- (Topic 2)
The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

1. A. A statement that identifies the purpose of the contract
2. B. A statement that defines in legal terms the parties to the contract
3. C. A statement that identifies the Sailboat products to be covered by the contractOf these statements, the ones that are likely to be included in the recitals section of D
4. D. Cartier's contract are statements:
5. E. A, B, and C
6. F. A and B only
7. G. A and C only
8. H. B and C only

Correct Answer: A

- (Topic 2)
The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
The clause which specifies that Dr. Enberg cannot sue or file any claims against a Canyon plan member for covered services is known as:

1. A. Atermination with cause clause
2. B. Ahold-harmless clause
3. C. An indemnification clause
4. D. Acorrective action clause

Correct Answer: B

- (Topic 2)
Assume that the national average cost per covered employee for PPO rental networks is
$3 per member per month (PMPM) and that the average monthly healthcare premium PMPM is $300. This information indicates that, if the number of health plan members is 10,000, then the annual network rental cost to the health plan would be:

1. A. $30,000
2. B. $360,000
3. C. $9,000,000
4. D. $12,000,000

Correct Answer: B

- (Topic 2)
With regard to the laws and regulations on access and adequacy of provider networks, it can correctly be stated that:

1. A. most access and adequacy guidelines relate to preferred provider organizations (PPOs) or managed indemnity products
2. B. corporate practice of medicine laws require staff model HMOs to hire physicians directly,even if the physicians do not own the HMO
3. C. any willing provider laws prevent a health plan from making exclusive or semi-exclusive arrangements with a provider or a group of providers
4. D. the NAIC Managed Care Plan Network Adequacy Model Act requires states to use provider-enrollee ratios as the sole measure of network adequacy

Correct Answer: C

- (Topic 2)
The following activities are the responsibility of either the Nova Health Plan's risk management department or its medical management department:

1. A. Protecting Nova's members against harm from medical care
2. B. Improving the overall health status of Nova members by coordinating care across individual episodes of care and the different providers who treat the member
3. C. Protecting Nova against financial loss associated with the delivery of healthcare
4. D. Establishing outreach programs to encourage the use of preventive health services by Nova's members of these activities, the ones that are more likely to be the responsibility of Nova's risk management department rather than its medical management department are activities:
5. E. A, B, and C
6. F. A, C, and D
7. G. A and C
8. H. B and D

Correct Answer: C