AHIP AHIP Certifications AHM-250 Questions & Answers

• Question 61:

  The following statements are about preferred provider organizations (PPOs). Select the answer choice that contains the correct statement.

  A. PPOs generally assume full financial risk for arranging medical services for their members.

  B. PPOs generally pay a larger portion of a member's medical expenses when that member uses in-network providers than when the member uses out-of-network providers.

  C. PPO networks may include primary care physicians and hospitals, but generally do not include specialists.

  D. In a PPO, the most common method used to reimburse physicians is capitation.

  Correct Answer: B

• Question 62:

  The following statements are about the underwriting function within a health plan. Select the answer choice containing the correct statement.

  A. The underwriting function in a health plan is primarily concerned with ensuring that the group being underwritten does not include any individuals who are likely to have higher than average utilization of medical services.

  B. Compared to a health plan with relaxed underwriting requirements, a similar health plan with very strict underwriting requirements can expect to experience increased healthcare costs and to have significantly higher plan enrollment.

  C. Typically, a health plan guarantees the premium rate for a group health contract for a period of no more than six months.

  D. In order to determine the actual premium to charge a group, a group underwriter typically considers such factors as level of participation, benefits, and the age and gender distribution of group members.

  Correct Answer: D

• Question 63:

  The Granite Health Plan is a coordinated care plan (CCP) that participates in the Medicare+Choice program. This information indicates that Granite

  A. must comply with all state-mandated benefits and provider requirements

  B. must offer each of its enrollees a Medicare supplement

  C. places primary care t the censer of the delivery system and focuses on managing patient care at all levels

  D. most likely must cover Medicare Part A, but not Medicare Part B, benefits

  Correct Answer: C

• Question 64:

  The nature of the claims function within health plans varies by type of plan and by the compensation arrangement that the plan has made with its providers. For example, it is generally correct to say that, in a Preferred provider organization (PPO)

  A. Both A and B

  B. A only

  C. B only

  D. Neither A nor B

  Correct Answer: A

• Question 65:

  The following statements are about issues associated with marketing healthcare plans to small groups and large groups. Select the answer choice that contains the correct statement.

  A. In the large group market, large group accounts that have employees in more than one geographic area who are covered through a single national contract for healthcare coverage are known as large local groups.

  B. Because providing healthcare coverage for employees is often a burden for small businesses, price is typically the most critical consideration for small businesses in selecting a healthcare plan.

  C. health plans typically treat an employer purchasing coalition as a small group for marketing purposes.

  D. Large groups rarely use self-funding to finance their healthcare plans.

  Correct Answer: B

• Question 66:

  Renewal underwriting involves a reevaluation of

  A. The group's experience

  B. Level of participation in the health plan

  C. Both A and B

  D. None of the Above

  Correct Answer: C

• Question 67:

  What is a mathematical process that involves using a number of hypothetical situations that, in total, will reasonably reflect an event that will occur in real life

  A. Forecasting

  B. Modelling

  C. Both a and b

  D. None of the above

  Correct Answer: B

• Question 68:

  Which of the following is NOT a reason for conducting utilization reviews?

  A. Improve the quality and cost effectiveness of patient care

  B. Reduce unnecessary practice variations

  C. Make appropriate authorization decisions

  D. Accommodate special requirements of inpatient care

  Correct Answer: D

• Question 69:

  Medigap policies were standardized into ten standard benefit pl ranging from A-J by the ____

  A. Omnibus Budget Reconciliation Act (OBRA) of 1990

  B. Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982

  C. Medicare Modernization Act (MMA) of 2003

  D. Balanced Budget Act (BBA) of 1997

  Correct Answer: A

• Question 70:

  One among the following is a reason that limit access to health care for US people.

  A. Life Style of the people

  B. Concentration of physicians in highly populated areas.

  C. Advancement in information technology

  Correct Answer: B