AHIP Governance and Regulation : AHM-510

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. 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.
• C. Market conduct examinations of a health plan's advertising and sales materials include comparing the advertising materials to the policies they advertise.
• D. In imposing sanctions on health plans, state insurance departments are required to follow federal sentencing guidelines.

The National Association of Insurance Commissioners (NAIC) adopted the Health Maintenance Organization Model Act (HMO Model Act) to regulate the development and operations of HMOs. One true statement regarding the HMO Model Act is that the act

• A. includes mental health services in its definition of basic healthcare services
• B. authorizes only one state agency-the department of insurance-to regulate HMOs
• C. requires HMOs to place a deposit in trust with the state insurance commissioner for the purpose of protecting the interests of enrollees should an HMO become financially impaired
• D. requires HMOs that wish to offer a point-of-service (POS) product to contract with a licensed insurance company to provide POS options to plan members

The Balanced Budget Act (BBA) of 1997 created the Medicare+Choice plan. One provision of the BBA under Medicare+Choice is that the BBA

• A. Requires health plans to qualify as either a competitive medical plan (CMP) or a federally qualified HMO in order to participate in the Medicare program
• B. Eliminates funding for demonstration projects such as the Medicare Enrollment Demonstration Project
• C. Increases Graduate Medical Education (GME) payments to hospitals for the training and cost of educating and training residents
• D. Narrows the geographic variations in payments to Medicare health plans by lowering the growth rate of payments in high-payment counties and raising the rates in low-payment counties

Health plans are allowed to appeal rules or regulations that affect them. Generally, the grounds for such appeals are limited either to procedural grounds or jurisdictional grounds. The Kabyle Health Plan appealed the following new regulations:
Appeal 1 - Kabyle objected to this regulation on the ground that this regulation is inconsistent with the law.
Appeal 2 - Kabyle objected to this regulation because it believed that the subject matter was outside the realm of issues that are legal for inclusion in the regulatory agency's regulations.
Appeal 3 - Kabyle objected to the process by which this regulation was adopted.
Of these appeals, the ones that Kabyle appealed on jurisdictional grounds were

• A. Appeals 1 and 2 only
• B. Appeals 1, 2, and 3
• C. Appeals 1 and 3 only
• D. Appeals 2 and 3 only

The board of directors of the Garnet Health Plan, an integrated delivery system (IDS), includes physicians and hospital representatives who sometimes feel compelled to represent a specific organization that is only one part of the IDS. Such a circumstance can lead to ___________, which is a situation in which the members of the board focus on the best interests of component parts of the enterprise rather than on the best interests of Garnet as a whole.

• A. Boundary spanning
• B. Representational governance
• C. Enterprise liability
• D. An enterprise-focused board