AHIP AHM-520 - Health Plan Finance and Risk Management Exam
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Total 215 questions
Question #11 (Topic: Topic 1)
In order to calculate a simple monthly capitation payment, the Argyle Health Plan used the
following information:
? The average number of office visits each member makes in a year is two
? The FFS rate per office visit is $55
? The member copayment is $5 per office visit
? The reimbursement period is one month
Given this information, Argyle would correctly calculate that the per member per month
(PMPM) capitation rate should be
following information:
? The average number of office visits each member makes in a year is two
? The FFS rate per office visit is $55
? The member copayment is $5 per office visit
? The reimbursement period is one month
Given this information, Argyle would correctly calculate that the per member per month
(PMPM) capitation rate should be
A. $4.17
B. $8.33
C. $9.17
D. $10.00
Answer: B
Question #12 (Topic: Topic 1)
Three general strategies that health plans use for controlling types of risk are risk
avoidance, risk transfer, and risk acceptance. The following statements are about these
strategies. Three of these statements are true, and one statement is false. Select the
answer choice containing the FALSE statement.
avoidance, risk transfer, and risk acceptance. The following statements are about these
strategies. Three of these statements are true, and one statement is false. Select the
answer choice containing the FALSE statement.
A. Generally, the smaller the likely benefits of accepting a risk, and the lower the costs of avoiding that risk, the greater the likelihood that a health plan will elect to avoid the risk.
B. A health plan is seldom able to transfer any of the risk that utilization rates will be higher than expected and that its cost of providing healthcare will exceed the revenues it receives.
C. If a risk is a pure risk from the point of view of a health plan, then the health plan most likely will attempt to avoid the risk.
D. A health plan would most likely transfer some or all of its utilization risk if it pays a provider a rate that is based on the number of plan enrollees that choose the provider as their primary care provider (PCP).
Answer: B
Question #13 (Topic: Topic 1)
Over time, health plans and their underwriters have gathered increasingly reliable
information about the morbidity experience of small groups.
Generally, in comparison to large groups, small groups tend to
information about the morbidity experience of small groups.
Generally, in comparison to large groups, small groups tend to
A. Have more frequent and larger claims fluctuations
B. Generate lower administrative expenses as a percentage of the total premium amount the group pays
C. More closely follow actuarial predictions regarding morbidity rates
D. All of the above
Answer: A
Question #14 (Topic: Topic 1)
One true statement about mandated benefit laws is that they
A. Apply equally to self-funded and fully funded groups
B. Require a health plan to cover certain conditions or treatments or to pay a specified level of benefits for certain conditions or treatments
C. Have no impact on a health plan's underwriting and rating decisions
D. Typically decrease a health plan's risk because the health plan may need to delay premium rate decreases or may be prevented from increasing premium rates
Answer: B
Question #15 (Topic: Topic 1)
The Newfeld Hospital has contracted with the Azalea Health Plan to provide inpatient
services to Azalea's enrolled members. The contract calls for Azalea to provide specific
stop-loss coverage to Newfeld once Newfeld's treatment costs reach $20,000 per case and
for Newfeld to pay 20% of the next $50,000 of expenses for this case. After Newfeld's
treatment costs on a case reach $70,000, Azalea reimburses the hospital for all
subsequent treatment costs.
The maximum amount for which Newfeld is at risk for any one Azalea plan member's
treatment costs is
services to Azalea's enrolled members. The contract calls for Azalea to provide specific
stop-loss coverage to Newfeld once Newfeld's treatment costs reach $20,000 per case and
for Newfeld to pay 20% of the next $50,000 of expenses for this case. After Newfeld's
treatment costs on a case reach $70,000, Azalea reimburses the hospital for all
subsequent treatment costs.
The maximum amount for which Newfeld is at risk for any one Azalea plan member's
treatment costs is
A. $10,000
B. $14,000
C. $30,000
D. $34,000
Answer: C
