All About Highest Quality AHM-530 Training Tools

NEW QUESTION 1

One true statement about the Medicaid program in the United States is that:

• A. The federal financial participation (FFP) in a state's Medicaid program ranges from 20% to 40% of the state's total Medicaid costs
• B. Medicaid regulations mandate specific minimum benefits, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, for all Medicaid recipients younger than age 30
• C. The individual states have responsibility for administering the Medicaid program
• D. Non-disabled adults and children in low-income families account for the majority of direct Medicaid spending

Answer: C

NEW QUESTION 2

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.
In most states, a health plan can be held responsible for a provider’s negligent malpractice. This legal concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce their exposure to malpractice lawsuits is to state in health plan-provider agreements,marketing collateral, and membership literature that the providers are (employees of the health plan / independent contractors).

• A. Vicarious liability / employees of the health plan
• B. Vicarious liability / independent contractors
• C. Risk sharing / employees of the health plan
• D. Risk sharing / independent contractors

Answer: B

NEW QUESTION 3

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 4

The Elizabethan Health Plan uses a direct referral program, which means that

• A. PCPs in Elizabethan’s network can make most referrals without obtaining prior authorization from Elizabethan
• B. PCPs in Elizabethan’s network must always refer plan members to other specialists within the network
• C. Elizabethan’s plan members can bypass the PCP and obtain medical services from a specialist without a referral
• D. Elizabethan’s plan members must obtain referrals directly from Elizabethan

Answer: A

NEW QUESTION 5

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 6

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This reportincluded such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
The report that helped Canyon determine how well Dr. Enberg met the health plan's standards is known as:

• A. An encounter report
• B. An external standards report
• C. Aprovider profile
• D. An access to care report

Answer: C

NEW QUESTION 7

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 8

Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

• A. Includes only primary care services
• B. Covers such services as immunizations and laboratory tests
• C. Can be used only if the provider's panel size is less than 50 providers
• D. Covers such services as cardiology and orthopedics

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

The method of pharmaceutical reimbursement under which a plan member obtains prescription drugs from participating network pharmacies by presenting proper identification and paying a specified copayment is the

• A. Wholesale acquisition cost (WAC) approach
• B. Reimbursement approach
• C. Service approach
• D. Cognitive approach

Answer: C

NEW QUESTION 11

The BBA of 1997 specifies the ways in which a Medicare+Choice plan can establish and use provider networks. A Medicare+Choice plan that operates as a private fee for service (PFFS) plan is allowed to

• A. limit the size of its network to the number of providers necessary to meet the needs of its enrollees
• B. require providers to accept as payment in full an amount no greater than 115% of the Medicare payment rate
• C. refuse payment to non-network providers who submit claims for Medicare-coveredexpenses
• D. shift all risk for Medicare-covered services to network providers

Answer: B

NEW QUESTION 12

In most health plan pharmacy networks, the cost component of the reimbursement formula is based on the average wholesale price (AWP). One true statement about the AWP for prescription drugs is that

• A. AWPs tend to vary widely from region to region of the United States
• B. The AWP is often substantially higher than the actual price the pharmacy pays for prescription drugs
• C. A health plan’s contracted reimbursement to a pharmacy for prescription drugs is typically the AWP plus a percentage, such as 5%
• D. The AWP usually is lower than the estimated acquisition cost (EAC) for most prescription drugs

Answer: B

NEW QUESTION 13

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method

• A. is typically used for outpatient care
• B. assigns a single code for treatment
• C. applies to treatment received during an entire hospital stay
• D. is considered to be a retrospective payment system

Answer: A

NEW QUESTION 14

The Enterprise Health Plan has indicated an interest in delegating its medical records review activities to the Teal Group and has forwarded a typical letter of intent to Teal. One true statement about this letter of intent is that it:

• A. Is a contract that creates a legally binding relationship between Enterprise and Teal
• B. Cannot include a confidentiality clause
• C. Serves as a delegation agreement between Enterprise and Teal
• D. Outlines the delegation oversight process

Answer: D

NEW QUESTION 15

Martin Breslin, age 72 and permanently disabled, is classified as dually-eligible. This information indicates that Mr. Breslin qualifies for coverage by both

• A. Medicare and private indemnity insurance, and Medicare provides primary coverage
• B. Medicare and Medicaid, and Medicare provides primary coverage
• C. Medicaid and private indemnity insurance, and Medicaid provides primary coverage
• D. Medicare and Medicaid, and Medicaid provides primary coverage

Answer: B

NEW QUESTION 16
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