QUESTION: 41

Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members. Dr. Ware's provider contract with Riverside contains a typical no-balance billi

prevent Dr. Ware from requiring a Riverside member to pay any coinsurance, copayment, or deductibles that the member would normally pay under Riverside's plan
require Dr. Ware to accept the amount that Riverside pays for medical services as payment in full and not to bill plan members for additional amounts
prevent Dr. Ware from seeking compensation from patients if Riverside fails to compensate him because of the MCO's insolvency
prevent Dr. Ware from billing a Riverside member for medical services that are not included in Riverside's plan

Answer(s): B

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QUESTION: 42

Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:

State that Dr. Aldridge's provider contract with Badger will automatically terminate if he loses his medical license or hospital privileges.
Specify a time period during which the party that breaches the provider contract must remedy the problem in order to avoid termination of the contract.
Give Dr. Aldridge the right to appeal Badger's decision if he is terminated with cause from Badger's provider network.
Specify that Badger can terminate this provider contract without providing a reason, but only if Badger gives Dr. Aldridge at least 90-days' notice of its intent to terminate the contract.

Answer(s): C

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QUESTION: 43

During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, fo

the angina, the high blood pressure, and the broken ankle
the angina and the high blood pressure only
none of these conditions
the broken ankle only

Answer(s): A

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QUESTION: 44

During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a group's geographic location, the size and gender mix of the group, and the level of participation in the grou

Healthcare costs are typically higher in rural areas than in large urban areas.
The morbidity rate for males is higher than the morbidity rate for females.
The larger the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.
All of the above

Answer(s): C

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QUESTION: 44

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