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Get Certified: Proven Methods to Pass the AHIP AHM-530 Exam

Questions 41

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:

Options:

A.

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

B.

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

C.

customized networks is that they typically are inexpensive to operate.

D.

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

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Questions 42

Prior to the enactment of the Balanced Budget Act (BBA) of 1997, payment for Medicare-covered primary and acute care services was based on the adjusted average per capita cost (AAPCC). The AAPCC is defined as the

Options:

A.

average cost of services delivered to all patients living in a specified geographic region

B.

actuarial value of the deductible and coinsurance amounts for basic Medicare-covered benefits

C.

fee-for-service amount that the Centers for Medicaid and Medicare Services (CMS) would pay for a Medicare beneficiary, adjusted for age, sex, and institutional status

D.

average fixed monthly fee paid by all Medicare enrollees in a specified geographic region

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Questions 43

The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.

During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This report included such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.

The report that helped Canyon determine how well Dr. Enberg met the health plan's standards is known as:

Options:

A.

An encounter report

B.

An external standards report

C.

Aprovider profile

D.

An access to care report

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Questions 44

The Medicaid program subsidizes indigent care through payments to disproportionate share hospitals (DSHs). The Preamble Hospital is a DSH. As a DSH, Preamble most likely:

Options:

A.

Receives financial assistance from the federal government but not a state government.

B.

Is at a higher risk of operating at a loss than are most other hospitals.

C.

Receives no payments directly from Medicaid for services rendered but rather receives a portion of the capitation payment that Medicaid makes to the health plans with which Preamble contracts.

D.

Is eligible for capitation rates that are significantly higher than the FFS average for all covered Medicaid services.

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Questions 45

Reimbursement for prescription drugs and services in a third-party prescription drug plan typically follows one of two approaches: a reimbursement approach or a service approach. One true statement about these approaches is that:

Options:

A.

Payments under the reimbursement method typically are not subject to any copayment or deductible requirements

B.

Payments under the reimbursement approach are typically based on a structured reimbursement schedule rather than on usual, customary, and reasonable (UCR) charges

C.

Most major medical plans follow a service approach

D.

Most current health plan prescription drug plans are service plans

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Questions 46

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements:

Options:

A.

A statement that identifies the purpose of the contract

B.

A statement that defines in legal terms the parties to the contract

C.

A statement that identifies the Sailboat products to be covered by the contract

Of these statements, the ones that are likely to be included in the recitals section of Dr. Cartier's contract are statements:

D.

A, B, and C

E.

A and B only

F.

A and C only

G.

B and C only

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Questions 47

The following statement(s) can correctly be made about contracting and reimbursement of specialty care physicians (SCPs):

Options:

A.

Typically, a health plan should attempt to control utilization of SCPs before attempting to place these providers under a capitation arrangement.

B.

Forms of specialty physician reimbursement used by health plans include a retainer and a bundled case rate.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

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Questions 48

The Elizabethan Health Plan uses a direct referral program, which means that

Options:

A.

PCPs in Elizabethan’s network can make most referrals without obtaining prior authorization from Elizabethan

B.

PCPs in Elizabethan’s network must always refer plan members to other specialists within the network

C.

Elizabethan’s plan members can bypass the PCP and obtain medical services from a specialist without a referral

D.

Elizabethan’s plan members must obtain referrals directly from Elizabethan

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Questions 49

With regard to the laws and regulations on access and adequacy of provider networks, it can correctly be stated that:

Options:

A.

most access and adequacy guidelines relate to preferred provider organizations (PPOs) or managed indemnity products

B.

corporate practice of medicine laws require staff model HMOs to hire physicians directly, even if the physicians do not own the HMO

C.

any willing provider laws prevent a health plan from making exclusive or semi-exclusive arrangements with a provider or a group of providers

D.

the NAIC Managed Care Plan Network Adequacy Model Act requires states to use provider-enrollee ratios as the sole measure of network adequacy

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Questions 50

The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

Options:

A.

Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles.

B.

It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover.

C.

An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers.

D.

In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities.

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Exam Code: AHM-530
Exam Name: Network Management
Last Update: Jul 25, 2024
Questions: 202

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