Question 1

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in the same provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne's patients are generally healthy and rarely present complications. As a result, Dr. Comer typically uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare Dr. Comer's performance with Dr. Donne's performance, the health plan modified its evaluation to account for differences in the providers' patient populations and treatment protocols. The health plan modified Dr. Comer's and Dr. Donne's performance data by means of

Accepted Answer

The health plan modified Dr. Comer's and Dr. Donne's performance data by means of case mix/severity adjustment, which takes into account the differences in their patient populations and treatment protocols. This allows for a more equitable comparison of their performance.

Question 2

Martin Breslin, age 72 and permanently disabled, is classified as dually-eligible. This information indicates that Mr. Breslin qualifies for coverage by both

Accepted Answer

Dually-eligible individuals qualify for both Medicare and Medicaid. In most cases, Medicare provides primary coverage, while Medicaid covers additional services and costs not covered by Medicare.

Question 3

In most states, workers' compensation is first-dollar and last-dollar coverage, which means that workers' compensation programs

Accepted Answer

Workers' compensation programs must pay 100% of work-related medical and disability expenses, regardless of fault or limits.

Question 4

One true statement about the Employee Retirement Income Security Act of 1974 (ERISA) is that:

Accepted Answer

ERISA preempts any state laws that regulate employee welfare benefit plans. However, state insurance laws may still apply to insurance companies providing coverage under these plans. ERISA applies to both pension plans and employee welfare plans, and self-funded plans must comply with ERISA requirements instead of state mandates. ERISA does not apply to all issuers of health insurance products, only to those that provide coverage as part of an employee welfare benefit plan.

Question 5

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

Accepted Answer

Section 1915(b) waivers allow states to mandate certain categories of Medicaid recipients to enroll in managed care plans, limiting their freedom to choose any healthcare provider.

Question 6

Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans: Dr. Shah receives $40 per enrollee per month for providing primary care and an additional $10 per enrollee per month if the cost of referral services falls below a specified level Dr. Owen receives $30 per enrollee per month for providing primary care and an additional $15 per enrollee per month if the cost of referral services falls below a specified level The use of a physician incentive plan creates substantial risk for

Accepted Answer

The answer of Dr. Ahmad Shah and Dr. Shantelle Owen...

Question 7

As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must

Accepted Answer

Brightwell must define its service area based on community patterns of care to ensure that its network provides adequate access to covered services. This ensures that enrollees have access to needed services within a reasonable distance from their residence. Allowing enrollees to determine their primary care provider (choice A) and basing a provider's participation and reimbursement on their license or certification (choice B) are not related to ensuring adequate access to covered services. Requiring prior authorization for emergency or urgently needed services (choice D) could potentially delay necessary care and is not a suitable way to ensure access.

Question 8

Dr. Sarah Carmichael is one of several network providers who serve on one of the Apex Health Plan's organizational committees. The committee reviews cases against providers identified through complaints and grievances or through clinical monitoring activities. If needed, the committee formulates, approves, and monitors corrective action plans for providers. Although Apex administrators and other employees also serve on the committee, only participating providers have voting rights. The committee that Dr. Carmichael serves on is a

Accepted Answer

Dr. Sarah Carmichael serves on a committee that reviews cases against providers and formulates corrective action plans for providers. This is the description of a peer review committee, which is focused on evaluating the quality of care provided by network providers. The other choices, utilization management, medical advisory, and credentialing committees, have different functions within a healthcare network.

Question 9

The provider contract that the Danube Health Plan has with the Viola Home Health Services Organization states that Danube will use a typical flat rate reimbursement arrangement to compensate Viola for the skilled nursing services it provides to Danube's plan members. A portion of the contract's reimbursement schedule is shown below: Home Health Licensed Practical Nurse (LPN): $45 per visit or $90 per diem Home Health Registered Nurse (RN): $50 per visit or $110 per diem Last month, an LPN from Viola visited a Danube plan member and provided 1Ѕ hours of home healthcare, and an RN from Viola visited another Danube plan member and provided 7 hours of home healthcare. The following statement(s) can correctly be made about Danube's payment to Viola for these services:

Accepted Answer

The answer of The provider contract that the Danube Health...

Question 10

Prior to the enactment of the Balanced Budget Act (BBA) of 1997, payment for Medicare-covered primary and acute care services was based on the adjusted average per capita cost (AAPCC). The AAPCC is defined as the

Accepted Answer

The AAPCC was the fee-for-service amount that CMS would pay for a Medicare beneficiary, adjusted for factors like age, sex, and institutional status.

