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質問 1：
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. 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
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. Always qualifies as a material change in the plan, and Greenpath must report the change to all plan enrollees
正解：A
質問 2：
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 providernetwork. 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: at least every three years
D. Type of examination: target; Required frequency: annually
正解：B
質問 3：
SoundCare Health Services, a health plan, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detectingviolations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.
By definition, the activity that SoundCare conducted when it examined its strengths, weaknesses, and capabilities is known as
A. An environmental forecast
B. A community analysis
C. An environmental analysis
D. An internal assessment
正解：D
質問 4：
One federal law amended the Social Security Act to allow states to set their own qualification standards for HMOs that contracted with state Medicaid programs and revised the requirement that participating HMOs have an enrollment mix of no more than 50% combined Medicare and Medicaid members.
This act, which was the true stimulus for increasing participation by health plans in Medicaid, is called the
A. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
B. Employee Retirement Income Security Act of 1974 (ERISA)
C. Omnibus Budget Reconciliation Act of 1981 (OBRA-81)
D. Federal Employees Health Benefits Act of 1958 (FEHB Act)
正解：C
質問 5：
SoundCare Health Services, a health plan, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detectingviolations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.
With respect to the Federal Sentencing Guidelines, actions that SoundCare should take in developing its compliance program include
A. All of the above
B. Assigning a high-level member of management to the position of compliance coordinator or administrator
C. Creating a system through which employees and other agents can report suspected misconduct without fear of retribution
D. Holding management accountable for the misconduct of their subordinates
正解：A
質問 6：
The following statements are about market conduct examinations of health plans. Select the answer choice that contains the correct statement.
A. Multistate examinations are not appropriate for financial examinations, because regulatory requirements concerning a health plan's financial condition tend to vary from state to state.
B. Market conduct examinations of a health plan's advertising and sales materials include comparing the advertising materials to the policies they advertise.
C. Once an examination report is provided to the state insurance department, a health plan is not given an opportunity to present a formal objection to the report.
D. In imposing sanctions on health plans, state insurance departments are required to follow federal sentencing guidelines.
正解：B
質問 7：
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 officer of Verity
D. Applications solicited by Ms. Pensky must be signed by an individual who holds a resident License
正解：D
質問 8：
Determine whether the following statement is true or false:
Although most-favored-nation (MFN) clauses in contracts between health plans and healthcare providers are not per se illegal, they should be reviewed under the rule of reason analysis for antitrust purposes.
A. True, because the Federal Trade Commission (FTC) ruled that MFN clauses are not per se illegal and the FTC encourages health plans to include them in provider contracts.
B. True, because although MFN clauses are not per se illegal, they violate antitrust laws if they have a predatory purpose and an anticompetitive effect.
C. False, because MFN clauses are not per se illegal, and thus they are exempt from antitrust laws and regulation by the FTC.
D. False, because MFN clauses involve decisions by providers concerning the level of fees to charge, and thus they are per se illegal.
正解：B
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. 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
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. Always qualifies as a material change in the plan, and Greenpath must report the change to all plan enrollees
正解：A
質問 2：
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 providernetwork. 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: at least every three years
D. Type of examination: target; Required frequency: annually
正解：B
質問 3：
SoundCare Health Services, a health plan, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detectingviolations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.
By definition, the activity that SoundCare conducted when it examined its strengths, weaknesses, and capabilities is known as
A. An environmental forecast
B. A community analysis
C. An environmental analysis
D. An internal assessment
正解：D
質問 4：
One federal law amended the Social Security Act to allow states to set their own qualification standards for HMOs that contracted with state Medicaid programs and revised the requirement that participating HMOs have an enrollment mix of no more than 50% combined Medicare and Medicaid members.
This act, which was the true stimulus for increasing participation by health plans in Medicaid, is called the
A. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
B. Employee Retirement Income Security Act of 1974 (ERISA)
C. Omnibus Budget Reconciliation Act of 1981 (OBRA-81)
D. Federal Employees Health Benefits Act of 1958 (FEHB Act)
正解：C
質問 5：
SoundCare Health Services, a health plan, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detectingviolations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.
With respect to the Federal Sentencing Guidelines, actions that SoundCare should take in developing its compliance program include
A. All of the above
B. Assigning a high-level member of management to the position of compliance coordinator or administrator
C. Creating a system through which employees and other agents can report suspected misconduct without fear of retribution
D. Holding management accountable for the misconduct of their subordinates
正解：A
質問 6：
The following statements are about market conduct examinations of health plans. Select the answer choice that contains the correct statement.
A. Multistate examinations are not appropriate for financial examinations, because regulatory requirements concerning a health plan's financial condition tend to vary from state to state.
B. Market conduct examinations of a health plan's advertising and sales materials include comparing the advertising materials to the policies they advertise.
C. Once an examination report is provided to the state insurance department, a health plan is not given an opportunity to present a formal objection to the report.
D. In imposing sanctions on health plans, state insurance departments are required to follow federal sentencing guidelines.
正解：B
質問 7：
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 officer of Verity
D. Applications solicited by Ms. Pensky must be signed by an individual who holds a resident License
正解：D
質問 8：
Determine whether the following statement is true or false:
Although most-favored-nation (MFN) clauses in contracts between health plans and healthcare providers are not per se illegal, they should be reviewed under the rule of reason analysis for antitrust purposes.
A. True, because the Federal Trade Commission (FTC) ruled that MFN clauses are not per se illegal and the FTC encourages health plans to include them in provider contracts.
B. True, because although MFN clauses are not per se illegal, they violate antitrust laws if they have a predatory purpose and an anticompetitive effect.
C. False, because MFN clauses are not per se illegal, and thus they are exempt from antitrust laws and regulation by the FTC.
D. False, because MFN clauses involve decisions by providers concerning the level of fees to charge, and thus they are per se illegal.
正解：B
Turuta -
AHM-510問題集はとてもほうふで、なのにわかりやすかったです。今回の試験には受かる気がします。