Question 1

The provider contract that Dr. Nick Mancini has with the Utopia Health Plan includes a clause that requires Utopia to reimburse Dr. Mancini on a fee-for-service (FFS) basis until 100 Utopia members have selected him as their primary care provider (PCP). At that time, Utopia will begin reimbursing him under a capitated arrangement. This clause in Dr. Mancini's provider contract is known as:

Options :

A : an antidisparagement clause

B : a low-enrollment guarantee clause

C : a retroactive enrollment changes clause

D : an eligibility guarantee clause

Answer: B

Question 2

With respect to hiring practices, one step that a health plan most likely can take to avoid violating the terms of the Americans with Disabilities Act (ADA) is to

Options :

A : Require a medical examination prior to accepting an application for employment

B : Include in the employment application questions pertaining to health status

C :

Make a conditional offer of employment, and then require the candidate to have an examination prior to granting specific staff privileges

D : Require applicants to answer questions pertaining to the use of drugs and alcohol

Answer: C

Question 3

Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

Options :

A : Specialty IPA

B : Disease management company

C : Single specialty management specialist

D : Specialty network management company

Answer: B

Question 4

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

Options :

A : Applies to group health insurance plans only

B :

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.

C :

Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.

D :

Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Answer: C

Question 5

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

Options :

A : Encouraging patients to switch from one health plan to another

B : Disclosing confidential information about the health plan’s reimbursement structure

C : Dispersing confidential financial information regarding the health plan

D : Discussing alternative treatment plans with patients

Answer: A

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