QUESTION: 13

In the paragraph below, two statements each contain a pair of terms enclosed in parentheses.

Determine which term correctly completes each statement. Then select the answer choice that contains the two terms you have chosen.

In most states, a health plan can be held responsible for a provider's negligent malpractice. This legal concept is known as (vicarious liability / risk sharing). One step that health plans can take to reduce their exposure to malpractice lawsuits is to state in health plan-provider agreements, marketing collateral, and membership literature that the providers are (employees of the health plan / independent contractors).

Vicarious liability / employees of the health plan
Vicarious liability / independent contractors
Risk sharing / employees of the health plan
Risk sharing / independent contractors

Answer(s): B

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QUESTION: 14

The National Committee for Quality Assurance (NCQA) has integrated accreditation with Health Employer Data and Information Set (HEDIS) measures into a program called Accreditation '99. One statement that can correctly be made about these accreditation standards is that

Health plans are required by law to report HEDIS results to NCQA
HEDIS restricts its reporting criteria to a narrow group of quantitative performance measures, while NCQA includes a broad range of qualitative performance measures
Private employer groups purchasing health care coverage increasingly require both NCQA accreditation and HEDIS reporting
HEDIS includes measures of a health plan's effectiveness of care rather than its cost of care

Answer(s): C

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QUESTION: 15

The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to

Hold plan members responsible for unreimbursed charges or unpaid claims
Allow providers to develop their own standards of care
Adhere to specified disclosure requirements related to provider contract termination
File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)

Answer(s): C

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QUESTION: 16

The following statement(s) can correctly be made about the TRICARE managed healthcare program of the U.S. Department of Defense.

1. Active-duty military personnel are automatically enrolled in TRICARE's HMO option (TRICARE Prime).
2. Eligible family members and dependents can enroll in TRICARE Prime, the PPO plan (TRICARE Extra), or an indemnity plan (TRICARE Standard).

Both 1 and 2
1 only
2 only
Neither 1 nor 2

Answer(s): A

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