AHIP AHIP Certification AHM-510 Questions & Answers

• Question 1:

  While traditional workers' compensation laws have restricted the use of managed care techniques, many states now allow managed workers' compensation. One common characteristic of managed workers' compensation plans is that they

  A. Discourage injured employees from returning to work until they are able to assume all the duties of their jobs

  B. Use low copayments to encourage employees to choose preferred providers

  C. Cover an employee's medical costs, but they do not provide coverage for lost wages

  D. Rely on total disability management to control indemnity benefits

  Correct Answer: D

• Question 2:

  In the course of doing business, health plans conduct basic corporate transactions. For example, when a health plan engages in the corporate transaction known as aggressive sourcing, the health plan

  A. Chooses to contract with vendors who provide specific functions that would otherwise be performed in-house, such as paying claims

  B. Seeks to obtain the best deals from various vendors for equipment, supplies, and services such as telephones, overnight mail, computer hardware and software, and copy machines

  C. Merges with one or more companies to form an entirely new company

  D. Joins with one or more companies, but retains its autonomy and relies on the other companies to perform specific functions

  Correct Answer: B

• Question 3:

  SoundCare Health Services, a health plan, recently conducted a situation analysis. One step in this analysis required SoundCare to examine its current activities, its strengths and weaknesses, and its ability to respond to potential threats and opportunities in the environment. This activity provided SoundCare with a realistic appraisal of its capabilities. One weakness that SoundCare identified during this process was that it lacked an effective program for preventing and detectingviolations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.

  By definition, the activity that SoundCare conducted when it examined its strengths, weaknesses, and capabilities is known as

  A. An environmental analysis

  B. An internal assessment

  C. An environmental forecast

  D. A community analysis

  Correct Answer: B

• Question 4:

  Regulators of health plans have set standards in a number of areas of plan operations. Requirements with which health plans must comply typically include

  A. providing enrollees and prospective enrollees with detailed information about various aspects of health plan policies and operations

  B. maintaining internal grievance and appeals processes to resolve enrollee complaints against the organization

  C. maintaining quality assurance programs that reflect the plan's activities in monitoring quality

  D. all of the above

  Correct Answer: D

• Question 5:

  The National Association of Insurance Commissioners (NAIC) adopted the Health Maintenance Organization Model Act (HMO Model Act) to regulate the development and operations of HMOs. One true statement regarding the HMO Model Act is that the act

  A. includes mental health services in its definition of basic healthcare services

  B. authorizes only one state agency-the department of insurance-to regulate HMOs

  C. requires HMOs to place a deposit in trust with the state insurance commissioner for the purpose of protecting the interests of enrollees should an HMO become financially impaired

  D. requires HMOs that wish to offer a point-of-service (POS) product to contract with a licensed insurance company to provide POS options to plan members

  Correct Answer: C

• Question 6:

  The board of directors of the Garnet Health Plan, an integrated delivery system (IDS), includes physicians and hospital representatives who sometimes feel compelled to represent a specific organization that is only one part of the IDS. Such a circumstance can lead to ___________, which is a situation in which the members of the board focus on the best interests of component parts of the enterprise rather than on the best interests of Garnet as a whole.

  A. An enterprise-focused board

  B. Representational governance

  C. Enterprise liability

  D. Boundary spanning

  Correct Answer: B

• Question 7:

  Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any time, without providing any reason for the termination, by giving the other party a specified period of notice.

  The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its provider network. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements. The contracts between Greenpath and its healthcare providers contain a termination provision known as

  A. An 'economic credentialing' termination provision

  B. A 'breach of contract' termination provision

  C. A 'fair procedure' termination provision

  D. A 'without cause' termination provision

  Correct Answer: D

• Question 8:

  One provision of the Mental Health Parity Act of 1996 (MHPA) is that the MHPA prohibits group health plans from

  A. Setting a cap for a group member's lifetime medical health benefits that is higher than the cap for the member's lifetime mental health benefits

  B. Imposing limits on the number of days or visits for mental health treatment

  C. Charging deductibles for mental health benefits that are higher than the deductibles for medical benefits

  D. Imposing annual limits on the number of outpatient visits and inpatient hospital stays for mental health services

  Correct Answer: A

• Question 9:

  From the following answer choices, choose the term that best corresponds to this description. The SureQual Group is a group of practicing physicians and other healthcare professionals paid by the federal government to review services ordered or furnished by other practitioners in the same medical fields for the purpose of determining whether medical services provided were reasonable and necessary, and to monitor the quality of care given to Medicare patients.

  A. Health insuring organization (HIO)

  B. Independent practice association (IPA)

  C. Physician practice management (PPM) company

  D. Peer review organization (PRO)

  Correct Answer: D

• Question 10:

  Indigo Health Plan advertised a specific individual health insurance policy through a direct mail advertisement that provided detailed information about the product. In order to comply with theNAIC Model Rules Governing Advertisements of Accident and Sickness Insurance, Indigo must disclose whether the advertised policy contains any exceptions, reductions, or limitations. Thus, Indigo disclosed in the advertisement that one policy provision limits coverage for dental exams to $50 per exam and to one exam per calendar year. This information indicates that, with respect to the definitions in the NAIC Model Rules, Indigo's advertisement is an example of an

  A. Invitation to contract, and it discloses a policy provision known as an exception

  B. Invitation to contract, and it discloses a policy provision known as a reduction

  C. Invitation to inquire, and it discloses a policy provision known as an exception

  D. Invitation to inquire, and it discloses a policy provision known as a reduction

  Correct Answer: B