AHIP AHM-250 Free Practice Questions

NEW QUESTION 1

Many HMOs are compensated for the delivery of healthcare to members under a prepaid care arrangement. Under a prepaid care arrangement, a plan member typically pays a

• A. fixed amount in advance for each medical service the member receives
• B. a small fee such as $10 or $15 that a member pays at the time of an office visit to a network provider
• C. a fixed, monthly premium paid in advance of the delivery of medical care that covers most healthcare services that a member might need, no matter how often the member uses medical services
• D. specified amount of the member's medical expenses before any benefits are paid by the HMO

Answer: C

NEW QUESTION 2

HMOs can't medically underwrite any group – incl small groups.

• A. State
• B. Not-for-profit
• C. For-profit
• D. Federally qualified

Answer: B

NEW QUESTION 3

Prescription drug benefits in Medicare can be obtained through:

• A. Stand alone prescription drug pl (PDPs)
• B. Traditional fee for service (FFS) Medicare
• C. Medicare Advantage pl
• D. Both A & C

Answer: A

NEW QUESTION 4

Member satisfaction is a critical element of a health plan's quality management program. A health plan can obtain information about member satisfaction with various aspects of the
health plan from

• A. surveys completed by members following a visit to a provider
• B. surveys sent to plan members who have not received healthcare services during a specified time period
• C. periodic reports of complaints received by member services personnel
• D. all of the above

Answer: D

NEW QUESTION 5

The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive Committee serves as a long-term advisory body on issues

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: B

NEW QUESTION 6

Health plans use the following to determine the number of providers to add to a network:

• A. Staffing ratios
• B. Drive time
• C. Geographic availability
• D. All of the above

Answer: D

NEW QUESTION 7

Exclusive provider organizations (EPO) is similar and operates like a PPO in administration, structure but however in an EPO an out-of-network care is

• A. Partially Covered
• B. Covered with more out of pocket
• C. Not covered

Answer: C

NEW QUESTION 8

The Conquest Corporation contracts with the Apex health plan to provide basic medical
and surgical services to Conquest employees. Conquest entered into a separate contract with the Bright Dental Group to provide and manage a dental care program for employee

• A. a negotiated rebate agreement
• B. a carve-out arrangement
• C. an indemnity plan
• D. PBM

Answer: B

NEW QUESTION 9

An exclusive provider organization (EPO) operates much like a PPO. However, one difference between an EPO and a PPO is that an EPO

• A. Is regulated under federal HMO legislation
• B. Generally provides no benefits for out-of-network care
• C. Has no provider network of physicians
• D. Is not subject to state insurance laws

Answer: B

NEW QUESTION 10

Utilization review offers health plans a means of managing costs by managing

• A. Cost effectiveness of healthcare services.
• B. Cost of paying healthcare benefits.
• C. Both of the above

Answer: C

NEW QUESTION 11

In preparation for its expansion into a new service area, the Regal MCO is meeting with Dr. Nancy Buhner, a cardiologist who practices in Regal's new service area, in order to convince her to become one of the plan's participating providers. As part of the

• A. ensure that D
• B. Buhner complies with all of the provisions of the Ethics in Patient Referrals Act
• C. learn whether D
• D. Buhner is a licensed medical practitioner
• E. confirm D
• F. Buhner's membership in the National Committee for Quality Assurance (NCQA)
• G. learn whether D
• H. Buhner has had a medical malpractice claim filed or other disciplinary actions taken against her

Answer: D

NEW QUESTION 12

Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokers

• A. Are not required to be licensed by the states in which they market health plans
• B. Are compensated on a salary basis
• C. Represent only one health plan or insurer
• D. Are considered to be an agent of the buyer rather than an agent of the health plan or Insurer

Answer: D

NEW QUESTION 13

The Titanium Health Plan and a third-party administrator (TPA) have entered into a TPA agreement with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. One of the TPA's

• A. Hold all funds it receives on behalf of Titanium in trust.
• B. Assume full responsibility for ensuring that the health plan is administered properly
• C. Obtain from the federal government a certificate of authority designating the organization as a TPA.
• D. Assume full responsibility for determining the claim payment procedures for the plan

Answer: A

NEW QUESTION 14

Mr. George Bush is covered by a PBM plan that uses a closed formulary. This indicates that

• A. he can receive coverage for pharmaceuticals only if they are on the PBM plan's preferred list of drugs
• B. he must receive all of his pharmaceuticals from a mail-order pharmacy program
• C. he can receive coverage for pharmaceuticals that are on the PBM plan's preferred list of drugs, as well as for pharmaceuticals that are not on the preferred list
• D. the PBM plan cannot receive a rebate on any pharmaceuticals it obtains from the pharmaceutical facture

Answer: A

NEW QUESTION 15

Which of the following best describes an organization that is owned by a hospital or group of investors and provides management and administrative support services to individual physicians or small group practices?

• A. Independent Practice Association (IPA).
• B. Group Practice Without Walls (GPWW)
• C. Management Services Organization (MSO).
• D. Consolidated Medical Group.

