AHIP AHIP Certifications AHM-250 Questions & Answers

• Question 151:

  Which of the following is NOT a factor that is used by MCOs to determine which services will undergo utilization review?

  A. Cost per procedure

  B. Concurrent review

  C. Cost of review

  D. Access requirements

  Correct Answer: D

• Question 152:

  Diabetic patients with high glucose levels requiring stabilization following treatment of an acute attack would best be served in an ___________

  A. Emergency Department

  B. Urgent Care Centre

  C. Hospice Care

  D. Observation Care Unit

  Correct Answer: D

• Question 153:

  The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the highest and lowest rates that a health plan charges small groups, to a particular ratio.

  According to the Model Act, for example, if the lowest rate an HMO charges a small group for a given set of medical benefits is $40, then the maximum rate the HMO can charge for the same set of benefits is

  A. $60

  B. $80

  C. $120

  D. $160

  Correct Answer: B

• Question 154:

  Maternity management programs are commonly included in?

  A. Screening Programs

  B. Health promotion Programs

  C. Immunization programs

  Correct Answer: C

• Question 155:

  Health plans often carve out specialty services that have one or more of the following characteristics

  A. A poorly defined patient population

  B. High or increasing costs

  C. Appropriate utilization

  D. All the above

  Correct Answer: B

• Question 156:

  The Koster Company plans to purchase a health plan for its employees from Intuitive HMO. Intuitive will administer the plan and will bear the responsibility of guaranteeing claim payments by paying all incurred covered benefits. Koster will pay for the he

  A. fully funded plan

  B. stop-loss plan

  C. self-pay plan

  D. self-funded plan

  Correct Answer: A

• Question 157:

  When determining the rates it will charge a small group, the Eagle HMO, a federally qualified HMO, divides its members into classes or groups based on demographic factors such as geography, family composition, and age. Eagle then charges all members of a

  A. Retrospective experienced rating.

  B. Adjusted community rating (ACR).

  C. Pure community rating.

  D. Standard community rating.

  Correct Answer: B

• Question 158:

  The following statements are about the accessibility of healthcare coverage and medical care in the United States. Select the answer choice that contains the correct statement.

  A. A person's employment status as a full-time employee guarantees that person access to healthcare coverage.

  B. Most people who have healthcare coverage are covered under an individual insurance policy rather than a group insurance plan.

  C. The percentage of the population without healthcare coverage is evenly distributed throughout the United States.

  D. Hospital closings have occurred disproportionately in rural areas and inner cities and have reduced access to healthcare in these areas.

  Correct Answer: D

• Question 159:

  The HMO Act of 1973 was significant in that the Act

  A. mandated certain requirements that all HMOs had to meet in order to conduct business

  B. required that all HMOs be licensed as insurance companies

  C. offered HMOs federal financial assistance through grants and loans, and provided access to the employer-based insurance market

  D. encouraged the use of pre-existing condition exclusion provisions in all HMO contracts

  Correct Answer: C

• Question 160:

  The measures used to evaluate healthcare quality are generally divided into three categories: process, structure and outcomes. An example of a process measure that can be used to evaluate an MCO's performance is the

  A. percentage of board certified physicians within the MCO's network

  B. number of hospital admissions for plan members with certain medical conditions

  C. number of plan members contracting an infection in the hospital

  D. percentage of adult plan members who receive regular medical checkups

  Correct Answer: D