AHIP AHIP Certifications AHM-250 Questions & Answers

• Question 241:

  Medicaid is a jointly funded federal and state program that provides hospital and medical expense coverage to low-income individuals and certain aged and disabled individuals. One characteristic of Medicaid is that

  A. providers who care for Medicaid recipients must accept Medicaid payment as payment in full for services rendered

  B. Medicaid requires recipients to pay deductibles, copayments, and coinsurance amounts for all services

  C. Medicaid is always the primary payer of benefits

  D. benefits offered by Medicaid programs are federally mandated and do not vary by state

  Correct Answer: A

• Question 242:

  Medicare is the federal government program established under Title XVIII of the Social Security Act of 1965 to provide hospital, medical and other covered benefits to elderly and disabled persons. Medicare is available for:

  A. Persons age 63 or older.

  B. Persons with qualifying disabilities (over the age of 63)

  C. Persons with end-stage renal disease (ESRD)

  D. Low income individuals

  Correct Answer: C

• Question 243:

  Primary care case managers (PCCMs) provide case management services to eligible Medicaid recipients. With regard to PCCMs it is correct to say that:

  A. PCCMs typically receive a case management fee, rather than reimbursement for medical services on a FFS basis, for the services they provide to Medicaid recipients.

  B. All Medicaid recipients who live in rural areas must be given a choice of at least four PCCMs.

  C. PCCMs receive a case management fee in addition to reimbursement for medical services on a FFS basis.

  D. PCCMs contract directly with the federal government to provide case management services to Medicaid recipients.

  Correct Answer: C

• Question 244:

  The following programs are part of the Alcove Health Plan's utilization management (UM) program:

  Preventive care initiatives A telephone triage program A shared decision-making program A self-care program

  With regard to the UM programs, it is most

  A. Preventive care initiatives include immunization programs but not health promotion programs.

  B. Telephone triage program is staffed by physicians only.

  C. Shared decision-making program is appropriate for virtually any medical condition.

  D. Self-care program is intended to complement physicians' services, rather than to supersede or eliminate these services.

  Correct Answer: D

• Question 245:

  One way in which a health plan can support an ethical environment is by

  A. requiring organizations with which it contracts to adopt the plan's formal ethical policy

  B. developing and maintaining a culture where ethical considerations are integrated into decision making at the top organizational level only

  C. establishing a formal method of managing ethical conflicts, such as using an ethics task force or bioethics consultant

  D. maintaining control of policy development by removing providers and members from the process of developing and implementing policies and procedures that provide guidance to providers and members confronted with ethical issues

  Correct Answer: C

• Question 246:

  The Acme HMO recruits and contracts directly with a wide range of physicians--both PCPs and specialists--in its geographic area on a non-exclusive basis. There is no separate legal entity that represents and negotiates the contracts for the physicians. The

  A. an independent practice association (IPA) model HMO

  B. a staff model HMO

  C. a direct contract model HMO

  D. a group model HMO

  Correct Answer: C

• Question 247:

  One typical characteristic of preferred provider organization (PPO) benefit plans is that PPOs:

  A. Assume full financial risk for arranging medical services for their members.

  B. Require plan members to obtain a referral before getting medical services from specialists.

  C. Use a capitation arrangement, instead of a fee schedule, to reimburse physicians.

  D. Offer some coverage, although at a higher cost, for plan members who choose to use the services of non-network providers.

  Correct Answer: D

• Question 248:

  The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.

  A. True

  B. False

  Correct Answer: B

• Question 249:

  The following programs are typically included in TRICARE medical management efforts:

  A. Utilization management

  B. Self-care

  C. Case management

  A. A and B only

  B. A and C only

  C. All of the listed options

  D. B and C only

  Correct Answer: C

• Question 250:

  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

  Correct Answer: A