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AHM-530
Network Management Questions and Answers

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Questions # 41:

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

Options:

a conscience protection exception

a hold harmless clause

a medical necessity determination

an intermediate sanction

Answer

Questions # 42:

Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

Options:

Includes only primary care services

Covers such services as immunizations and laboratory tests

Can be used only if the provider's panel size is less than 50 providers

Covers such services as cardiology and orthopedics

Answer

Questions # 43:

One true statement about the Medicaid program in the United States is that:

Options:

The federal financial participation (FFP) in a state's Medicaid program ranges from 20% to 40% of the state's total Medicaid costs

Medicaid regulations mandate specific minimum benefits, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, for all Medicaid recipients younger than age 30

The individual states have responsibility for administering the Medicaid program

Non-disabled adults and children in low-income families account for the majority of direct Medicaid spending

Answer

Questions # 44:

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

Options:

Allows enrollees to choose from among a greater variety of health plans

Reduces the competition among health plans

Increases the ability of new, local plans to participate in Medicaid programs

Encourages the development of products that offer enhanced benefits and more effective approaches to health plans

Answer

Questions # 45:

Factors that are likely to indicate increased health plan market maturity include:

Options:

Increased consolidation among health plans.

Increased rate of growth in health plan premium levels.

Areduction in the market penetration of HMO and point-of-service (POS) products.

Areduction in the frequency of performance-based reimbursement of providers.

Answer

Questions # 46:

The Enterprise Health Plan has indicated an interest in delegating its medical records review activities to the Teal Group and has forwarded a typical letter of intent to Teal. One true statement about this letter of intent is that it:

Options:

Is a contract that creates a legally binding relationship between Enterprise and Teal

Cannot include a confidentiality clause

Serves as a delegation agreement between Enterprise and Teal

Outlines the delegation oversight process

Answer

Questions # 47:

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.

The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

Options:

Atermination with cause clause

Ahold-harmless clause

An indemnification clause

Acorrective action clause

Answer

Questions # 48:

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

Options:

Can place limits on the benefits they will pay for a given claim

Can deny coverage for work-related illness or injury if the employer is not at fault

Must pay 100% of work-related medical and disability expenses

Can hold employers liable for additional amounts that result from court decisions

Answer

Questions # 49:

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:

Options:

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.

Tuba is required to report all HEDIS results to the NAIC.

Both A and B

A only

B only

Neither A nor B

Answer

Questions # 50:

The following activities are the responsibility of either the Nova Health Plan's risk management department or its medical management department:

Options:

Protecting Nova's members against harm from medical care

Improving the overall health status of Nova members by coordinating care across individual episodes of care and the different providers who treat the member

Protecting Nova against financial loss associated with the delivery of healthcare

Establishing outreach programs to encourage the use of preventive health services by Nova's members of these activities, the ones that are more likely to be the responsibility of Nova's risk management department rather than its medical management department are activities:

A, B, and C

A, C, and D

A and C

Answer

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