- (Topic 1)
Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

1. A. $42,857
2. B. $56,700
3. C. $272,160
4. D. $680,400

Correct Answer: C

- (Topic 2)
The provider contract that Dr. Lorena Chau has with the Fiesta Health Plan includes an evergreen clause. The purpose of this clause is to:

1. A. Allow Fiesta to change or amend the contract without D
2. B. Chau's approval as long as the modifications are made in order to comply with new legal and regulatory requirements
3. C. Prohibit D
4. D. Chau from encouraging her patients to switch from Fiesta to another health plan
5. E. Prohibit D
6. F. Chau from encouraging her patients to switch from Fiesta to another health plan
7. G. Assure that D
8. H. Chau provides Fiesta members with healthcare services in a timely manner appropriate to the member's medical condition

Correct Answer: C

- (Topic 2)
Dr. Ahmad Shah and Dr. Shantelle Owen provide primary care services to Medicare+Choice enrollees of health plans under the following physician incentive plans:
Dr. Shah receives $40 per enrollee per month for providing primary care and an additional
$10 per enrollee per month if the cost of referral services falls below a specified level
Dr. Owen receives $30 per enrollee per month for providing primary care and an additional
$15 per enrollee per month if the cost of referral services falls below a specified level The use of a physician incentive plan creates substantial risk for

1. A. Both D
2. B. Shah and D
3. C. Owen
4. D. D
5. E. Shah only
6. F. D
7. G. Owen only
8. H. Neither D
9. I. Shah nor D
10. J. Owen

Correct Answer: C

- (Topic 1)
In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

1. A. Applies to group health insurance plans only
2. B. Limits the length of a health plan’s pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment.
3. C. Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.
4. D. Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Correct Answer: C

- (Topic 2)
The Azure Health Plan strives to ensure for its plan members the best possible level of care from its providers. In order to maintain such high standards, Azure uses a variety of quantitative and qualitative (behavioral) measures to determine the effectiveness of its providers. Azure then compares the clinical and operational practices of its providers with those of other providers outside the network, with the goal of identifying and implementing the practices that lead to the best outcomes.
The comparative method of evaluation that Azure uses to identify and implement the practices that lead to the best outcomes is known as

1. A. Case mix analysis
2. B. Outcomes research
3. C. Benchmarking
4. D. Provider profiling

Correct Answer: C