NEW QUESTION 1
SoundCare Health Services, a health plan, recently conducted a situation analysis. One step in
this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detecting violations of law. SoundCare decided to remedy this weakness by using the 1991 Federal
Sentencing Guidelines for Organizations as a model for its compliance program.
By definition, the activity that SoundCare conducted when it examined its strengths, weaknesses, and capabilities is known as

• A. An environmental analysis
• B. An internal assessment
• C. An environmental forecast
• D. A community analysis

Answer: B

NEW QUESTION 2
The board of directors of the Garnet Health Plan, an integrated delivery system (IDS), includes
physicians and hospital representatives who sometimes feel compelled to represent a specific organization that is only one part of the IDS. Such a circumstance can lead to , which is a situation in which the members of the board focus on the best interests of component parts of the enterprise rather than on the best interests of Garnet as a whole.

• A. An enterprise-focused board
• B. Representational governance
• C. Enterprise liability
• D. Boundary spanning

Answer: B

NEW QUESTION 3
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 4
Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any
time, without providing any reason for the termination, by giving the other party a specified period of notice.
The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its provider network. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements. The contracts between Greenpath and its healthcare providers contain a termination provision known as

• A. An 'economic credentialing' termination provision
• B. A 'breach of contract' termination provision
• C. A 'fair procedure' termination provision
• D. A 'without cause' termination provision

Answer: D

NEW QUESTION 5
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 6
The government uses various tools within the realm of two broad categories of public policyallocative policies and regulatory policies. In the context of public policy, laws that fall into the
category of allocative policy include

• A. The Balanced Budget Act (BBA) of 1997
• B. The Health Insurance Portability and Accountability Act (HIPAA) of 1996
• C. Laws affecting health plan quality oversight
• D. Laws specifying procedures for health plan handling of consumer appeals and grievances

Answer: A

NEW QUESTION 7
Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in
response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any
time, without providing any reason for the termination, by giving the other party a specified period of notice.
The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its provider network. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements. From the following answer choices, select the response that identifies the type of market conduct examination that is being performed on Greenpath and the frequency with which the HMO Model Act requires state insurance departments to conduct an examination of an HMO's operations.

• A. Type of examination: comprehensive; Required frequency: annually
• B. Type of examination: comprehensive; Required frequency: at least every three years
• C. Type of examination: target; Required frequency: annually
• D. Type of examination: target; Required frequency: at least every three years

Answer: B

NEW QUESTION 8
Indigo Health Plan advertised a specific individual health insurance policy through a direct mail advertisement that provided detailed information about the product. In order to comply with the NAIC Model Rules Governing Advertisements of Accident and Sickness Insurance, Indigo must disclose whether the advertised policy contains any exceptions, reductions, or limitations. Thus, Indigo disclosed in the advertisement that one policy provision limits coverage for dental exams to
$50 per exam and to one exam per calendar year. This information indicates that, with respect to the definitions in the NAIC Model Rules, Indigo's advertisement is an example of an

• A. Invitation to contract, and it discloses a policy provision known as an exception
• B. Invitation to contract, and it discloses a policy provision known as a reduction
• C. Invitation to inquire, and it discloses a policy provision known as an exception
• D. Invitation to inquire, and it discloses a policy provision known as a reduction

Answer: B

NEW QUESTION 9
The Sawgrass Health Center is an institution that trains healthcare professionals and performs various clinical and other types of healthcare-related research. Because Sawgrass receives government funding, it is required to provide medical care for the poor. Of the following types of health plans, Sawgrass can best be described as:

• A. A medical foundation
• B. An academic medical center (AMC)
• C. A healthcare cooperative
• D. A community health center (CHC)

Answer: B

NEW QUESTION 10
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 11
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.
By combining under Diversified a group of businesses that produce unrelated products and by consolidating the management of the businesses, Tidewater has achieved the type(s) of integration known as

• A. Conglomerate integration and operational integration
• B. Horizontal integration and operational integration
• C. Horizontal integration and virtual integration
• D. Conglomerate integration only

Answer: A

NEW QUESTION 12
TRICARE, a military healthcare program, offers eligible beneficiaries three options for healthcare services: TRICARE Prime, TRICARE Extra, and TRICARE Standard. With respect to plan features, both an annual deductible and claims filing requirements must be met, regardless of whether care is delivered by network providers, under

• A. TRICARE Prime and TRICARE Extra only
• B. TRICARE Extra and TRICARE Standard only
• C. TRICARE Standard only
• D. None of these healthcare options

Answer: C

NEW QUESTION 13
In the paragraph below, a statement contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the statement. Then select the answer choice containing the two terms that you have chosen.
Inflation plays a role in the health plan environment by influencing the prices of healthcare services, supplies, and coverage. During an inflationary period, consumers typically have (more / less) purchasing power because the prices of goods and services increase (more / less) quickly than income.

• A. More / more
• B. More / less
• C. Less / more
• D. Less / less

Answer: C

NEW QUESTION 14
Health plans typically divide their costs into medical and administrative expenses. Examples of medical expenses are.

• A. Equipment costs
• B. Salaries and benefits for executives and for all functional areas
• C. Sales and marketing costs
• D. Payments to providers for the delivery of healthcare

Answer: D

NEW QUESTION 15
In the course of doing business, health plans conduct basic corporate transactions. For example, when a health plan engages in the corporate transaction known as aggressive sourcing, the health plan

• A. Chooses to contract with vendors who provide specific functions that would otherwise be performed in-house, such as paying claims
• B. Seeks to obtain the best deals from various vendors for equipment, supplies, and services such as telephones, overnight mail, computer hardware and software, and copy machines
• C. Merges with one or more companies to form an entirely new company
• D. Joins with one or more companies, but retains its autonomy and relies on the other companies to perform specific functions

Answer: B

NEW QUESTION 16
The following statements are about various provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Three of the statements are true and one statement is false. Select the answer choice that contains the FALSE statement.

• A. HIPAA permits group health plans that offer coverage through an HMO to impose affiliation periods during which no benefits or services are provided to a plan member.
• B. HIPAA created a new category of federal healthcare crimes, called federal healthcare offenses that apply to private healthcare plans as well as to federally funded healthcare programs.
• C. One effect of Section 231(h) of HIPAA, which amended the Social Security Act, has been to permit health plans with Medicare contracts to provide enrollees with value-added services such as discounted memberships to health clubs.
• D. HIPAA provides that any fines and penalties recovered through regulatory proceedings to enforce the federal fraud and abuse statutes will be turned over to enforcement agencies to conduct additional investigations.

Answer: C

NEW QUESTION 17
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