• A. Increased consolidation among health plans.
• B. Increased rate of growth in health plan premium levels.
• C. Areduction in the market penetration of HMO and point-of-service (POS) products.
• D. Areduction in the frequency of performance-based reimbursement of providers.

Answer: A

NEW QUESTION 13

Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically

• A. Require access to greater numbers of obstetricians and pediatricians
• B. Have stronger relationships with primary care providers
• C. Are less reliant on emergency rooms as a source of first-line care
• D. Need fewer support and ancillary services

Answer: A

NEW QUESTION 14

The vision benefits offered by the Omni Health Plan include clinical eye care only. The following statements describe vision care received by Omni plan members:
•Brian Pollard received treatment for a torn retina he suffered as a result of an accident
•Angelica Herrera received a general eye examination to test her vision
•Megan Holtz received medical services for glaucoma
Of these medical services, the ones that most likely would be covered by Omni's vision coverage would be the services received by:

• A. M
• B. Pollard, M
• C. Herrera, and M
• D. Holtz
• E. M
• F. Pollard and M
• G. Herrera only
• H. M
• I. Pollard and M
• J. Holtz only
• K. M
• L. Herrera and M
• M. Holtz only

Answer: C

NEW QUESTION 15

One true statement about the responsibilities of providers under typical provider contracts is that most provider contracts:

• A. include a clause which states that providers must maintain open communications with patients regarding appropriate treatment plans, unless the services are not covered by the member's health plan
• B. hold that the responsibility of the provider to deliver services is usually subject to theprovider's receipt of information regarding the eligibility of the member
• C. contain a gag clause or a gag rule
• D. include a clause that explicitly places the responsibility for medical care on the health plan rather than on the provider of medical services

Answer: B

NEW QUESTION 16

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 17

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in
the same provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne’s patients are generally healthy and rarely present complications. As a result, Dr. Comer typically uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer’s performance with Dr. Donne’s performance, the health plan modified its evaluation to account for differences in the providers’ patient populations and treatment protocols. The health plan modified Dr. Comer’s and Dr. Donne’s performance data by means of

• A. Acase mix/severity adjustment
• B. An external performance standard
• C. Structural measures
• D. Behavior modification

Answer: A

NEW QUESTION 18
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