AHIP AHIP Certifications AHM-250 Questions & Answers

• Question 221:

  Natalie Chan is a member of the Ultra Health Plan, a health plan. Whenever she needs nonemergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self- refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Cr

  A. Within Ultra's system, Ms. Chan received primary care from both Dr. Craig and Dr. Lee

  B. Ultra's system allows its members open access to all of Ultra's participating providers.

  C. Within Ultra's system, Dr. Craig serves as a coordinator of care or gatekeeper for the medical services that Ms. Chan receives.

  D. Ultra's network of providers includes Dr. Craig and Dr. Lee but not Arrow Hospital

  Correct Answer: C

• Question 222:

  Janet Riva is covered by a 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. She incurred

  A. $1,750

  B. $1,800

  C. $2,000

  D. $2,250

  Correct Answer: B

• Question 223:

  One typical characteristic of an integrated delivery system (IDS) is that an IDS.

  A. Is more highly integrated structurally than it is operationally.

  B. Provides a full range of healthcare services, including physician services, hospital services, and ancillary services.

  C. Cannot negotiate directly with health plans, plan sponsors, or other healthcare purchasers.

  D. Performs a single business function, such as negotiating with health plans on behalf of all of the member providers.

  Correct Answer: B

• Question 224:

  One way that MCOs involve providers in risk sharing is by retaining a percentage of the providers' payment during a plan year. At the end of the plan year, the MCO may use the amount retained to offset or pay for any cost overruns for referral or hospital

  A. withholds

  B. usual, customary, and reasonable (UCR) fees

  C. risk pools

  D. per diems

  Correct Answer: A

• Question 225:

  In the United States, the Department of Defense offers ongoing healthcare coverage to military personnel and their families through the TRICARE health plan. One true statement about TRICARE is that:

  A. Active duty military personnel are automatically considered enrolled in TRICARE Prime

  B. TRICARE covers inpatient and outpatient services, physician and hospital charges, and medical supplies, but not mental health services.

  C. TRICARE enrollees are not entitled to appeal authorization or coverage decisions

  D. Hospitals participating in the TRICARE program are exempt from JCAHO accreditation and Medicare certification.

  Correct Answer: A

• Question 226:

  The Employee Retirement Income Security Act (ERISA) requires health plan members who receive healthcare benefits through employee benefit plans to file legal challenges involving coverage decisions or plan administration at the federal level. Under the te

  A. contract damages, which cover the cost of denied treatment

  B. compensatory damages, which compensate the injured party for his or her injuries

  C. punitive damages, which are designed to punish or make an example of the wrongdoer

  D. all of the above

  Correct Answer: A

• Question 227:

  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

  Correct Answer: B

• Question 228:

  One type of physician-only integration model is a consolidated medical group. Typical characteristics of a consolidated medical group include

  A. that it may be a single-specialty or multi-specialty practice

  B. operates in one or a few facilities rather than in many independent offices

  C. achieves economies of scale in the group's integrated operations

  D. all of the above

  Correct Answer: D

• Question 229:

  One of the most influential pieces of legislation in the advancement of managed care within the United States was the HMO Act of 1973. One provision of the HMO Act of 1973 was that it

  A. emphasized compensating physicians based solely on the volume of medical services they provide

  B. exempted HMOs from all state licensure requirements

  C. established a process under which HMOs could elect to be federally qualified

  D. required federally qualified HMOs to relate premium levels to the health status of the individual enrollee or employer group

  Correct Answer: C

• Question 230:

  One HMO model can be described as an extension of a group model HMO because it contracts with multiple group practices, rather than with a single group practice. This HMO model is known as the

  A. staff model HMO

  B. IPA model HMO

  C. direct contract model HMO

  D. network model HMO

  Correct Answer: D