NEW QUESTION 1

The sizes of the businesses in a market affect the types of health programs that are likely to be purchased. Compared to smaller employers (those with fewer than 100 employees), larger employers (those with more than 1,000 employees) are

• A. more likely to contract with indemnity health plans
• B. more likely to offer their employees a choice in health plans
• C. less likely to contract with health plans
• D. less likely to require a wide variety of benefits

Answer: B

NEW QUESTION 2

Many health plans opt to carve out behavioral healthcare (BH) services. However, one argument against carving out BH services is that this action most likely can result in

• A. Slower access to BH care for plan members
• B. Increased collaboration between BH providers and PCPs
• C. Fewer specialized BH services for plan members
• D. Decreased continuity of BH care for plan members

Answer: D

NEW QUESTION 3

The introductory paragraph of a provider contract is generally followed by a section called the recitals. The recitals section of the contract typically specifies the

• A. Purpose of the agreement
• B. Manner in which the provider is to bill for services
• C. Definitions of key terms to be used in the contract
• D. Rate at which the provider will be compensated

Answer: A

NEW QUESTION 4

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

• A. A statement that identifies the purpose of the contract
• B. A statement that defines in legal terms the parties to the contract
• C. A statement that identifies the Sailboat products to be covered by the contractOf these statements, the ones that are likely to be included in the recitals section of D
• D. Cartier's contract are statements:
• E. A, B, and C
• F. A and B only
• G. A and C only
• H. B and C only

Answer: A

NEW QUESTION 5

The Holiday Health Plan is preparing to enter a new market. In order to determine the optimal size of its provider panel in the new market, Holiday is conducting a competitive analysis of provider networks of the market’s existing health plans. Consider whether, in conducting its competitive analysis, Holiday should seek answers to the following questions:
Question 1: What are the cost-containment strategies of the health plans with increasing market shares?
Question 2: What are the premium strategies of the health plans with large market shares?
Question 3: What are the characteristics of health plans that are losing market share?
In its competitive analysis, Holiday should most likely obtain answers to questions

• A. 1, 2, and 3
• B. 1 and 2 only
• C. 1 and 3 only
• D. 2 and 3 only

Answer: A

NEW QUESTION 6

Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans:
Dr. Shah receives $40 per enrollee per month for providing primary care and an additional
$10 per enrollee per month if the cost of referral services falls below a specified level
Dr. Owen receives $30 per enrollee per month for providing primary care and an additional
$15 per enrollee per month if the cost of referral services falls below a specified level The use of a physician incentive plan creates substantial risk for

• A. Both D
• B. Shah and D
• C. Owen
• D. D
• E. Shah only
• F. D
• G. Owen only
• H. Neither D
• I. Shah nor D
• J. Owen

Answer: C

NEW QUESTION 7

The Justice Health Plan is eligible to submit reportable actions against medical practitioners to the National Practitioner Data Bank (NPDB). Justice is considering whether it should report the following actions to the NPDB:
Action 1—A medical malpractice insurer made a malpractice payment on behalf of a dentist in Justice’s network for a complaint that was settled out of court.
Action 2—Justice reprimanded a PCP in its network for failing to follow the health plan’s referral procedures.
Action 3—Justice suspended a physician’s clinical privileges throughout the Justice network because the physician’s conduct adversely affected the welfare of a patient.
Action 4—Justice censured a physician for advertising practices that were not aligned with Justice’s marketing philosophy.
Of these actions, the ones that Justice most likely must report to the NPDB include Actions

• A. 1, 2, and 3 only
• B. 1 and 3 only
• C. 2 and 4 only
• D. 3 and 4 only

Answer: B

NEW QUESTION 8

Although a health plan is allowed to delegate many activities to outside sources, the National Committee for Quality Assurance (NCQA) has determined that some activities are not delegable.
These activities include

• A. evaluation of new medical technologies
• B. overseeing delegated medical records activities
• C. developing written statements of members’ rights and responsibilities
• D. all of the above

Answer: D

NEW QUESTION 9

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 10

The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to

• A. Hold plan members responsible for unreimbursed charges or unpaid claims
• B. Allow providers to develop their own standards of care
• C. Adhere to specified disclosure requirements related to provider contract termination
• D. File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)

Answer: C

NEW QUESTION 11

A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:

• A. $200
• B. $1,000
• C. $1,800
• D. $9,000

Answer: C

NEW QUESTION 12

A population’s demographic factors—such as income levels, age, gender, race, and ethnicity—can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

• A. higher-income populations have a higher incidence of chronic illnesses than do lowerincome populations
• B. compared to other groups, young men are more likely to be attached to particular providers
• C. a population with a high proportion of women typically requires more providers than does a population that is predominantly male
• D. Health plans should not recognize, in either the design of networks or the evaluation of provider performance, racial and ethnic differences in the member population

Answer: C

NEW QUESTION 13

Dr. Michelle Kubiak has contracted with the Gem Health Plan, a Medicare+Choice health plan, to provide medical services to Gem's enrollees. Gem pays Dr. Kubiak $40 per enrollee per month for providing primary care. Gem also pays her an additional $10 per enrollee per month if the cost of referral services falls below a targeted level. This information indicates that, according to the substantial financial risk formula, Dr. Kubiak's referral risk under this contract is equal to:

• A. 20%, and therefore this arrangement puts her at substantial financial risk
• B. 20%, and therefore this arrangement does not put her at substantial financial risk
• C. 25%, and therefore this arrangement puts her at substantial financial risk
• D. 25%, and therefore this arrangement does not put her at substantial financial risk

Answer: B

NEW QUESTION 14

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 15

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 16

The National Committee for Quality Assurance (NCQA) has integrated accreditation with Health Employer Data and Information Set (HEDIS) measures into a program called Accreditation ’99. One statement that can correctly be made about these accreditation standards is that

• A. Health plans are required by law to report HEDIS results to NCQA
• B. HEDIS restricts its reporting criteria to a narrow group of quantitative performance measures, while NCQA includes a broad range of qualitative performance measures
• C. Private employer groups purchasing health care coverage increasingly require both NCQA accreditation and HEDIS reporting
• D. HEDIS includes measures of a health plan’s effectiveness of care rather than its cost of care

Answer: C

NEW QUESTION 17

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 18
......