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How to Pass the AHIP AHM-510 Exam: Comprehensive Governance and Regulation Guide and Tips

Questions 1

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

Options:

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

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Questions 2

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 detecting violations 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

Options:

A.

An environmental analysis

B.

An internal assessment

C.

An environmental forecast

D.

A community analysis

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Questions 3

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 the NAIC 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

Options:

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

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Questions 4

The Tidewater Life and Health Insurance Company is owned by its policy owners, who are entitled to certain rights as owners of the company, and it issues both participating and nonparticipating insurance policies. Tidewater is considering converting to the type of company that is owned by individuals who purchase shares of the company's stock. Tidewater is incorporated under the laws of Illinois, but it conducts business in the Canadian provinces of Ontario and Manitoba.

With regard to the state in which Tidewater is domiciled, it is correct to say that, from the perspective of both Ontario and Manitoba, Tidewater is considered to be the type of corporation known as:

Options:

A.

A foreign corporation

B.

An alien corporation

C.

A sister corporation

D.

A domestic corporation

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Questions 5

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 detecting violations of law. SoundCare decided to remedy this weakness by using the 1991 Federal Sentencing Guidelines for Organizations as a model for its compliance program.

With respect to the Federal Sentencing Guidelines, actions that SoundCare should take in developing its compliance program include

Options:

A.

Creating a system through which employees and other agents can report suspected misconduct without fear of retribution

B.

Holding management accountable for the misconduct of their subordinates

C.

Assigning a high-level member of management to the position of compliance coordinator or administrator

D.

All of the above

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Questions 6

One typical difference between a for-profit health plan's board of directors and a not-for-profit health plan's board of directors is that the directors in a for-profit health plan

Options:

A.

Can serve on the board for a period of no more than ten years, whereas the terms of service for a not-for-profit board's directors are usually unlimited by the director's age or by a preset maximum number of years of service

B.

Must participate in raising capital for the health plan, whereas a not-for-profit board's directors are prohibited from participating directly in raising capital for the health plan

C.

Are directly accountable to shareholders, whereas a not-for-profit board's directors are accountable to plan members and the community

D.

Are not compensated for board participation, whereas a not-for-profit board's directors are compensated for board participation

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Questions 7

In the paragraph below, a statement contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the statement. Then select the answer choice containing the two terms that you have chosen.

One type of acquisition is called a stock purchase. In a typical stock purchase, a company acquires (51% / 100%) of the voting shares of another company's stock, thereby making the acquired company a subsidiary. The (acquired / acquiring) company holds all of the assets and liabilities of the acquired company.

Options:

A.

51% / acquired

B.

51% / acquiring

C.

100% / acquired

D.

100% / acquiring

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Questions 8

The following statements appear in the Twilight Health Plan's strategic plan:

Increase the percentage of preventive health interventions for total eligible membership during each of the next three calendar years for the following services: mammography, Pap smears, immunizations, and first trimester visits for prenatal mothers

Improve customer satisfaction on an annual basis for each of the next three calendar years, as measured by satisfaction surveys for members, providers, and employer groups

Increase by 30% the number of claims processed by the automated claim payment system and reduce by 10% the cost of paying claims during the next three years

These statements are examples of Twilight's

Options:

A.

Corporate objectives

B.

Company mission

C.

Company vision

D.

Corporate strategies

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Questions 9

Directors on a health plan's board must demonstrate their compliance with three duties in all their decisions. Directors who exercise their duties in good faith and with the same degree of diligence and skill that an ordinary, reasonable person would be expected to display in the same situation are meeting the duty known as the

Options:

A.

Duty of loyalty

B.

Duty to supervise

C.

Duty of care

D.

Trustee duty

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Questions 10

Determine whether the following statement is true or false:

Although most-favored-nation (MFN) clauses in contracts between health plans and healthcare providers are not per se illegal, they should be reviewed under the rule of reason analysis for antitrust purposes.

Options:

A.

True, because the Federal Trade Commission (FTC) ruled that MFN clauses are not per se illegal and the FTC encourages health plans to include them in provider contracts.

B.

True, because although MFN clauses are not per se illegal, they violate antitrust laws if they have a predatory purpose and an anticompetitive effect.

C.

False, because MFN clauses involve decisions by providers concerning the level of fees to charge, and thus they are per se illegal.

D.

False, because MFN clauses are not per se illegal, and thus they are exempt from antitrust laws and regulation by the FTC.

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Exam Code: AHM-510
Exam Name: Governance and Regulation
Last Update: Jun 16, 2024
Questions: 76

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