AHIP AHM-530 Dumps PDF Free Download - Page: 6

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 evelopment, 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.

Both 1 and 2
Neither 1 nor 2
1 Only
2 Only

Answer(s): D

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QUESTION: 27

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

Answer(s): D

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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

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

Answer(s): D

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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

require incorporated HMOs to practice medicine through licensed employees
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
restrict the ability of staff model HMOs to hire physicians directly, unless the physicians own the HMO
encourage incorporated HMOs to obtain profits from their provisions of physician professional services

Answer(s): C

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QUESTION: 30

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

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

Answer(s): B

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QUESTION: 26

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QUESTION: 30