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AHM-530 Questions and Answers

Question # 1

Federal lawsâ€”including the Ethics in Patient Referrals Act, the Health Maintenance Organization (HMO) Act of 1973, the Employee Retirement Income Security Act (ERISA), and the Federal Trade Commission Actâ€”have impacted the ways that health plans conduct business. For instance, the Mosaic Health Plan must comply with the following federal laws in order to operate:

Regulation 1: Mosaic must establish a mandated grievance resolution mechanism, including a method for members to address grievances with network providers.

Regulation 2: Mosaic must not allow its providers to refer Medicare and Medicaid patients to entities in which they have a financial or ownership interest.

From the answer choices below, select the response that correctly identifies the federal legislation on which Regulation 1 and Regulation 2 are based.

Regulation 1 - The Ethics in Patient Referrals Act Regulation 2 - The HMO Act of 1973

Regulation 1 - The HMO Act of 1973 Regulation 2 - The Ethics in Patient Referrals Act

Regulation 1 - ERISA Regulation 2 - The Federal Trade Commission Act

Regulation 1 - The Federal Trade Commission Act Regulation 2 - ERISA

Question # 2

Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a planâ€™s

Premium rates

Ability to monitor utilization

Number of primary care providers (PCPs)

Number of specialists and ancillary providers

Question # 3

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

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