Answer: C

NEW QUESTION 16

Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:

• A. Hospital emergency departments
• B. Physician's offices
• C. Urgent care centersIf these settings are ranked in order of the cost of providing c
• D. A, B, C
• E. A, C, B
• F. B, C, A
• G. C, A, B

Answer: B

NEW QUESTION 17

The Mirror Health Plan uses a form of computer/telephony integration (CTI) to manage telephone calls coming into its member services department. When a member calls the plan's central telephone number, a device answers the call with a recorded message and

• A. a member outreach program
• B. a complaint resolution procedure (CRP)
• C. an automatic call distributor (ACD)
• D. an interactive voice response (IVR) system

Answer: C

NEW QUESTION 18

The process of identifying and classifying the risk represented by an individual or group is called

• A. Rating
• B. Anti selection
• C. Underwriting
• D. None of the above

Answer: C

NEW QUESTION 19

Parable Healthcare Providers, a health plan, recently segmented the market for a new healthcare service. Parable began the process by dividing the healthcare market into two broad categories: non-group and group. Next, Parable further segmented the non-gr

• A. channel segmentation
• B. geographic segmentation
• C. demographic segmentation
• D. product segmentation

Answer: C

NEW QUESTION 20

One feature of the Employee Retirement Income Security Act (ERISA) is that it:

• A. Requires self-funded employee benefit plans to pay premium taxes at the state level.
• B. Contains a pre-emption provision, which typically makes the terms of ERISA take precedence over any state laws that regulate employee welfare benefit plans.
• C. Contains strict reporting and disclosure requirements for all employee benefit plans except health plans.
• D. Requires that state insurance laws apply to all employee benefit plans except insured plans.

Answer: B

NEW QUESTION 21

The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be

• A. Credentialing
• B. Accreditation
• C. A sentinel event
• D. A screening program

Answer: A

NEW QUESTION 22

The Polestar Company's sole business is the ownership of Polaris Medical Group, a health plan and subsidiary of Polestar. Some members of Polestar's board of directors hold positions with Polestar in addition to their positions on the board; the rest are

• A. Polestar's relationship to Polaris: partnership Type of board member: operations director
• B. Polestar's relationship to Polaris: partnership Type of board member: outside director
• C. Polestar's relationship to Polaris: holding company Type of board member: operations director
• D. Polestar's relationship to Polaris: holding company Type of board member: outside director

Answer: D

NEW QUESTION 23

The following statements are about the make-up and function of an HMO's board of
directors.
Select the answer choice that contains the correct statement.

• A. The make-up of an HMO's board of directors is prescribed by state regulations and does not vary according to whether the plan is a for-profit or not-for-profit plan.
• B. The board of directors of a not-for-profit HMO is exempt from liability for its actions.
• C. An HMO's board of directors is not responsible for supervising the performance of its officers and outside advisors.
• D. A primary function of the board of directors is to approve and evaluate the organization's operational policies and procedures.

Answer: D

NEW QUESTION 24

Before the Hill Health Maintenance Organization (HMO) received a certificate of authority (COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the

• A. Receive compensation based on the volume and variety of medical services they perform for Hill plan members, whereas the specialists receive compensation based solely on the number of plan members who are covered for specific services.
• B. Have no financial incentive to practice preventive care or to focus on improving the health of their plan members, whereas the specialists have a positive incentive to help their plan members stay healthy.
• C. Receive from the IPA the same monthly compensation for each Hill plan member under the PCP's care, whereas the specialists receive compensation based on a percentage discount from their normal fees.
• D. Receive compensation based on a fee schedule, whereas the specialists receive compensation based on per diem charges.

Answer: C

NEW QUESTION 25

One characteristic of the accreditation process for MCOs is that

• A. an accrediting agency typically conducts an on-site review of an MCO's operations, but it does not review an MCO's medical records or assess its member service systems
• B. each accrediting organization has its own standards of accreditation
• C. the accrediting process is mandatory for all MCOs
• D. government agencies conduct all accreditation activities for MCOs

Answer: B

NEW QUESTION 26

The following statements are about standards set forth in the Quality Improvement System for Managed Care (QISMC), established by the Health Care Financing Administration (HCFA, now known as the Centers for Medicare and Medicaid Services).

• A. As a result of the Balanced Budget Refinement Act (BBRA), PPOs are required to meet all QISMC quality requirements.
• B. QISMC standards typically do not apply to such Medicare services as mental health or substance abuse services.
• C. Medicaid primary care case manager (PCCM) programs are subject to the same QISMC quality standards and performance measures as are all other Medicare and Medicaid programs.
• D. QISMC standards and guidelines are required for Medicare MCOs, but they are applicable to Medicaid MCOs at the discretion of the individual states.

Answer: D

NEW QUESTION 27

Janet Riva is covered by a traditional indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan.

• A. $1,750
• B. $1,800
• C. $2,000
• D. $2,250

Answer: B

NEW QUESTION 28

The administrative simplification standards described under Title II of HIPAA include
privacy standards to control the use and disclosure of health information. In general, these privacy standards prohibit

• A. all health plans, healthcare providers, and healthcare clearinghouses from using any protected health information for purposes of treatment, payment, or healthcare operations without an individual's written consent
• B. patients from requesting that restrictions be placed on the accessibility and use of protected health information
• C. transmission of individually identifiable health information for purposes other than treatment, payment, or healthcare operations without the individual's written authorization
• D. patients from accessing their medical records and requesting the amendment of incorrect or incomplete information

Answer: D

NEW QUESTION 29

The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On

• A. hold all funds it receives on behalf of Alexander in trust
• B. assume full responsibility for determining the claim payment procedures for the plan
• C. assume full responsibility for ensuring that the health plan is administered properly
• D. obtain from the federal government a certificate of authority designating the Cleopatra Group as a TPA

Answer: A

NEW QUESTION 30

In order to measure the expenses of institutional utilization, Holt Health care group uses standard formula to calculate hospital bed stays per 1000 plan members. On 26 November, Holt uses the following information to:
Calculate the bed days per 1000 members for the MTD Total gross hospital bed days in MTD = 500
Plan membership = 15000
Calculate Holt's number of bed days per 1000 members for the month to date, rounded to the nearest whole number.

• A. 468
• B. 365
• C. 920
• D. 500

Answer: A

NEW QUESTION 31
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