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NEW QUESTION 1
In examining accountability in the current managed care environment, one is likely to find that combinations of various models of accountability are in operation. Under one model of accountability, the primary mechanisms for accountability are the mechanisms of the marketplace- failure to meet standards will result in a loss of demand for services. By definition, this model of accountability is called the

  • A. Professional model of accountability
  • B. Political model of accountability
  • C. Due diligence model of accountability
  • D. Economic model of accountability

Answer: D

NEW QUESTION 2
States may impose nominal deductibles, coinsurance, or copayments on some Medicaid recipients for certain services. Services for which states can require copayments from Medicaid recipients include:

  • A. Emergency services
  • B. Family planning services
  • C. Both A and B
  • D. A only
  • E. B only
  • F. Neither A nor B

Answer: D

NEW QUESTION 3
In 1994, the Department of Justice (DOJ) and the Federal Trade Commission (FTC) revised their 1993 healthcare-specific antitrust guidelines to include analytical principles relating to multiprovider networks. Under the new guidelines, the regulatory agencies will use the rule of reason to analyze joint pricing activities by competitors in physician or multiprovider networks only if

  • A. Provider integration under the network is likely to produce significant efficiencies that benefit consumers
  • B. The providers in a network share substantial financial risk
  • C. The combining of providers into a joint venture enables the providers to offer a new product
  • D. All of the above

Answer: A

NEW QUESTION 4
One provision of the Mental Health Parity Act of 1996 (MHPA) is that the MHPA prohibits group health plans from

  • A. Setting a cap for a group member's lifetime medical health benefits that is higher than the cap for the member's lifetime mental health benefits
  • B. Imposing limits on the number of days or visits for mental health treatment
  • C. Charging deductibles for mental health benefits that are higher than the deductibles for medical benefits
  • D. Imposing annual limits on the number of outpatient visits and inpatient hospital stays for mental health services

Answer: A

NEW QUESTION 5
The Tidewater Life and Health Insurance Company is owned by its policy owners, who are entitled to certain rights as owners of the company, and it issues both participating and nonparticipating insurance policies. Tidewater is considering converting to the type of company that is owned by individuals who purchase shares of the company's stock. Tidewater is incorporated under the laws of Illinois, but it conducts business in the Canadian provinces of Ontario and Manitoba.
Tidewater established the Diversified Corporation, which then acquired various subsidiary firms that produce unrelated products and services. Tidewater remains an independent corporation and continues to own Diversified and the subsidiaries. In order to create and maintain a common vision and goals among the subsidiaries, the management of Diversified makes decisions about strategic planning and budgeting for each of the businesses.
Tidewater's participating policy owners have the right to

  • A. Elect the board of directors on the basis of one vote per policy owner
  • B. Elect the board of directors on the basis of one vote for each policy a person owns
  • C. Participate in developing a corporate mission statement and strategic plans
  • D. Receive stock dividends for each policy they own

Answer: A

NEW QUESTION 6
Regulators of health plans have set standards in a number of areas of plan operations. Requirements with which health plans must comply typically include

  • A. providing enrollees and prospective enrollees with detailed information about various aspects of health plan policies and operations
  • B. maintaining internal grievance and appeals processes to resolve enrollee complaints against the organization
  • C. maintaining quality assurance programs that reflect the plan's activities in monitoring quality
  • D. all of the above

Answer: D

NEW QUESTION 7
From the following answer choices, choose the term that best corresponds to this description. Barrington Health Services, Inc. contracts with a state Medicaid agency as a fiscal intermediary. Barrington does not provide medical services, but contracts with medical providers on behalf of the state Medicaid agency.

  • A. Health insuring organization (HIO)
  • B. Independent practice association (IPA)
  • C. Physician practice management (PPM) company
  • D. Peer review organization (PRO)

Answer: A

NEW QUESTION 8
The following statements are about the Federal Employees Health Benefits Program (FEHBP), which is administered by the Office of Personnel Management (OPM). Three of the statements are true and one statement is false. Select the answer choice that contains the FALSE statement.

  • A. For every plan in the FEHBP, OPM annually determines the lowest premium that is actuarially sound and then negotiates with each plan to establish that premium rate.
  • B. Once a health plan has submitted its rate proposals for a contract year to the OPM, it cannot adjust its premium rate for any reason.
  • C. To cover its administrative costs, OPM sets aside 1% of all FEHBP premiums.
  • D. Each spring, OPM sends all plan providers its call letter, a document that specifies the kinds of benefits that must be available to plan participants and cost goals and procedural changes that the plans need to adopt.

Answer: A

NEW QUESTION 9
The following answer choices describe various approaches that a health plan can take to voice its opinions on legislation. Select the answer choice that best describes a health plan's use of grassroots lobbying.

