Question 1

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

Options :

A : Require Dr. Barlow and Amity to use arbitration to resolve any disputes regarding the contract

B : Specify that the contract is to be governed by the laws of the state in which Amity has its headquarters

C : Require Dr. 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

D : State that the contract creates an employment or agency relationship, rather than an independent contractor relationship, between Dr. Barlow and Amity

Answer: C

Question 2

Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically

Options :

A : Require access to greater numbers of obstetricians and pediatricians

B : Have stronger relationships with primary care providers

C : Are less reliant on emergency rooms as a source of first-line care

D : Need fewer support and ancillary services

Answer: A

Question 3

Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

Options :

A : Specialty IPA

B : Disease management company

C : Single specialty management specialist

D : Specialty network management company

Answer: B

Question 4

The Walnut Health Plan provides a number of specialty services for its members. Walnut offers coverage of alternative healthcare, including coverage of treatment methods such as homeopathy and naturopathy. Walnut also offers home healthcare services, and it contracts with home healthcare providers on a non-risk basis to the health plan. The following statements are about the specialty services offered by Walnut. Select the answer choice containing the correct statement:

Options :

A : Homeopathy treats diseases by using small doses of substances which, in healthy people, are capable of producing symptoms like those of the disease being treated.

B : Naturopathy is an approach to healthcare that uses electronic monitoring devices to teach a patient to develop conscious control of involuntary bodily functions, such as heart rate.

C : Under a non-risk contract, Walnut most likely transfers the responsibility for arranging home healthcare to the home healthcare provider organizations.

D : Federal law allows Walnut to contract with a home healthcare provider organization only if the provider organization has received accreditation by the Utilization Review Accreditation Commission (URAC).

Answer: A

Question 5

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

Options :

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

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