- (Topic 1)
The following statements can correctly be made about the advantages and disadvantages to an health plan of using the various delivery options for pharmacy services.

1. A. A disadvantage of using open pharmacy networks is that the health plan’s control over costs is limited to setting reimbursement levels.
2. B. An advantage of using performance-based systems is that they tend to increase participation in the health plan’s pharmacy network.
3. C. A disadvantage of using customized pharmacy networks is that these networks typically can be implemented only in companies with fewer than 500 employees.
4. D. All of these statements are correct.

Correct Answer: A

- (Topic 2)
The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:

1. A. Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
2. B. Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
3. C. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
4. D. Provides the employees with 24-hour coverage.

Correct Answer: C

- (Topic 1)
The following statements are about some of the issues surrounding the contractual responsibilities of health plans. Select the answer choice containing the correct statement.

1. A. Typically, health plans are required to pay completed claims within 10 days of submission.
2. B. Health plans typically are prohibited from examining the financial soundness of a self- funded employer plan that relies on the health plan to pay providers for services received by the plan’s members.
3. C. Patient delivery is one of the most significant factors that health plans consider when determining whether provider services should be reimbursed on a capitated or fee-for- service (FFS) basis.
4. D. Health plans require all providers to agree to an exclusive provider contract.

Correct Answer: C

- (Topic 1)
Open panel health plans can contract with individual providers or with various provider groups when developing their networks. The following statements are about factors that an open panel health plan might consider in contracting with different types of provider organizations. Select the answer choice that contains the correct statement.

1. A. One limitation of contracting with multispecialty groups is that a health plan obtains only specialty consultants, but not PCPs.
2. B. One benefit to a health plan in contracting with an integrated delivery system (IDS) is the ability to have a network in rapid order and to enter into a new market or one that is already competitive.
3. C. A health plan that contracts with an individual practice association (IPA) has a greater ability to select and deselect individual physicians than when contracting directly with the providers.
4. D. A health plan that contracts with an IDS is able to eliminate the antitrust risk that exists when contracting with an IPA.

Correct Answer: B

- (Topic 1)
The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon’s network providers to

1. A. Agree not to sue or file claims against an Octagon plan member for covered services
2. B. Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider’s actions
3. C. Maintain the confidentiality of the health plan’s proprietary information
4. D. Agree to accept Octagon’s payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles

Correct Answer: B