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The Omni Health Plan is interested in expanding the specialty services it offers to its plan members and is considering contracting with the following providers of specialty services:
The Apex Company, a managed vision care organization (MVCO) The Baxter Managed Behavioral Healthcare Organization (MBHO) The Cheshire Dental Health Maintenance Organization (DHMO)
As part of its credentialing process, Omni would like to verify that each of these providers has met NCQA’s accreditation standards. However, with regard to these three specialty service providers, an NCQA accreditation program currently exists for

  • A. Apex and Baxter only
  • B. Apex and Cheshire only
  • C. Baxter and Cheshire only
  • D. Baxter only

Answer: D


In contracting with providers, a health plan can use a closed panel or open panel approach. One statement that can correctly be made about an open panel health plan is that the participating providers

  • A. must be employees of the health plan, rather than independent contractors
  • B. are prohibited from seeing patients who are members of other health plans
  • C. typically operate out of their own offices
  • D. operate according to their own standards of care, rather than standards of care established by the health plan

Answer: C


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

  • 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

Answer: C


The following statements are about Medicaid health plan entities. Select the answer choice containing the correct statement:

  • A. To keep Medicaid enrollment costs as low as possible, states typically prohibit the use of third-party entities known as enrollment brokers to handle the recruitment and enrollment of Medicaid recipients in health plan plans
  • B. Primary care case managers (PCCMs) are individuals who contract with a state's Medicaid agency to provide primary care services mainly to urban areas.
  • C. Typically, Medicaid beneficiaries must be given a choice between at least two health plan entities.
  • D. Medicaid health plan entities are responsible for providing primary coverage for all dually-eligible beneficiaries.

Answer: C


Dr. Eve Barlow is a specialist in the Amity Health Plan’s provider network. Dr. Barlow’s provider contract with Amity contains a typical most-favored-nation arrangement. The purpose of this arrangement is to

  • A. Require D
  • B. Barlow and Amity to use arbitration to resolve any disputes regarding the contract
  • C. Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters
  • D. Require D
  • E. Barlow to charge Amity her lowest rate for a medical service she has provided to an Amity plan member, even if the rate is lower than the price negotiated in the contract
  • F. State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between D
  • G. Barlow and Amity

Answer: C


The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
The comparative method of evaluation that Azure uses to identify and implement the practices that lead to the best outcomes is known as

  • A. Case mix analysis
  • B. Outcomes research
  • C. Benchmarking
  • D. Provider profiling

Answer: C


Dr. Leona Koenig removed the appendix of a plan member of the Helium health plan. In order to increase the level of reimbursement that she would receive from Helium, Dr. Koenig submitted to the health plan separate charges for the preoperative physical examination, the surgicalprocedure, and postoperative care. All of these charges should have been included in the code for the surgical procedure itself. Dr. Koenig's submission is a misuse of the coding system used by health plans and is an example of:

  • A. Upcoding
  • B. A wrap-around
  • C. Churning
  • D. Unbundling

Answer: D


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

  • 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

Answer: A


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


Medicaid is a joint federal and state program that provides healthcare coverage for low- income, medically needy, and disabled individuals. Under the terms of this joint sponsorship, the

  • A. Federal government is responsible for making all claim payments
  • B. Federal government is responsible for determining the basic benefits that must be provided to eligible Medicaid beneficiaries
  • C. State governments are responsible for setting minimum standards regarding eligibility, benefit coverage, and provider participation and reimbursement
  • D. State governments are responsible for establishing overall regulation of the Medicaid program

Answer: B


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


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

  • A. Enrollment brokers
  • B. Primary care case managers (PCCMs)
  • C. Certified medical assistants (CMAs)
  • D. Prepaid health plans (PHPs)

Answer: B


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

  • A. Allow members direct access to OB/GYN services
  • B. Allow members direct access to prescription drug services
  • C. Provide access to Title X family-planning clinics
  • D. Provide average office waiting times of no more than 30 minutes for appointments with plan providers

Answer: D


The Foxfire Health Plan, which has 20,000 members, contracts with dermatologists on a contact capitation basis. The contact capitation arrangement has the following features:
Foxfire distributes the money in the contact capitation fund once each quarter and the distribution is based on the point totals accumulated by each dermatologist.
Foxfire's per member per month (PMPM) capitation for dermatology services is $1.
The dermatologist receives 1 point for each new referral that is not classified as a complicated referral and 1.5 points for each new referral that is classified as complicated.
During the first quarter, Foxfire's PCPs made 450 referrals to dermatologists and 100 of these referrals were classified as complicated. One dermatologist, Dr. Shareef Rashad, received 42 of these referrals; 6 of his referrals were classified as complicated. Statements that can correctly be made about Foxfire's contact capitation arrangement include:

  • A. that the value of each referral point for the first quarter was $120
  • B. that the value of Foxfire's contact capitation fund for dermatologists for the first quarter was $20,000
  • C. that the payment that Foxfire owed D
  • D. Rashad for the first quarter was $6,120
  • E. all of the above

Answer: A


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

  • A. Give Medicaid recipients complete freedom in choosing healthcare providers
  • B. Give Medicaid recipients the option to choose not to enroll in a healthcare plan
  • C. Mandate certain categories of Medicaid recipients to enroll in health plans
  • D. Establish demonstration projects to test new approaches for delivering care to Medicaid recipients

Answer: C


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