- (Topic 2)
Although ambulatory payment classifications (APCs) bear some resemblance to diagnosis- related groups (DRGs), there are significant differences between APCs and DRGs. One of these differences is that APCs:

1. A. typically allow for the assignment of multiple classifications for an outpatient visit
2. B. always apply to a patient's entire hospital stay
3. C. typically serve as a payment system for inpatient services
4. D. typically include reimbursements for professional fees

Correct Answer: A

- (Topic 1)
One reason that an health plan would want to use the actual acquisition cost (AAC) pricing system to calculate its drug costs is that, of the systems commonly used to calculate drug costs, the AAC system

1. A. Provides the lowest level of cost for the health plan
2. B. Most closely represents what pharmacies are actually charged for prescription drugs
3. C. Offers the best control over multiple-source pharmaceutical products
4. D. Is the least expensive pricing system for the health plan to implement

Correct Answer: A

- (Topic 1)
A population’s demographic factors—such as income levels, age, gender, race, and ethnicity—can influence the design of provider networks serving that population. With respect to these demographic factors, it is correct to say that

1. A. higher-income populations have a higher incidence of chronic illnesses than do lowerincome populations
2. B. compared to other groups, young men are more likely to be attached to particular providers
3. C. a population with a high proportion of women typically requires more providers than does a population that is predominantly male
4. D. Health plans should not recognize, in either the design of networks or the evaluation of provider performance, racial and ethnic differences in the member population

Correct Answer: C

- (Topic 1)
The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to

1. A. Hold plan members responsible for unreimbursed charges or unpaid claims
2. B. Allow providers to develop their own standards of care
3. C. Adhere to specified disclosure requirements related to provider contract termination
4. D. File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)

Correct Answer: C

- (Topic 2)
Grant Pelham is covered by both a workers’ compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Mr. Pelham’s group health insurance plan and workers’ compensation both provide benefits to cover expenses incurred as a result of illness or injury. However, unlike traditional group insurance coverage, workers’ compensation

1. A. Provides reimbursement for lost wages
2. B. Requires employees who suffer a work-related illness or injury to obtain care from specified network providers
3. C. Covers all injuries and illnesses, regardless of their cause
4. D. Requires employees to share the cost of treatment through deductible, coinsurance, and benefit limits

Correct Answer: A