Free AHIP AHM-530 Practice Exam with Questions & Answers | Set: 5

performance-based open networks is that they tend to increase participation in the pharmacy network.

closed networks is that they improve the health plan's ability to set standards and implement cost-control programs for pharmacy services.

customized networks is that they typically are inexpensive to operate.

open networks is that they tend to improve the health plan's ability to control pharmaceutical costs.

average cost of services delivered to all patients living in a specified geographic region

actuarial value of the deductible and coinsurance amounts for basic Medicare-covered benefits

fee-for-service amount that the Centers for Medicaid and Medicare Services (CMS) would pay for a Medicare beneficiary, adjusted for age, sex, and institutional status

average fixed monthly fee paid by all Medicare enrollees in a specified geographic region

An encounter report

An external standards report

Aprovider profile

An access to care report

Receives financial assistance from the federal government but not a state government.

Is at a higher risk of operating at a loss than are most other hospitals.

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.

Is eligible for capitation rates that are significantly higher than the FFS average for all covered Medicaid services.

Payments under the reimbursement method typically are not subject to any copayment or deductible requirements

Payments under the reimbursement approach are typically based on a structured reimbursement schedule rather than on usual, customary, and reasonable (UCR) charges

Most major medical plans follow a service approach

Most current health plan prescription drug plans are service plans

A statement that identifies the purpose of the contract

A statement that defines in legal terms the parties to the contract

A statement that identifies the Sailboat products to be covered by the contract

Of these statements, the ones that are likely to be included in the recitals section of Dr. Cartier's contract are statements:

A, B, and C

A and B only

A and C only

B and C only

Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.

Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.

Both A and B

A only

B only

Neither A nor B

PCPs in Elizabethan’s network can make most referrals without obtaining prior authorization from Elizabethan

PCPs in Elizabethan’s network must always refer plan members to other specialists within the network

Elizabethan’s plan members can bypass the PCP and obtain medical services from a specialist without a referral

Elizabethan’s plan members must obtain referrals directly from Elizabethan

most access and adequacy guidelines relate to preferred provider organizations (PPOs) or managed indemnity products

corporate practice of medicine laws require staff model HMOs to hire physicians directly, even if the physicians do not own the HMO

any willing provider laws prevent a health plan from making exclusive or semi-exclusive arrangements with a provider or a group of providers

the NAIC Managed Care Plan Network Adequacy Model Act requires states to use provider-enrollee ratios as the sole measure of network adequacy

Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles.

It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover.

An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers.

In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities.