AHIP AHM-530 Free Practice Questions

NEW QUESTION 1

In contracting with providers, a health plan can use a closed panel or open panel approach. One statement that can correctly be made about an open panel health plan is that the participating providers

• A. must be employees of the health plan, rather than independent contractors
• B. are prohibited from seeing patients who are members of other health plans
• C. typically operate out of their own offices
• D. operate according to their own standards of care, rather than standards of care established by the health plan

Answer: C

NEW QUESTION 2

Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans

• A. Allow members direct access to OB/GYN services
• B. Allow members direct access to prescription drug services
• C. Provide access to Title X family-planning clinics
• D. Provide average office waiting times of no more than 30 minutes for appointments with plan providers

Answer: D

NEW QUESTION 3

The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.

• A. When pharmacy benefits management is incorporated into an health plan’s operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations.
• B. Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members.
• C. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.
• D. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.

Answer: C

NEW QUESTION 4

Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically

• A. Require access to greater numbers of obstetricians and pediatricians
• B. Have stronger relationships with primary care providers
• C. Are less reliant on emergency rooms as a source of first-line care
• D. Need fewer support and ancillary services

Answer: A

NEW QUESTION 5

State Medicaid agencies can contract with health plans through open contracting or selective contracting. One advantage of selective contracting is that it

• A. Allows enrollees to choose from among a greater variety of health plans
• B. Reduces the competition among health plans
• C. Increases the ability of new, local plans to participate in Medicaid programs
• D. Encourages the development of products that offer enhanced benefits and more effective approaches to health plans

Answer: D

NEW QUESTION 6

The following statements are about the delegation of network management activities from a health plan to another party. Three of the statements are true and one statement is false. Select the answer choice containing the FALSE statement:

• A. The NCQA requires a health plan to conduct all delegation oversight functions rather than delegating the responsibility for oversight to another entity.
• B. Credentialing and UM activities are the most frequently delegated functions, whereas delegation is less common for quality management (QM) and preventive health services.
• C. One reason that a health plan may choose to delegate a function is because the health plan's staff seeks external expertise for the delegated activity.
• D. When the health plan delegates authority for a function, it transfers the power to conduct the function on a day-to-day basis, as well as the ultimate accountability for the function.

Answer: D

NEW QUESTION 7

From the following answer choices, choose the type of clause or provision described in this situation.
The Aviary Health Plan includes in its provider contracts a clause or provision that places the ultimate responsibility for an Aviary plan member’s medical care on the provider.

• A. Cure provision
• B. Hold-harmless provision
• C. Evergreen clause
• D. Exculpation clause

Answer: D

NEW QUESTION 8

From the following answer choices, choose the term that best matches the description.
An integrated delivery system (IDS), which controls most providers in a particular specialty, agrees to provide that specialty service to a health plan only on thecondition that the health planagree to contract with the IDS for other services.

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

Answer: C

NEW QUESTION 9

As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must

• A. Allow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider
• B. Base a provider’s participation in the network, reimbursement, and indemnification levels on the provider’s license or certification
• C. Define its service area according to community patterns of care
• D. Require enrollees to obtain prior authorization for all emergency or urgently needed services

Answer: C

NEW QUESTION 10

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. Allow providers to develop their own standards of care
• C. Adhere to specified disclosure requirements related to provider contract termination
• D. File written access plans and sample contracts with the Centers for Medicaid and Medicare Services (CMS)

Answer: C

NEW QUESTION 11

The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:

• A. Must provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits
• B. Does not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO
• C. Receives a payment that is based on reasonable costs and reasonable charges
• D. Most likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care

Answer: A

NEW QUESTION 12

Salvatore Arris is a member of the Crescent Health Plan, which provides its members with a full range of medical services through its provider network. After suffering from debilitating headaches for several days, Mr. Arris made an appointment to see Neal Prater, a physician’s assistant in the Crescent network who provides primary care under the supervision of physician Dr. Anne Hunt. Mr. Prater referred Mr. Arris to Dr. Ginger Chen, an ophthalmologist, who determined that Mr. Arris’ symptoms were indicative of migraine headaches. Dr. Chen prescribed medicine for Mr. Arris, and Mr. Arris had the prescription filled at a pharmacy with which Crescent has contracted. The pharmacist, Steven Tucker, advised Mr. Arris to take the medicine with food or milk. In this situation, the person who functioned as an ancillary service provider is

• A. M
• B. Prater
• C. D
• D. Hunt
• E. D
• F. Chen
• G. M
• H. Tucker

Answer: D

NEW QUESTION 13

Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

• A. $42,857
• B. $56,700
• C. $272,160
• D. $680,400

Answer: C

NEW QUESTION 14

The following statements can correctly be made about the advantages and disadvantages to an health plan of using the various delivery options for pharmacy services.

• A. A disadvantage of using open pharmacy networks is that the health plan’s control over costs is limited to setting reimbursement levels.
• B. An advantage of using performance-based systems is that they tend to increase participation in the health plan’s pharmacy network.
• C. A disadvantage of using customized pharmacy networks is that these networks typically can be implemented only in companies with fewer than 500 employees.
• D. All of these statements are correct.

Answer: A

NEW QUESTION 15

If a third party is responsible for injuries to a plan member of the Hope Health Plan, then Hope has a contractual right to file a claim for the resulting healthcare costs against the third party. This contractual right to recovery from the third party is known as

• A. Subrogation
• B. Partial capitation
• C. Coordination of benefits
• D. Aremedy provision

Answer: A

NEW QUESTION 16

Promise, Inc., a corporation that specializes in cancer services, employs its physicians and support staff and provides facilities and ancillary services for cancer patients. Promise has contracted with the Cordelia Health Plan to provide all specialty services for Cordelia plan members who are undergoing cancer treatment. In return, Promise receives a capitated amount from Cordelia. Promise is an example of a type of specialty services organization known as a

• A. Specialty IPA
• B. Disease management company
• C. Single specialty management specialist
• D. Specialty network management company

Answer: B

NEW QUESTION 17

The Medea Clinic is a network provider for Delphic Healthcare. Delphic transferred the contract it held with Medea to the Elixir HMO, an entity that was not party to the original contract. The process by which Delphic transferred the contract it held with Medea to Elixir is known as

• A. Most-favored- nation arrangement
• B. Alimit on action
• C. Aconsideration
• D. An assignment

Answer: D

NEW QUESTION 18
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