Question 1

For this question, if answer choices (A) through C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. Understanding the level of health plan penetration in a particular market can help a health plan determine which products are most appropriate for that market. Indicators of a mature health plan market include

Accepted Answer

A)  Areduction in the rate of growth in health plan premium levels 
B)  Areduction in the level of outcomes management and improvement 
C)  An increase in the rate of inpatient hospital utilization 
D)  All of the above

Question 2

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

Accepted Answer

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

Question 3

The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.

Accepted Answer

A)  When pharmacy benefits management is incorporated into an health plan's operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations. 
B)  Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members. 
C)  Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs. 
D)  Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.

Question 4

The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO. One statement that can correctly be made about Gardenia's two-level POS product is that

Accepted Answer

A)  members who self-refer without first seeing their PCPs will receive no benefits 
B)  both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow 
C)  members will pay higher coinsurance or copayments if they first see their PCPs each time 
D)  the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

Question 5

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

Accepted Answer

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-covered expenses 
D)  shift all risk for Medicare-covered services to network providers

Question 6

When the Rialto Health Plan determines which of the emergency services received by its plan members should be covered by the health plan, it is guided by a standard which describes emergencies as medical conditions manifesting themselves by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy. This standard, which was adopted by the NAIC in 1996, is referred to as the

Accepted Answer

A)  medical necessity standard 
B)  prudent layperson standard 
C)  "all-or-none" standard 
D)  reasonable and customary standard

Question 7

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.

Accepted Answer

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 (IP
A)  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.

Question 8

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:

Accepted Answer

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 contract Of these statements, the ones that are likely to be included in the recitals section of Dr. Cartier's contract are statements: 
D)  A, B, and C 
E)  A and B only
F) A and C only
G) B and C only

Question 9

Under the compensation arrangement that the Falcon Health Plan has with some of its providers, Falcon holds back 10% of the negotiated payments to these providers in order to offset or pay for any claims that exceed the budgeted costs for referral or hospital services. If the providers keep costs within the budgeted amount, Falcon distributes to them the entire amount of money held back. This way of motivating providers to control costs while providing high-quality, appropriate care is known as a:

Accepted Answer

A)  Risk pool arrangement 
B)  Withhold arrangement 
C)  Cost-shifting arrangement 
D)  Bonus pool arrangement

Question 10

Health plans use a variety of sources to find candidates to recruit for their provider networks. In general, two of the most effective methods of finding candidates are through

Accepted Answer

A)  Word of mouth and on-site training programs 
B)  Word of mouth and direct mail 
C)  Advertisements in local newspapers and on-site training programs 
D)  Advertisements in local newspapers and direct mail

Question 11

The Tuba Health Plan recently underwent an accreditation process under a program known as Accreditation '99, which includes selected Health Employer Data and Information Set (HEDIS) measures. Under Accreditation '99, Tuba received a rating of Excellent. The following statement(s) can correctly be made about this quality assessment of Tuba's operations:

Accepted Answer

A)  In arriving at its rating of Excellent for Tuba, the Accreditation '99 program most likely focused on Tuba's demonstrated results and evaluated the processes that Tuba used to achieve those results. 
B)  Tuba is required to report all HEDIS results to the NAIC. 
C)  Both A and B 
D)  A only 
E)  B only
F) Neither A nor B

Question 12

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 report included 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. Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

Accepted Answer

A)  Dr. Enberg's young patients receive appropriate immunizations at the right ages 
B)  Dr. Enberg conforms to standards for prescribing controlled substances  87 
C)  The condition of one of Dr. Enberg's patients improved after the patient received medical treatment from Dr. Enberg 
D)  Dr. Enberg's procedures are adequate for ensuring patients' access to medical care

Question 13

CMS Medicare + Choice regulations include a provision that allows health plans to deny benefits for any services the health plan objects to on moral or religious grounds. The provision that exempts health plans from providing such services is known as

Accepted Answer

A)  a conscience protection exception 
B)  a hold harmless clause 
C)  a medical necessity determination 
D)  an intermediate sanction

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

Accepted Answer

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

Question 15

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

Accepted Answer

A)  Wholesale acquisition cost (WA
C)  approach 
B)  Reimbursement approach 
C)  Service approach 
D)  Cognitive approach

Question 16

By definition, a measure of the extent to which a health plan member can obtain necessary medical services in a timely manner is known as

Accepted Answer

A)  Network management 
B)  Quality 
C)  Cost-effectiveness 
D)  Accessibility

Question 17

The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of

Accepted Answer

A)  Potential providers in a plan's network to the number of individuals in the area to be served by the plan 
B)  Providers in a plan's network to the number of enrollees in the plan 
C)  Providers outside a plan's network to the number of providers in the plan's network 
D)  Support staff in a plan's network to the number of medical practitioners in the plan's network

Question 18

Participating providers in a health plan's network must undergo recredentialing on a regular basis. During recredentialing, a health plan typically reviews

Accepted Answer

A)  a provider's current, updated application information, as well as provider's peer reviews and performance reports on the provider 
B)  a provider's current, updated application information, as well as the provider's education and prior work history 
C)  a provider's education and prior work history only 
D)  peer reviews and performance reports on a provider and the provider's prior work history only

Question 19

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

Accepted Answer

A)  Applies to group health insurance plans only 
B)  Limits the length of a health plan's pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment. 
C)  Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements. 
D)  Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Question 20

An health plan enters into a professional services capitation arrangement whenever the health plan

Accepted Answer

A)  Contracts with a medical group, clinic, or multispecialty IPA that assumes responsibility for the costs of all physician services related to a patient's care 
B)  Pays individual specialists to provide only radiology services to all plan members 
C)  Transfers all financial risk for healthcare services to a provider organization and the provider, in turn, covers virtually all of a patient's medical expenses 
D)  Contracts with a primary care provider to cover primary care services only

Exam 4: Network Management