AHIP AHM-530 問題集

質問 1：
Grant Pelham is covered by both a workers' compensation program and a group health plan provided by his employer. The Shipwright Health Plan administers both programs. Mr. Grant was injured while on the job and applied for benefits.
Mr. Pelham's group health insurance plan and workers' compensation both provide benefits to cover expenses incurred as a result of illness or injury. However, unlike traditional group insurance coverage, workers' compensation
A. Requires employees who suffer a work-related illness or injury to obtain care from specified network providers
B. Covers all injuries and illnesses, regardless of their cause
C. Requires employees to share the cost of treatment through deductible, coinsurance, and benefit limits
D. Provides reimbursement for lost wages
正解：D

質問 2：
The Elizabethan Health Plan uses a direct referral program, which means that
A. Elizabethan's plan members must obtain referrals directly 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. PCPs in Elizabethan's network can make most referrals without obtaining prior authorization from Elizabethan
正解：D

質問 3：
The following statements describe two types of HMOs:
The Elm HMO requires its members to select a PCP but allows the members to go to any other provider on its panel without a referral from the PCP.
The Treble HMO does not require its members to select a PCP. Treble allows its members to go to any doctor, healthcare professional, or facility that is on its panel without a referral from a primary care doctor. However, care outside of Treble's network is not reimbursed unless the provider obtains advance approval from the HMO.
Both HMOs use delegation to transfer certain functions to other organizations. Following the guidelines established by the NCQA, Elm delegated its credentialing activities to the Newnan Group, and the agreement between Elm and Newnan lists the responsibilities of both parties under the agreement. Treble delegated utilization management (UM) to an IPA. The IPA then transferred the authority for case management to the Quest Group, an organization that specializes in case management.
Both HMOs also offer pharmacy benefits. Elm calculates its drug costs according to a pricing system that requires establishing a purchasing profile for each pharmacy and basing reimbursement on the profile. Treble and the Manor Pharmaceutical Group have an arrangement that requires the use of a typical maximum allowable cost (MAC) pricing system to calculate generic drug costs under Treble's pharmacy program. The following statements describe generic drugs prescribed for Treble plan members who are covered by Treble's pharmacy benefits:
The MAC list for Drug A specifies a cost of 12 cents per tablet, but Manor pays 14 cents per tablet for this drug.
The MAC list for Drug B specifies a cost of 7 cents per tablet, but Manor pays 5 cents per tablet for this drug.
From the following answer choices, select the response that best identifies Elm and Treble:
A. Elm: direct access HMO Treble: open access (OA) HMO
B. Elm: open access (OA) HMO Treble: direct access HMO
C. Elm: open access (OA) HMO Treble: gatekeeper HMO
D. Elm: direct access HMO Treble: gatekeeper HMO
正解：A

質問 4：
If the Oconee Health Plan reimburses its specialty care physicians (SCPs) under a typical retainer method, then Oconee pays SCPs
A. Aseparate amount for each service provided, and the payment amount is based solely on a resource-based relative value scale (RBRVS)
B. Aspecified fee that remains the same regardless of how much or how little time or effort is spent on the medical service performed
C. Aset amount of cash equivalent to a defined time period's expected reimbursable charges
D. Aset amount each month, and Oconee reconciles its payment at periodic intervals on the basis of actual utilization
正解：D

質問 5：
The Octagon Health Plan includes a typical indemnification clause in its provider contracts. The purpose of this clause is to require Octagon's network providers to
A. Maintain the confidentiality of the health plan's proprietary information
B. Agree to accept Octagon's payment as payment in full and not to bill members for anything other than contracted copayments, coinsurance, or deductibles
C. Reimburse Octagon for costs, expenses, and liabilities incurred by the health plan as a result of a provider's actions
D. Agree not to sue or file claims against an Octagon plan member for covered services
正解：C