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Ace the AHIP AHM-250 Exam: Ultimate Preparation Guide

Questions 61

As part of its utilization management (UM) system, the Creole Health Plan uses a process known as case management. The following individuals are members of the Creole Health Plan:

  • Jill Novacek, who has a chronic respiratory condition.
  • Abraham Rashad.

Options:

A.

Ms. Novacek, Mr. Rashad, and Mr. Devereaux

B.

Ms. Novacek and Mr. Rashad only

C.

Ms. Novacek and Mr. Devereaux only

D.

None of these members

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Questions 62

If a state commissioner of insurance places an HMO under administrative supervision, then the purpose of this action most likely is to:

Options:

A.

Transfer all of the HMO's business to other carriers.

B.

Allow the state commissioner, acting for a state court, to take control of and administer the HMO's assets and liabilities.

C.

Sell the HMO's assets in order to satisfy the HMO's obligations.

D.

Place the HMO's operations under the direction and control of the state commissioner or a person appointed by the commissioner.

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Questions 63

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

Options:

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

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Questions 64

A health savings account must be coupled with an HDHP that meets federal requirements for minimum deductible and maximum out-of-pocket expenses. Dollar amounts are indexed annually for inflation. For 2006, the annual deductible for self-only coverage must

Options:

A.

$525

B.

$1,050

C.

$2,100

D.

$5,250

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Questions 65

In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known

Options:

A.

dual choice

B.

cost shifting

C.

accreditation

D.

defensive medicine

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Questions 66

Ed O'Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O'Brien was hospitalized for an aneurysm. Later, he was transferred by

Options:

A.

Confinement in the extended-care facility after his hospitalization.

B.

Transportation by ambulance from the hospital to the extended-care facility.

C.

Physicians' professional services while he was hospitalized.

D.

physicians' professional services while he was at the extended-care facility.

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Questions 67

In addition to the credentialing activities that an health plan performs when initially accepting a provider into its network, the health plan must also perform recredentialing of the same providers on an ongoing basis. Many of the same activities are per

Options:

A.

verification of a network provider's medical education and residency

B.

performance of site inspections in a provider's facilities

C.

review of information from a provider's quality improvement activities

D.

verification of a provider's licensure and certification

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Questions 68

By definition, a health plan's network refers to the

Options:

A.

organizations and individuals involved in the consumption of healthcare provided by the plan

B.

relative accessibility of the plan's providers to the plan's participants

C.

group of physicians, hospitals, and other medical care providers with whom the plan has contracted to deliver medical services to its members

D.

integration of the plan's participants with the plan's providers

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Questions 69

An HMO that combines characteristics of two or more HMO models is sometimes referred to as a

Options:

A.

Network model HMO

B.

Group model HMO

C.

Staff model HMO

D.

Mixed model HMO

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Questions 70

Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health di

Options:

A.

Hospital observation units or psychiatric hospitals.

B.

Psychiatric hospitals or rehabilitation hospitals.

C.

Subacute care facilities or skilled nursing facilities.

D.

Psychiatric units in general hospitals or hospital observation units.

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