AHIP AHIP Certifications AHM-250 Questions & Answers

• Question 291:

  Health plans may use different capitation arrangements for different levels of service. One typical capitation arrangement provides a capitation payment that may include primary care only, or both primary and secondary care, but not ancillary services. The

  A. global capitation arrangement

  B. gatekeeper arrangement

  C. carve-out arrangement

  D. partial capitation arrangement

  Correct Answer: D

• Question 292:

  A common physician-only integrated model is a group practice without walls (GPWW). One characteristic of a typical GPWW is that the

  A. GPWW combines multiple independent physician practices under one umbrella organization

  B. GPWW generally has a lesser degree of integration than does an IPA

  C. member physicians cannot own the GPWW

  D. GPWW's member physicians must perform their own business operations

  Correct Answer: A

• Question 293:

  Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:

  A. Provides Ms. Giambi with healthcare coverage for any illness or injury, but only if the cause of the illness or injury is work-related.

  B. Combines the group health plan and disability plan offered by Ms. Giambi's employer with workers' compensation coverage.

  C. Requires Ms. Giambi and her employer to each pay half of the cost of this coverage.

  D. Requires Ms. Giambi to pay specified deductibles and copayments before receiving benefits under this program for any illness or injury.

  Correct Answer: B

• Question 294:

  Before the Leo 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 for medical services they perform for Leo 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 Leo 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

  Correct Answer: C

• Question 295:

  The following statements describe two types, or models, of HMOs:

  The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of the group practice, have an equity interest in the practice, and provide

  A. A captive group a staff model

  B. A captive group a network model

  C. An independent group a network model

  D. An independent group a staff model

  Correct Answer: B

• Question 296:

  From the following choices, choose the definition that best matches the term health risk assessment (HRA)

  A. A technique used to educate plan members on how to distinguish between minor problems and serious conditions and effectively treat minor problems themselves

  B. A technique used to determine if a health condition is present even if a member has not experienced symptoms of the problem

  C. A technique in which information about a plan member's health status, personal and family health history, and health-related behaviors is used to predict the member's likelihood of experiencing specific illnesses or injuries

  D. A technique used to evaluate the medical necessity, appropriateness, and cost- effectiveness of healthcare services for a given patient

  Correct Answer: C

• Question 297:

  A particular health plan offers a higher level of benefits for services provided in-network than for out-ofnetwork services. This health plan requires preauthorization for certain medical services.

  With regard to the steps that the health plan's claims e

  A. should assume that all services requiring preauthorization have been preauthorized

  B. should investigate any conflicts between diagnostic codes and treatment codes before approving the claim to ensure that the appropriate payment is made for the claim

  C. need not verify that the provider is part of the health plan's network before approving the claim at the in-network level of benefits

  D. need not determine whether the member is covered by another health plan that allows for coordination of benefits

  Correct Answer: B

• Question 298:

  From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy

  A. Health plans and their providers are obligated not to harm their members

  B. Health plans and their providers should treat each member in a manner that respects the member's goals and values, and they also have a duty to promote the good of the members as a group

  C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members

  D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives

  Correct Answer: D

• Question 299:

  A health plan may use one of several types of community rating methods to set premiums for a health plan. The following statements are about community rating. Select the answer choice containing the correct statement.

  A. Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.

  B. Under standard (pure) community rating, a health plan charges all employers or other group sponsors the same dollar amount for a given level of medical benefits or health plan, without adjusting for factors such as age, gender, or experience.

  C. In using the adjusted community rating (ACR) method, a health plan must consider the actual experience of a group in developing premium rates for that group.

  D. The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) me

  Correct Answer: B

• Question 300:

  Federal legislation has placed the primary responsibility for regulating health insurance companies and HMOs that service private sector (commercial) plan members at the state level.

  This federal legislation is the

  A. Clayton Act

  B. Federal Trade Commission Act

  C. McCarran-Ferguson Act

  D. Sherman Act

  Correct Answer: C