  • A. The Delancey Health Plan is launching a media campaign in an effort to persuade the public that proposed health care legislation will increase the cost of healthcare.
  • B. The Stellar Health Plan is using direct mail and telephone calls to encourage people who support a patient rights bill to contact key legislators and voice their support for the bill.
  • C. The Bestway Health Plan is encouraging its employees to contribute to a political action committee (PAC) that is funding the political campaign of a pro-health plan candidate.
  • D. A representative of the Palmer Health Plan is attending a one-on-one meeting with a legislator to present Palmer's position on pending managed care legislation.

Answer: B

NEW QUESTION 10
One example of health plan's influence on the practice of medicine is that, during the past decade, the focus of healthcare has moved toward , which is designed to reduce the overall need for healthcare services by providing patients with decision-making information.

  • A. Demand management
  • B. Managed competition
  • C. Comprehensive coverage
  • D. Private inurement

Answer: A

NEW QUESTION 11
The National Association of Insurance Commissioners (NAIC) adopted the Health Maintenance Organization Model Act (HMO Model Act) to regulate the development and operations of HMOs. One true statement regarding the HMO Model Act is that the act

  • A. includes mental health services in its definition of basic healthcare services
  • B. authorizes only one state agency-the department of insurance-to regulate HMOs
  • C. requires HMOs to place a deposit in trust with the state insurance commissioner for the purpose of protecting the interests of enrollees should an HMO become financially impaired
  • D. requires HMOs that wish to offer a point-of-service (POS) product to contract with a licensed insurance company to provide POS options to plan members

Answer: C

NEW QUESTION 12
The Good & Well Pharmacy, a Medicaid provider of outpatient drugs, is subject to the prospective drug utilization review (DUR) mandates of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90). One component of prospective DUR is screening. In this context, when Good & Well is involved in the process of screening, the pharmacy is

  • A. Updating a formulary to represent the current clinical judgment of providers and experts in the diagnosis and treatment of disease
  • B. Reviewing patient profiles for the purpose of identifying potential problems
  • C. Consulting directly with prescribers and patients in the planning of drug therapy
  • D. Denying coverage for the off-label use of approved drugs

Answer: B

NEW QUESTION 13
The following statements are about market conduct examinations of health plans. Select the answer choice that contains the correct statement.

  • A. Multistate examinations are not appropriate for financial examinations, because regulatory requirements concerning a health plan's financial condition tend to vary from state to state.
  • B. Market conduct examinations of a health plan's advertising and sales materials include comparing the advertising materials to the policies they advertise.
  • C. Once an examination report is provided to the state insurance department, a health plan is not given an opportunity to present a formal objection to the report.
  • D. In imposing sanctions on health plans, state insurance departments are required to follow federal sentencing guidelines.

Answer: B

NEW QUESTION 14
Certificate of need (CON) laws apply to health plans in a variety of ways, depending upon the state. By definition, CON laws are laws that are designed to

  • A. Regulate the construction, renovation, and acquisition of healthcare facilities as well as the purchase of major medical equipment in a geographical area
  • B. Protect commerce from unlawful restraint of trade, price discrimination, price fixing, reduced competition, and monopolies
  • C. Determine benefit payments when a person is covered by more than one plan, such as two group health plans
  • D. License and regulate health plans that wish to establish and operate an HMO

Answer: A

NEW QUESTION 15
One typical difference between a for-profit health plan's board of directors and a not-for-profit health plan's board of directors is that the directors in a for-profit health plan

  • A. Can serve on the board for a period of no more than ten years, whereas the terms of service fora not-for-profit board's directors are usually unlimited by the director's age or by a preset maximum number of years of service
  • B. Must participate in raising capital for the health plan, whereas a not-for-profit board's directors are prohibited from participating directly in raising capital for the health plan
  • C. Are directly accountable to shareholders, whereas a not-for-profit board's directors are accountable to plan members and the community
  • D. Are not compensated for board participation, whereas a not-for-profit board's directors are compensated for board participation

Answer: C

NEW QUESTION 16
The Hanford Health Plan has delegated the credentialing of its providers to the Sienna Group, a credential verification organization (CVO). If the contract between Hanford and Sienna complies with all of the National Committee for Quality Assurance (NCQA) guidelines for delegation of credentialing, then this contract

  • A. Transfers to Sienna all rights to terminate or suspend individual practitioners or providers in Hanford's provider network
  • B. Describes the process by which Hanford evaluates Sienna's performance in credentialing providers
  • C. Both A and B
  • D. A only
  • E. B only
  • F. Neither A nor B

Answer: C

NEW QUESTION 17
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