QUESTION: 5

Network managers rely on a health plan's claims administration department for much of the information needed to manage the performance of providers who are not under a capitation arrangement. Examining claims submitted to a health plan's claims administration department enables the health plan to

determine the number of healthcare services delivered to plan members
monitor the types of services provided by the health plan's entire provider network
evaluate providers' practice patterns and compliance with the health plan's procedures for the delivery of care
all of the above

Answer(s): D

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QUESTION: 6

The Avignon Company discontinued its contract with a traditional indemnity insurer and contracted exclusively with the Minaret Health Plan to provide the sole healthcare plan to Avignon's employees. By agreeing to an exclusive contract with Minaret, Avignon has entered into a type of healthcare contract known as

a carrier guarantee arrangement
open access
total replacement coverage
selective contract coverage

Answer(s): C

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QUESTION: 7

Federal laws--including the Ethics in Patient Referrals Act, the Health Maintenance Organization (HMO) Act of 1973, the Employee Retirement Income Security Act (ERISA), and the Federal Trade Commission Act--have impacted the ways that health plans conduct business. For instance, the Mosaic Health Plan must comply with the following federal laws in order to operate:

Regulation 1: Mosaic must establish a mandated grievance resolution mechanism, including a method for members to address grievances with network providers.

Regulation 2: Mosaic must not allow its providers to refer Medicare and Medicaid patients to entities in which they have a financial or ownership interest.

From the answer choices below, select the response that correctly identifies the federal legislation on which Regulation 1 and Regulation 2 are based.

Regulation 1 - The Ethics in Patient Referrals Act Regulation 2 - The HMO Act of 1973
Regulation 1 - The HMO Act of 1973 Regulation 2 - The Ethics in Patient Referrals Act
Regulation 1 - ERISA Regulation 2 - The Federal Trade Commission Act
Regulation 1 - The Federal Trade Commission Act Regulation 2 - ERISA

Answer(s): B

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QUESTION: 8

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

Applies to group health insurance plans only
Limits the length of a health plan's pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment.
Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.
Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Answer(s): C

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