AHM-520 AHIP Health Plan Finance and Risk Management exact Exam Questions

Health Plan Finance and Risk Management

Last Update 22 hours ago Total Questions : 215

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Question # 4

One true statement about the rate ratios used by a health plan is that the

End result of a typical family rate ratio is that the health plan's family rate is subsidized by its single premium rate

health plan cannot arbitrarily increase or decrease its rate ratio for a rate category

rate ratios used by the health plan most likely have been established by government regulations

health plan should determine its rate ratios by considering family size alone rather than competitive factors such as the ratios that competitors are using

Question # 5

The Eclipse Health Plan is a not-for-profit health plan that qualifies under the Internal Revenue Code for tax-exempt status. This information indicates that Eclipse

Has only one potential source of funding: borrowing money

Does not pay federal, state, or local taxes on its earnings

Must distribute its earnings to its owners-investors for their personal gain

Is a privately held corporation

Question # 6

The Kayak Company self funds the health plan for its employees. This plan is an example of a type of self-funded plan known as a general asset plan. The fact that this is a completely self-funded plan indicates that

The plan has no funding vehicle

Kayak passes to its employees the financial risk of providing healthcare coverage

The plan most likely is exempt from ERISA requirements concerning the limits on benefit discrimination for classes of employees

The plan is exempt from the state laws and regulations that apply to health insurance policies

Question # 7

Reconciliation is the process by which a health plan assesses providers' performance relative to contractual terms and reimbursement.

With regard to this process, it can correctly be stated that

Areconciliation typically includes payment to the providers of any withholds or bonuses due to them

Ahealth plan typically should conduct a reconciliation immediately after the evaluation period has ended

Most agreements between health plans and providers require reconciliations to be performed quarterly

Ahealth plan typically should not conduct reconciliation for a provider until the plan has received all claims or other documentation of services that the physician provided during the evaluation period

Question # 8

Health plans sometimes use global fees to reimburse providers. Health plans would use this method of provider reimbursement for all of the following reasons EXCEPT that global fees

Eliminate any motivation the providermay have to engage in churning

Transfer some of the risk of overutilization of care from the health plan to the providers

Eliminate the practice of upcoding within specific treatments

Reward providers who deliver cost-effective care

Question # 9

If Grace Wilson is eligible for benefits under both the Medicare and Medicaid programs, then

Medicare is Ms. Wilson's primary insurer

A Medicare- or Medicaid-contracting health plan is allowed to lock-in Ms. Wilson's enrollment for a maximum period of 24 months

The BBA requires the state to guarantee Ms. Wilson's eligibility for a minimum of 18 months once she enrolls in a health plan network

Ms. Wilson can only receive Medicare- or Medicaid-covered services from a provider who participates in a health plan network

Question # 10

With regard to a health plan's underwriting of groups, it can correctly be stated that, generally, a

Health plan will require that contributory healthcare plans have a participation level of between 50% and 70%

Health plan will decline to cover a group that has been formed for the sole purpose of obtaining healthcare coverage

Health plan's underwriters will not examine the age spread of the entire group being underwritten

Health plan would expect a group with a large proportion of young females to have lower healthcare costs than does a similar group with a large proportion of young males