AHIP AHM-250 - Healthcare Management: An Introduction

that it may be a single-specialty or multi-specialty practice

operates in one or a few facilities rather than in many independent offices

achieves economies of scale in the group's integrated operations

all of the above

he can receive coverage for pharmaceuticals only if they are on the PBM plan's preferred list of drugs

he must receive all of his pharmaceuticals from a mail-order pharmacy program

he can receive coverage for pharmaceuticals that are on the PBM plan's preferred list of drugs, as well as for pharmaceuticals that are not on the preferred list

the PBM plan cannot receive a rebate on any pharmaceuticals it obtains from the pharmaceutical facture

specified dollar amount charge that a plan member must pay out-of-pocket for a specified medical service at the time the service is rendered

percentage of the fees for medical services that a plan member must pay after Magellan has paid its share of the costs of those services

flat amount that a plan member must pay each year before Magellan will make any benefit payments on behalf of the plan member

specified payment for services that was negotiated between the provider and Magellan

can exclude coverage for treatment of Ms. Gupta's diabetes for one year, because she did not have at least two years of creditable coverage under her previous health plan

cannot exclude Ms. Gupta's diabetes as a pre-existing condition, because the one-year pre-existing condition provision is offset by at least one year of continuous coverage under her previous health plan

can exclude coverage for treatment of Ms. Gupta's diabetes for one year, because HIPAA does not impact a group health plan's pre-existing condition provision

can exclude coverage for treatment of Ms. Gupta's diabetes for four months, because that is the length of time she received treatment for this medical condition prior to her enrollment in the new health plan

PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipients.

All Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs.

PCCMs receive a case management fee in addition to reimbursement for medical services on a FFS basis.

PCCMs contract directly with the federal government to provide case management services to Medicaid recipients.

Individuals enrolled in a MA plan must enroll in a stand-alone Part D prescription drug plan.

Individuals enrolled in a MA plan do not have to be eligible for Medicare Part A

Individuals enrolled in an MSA plan or a PFFS plan without Medicare drug coverage can enroll in Medicare Part D.

Individuals can enroll in MA plan in multiple regions.

all health plans, healthcare providers, and healthcare clearinghouses from using any protected health information for purposes of treatment, payment, or healthcare operations without an individual's written consent

patients from requesting that restrictions be placed on the accessibility and use of protected health information

transmission of individually identifiable health information for purposes other than treatment, payment, or healthcare operations without the individual's written authorization

patients from accessing their medical records and requesting the amendment of incorrect or incomplete information

$1,750

$1,800

$2,000

$2,250

fixed amount in advance for each medical service the member receives

a small fee such as $10 or $15 that a member pays at the time of an office visit to a network provider

a fixed, monthly premium paid in advance of the delivery of medical care that covers most healthcare services that a member might need, no matter how often the member uses medical services

specified amount of the member's medical expenses before any benefits are paid by the HMO