- (Topic 1)
The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
One statement that can correctly be made about Gardenia’s two-level POS product is that

1. A. members who self-refer without first seeing their PCPs will receive no benefits
2. B. both Gardenia and the PCPs stand to benefit if the non-provider panels are kept relatively narrow
3. C. members will pay higher coinsurance or copayments if they first see their PCPs each time
4. D. the plan offers no financial incentives to members to choose an in-network specialist over a non-network specialist

Correct Answer: D

- (Topic 1)
The Sweeney Health Plan uses the discounted fee-for-service (DFFS) method to compensate some of its providers. Under this method of compensation, Sweeney calculates payments based on

1. A. The standard fees of indemnity health insurance plans, adjusted by region
2. B. The Medicare fee schedules used by other health plans, adjusted by region
3. C. Whichever amount is higher, the billed charge or the DFFS amount
4. D. Whichever amount is lower, the billed charge or the DFFS amount

Correct Answer: D

- (Topic 2)
Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

1. A. Includes only primary care services
2. B. Covers such services as immunizations and laboratory tests
3. C. Can be used only if the provider's panel size is less than 50 providers
4. D. Covers such services as cardiology and orthopedics

Correct Answer: A

- (Topic 1)
The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.

1. A. When pharmacy benefits management is incorporated into an health plan’s operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations.
2. B. Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members.
3. C. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.
4. D. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.

Correct Answer: C

- (Topic 1)
The Medea Clinic is a network provider for Delphic Healthcare. Delphic transferred the contract it held with Medea to the Elixir HMO, an entity that was not party to the original contract. The process by which Delphic transferred the contract it held with Medea to Elixir is known as

1. A. Most-favored- nation arrangement
2. B. Alimit on action
3. C. Aconsideration
4. D. An assignment

Correct Answer: D