- (Topic 3)
Which of the following statements is NOT a requirement for a service to be deemed a 'medically necessary service'?

1. A. Furnished in the least intensive type of medical care setting required by the member's condition.
2. B. Solely for the convenience of the member.
3. C. In accordance with the standards of good medical practice.
4. D. Consistent with the symptoms of the member's condition.

Correct Answer: B

- (Topic 2)
Provider integration has two components: operational integration and structural integration. An example of operational integration in health plans is the:

1. A. Acquisition of the Leopard Health Plan by the Hickory Health Plan.
2. B. Joint venture entered into by the Eclipse Health Plan and a local hospital system to create a new health plan in which Eclipse and the hospital system share ownership.
3. C. Formation of an organization by a group of providers to carry out billing, collections, and contracting with health plans for the entire group of providers.
4. D. Consolidation of the Carver Health Plan and the Limestone Health Plan.

Correct Answer: C

- (Topic 2)
The Citywide Health Group is a large provider-based health plan that includes physician groups, hospitals, and other facilities. In order to oversee and manage the operation of the organization, Citywide has established an enterprise scheduling system. The

1. A. provide information to Citywide's management regarding provider licensure, certification, and malpractice history
2. B. detect instances of overutilization, underutilization, or inappropriate utilization of medical resources
3. C. allow Citywide's different components to function as a single organization in arranging access to facilities and resources
4. D. facilitate the processing of requests for authorization of payment of benefits

Correct Answer: C

- (Topic 2)
One distinguishing characteristic of a health maintenance organization (HMO) is that, typically, an HMO

1. A. arranges for the delivery of medical care and provides, or shares in providing, the financing of that care
2. B. must be organized on a not-for-profit basis
3. C. may be organized as a corporation, a partnership, or any other legal entity
4. D. must be federally qualified in order to conduct business in any state

Correct Answer: A

- (Topic 3)
The NAIC adopted the HMO Model Act in order to provide a system of ongoing regulatory monitoring of HMOs. All of the following statements are correct about the HMO Model Act EXCEPT that it:

1. A. Regulates HMO operations in two critical areas: financial responsibility and healthcare delivery.
2. B. Requires each HMO to send state regulators an annual report describing the HMO's finances and operations.
3. C. Focuses on three key aspects of healthcare delivery: network adequacy, quality assurance, and grievance procedures.
4. D. Requires state insurance departments to conduct annual examinations of an HMO's operations, quality assurance programs, and provider networks.

Correct Answer: D