AHM-250 Sample Questions & Answers

A health plan may use one of several types of community rating methods to set premiums for a health plan. The following statements are about community rating. Select the answer choice containing the correct statement. A.Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.B.Under standard (pure) community rating, a health plan charges all employers or other group sponsors the same dollar amount for a given level of medical benefits or health plan, without adjusting for factors such as age, gender, or experience.C.In using the adjusted community rating (ACR) method, a health plan must consider the actual experience of a group in developing premium rates for that group.D.The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) me

A health plan's ability to establish an effective provider network depends on the characteristics of the proposed service area and the needs of proposed plan members. It is generally correct to say that A.health plans have more contracting options if providers are affiliated with single entities than if providers are affiliated with multiple entitiesB.urban areas offer more flexibility in provider contracting than do rural areasC.consumers and purchasers in markets with little health plan activity are likely to be more receptive to HMOs than to loosely managed plans such as PPOsD.large employers tend to adopt health plans more slowly than do small companies

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 A.$525B.$1,050C.$2,100D.$5,250

A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must A.Provide significant benefit to the communityB.Employ, rather than contract with, participating physiciansC.Achieve economies of scale through facility consolidation and practice managementD.Refrain from the corporate practice of medicine

A particular health plan offers a higher level of benefits for services provided in-network than for out-of-network services. This health plan requires preauthorization for certain medical services. With regard to the steps that the health plan's claims enforcement policy, clients: A.should assume that all services requiring preauthorization have been preauthorizedB.should investigate any conflicts between diagnostic codes and treatment codes before approving the claim to ensure that the appropriate payment is made for the claimC.need not verify that the provider is part of the health plan's network before approving the claim at the in-network level of benefitsD.need not determine whether the member is covered by another health plan that allows for coordination of benefits

A physician-hospital organization (PHO) may be classified as an open PHO or a closed PHO. With respect to a closed PHO, it is correct to say that A.the specialists in the PHO are typically compensated on a capitation basisB.the specialists in the PHO are typically compensated on a capitation basisC.it typically limits the number of specialists by type of specialtyD.it is available to a hospital's entire eligible medical staffE.physician membership in the PHO is limited to PCPs