Exam 4: Network Management

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:

The Omnibus Budget Reconciliation Act of 1986 (OBRA 1986) established the Programs of All- Inclusive Care for the Elderly (PACE). One characteristic of the PACE programs is that:

The Walton Health Plan uses the fee-for-service pharmaceutical reimbursement approach known as the maximum allowable cost (MAC) method. If Walton's MAC list specifies a cost of 8 cents per tablet for a particular drug but the participating pharmacy pays 10 cents per tablet for the drug, then Walton will be obligated to reimburse the pharmacy for

The Portway Hospital is qualified to receive Medicaid subsidy payments as a disproportionate share hospital (DHS). The DHS payments that Portway receives are

The following statements describe two types of HMOs: The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP. The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO. Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management. Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits: The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug. The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug. From the following answer choices, select the response that best identifies Elm and Treble:

The following statement(s) can correctly be made about the TRICARE managed healthcare program of the U.S. Department of Defense. 1. Active-duty military personnel are automatically enrolled in TRICARE's HMO option (TRICARE Prime). 2. Eligible family members and dependents can enroll in TRICARE Prime, the PPO plan (TRICARE Extra), or an indemnity plan (TRICARE Standard).

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

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

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

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:

Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

There are several approaches to providing Medicaid health plan. One such approach involves the use of organizations who contract with the state's Medicaid agency to provide primary care as well as administrative services. These organizations are known as

Provider panels can be either narrow or broad. Compared to a similarly sized health plan that uses a broad provider panel, a health plan that uses a narrow provider panel most likely can expect to

The Avignon Company discontinued its contract with a traditional indemnity insurer and contracted exclusively with the Minaret Health Plan to provide the sole healthcare plan to Avignon's employees. By agreeing to an exclusive contract with Minaret, Avignon has entered into a type of healthcare contract known as

The following statement(s) can correctly be made about hospitalists. 1. The hospitalist's main function is to coordinate diagnostic and treatment activities to ensure that the patient receives appropriate care while in the hospital. 2. The hospitalist's role clearly supports the health plan concept of disease management.

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

Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans

Member satisfaction surveys help an health plan determine whether its providers are consistently delivering services to plan members in a manner that lives up to member expectations. Member satisfaction surveys allow the health plan to gather information about

Dr. Janet Dubois is a radiologist who practices exclusively at the Rightway Healthcare Center. This information indicates that Dr. Dubois is employed by Rightway as

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