The Following Statements Describe Two Types of HMOs: the Elm

question 61

Multiple Choice

The following statements describe two types of HMOs: The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP. The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO. Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management. Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits: The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug. The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug. The following statements can correctly be made about the reimbursement for Drugs A and B under the MAC pricing system:

• A) Treble most likely is obligated to reimburse Manor 14 cents per tablet for Drug A.
• B) Manor most likely is allowed to bill the subscriber 2 cents per tablet for Drug A.
• C) Treble most likely is obligated to reimburse Manor 5 cents per tablet for Drug B.
• D) All of the above statements are correct.

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Definitions:

Highest Bidder

Refers to the individual or entity that offers the most amount of money for an item or service in an auction or bidding process.

Land

Natural resources used to produce goods and services.

Amount of Land

The quantity or measure of land available, often discussed in the context of its use for agriculture, development, conservation, or other purposes.

Variable

An element, feature, or factor that is liable to vary or change, often used in statistical or mathematical models to represent data or conditions.