- (Topic 2)
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.
Canyon used a process measure to evaluate the performance of Dr. Enberg when it evaluated whether:

1. A. D
2. B. Enberg's young patients receive appropriate immunizations at the right ages
3. C. D
4. D. Enberg's young patients receive appropriate immunizations at the right ages
5. E. The condition of one of D
6. F. Enberg's patients improved after the patient received medical treatment from D
7. G. Enberg
8. H. D
9. I. Enberg's procedures are adequate for ensuring patients' access to medical care

Correct Answer: A

- (Topic 1)
To protect providers against business losses, many health plan-provider contracts include carve-out provisions to help providers manage financial risk. The following statements are examples of such provisions:
The Apex Health Plan carves out immunizations from PCP capitations. Apex compensates PCPs for immunizations on a case rate basis.
The Bengal Health Plan carves out behavioral healthcare services from the scope of PCP services because these services require specialized knowledge and skills that most PCPs do not possess.
From the answer choices below, select the response that best identifies the types of carve- outs used by Apex and Bengal.

1. A. Apex: disease-specific carve-out Bengal: specialty services carve-out
2. B. Apex: disease-specific carve-out Bengal: specific-service carve-out
3. C. Apex: specific-service carve-out Bengal: specialty services carve-out
4. D. Apex: specific-service carve-out Bengal: disease-specific carve-out

Correct Answer: C

- (Topic 2)
The following statements are about Medicaid health plan entities. Select the answer choice containing the correct statement:

1. A. To keep Medicaid enrollment costs as low as possible, states typically prohibit the use of third-party entities known as enrollment brokers to handle the recruitment and enrollment of Medicaid recipients in health plan plans
2. B. Primary care case managers (PCCMs) are individuals who contract with a state's Medicaid agency to provide primary care services mainly to urban areas.
3. C. Typically, Medicaid beneficiaries must be given a choice between at least two health plan entities.
4. D. Medicaid health plan entities are responsible for providing primary coverage for all dually-eligible beneficiaries.

Correct Answer: C

- (Topic 1)
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. A credentials verification organization (CVO) can be certified to verify certain pertinent credentialing information, including

1. A. Liability claims histories of prospective providers
2. B. Hospital privileges of prospective providers
3. C. Malpractice insurance on prospective providers
4. D. All of the above

Correct Answer: D

- (Topic 2)
The actual number of providers included in a provider network can be based on staffing ratios. One true statement about staffing ratios is that, typically:

1. A. A small health plan needs fewer physicians per 1,000 than does a large plan.
2. B. A closely managed health plan requires fewer providers than does a loosely managedplan.
3. C. Physician-to-enrollee ratios can be used directly only by network-within-a-network model HMOs.
4. D. Medicare products require fewer providers than do employer-sponsored plans of the same size.

Correct Answer: B