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Question # 4

In examining accountability in the current managed care environment, one is likely to find that combinations of various models of accountability are in operation. Under one model of accountability, the primary mechanisms for accountability are the mechanisms of the marketplace-failure to meet standards will result in a loss of demand for services. By definition, this model of accountability is called the

A.

Professional model of accountability

B.

Political model of accountability

C.

Due diligence model of accountability

D.

Economic model of accountability

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Question # 5

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.

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Question # 6

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.

In creating Diversified, Tidewater formed the type of company known as

A.

A mutual holding company

B.

A spin-off company

C.

An upstream holding company

D.

A downstream holding company

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Question # 7

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 self-funding

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

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Question # 8

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

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Question # 9

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

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Question # 10

State X issued a nonresident license to Tamara Pensky, a sales representative of the Verity Health Plan. In doing so, State X imposed a countersignature requirement, which requires that

A.

An officer of Verity sign a written statement which indicates that Verity appoints Ms. Pensky as an agent who is authorized to market Verity's products

B.

An officer of Verity sign a written statement which certifies that Verity has investigated Ms. Pensky's qualifications and background and believes she is trustworthy and competent

C.

Applications solicited by Ms. Pensky must be signed by an individual who holds a resident License

D.

Applications solicited by Ms. Pensky must be signed by an officer of Verity

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Question # 11

Regulators of health plans have set standards in a number of areas of plan operations. Requirements with which health plans must comply typically include

A.

providing enrollees and prospective enrollees with detailed information about various aspects of health plan policies and operations

B.

maintaining internal grievance and appeals processes to resolve enrollee complaints against the organization

C.

maintaining quality assurance programs that reflect the plan's activities in monitoring quality

D.

all of the above

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