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NEW QUESTION 1
After HIPAA was enacted, Congress amended the law to include the Mental Health Parity Act (MHPA) of 1996, a federal requirement relating to mental health benefits. One true statement about the MHPA is that it
- A. requires all health plans to provide coverage for mental health services
- B. requires health plans to carve out mental/behavioral healthcare from other services provided by the plans
- C. allows health plans to require patients receiving mental health services to pay higher copayments than patients seeking treatment for physical illnesses
- D. prohibits health plans that offer mental health benefits from applying more restrictive limits on coverage for mental illness than on coverage for physical illness
Answer: D
NEW QUESTION 2
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
- A. a conscience protection exception
- B. a hold harmless clause
- C. a medical necessity determination
- D. an intermediate sanction
Answer: A
NEW QUESTION 3
One true statement about the Employee Retirement Income Security Act of 1974 (ERISA) is that:
- A. ERISA applies to all issuers of health insurance products, such as HMOs
- B. pension plans and employee welfare plans are exempt from any regulation under ERISA
- C. ERISA requires self-funded plans to comply with all state mandates affecting health insurance companies and health plans
- D. the terms of ERISA generally take precedence over any state laws that regulate employee welfare benefit plans
Answer: D
NEW QUESTION 4
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 5
The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:
- A. Receives financial assistance from the federal government but not a state government.
- B. Is at a higher risk of operating at a loss than are most other hospitals.
- C. Receives no payments directly from Medicaid for services rendered but rather receives a portion of the capitation payment that Medicaid makes to the health plans with which Preamble contracts.
- D. Is eligible for capitation rates that are significantly higher than the FFS average for all covered Medicaid services.
Answer: B
NEW QUESTION 6
Health plans can often reduce workers’ compensation costs by incorporating 24-hour coverage into their workers’ compensations programs. Twenty-four-hour coverage reduces costs by
- A. Maximizing the effects of cost shifting
- B. Eliminating the need for utilization management
- C. Requiring members to use separate points of entry for job-related and non-job related services
- D. Combining administrative services for workers’ compensation and non-workers’ compensation healthcare and disability coverage
Answer: D
NEW QUESTION 7
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 8
The following statement(s) can correctly be made about the Balanced Budget Act (BBA) of 1997:
- A. The BBA requires Medicare+Choice organizations to be licensed as non-risk-bearing entities under federal law.
- B. The Centers for Medicaid and Medicare Services (CMS) is responsible for implementing the BBA.
- C. Both A and B
- D. A only
- E. B only
- F. Neither A nor B
Answer: C
NEW QUESTION 9
The following statements are about the negotiation process of provider contracting. Three of the statements are true and one of the statements is false. Select the answer choice containing the FALSE statement.
- A. While preparing for negotiations, the health plan usually sends the provider an application to join the provider network, a list of credentialing requirements, and a copy of the proposed provider contract, which may or may not include the proposed reimbursement schedule.
- B. In general, the ideal negotiating style for provider contracting is a collaborative approach.
- C. Typically, the health plan and the provider negotiate the reimbursement arrangement between the parties before they negotiate the scope of services and the contract language.
- D. The actual signing of the provider contract typically takes place after negotiations are completed.
Answer: C
NEW QUESTION 10
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 11
The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of
- 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
Answer: B
NEW QUESTION 12
An health plan enters into a professional services capitation arrangement whenever the health plan
- 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
Answer: A
NEW QUESTION 13
The following statement(s) can correctly be made about financial arrangements between health plans and emergency departments of hospitals:
- A. These arrangements typically include payments for services rendered in the emergency department by a health plan's primary or specialty care providers.
- B. Most of these arrangements are structured through the health plan's contract with the hospital.
- C. Both A and B
- D. A only
- E. B only
- F. Neither A nor B
Answer: C
NEW QUESTION 14
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 15
The two basic approaches that Medicaid uses to contract with health plans are open contracting and selective contracting. One true statement about these approaches to contracting is that:
- A. Open contracting requires health plans to meet minimum performance standards outlined in a state's request for proposal (RFP)
- B. Open contracting makes it possible for the Medicaid agency to offer enrollment volume guarantees
- C. Selective contracting requires any health plan that meets the state's performance standards and the federal Medicaid requirements to enter into a Medicaid contract
- D. Selective contracting requires health plans to bid competitively for Medicaid contracts
Answer: D
NEW QUESTION 16
The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:
- A. A discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.
- B. A case rate payment system offers providers an incentive to take an active role in managing cost and utilization.
- C. One reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.
- D. One reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.
Answer: B
NEW QUESTION 17
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 18
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