AHM-530

AHM-530 practice questions, page 6 of 8, with answer review and explanations.

Question 26

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. The following statement(s) can correctly be made about Gardenia's establishment of the PPO and the staff model HMO in its new market: 1. When establishing its PPO network, Gardenia most likely initiated outcomes measurement tools and developed collaborative process improvement relationships with providers. 2. To avoid high overhead expenses in the early stages of market development, Gardenia's HMO most likely contracted with specialists and ancillary providers until the plan's membership grew to a sufficient level to justify employing these specialists.

  1. Both 1 and 2
  2. Neither 1 nor 2
  3. 1 only
  4. 2 only

Question 27

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

Question 28

Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans:

  1. Allow members direct access to OB/GYN services
  2. Allow members direct access to prescription drug services
  3. Provide access to Title X family-planning clinics
  4. Provide average office waiting times of no more than 30 minutes for appointments with plan providers

Question 29

Some jurisdictions have enacted corporate practice of medicine laws. One effect that corporate practice of medicine laws have had on HMO provider networks is that these laws typically:

  1. require incorporated HMOs to practice medicine through licensed employees
  2. require HMOs to form exclusive contracts with physician groups who agree to dedicate all or most of their practices to HMO patients in return for a set payment or revenue-sharing
  3. restrict the ability of staff model HMOs to hire physicians directly, unless the physicians own the HMO
  4. encourage incorporated HMOs to obtain profits from their provisions of physician professional services

Question 30

The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of:

  1. Potential providers in a plan's network to the number of individuals in the area to be served by the plan
  2. Providers in a plan's network to the number of enrollees in the plan
  3. Providers outside a plan's network to the number of providers in the plan's network
  4. Support staff in a plan's network to the number of medical practitioners in the plan's network