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NEW QUESTION 1
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 2
Some health plans qualify as tax-exempt organizations under Sections 501(c)(3) and 501(c)(4) of the Internal Revenue Code. One true statement regarding a health plan that qualifies as a 501(c)(4) social welfare organization, in comparison to a health plan that qualifies as a 501(c)(3) charitable organization, is that a

  • A. 501(c)(4) social welfare organization is allowed to distribute profits for the benefit of individuals,whereas a 501(c)(3) charitable organization can use surplus only for the benefit of the organization, the community, or a charity
  • B. 501(c)(4) social welfare organization can raise operating funds through the sale of tax-exempt bonds, whereas a 501(c)(3) charitable organization does not have this advantage
  • C. 501(c)(4) social welfare organization has less flexibility in determining use of funds for social or political activities than does a 501(c)(3) charitable organization
  • D. 501(c)(4) exemption is easier to obtain than a 501(c)(3) exemption, because 501(c)(4) social welfare organizations are allowed to benefit a comparatively smaller group of individuals

Answer: D

NEW QUESTION 3
The Surrey Medical Supply Company was formed as a limited partnership. In this partnership, Victoria Lewin is one of the limited partners and Oscar Gould is a general partner. This information indicates that, with respect to the typical characteristics of limited partnerships,

  • A. M
  • B. Lewin has more freedom to opt out of the partnership than does M
  • C. Gould
  • D. M
  • E. Lewin has more liability for the debts of Surrey than does M
  • F. Gould
  • G. both M
  • H. Lewin and M
  • I. Gould participate in the day-to-day management of Surrey
  • J. the partnership will continue upon the death of M
  • K. Gould, whereas it will end with the death of M
  • L. Lewin

Answer: A

NEW QUESTION 4
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 5
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 6
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 7
Brighton Health Systems, Inc., a health plan, wants to modify its advertising and marketing materials to avoid liability risk under the principle of ostensible agency. One step that Brighton can take to reduce the likelihood of being liable for provider negligence under the theory of ostensible agency is to

  • A. Guarantee the quality of medical care provided to Brighton members
  • B. Use advertising materials which state that Brighton itself provides healthcare
  • C. Add disclaimers to advertising materials indicating that only physicians and not Brighton make medical decisions
  • D. Use advertising materials to characterize Brighton's role as providing physicians, hospitals, and other healthcare professionals rather than arranging for healthcare.

Answer: C

NEW QUESTION 8
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 9
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 10
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 11
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 12
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. With respect to the type of change that constitutes a material change under the HMO Model Act's disclosure requirements, the termination of one healthcare provider from Greenpath's provider network

  • A. Always qualifies as a material change in the plan, and Greenpath must report the change to all plan enrollees
  • B. Always qualifies as a material change in the plan, and Greenpath must report the change to only those plan enrollees who have received care from the terminated provider
  • C. Qualifies as a material change in the plan only if the provider is a primary care provider, and in such a case Greenpath must report the change to all plan enrollees
  • D. Qualifies as a material change in the plan only if the provider is a primary care provider, and in such a case Greenpath must report the change to only those plan enrollees who receive primary care from the terminated provider

Answer: D

NEW QUESTION 13
The Department of Health and Human Services (HHS) has delegated its responsibility for development and oversight of regulations under the Health Insurance Portability and Accountability Act (HIPAA) to an office within the Centers for Medicaid & Medicare Services (CMS). The CMS office that is responsible for enforcing the federal requirements of HIPAA is the

  • A. Center for Health Plans and Providers (CHPPs)
  • B. Center for Medicaid and State Operations
  • C. Center for Beneficiary Services
  • D. Center for Managed Care

Answer: B

NEW QUESTION 14
The following statements appear in the Twilight Health Plan's strategic plan:
Increase the percentage of preventive health interventions for total eligible membership during each of the next three calendar years for the following services: mammography, Pap smears, immunizations, and first trimester visits for prenatal mothers
Improve customer satisfaction on an annual basis for each of the next three calendar years, as measured by satisfaction surveys for members, providers, and employer groups
Increase by 30% the number of claims processed by the automated claim payment system and reduce by 10% the cost of paying claims during the next three years
These statements are examples of Twilight's

  • A. Corporate objectives
  • B. Company mission
  • C. Company vision
  • D. Corporate strategies

Answer: A

NEW QUESTION 15
The Wentworth Corporation uses a self-funded plan to provide its employees with healthcare
benefits. One consequence of Wentworth's approach to providing healthcare benefits is that selffunding

  • A. Requires that Wentworth self-administer its healthcare benefit plan
  • B. Requires that Wentworth pay higher state premium taxes than do insurers and health plans
  • C. Eliminates the need for Wentworth to pay a risk charge to an insurer or health plan
  • D. Increases the number of benefit and rating mandates that apply to Wentworth's plan

Answer: C

NEW QUESTION 16
Congress enacted three clauses relating to the preemptive effect of the Employee Retirement Income Security Act of 1974 (ERISA). One of these clauses preserves from ERISA preemption any state law that regulates insurance, banking, or securities, with the exception of the exemption for self-funded employee benefit plans. This clause is called the

  • A. Savings clause
  • B. Preemption clause
  • C. Deemer clause
  • D. De novo clause

Answer: A

Explanation:
The savings clause preserves from preemption any state law that regulates insurance, banking or securities except as provided by the deemer clause.

NEW QUESTION 17
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