AHIP AHM-530 Exam Practice Test Instant Access

Question 1

The Bruin Health Plan is a Social Health Maintenance Organization (SHMO). As an SHMO, Bruin:

AMust provide Medicare participants with standard HMO benefits, as well as with limited long-term care benefits

BDoes not need as great a variety of provider types or as complex a reimbursement method as does a traditional HMO

CReceives a payment that is based on reasonable costs and reasonable charges

DMost likely provides fewer supportive services than does a traditional HMO, because one of Bruin's goals is to minimize the use of community-based care

Answer : A

Question 2

The Crimson Health Plan, a competitive medical plan (CMP), has entered into a Medicare risk contract. One true statement about Crimson is that, as a:

ACMP, Crimson is regulated by the federal government under the terms of the Tax Equity and Fiscal Responsibility Act (TEFRA)

BCMP, Crimson is not allowed to charge a Medicare enrollee a premium for any additional benefits it provides over and above Medicare benefits

CProvider under a Medicare risk contract, Crimson receives for its services a capitated payment equivalent to 85% of the AAPCC

DProvider under a Medicare risk contract, Crimson is required to deliver to members all Medicare-covered services, without regard to the cost of those services

Answer : D

Question 3

The vision benefits offered by the Omni Health Plan include clinical eye care only. The following statements describe vision care received by Omni plan members:

Brian Pollard received treatment for a torn retina he suffered as a result of an accident

Angelica Herrera received a general eye examination to test her vision

Megan Holtz received medical services for glaucoma

Of these medical services, the ones that most likely would be covered by Omni's vision coverage would be the services received by:

AMr. Pollard, Ms. Herrera, and Ms. Holtz

BMr. Pollard and Ms. Herrera only

CMr. Pollard and Ms. Holtz only

DMs. Herrera and Ms. Holtz only

Answer : C

Question 4

The following statements describe two types of HMOs:

The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.

The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.

Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IP

AThe IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
The following statements can correctly be made about the reimbursement for Drugs A and B under the MAC pricing system:

ATreble most likely is obligated to reimburse Manor 14 cents per tablet for Drug A.

BManor most likely is allowed to bill the subscriber 2 cents per tablet for Drug A.

CTreble most likely is obligated to reimburse Manor 5 cents per tablet for Drug B.

DAll of the above statements are correct.

Answer : C

Question 5

A health plan has several options for delivering pharmacy services to its subscribers. Each option has potential advantages to a health plan. An advantage to a health plan of using:

Aperformance-based open networks is that they tend to increase participation in the pharmacy network.

Bclosed networks is that they improve the health plan's ability to set standards and implement cost-control programs for pharmacy services.

Ccustomized networks is that they typically are inexpensive to operate.

Dopen networks is that they tend to improve the health plan's ability to control pharmaceutical costs.

Answer : B

Question 6

The provider contract that Dr. Lorena Chau has with the Fiesta Health Plan includes an evergreen clause. The purpose of this clause is to:

AAllow Fiesta to change or amend the contract without Dr. Chau's approval as long as the modifications are made in order to comply with new legal and regulatory requirements

BProhibit Dr. Chau from encouraging her patients to switch from Fiesta to another health plan

CProhibit Dr. Chau from encouraging her patients to switch from Fiesta to another health plan

DAssure that Dr. Chau provides Fiesta members with healthcare services in a timely manner appropriate to the member's medical condition

Answer : C

Question 7

The provider contract that Dr. Nick Mancini has with the Utopia Health Plan includes a clause that requires Utopia to reimburse Dr. Mancini on a fee-for-service (FFS) basis until 100 Utopia members have selected him as their primary care provider (PCP). At that time, Utopia will begin reimbursing him under a capitated arrangement. This clause in Dr. Mancini's provider contract is known as:

Aan antidisparagement clause

Ba low-enrollment guarantee clause

Ca retroactive enrollment changes clause

Dan eligibility guarantee clause

Answer : B

AHIP AHM-530 Network Management Exam Practice Test