Question 11

An increasing number of health plans offer coverage for alternative healthcare services. One such alternative healthcare service is biofeedback. Biofeedback is an approach that

Accepted Answer

Biofeedback is a technique that uses electronic monitoring devices to help an individual become more aware of and develop control over their involuntary bodily functions, such as heart rate, breathing, and body temperature. It is often used as a complementary therapy for conditions such as anxiety, migraines, and chronic pain.

Question 12

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

Accepted Answer

The federal government sets the basic benefits that must be provided, while states have flexibility in administering their own programs within federal guidelines.

Question 13

Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare + Choice health plans must ensure that a physician has adequate stop-loss protection if the

Accepted Answer

Stop-loss insurance is designed to protect physicians who face substantial financial risk as a result of physician incentive plans. Medicare + Choice health plans must ensure that a physician has adequate stop-loss protection if the physician is subject to a withhold that is greater than 25% of his or her potential payments. Therefore, option D is the correct answer.

Question 14

The Edgewood Health Plan uses a combination of structural, process, outcomes, and customer satisfaction measures to evaluate its network providers' performance. Edgewood would correctly use outcomes measures to evaluate a provider's

Accepted Answer

Outcomes measures are used to evaluate the results of medical treatment or services provided to patients. Therefore, patient progress following treatment would be the best use of outcomes measures. Compliance with specific regulatory or accrediting requirements would be evaluated using structural measures, appropriate use of specified procedures would be evaluated using process measures, and patient perceptions would be evaluated using customer satisfaction measures.

Question 15

Social health maintenance organizations (SHMOs) and Programs of All-Inclusive Care for the Elderly (PACE) are federal programs designed to provide coordinated healthcare services to the elderly. Unlike PACE, SHMOs

Accepted Answer

SHMOs limit benefits to a specified maximum amount, unlike PACE, which provides comprehensive care without such limits.

Question 16

Franklin Pitt selected a Medicare+Choice option under which he is covered by a catastrophic health insurance policy with a high annual deductible and a $6,000 out-of-pocket expense maximum. CMS pays the premiums for the insurance policy out of the usual Medicare+Choice payment and deposits any difference between the capitated amount and the policy premium in a savings account. Mr. Pitt can use funds in the savings account to pay qualified medical expenses not covered by his insurance policy. At the end of the benefit year, Mr. Pitt can carry any remaining funds into the next benefit year. The Medicare+Choice option Mr. Pitt selected is known as a

Accepted Answer

The Medicare+Choice option selected by Mr. Pitt, which involves a catastrophic health insurance policy with a high deductible and a savings account for qualified medical expenses, is a medical savings account (MSA) plan.

Question 17

The Elizabethan Health Plan uses a direct referral program, which means that

Accepted Answer

The passage states that Elizabethan Health Plan uses a direct referral program, and that PCPs in the network "can make most referrals without obtaining prior authorization from Elizabethan." This suggests that PCPs have the ability to refer plan members to other specialists without needing to go through Elizabethan for approval, making option A the correct choice. Option B is incorrect because it is too restrictive; the passage does not suggest that plan members must always be referred within the network. Option C is incorrect because it contradicts the direct referral program described in the passage. Option D is also incorrect because it suggests that plan members must obtain referrals from Elizabethan directly, whereas the passage indicates that PCPs can make most referrals without going through Elizabethan.

Question 18

State Medicaid agencies can contract with health plans through open contracting or selective contracting. One advantage of selective contracting is that it

Accepted Answer

Selective contracting allows Medicaid agencies to choose health plans that offer enhanced benefits and innovative approaches, encouraging the development of such products.

Question 19

Jay Mercer is covered under his health plan's vision care plan, which includes coverage for clinical eye care but not for routine eye care. Recently, Mr. Mercer had a general eye examination and got a prescription for corrective lenses. Mr. Mercer's vision care plan will cover.

Accepted Answer

Routine eye care, such as general eye examinations and prescriptions for corrective lenses, is not covered under Mr. Mercer's vision care plan, which only covers clinical eye care.

Question 20

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

Accepted Answer

Member satisfaction surveys gather information about a member's reaction to services received during a specific encounter, the reactions of specific subsets of the health plan's membership, and members' positive and negative experiences with the plan's services. Therefore, the best choice is D - all of the above.

Exam 4: Network Management