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NEW QUESTION 1
The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:
- A. Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits
- B. Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO
- C. Receives a payment that is based on reasonable costs and reasonable charges
- D. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care
Answer: A
NEW QUESTION 2
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 3
The following statements are about Medicaid health plan entities. Select the answer choice containing the correct statement:
- A. To keep Medicaid enrollment costs as low as possible, states typically prohibit the use of third-party entities known as enrollment brokers to handle the recruitment and enrollment of Medicaid recipients in health plan plans
- B. Primary care case managers (PCCMs) are individuals who contract with a state's Medicaid agency to provide primary care services mainly to urban areas.
- C. Typically, Medicaid beneficiaries must be given a choice between at least two health plan entities.
- D. Medicaid health plan entities are responsible for providing primary coverage for all dually-eligible beneficiaries.
Answer: C
NEW QUESTION 4
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 5
The Festival Health Plan is in the process of recruiting physicians for its provider network. Festival requires its network physicians to be board certified. The following individuals are provider applicants whose qualifications are being considered:
Applicant 1 has completed his surgical residency, and he recently passed a qualifying examination in his field.
Applicant 2 has completed her residency in dermatology, and she is scheduled to take qualifying examinations in the next Six months.
Applicant 3 completed his residency in pediatric medicine six years ago, but he has not yet passed a qualifying examination in his field.
With regard to these applicants, it can correctly be stated that only
- A. Applicants 1 and 2 are board certified
- B. Applicants 2 and 3 are board certified
- C. Applicant 1 is board certified
- D. Applicant 3 is board certified
Answer: C
NEW QUESTION 6
One characteristic of the workers' compensation program is that:
- A. workers' compensation coverage is available to all employees, regardless of their eligibility for health insurance coverage
- B. indemnity benefits currently account for less than 10% of all workers' compensation benefits
- C. workers' compensation programs in most states require eligible employees to obtain medical treatment only from members of a provider network
- D. workers' compensation programs include deductibles and coinsurance requirements
Answer: A
NEW QUESTION 7
Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan’s
- A. Premium rates
- B. Ability to monitor utilization
- C. Number of primary care providers (PCPs)
- D. Number of specialists and ancillary providers
Answer: B
NEW QUESTION 8
With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to
- A. Require a medical examination prior to accepting an application for employment
- B. Include in the employment application questions pertaining to health status
- C. Make a conditional offer of employment, and then require the candidate to have an examination prior to granting specific staff privileges
- D. Require applicants to answer questions pertaining to the use of drugs and alcohol
Answer: C
NEW QUESTION 9
The provider contract that Dr. Huang Kwan has with the Poplar Health Plan includes a typical scope of services provision. The medical service that Dr. Kwan provided to Alice Meyer, a Poplar plan member, is included in the scope of services. The following statement(s) can correctly be made about this particular medical service:
- A. D
- B. Kwan most likely was required to seek authorization from Poplar before performing this particular service.
- C. D
- D. Kwan most likely was paid on a FFS basis for providing this service.
- E. Both A and B
- F. A only
- G. B only
- H. Neither A nor B
Answer: D
NEW QUESTION 10
Open panel health plans can contract with individual providers or with various provider groups when developing their networks. The following statements are about factors that an open panel health plan might consider in contracting with different types of provider organizations. Select the answer choice that contains the correct statement.
- A. One limitation of contracting with multispecialty groups is that a health plan obtains only specialty consultants, but not PCPs.
- B. One benefit to a health plan in contracting with an integrated delivery system (IDS) is the ability to have a network in rapid order and to enter into a new market or one that is already competitive.
- C. A health plan that contracts with an individual practice association (IPA) has a greater ability to select and deselect individual physicians than when contracting directly with the providers.
- D. A health plan that contracts with an IDS is able to eliminate the antitrust risk that exists when contracting with an IPA.
Answer: B
NEW QUESTION 11
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 12
The Gladspell HMO has contracted with the Ellysium Hospital to provide subacute care to its plan members. Gladspell pays Ellysium by using a per diem reimbursement method.
If Gladspell’s per diem contract with Ellysium is typical, then the per diem payment will cover such medical costs as
- A. Laboratory tests
- B. Respiratory therapy
- C. Semiprivate room and board
- D. Radiology services
Answer: C
NEW QUESTION 13
Health plans typically conduct two types of reviews of a provider's medical records: an evaluation of the provider's medical record keeping (MRK) practices and a medical record review (MRR). One true statement about these types of reviews is that:
- A. An MRK covers the content of specific patient records of a provider.
- B. The NCQA requires an examination of MRK with all of a health plan's office evaluations.
- C. An MRR includes a review of the policies, procedures, and documentation standards the provider follows to create and maintain medical records.
- D. The NCQA requires MRR for both credentialing and recredentialing of providers in a health plan's network.
Answer: A
NEW QUESTION 14
Grant Pelham is covered by both a workers’ compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Mr. Pelham’s group health insurance plan and workers’ compensation both provide benefits to cover expenses incurred as a result of illness or injury. However, unlike traditional group insurance coverage, workers’ compensation
- A. Provides reimbursement for lost wages
- B. Requires employees who suffer a work-related illness or injury to obtain care from specified network providers
- C. Covers all injuries and illnesses, regardless of their cause
- D. Requires employees to share the cost of treatment through deductible, coinsurance, and benefit limits
Answer: A
NEW QUESTION 15
Assume that the national average cost per covered employee for PPO rental networks is
$3 per member per month (PMPM) and that the average monthly healthcare premium PMPM is $300. This information indicates that, if the number of health plan members is 10,000, then the annual network rental cost to the health plan would be:
- A. $30,000
- B. $360,000
- C. $9,000,000
- D. $12,000,000
Answer: B
NEW QUESTION 16
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