NEW QUESTION 1

The Crimson Health Plan, a competitive medical plan (CMP), has entered into a Medicare risk contract. One true statement about Crimson is that, as a:

• A. CMP, Crimson is regulated by the federal government under the terms of the Tax Equity and Fiscal Responsibility Act (TEFRA)
• B. CMP, Crimson is not allowed to charge a Medicare enrollee a premium for any additional benefits it provides over and above Medicare benefits
• C. Provider under a Medicare risk contract, Crimson receives for its services a capitated payment equivalent to 85% of the AAPCC
• D. Provider under a Medicare risk contract, Crimson is required to deliver to members all Medicare-covered services, without regard to the cost of those services

Answer: D

NEW QUESTION 2

The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:
Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.
Foxfire's per member per month (PMPM) capitation for dermatology services is $1.
The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.
During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:

• A. that the value of each referral point for the first quarter was $120
• B. that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000
• C. that the payment that Foxfire owed D
• D. Rashad for the first quarter was $6,120
• E. all of the above

Answer: A

NEW QUESTION 3

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.
The provider network that Shipwright uses to furnish services for its workers’ compensation program will most likely

• A. Emphasize primary care and consist mostly of generalists
• B. Focus treatment approaches on rapid recovery rather than cost
• C. Offer workers’ compensation beneficiaries the same types and levels of treatment that Shipwright’s traditional network furnishes to group health plan members
• D. Exempt participating providers from meeting standard credentialing requirements

Answer: B

NEW QUESTION 4

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.
The per diem reimbursement method will require Gladspell to pay Ellysium a

• A. Fixed rate for each day a plan member is treated in Ellysium’s subacute care facility
• B. Discounted charge for all subacute care services given by Ellysium
• C. Rate that varies depending on patient category
• D. Fixed rate per enrollee per month

Answer: A

NEW QUESTION 5

In contracting with providers, a health plan can use a closed panel or open panel approach. One statement that can correctly be made about an open panel health plan is that the participating providers

• A. must be employees of the health plan, rather than independent contractors
• B. are prohibited from seeing patients who are members of other health plans
• C. typically operate out of their own offices
• D. operate according to their own standards of care, rather than standards of care established by the health plan

Answer: C

NEW QUESTION 6

One true statement about the compensation arrangement known as the case rate system is that, under this system,

• A. Providers stand to gain or lose based on the number and types of treatments used for each case
• B. Providers have no incentives to take an active role in managing cost and utilization
• C. Payors cannot adjust standard case rates to reflect the severity of the patient’s condition or complications that arise from multiple medical problems
• D. Payors have the opportunity to benefit from the provider’s cost savings

Answer: A

NEW QUESTION 7

The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:
The Apex Company, a managed vision care organization (MVCO) The Baxter Managed Behavioral Healthcare Organization (MBHO) The Cheshire Dental Health Maintenance Organization (DHMO)
As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA’s accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

• A. Apex and Baxter only
• B. Apex and Cheshire only
• C. Baxter and Cheshire only
• D. Baxter only

Answer: D

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 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 10

A health plan that delegates designated credentialing activities to an NCQA-centered or a Commission/URAC-centered credentials verification organization (CVO) is exempt from the due-diligence oversight requirements specified in the NCQA credentialing standards for all
verification services for which the CVO has been certified:

• A. True
• B. False

Answer: A

NEW QUESTION 11

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 12

The following activities are the responsibility of either the Nova Health Plan's risk management department or its medical management department:

• A. Protecting Nova's members against harm from medical care
• B. Improving the overall health status of Nova members by coordinating care across individual episodes of care and the different providers who treat the member
• C. Protecting Nova against financial loss associated with the delivery of healthcare
• D. Establishing outreach programs to encourage the use of preventive health services by Nova's members of these activities, the ones that are more likely to be the responsibility of Nova's risk management department rather than its medical management department are activities:
• E. A, B, and C
• F. A, C, and D
• G. A and C
• H. B and D

Answer: C

NEW QUESTION 13

From the following answer choices, choose the type of clause or provision described in this situation.
The Aviary Health Plan includes in its provider contracts a clause or provision that places the ultimate responsibility for an Aviary plan member’s medical care on the provider.

• A. Cure provision
• B. Hold-harmless provision
• C. Evergreen clause
• D. Exculpation clause

Answer: D

NEW QUESTION 14

The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:

• A. Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
• B. Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
• C. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
• D. Provides the employees with 24-hour coverage.

Answer: C

NEW QUESTION 15

In open panel contracting, there are several types of delivery systems. One such delivery system is the faculty practice plan (FPP). One likely result that a health plan will experience by contracting with an FPP is that the health plan will

• A. be able to select most of the physicians in the FPP
• B. achieve the highest level of cost effectiveness possible
• C. experience limited control over utilization
• D. achieve the most effective case management possible

Answer: C

NEW QUESTION 16

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 17

Jay Mercer is covered under his health plan’s vision care plan, which includes coverage for clinical eye care but not for routine eye care. Recently, Mr. Mercer had a general eye examination and got a prescription for corrective lenses. Mr. Mercer’s vision care plan will cover.

• A. both the general eye examination and the prescription for corrective lenses
• B. the general eye examination only
• C. the prescription for corrective lenses only
• D. neither the general eye examination nor the prescription for corrective lenses

Answer: D

NEW QUESTION 18
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