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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. The contracts between Greenpath and its healthcare providers contain a termination provision known as

1. A. An 'economic credentialing' termination provision
2. B. A 'breach of contract' termination provision
3. C. A 'fair procedure' termination provision
4. D. A 'without cause' termination provision

Correct Answer: D

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

1. 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
2. B. Eliminates funding for demonstration projects such as the Medicare Enrollment Demonstration Project
3. C. 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
4. D. Increases Graduate Medical Education (GME) payments to hospitals for the training and cost of educating and training residents

Correct Answer: C

The government uses various tools within the realm of two broad categories of public policyallocative policies and regulatory policies. In the context of public policy, laws that fall into the
category of allocative policy include

1. A. The Balanced Budget Act (BBA) of 1997
2. B. The Health Insurance Portability and Accountability Act (HIPAA) of 1996
3. C. Laws affecting health plan quality oversight
4. D. Laws specifying procedures for health plan handling of consumer appeals and grievances

Correct Answer: A

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

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

Correct Answer: B

Health maintenance organizations (HMOs) seeking federal qualification under the HMO Act of 1973 and its amendments must meet requirements in four basic operational areas. One operational requirement for qualification is that an HMO must

1. A. Ensure that at least 1/3 of its policy-making body is comprised of HMO members
2. B. Ensure that there is adequate representation of underserved communities on its policy-making body
3. C. Have an ongoing quality assurance program that meets the requirements of the Centers for Medicaid & Medicare Services (CMS), stresses health outcomes, and provides for review by health professionals
4. D. Test, safeguard, and promote quality of care by following detailed programmatic techniques that are explained in CMS's Federally Qualified HMO (FQHMO) Manual

Correct Answer: C