Question 1

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 2

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

Options :

A : Encouraging patients to switch from one health plan to another

B : Disclosing confidential information about the health plan’s reimbursement structure

C : Dispersing confidential financial information regarding the health plan

D : Discussing alternative treatment plans with patients

Answer: A

Question 3

In health plan pharmacy networks, service costs consist of two components: costs for services associated with dispensing prescription drugs and costs for cognitive services. Cognitive services typically include:

Options :

A : making generic substitutions of drugs

B : counseling patients about prescriptions

C : providing patient monitoring

D : switching prescription drugs to preferred drugs

Answer: B

Question 4

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

Options :

A : A statement that identifies the purpose of the contract

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

C :

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:

D : A, B, and C

E : A and B only

F : A and C only

G : B and C only

Answer: A

Question 5

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

Options :

A : Acase mix/severity adjustment

B : An external performance standard

C : Structural measures

D : Behavior modification

Answer: A

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