From the following answer choices, choose the term that best matches the description.
Members of a physician-hospital organization (PHO) denied membership to a physician solely because the physician has admitting privileges at a competing hospital.

• A. Group boycott
• B. Horizontal division of territories
• C. Concerted refusal to admit
• D. Tying arrangements

Grant Pelham is covered by both a workers' compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Because Mr. Pelham was injured on the job, he is entitled to receive benefits through workers' compensation. Under the terms of the state-mandated exclusive remedy doctrine included in the workers' compensation agreement, Mr. Pelham will most likely be prohibited from

• A. Receiving workers' compensation benefits unless he can show that the employer was at fault for his injury
• B. Suing his employer for additional benefits
• C. Obtaining care from providers who are not members of a workers' compensation network
• D. Claiming benefits from both workers' compensation and his group health plan

With respect to contractual provisions related to provider-patient communications, nonsolicitation clauses prohibit providers from

• A. Dispersing confidential financial information regarding the health plan
• B. Discussing alternative treatment plans with patients
• C. Encouraging patients to switch from one health plan to another
• D. Disclosing confidential information about the health plan's reimbursement structure

Edward Patillo has established a Medicare+Choice medical savings account (MSA). This MSA will allow Mr. Patillo to:

• A. Make withdrawals from the MSA to meet qualified medical expenses that are not paid by his high-deductible health insurance policy, but these withdrawals are taxed as income to Mr. Patillo
• B. Make withdrawals at any time from the MSA, but only for medical expenses
• C. Obtain payment at 100% of the Medicare allowable payment for all Medicare-covered services he receives, without having to pay any deductibles or out-of-pocket expenses
• D. Carry over any money remaining in his MSA at the end of the benefit year to the next benefit year

The National Association of Insurance Commissioners (NAIC) Managed Care Plan Network Adequacy Model Act defines specific adequacy and accessibility standards that health plans must meet. In addition, the Model Act requires health plans to

• A. Hold plan members responsible for unreimbursed charges or unpaid claims
• B. File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)
• C. Allow providers to develop their own standards of care
• D. Adhere to specified disclosure requirements related to provider contract termination