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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:

  • A. M
  • B. Pollard, M
  • C. Herrera, and M
  • D. Holtz
  • E. M
  • F. Pollard and M
  • G. Herrera only
  • H. M
  • I. Pollard and M
  • J. Holtz only
  • K. M
  • L. Herrera and M
  • M. Holtz only

Answer: C


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.
If the Ellysium subacute care unit is typical of most hospital-based subacute skilled nursing units, then this unit could be used for patients who no longer need to be in the hospital’s acute care unit but who still require

  • A. Daily medical care and monitoring
  • B. Regular rehabilitative therapy
  • C. Respiratory therapy
  • D. All of the above

Answer: D


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


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


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


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

  • 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

Answer: A


The following statements are about waivers and the Medicaid program. Select the answer choice containing the correct statement:

  • A. The Balanced Budget Act (BBA) of 1997 eliminated the need for states to make formal applications for waivers.
  • B. Section 1115 waivers allow states to bypass the Medicaid program's usual requirement of giving recipients complete freedom of choice in selecting providers.
  • C. Title XVIII waivers allow states to mandate certain categories of Medicaid recipients to enroll in health plan plans.
  • D. Section 1915(b) waivers allow states to establish demonstration projects in order to test new approaches to benefits and services provided by Medicaid.

Answer: A


The Aegean Health Plan delegated its utilization management (UM) program to the Silhouette IPA. Silhouette, in turn, transferred authority for case management to Brandon Health Services. In this situation, Brandon is best described as the

  • A. delegator, and Aegean is ultimately responsible for Brandon’s performance
  • B. delegator, and Silhouette is ultimately responsible for Brandon’s performance
  • C. subdelegate, and Aegean is ultimately responsible for Brandon’s performance
  • D. subdelegate, and Silhouette is ultimately responsible for Brandon’s performance

Answer: C


The following statements are about the specialist component of a provider panel. Select the answer choice containing the correct statement.

  • A. Ideally, a health plan should have every specialist category represented on its provider panel with appropriate geographic distribution.
  • B. Most specialist contracts do not ensure the provider’s adherence to UM policies set up by the health plan.
  • C. No-balance-billing clauses are not desirable in health plan contracts with specialists.
  • D. In geographic regions where there is a shortage of PCPs, a health plan is not permitted to contract with specialists to perform primary care services, even for patients with chronic conditions.

Answer: A


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


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 NewnanGroup, 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.
The following statements can correctly be made about the reimbursement for Drugs A and B under the MAC pricing system:

  • A. Treble most likely is obligated to reimburse Manor 14 cents per tablet for Drug A.
  • B. Manor most likely is allowed to bill the subscriber 2 cents per tablet for Drug A.
  • C. Treble most likely is obligated to reimburse Manor 5 cents per tablet for Drug B.
  • D. All of the above statements are correct.

Answer: C


One difference between a fee-for-service (FFS) reimbursement arrangement and capitation is that the FFS arrangement:

  • A. Is a prospective payment system, whereas capitation is a retrospective payment system
  • B. Has a potential to induce providers to underutilize medical resources, whereas capitation does not have this potential disadvantage
  • C. Bases the amount of reimbursement on the actual medical services delivered, whereas reimbursement under capitation is independent of the actual volume and cost of services provided
  • D. Is most often used by health plans to reimburse healthcare facilities, whereas capitation is most often used by health plans to reimburse specialty care providers

Answer: C


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


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.
Because Mr. Pelham was injured on the job, he is entitled to receive benefits through workers’ compensation. Under the terms of the state-mandated exclusive remedy doctrine included in the workers’ compensation agreement, Mr. Pelham will most likely be prohibited from

  • A. Receiving workers’ compensation benefits unless he can show that the employer was at fault for his injury
  • B. Obtaining care from providers who are not members of a workers’ compensation network
  • C. Suing his employer for additional benefits
  • D. Claiming benefits from both workers’ compensation and his group health plan

Answer: C


Following statements are about accreditation of health plans:

  • A. The National Committee for Quality Assurance (NCQA) serves as the primary accrediting agency for most health maintenance organizations (HMOs).
  • B. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed standards that can be used for the accreditation of hospitals, but not for the accreditation of health plan provider networks or health plan plans.
  • C. States are required to adopt the model standards developed by the National Association of Insurance Commissioners (NAIC), an organization of state insurance regulators that develops standards to promote uniformity in insurance regulations.
  • D. Accreditation is an evaluative process in which a health plan undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the federal government or by the state governments.

Answer: A


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