QUESTION: 25 Exam Topic: 1, Volume A

The provider contract that Dr. Timothy Meyer, a pediatrician, has with the Cardigan health plan states that Cardigan will compensate him under a capitation arrangement. However, the contract also includes a typical low enrollment guarantee provision. Statements that can correctly be made about this arrangement include that the low enrollment guarantee provision most likely:

A Causes Dr. Meyer's capitation contract with Cardigan to transfer more risk to him than the contract otherwise would transfer
B) Specifies that Cardigan will pay Dr. Meyer under an arrangement other than capitation until a specified number of children covered by the plan use him as their PCP

Both A and B
A only
B only
Neither A nor B

Answer(s): C

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QUESTION: 26 Exam Topic: 1, Volume A

One true statement about a type of capitation known as a percent-of-premium arrangement is that this arrangement

Is the most common type of capitation
Is less attractive to providers when the arrangement sets provisions to limit risk
Sets provider reimbursement at a specific dollar amount per plan member
Transfers some of the risk associated with underwriting and rating from a health plan to a provider

Answer(s): D

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QUESTION: 27 Exam Topic: 1, Volume A

The provider contract that Dr. Zachery Cogan, an internist, has with the Neptune Health Plan calls for Neptune to reimburse him under a typical PCP capitation arrangement. Dr. Cogan serves as the PCP for Evelyn Pfeiffer, a Neptune plan member. After hospitalizing Ms. Pfeiffer and ordering several expensive diagnostic tests to determine her condition, Dr. Cogan referred her to a specialist for further treatment. In this situation, the compensation that Dr. Cogan receives under the PCP capitation arrangement most likely includes Neptune's payment for

All of the diagnostic tests that he ordered on Ms. Pfeiffer
His visits to Ms. Pfeiffer while she was hospitalized
The cost of the services that the specialist performed for Ms. Pfeiffer
All of the above

Answer(s): B

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QUESTION: 28 Exam Topic: 1, Volume A

The following statements illustrate common forms of capitation:
1. The Antler Health Plan pays the Epsilon Group, an integrated delivery system (IDS), a capitated amount to provide substantially all of the inpatient and outpatient services that Antler offers. Under this arrangement, Epsilon accepts much of the risk that utilization rates will be higher than expected. Antler retains responsibility for the plan's marketing, enrollment, premium billing, actuarial, underwriting, and member services functions.
2. The Bengal Health Plan pays an independent physician association (IPA) a capitated amount to provide both primary and specialty care to Bengal's plan members. The payments cover all physician services and associated diagnostic tests and laboratory work. The physicians in the IPA determine as a group how the individual physicians will be paid for their services.

From the following answer choices, select the response that best indicates the form of capitation used by Antler and Bengal.

Antler = subcapitation
Bengal = full-risk capitation
Antler = subcapitation
Bengal = full professional capitation
Antler = global capitation
Bengal = subcapitation
Antler = global capitation
Bengal = full professional capitation

Answer(s): D

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QUESTION: 25 Exam Topic: 1, Volume A

QUESTION: 26 Exam Topic: 1, Volume A

QUESTION: 27 Exam Topic: 1, Volume A

QUESTION: 28 Exam Topic: 1, Volume A