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AHIP AHM-520 - Health Plan Finance and Risk Management

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Total 215 questions

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

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

A.

$4.17

B.

$8.33

C.

$9.17

D.

$10.00

One true statement about a health plan's underwriting margin is that

A.

the only way that the health plan can effectively reduce its exposure to underwriting risk, and therefore adjust its underwriting margin, is to control anti selection

B.

a larger assumed underwriting margin will reduce the price of the health plan's product and will make the plan more competitive

C.

the health plan's purchase of stop-loss insurance has no effect on its underwriting margin because stop-loss insurance can help the health plan control its expenses but not its underwriting risk

D.

both the level of underwriting risk that the health plan assumes in providing benefits and the market competition it encounters most likely directly affect the size of its assumed underwriting margin

Providing services under Medicare or Medicaid can impose on health plans financial risks and costs that are greater than those related to providing services to the commercial population. Reasons that an health plan's financial risks and costs for providing services to Medicare and Medicaid enrollees tend to be higher include

A.

Most Medicare and Medicaid enrollees can disenroll from a health plan on a monthly basis

B.

The high incidences of chronic illness in both the Medicare and Medicaid populations results in higher costs related to coordinating care and case management

C.

Medicare and Medicaid enrollees tend to have a high level of costs in the first few months of enrollment as the health plan educates them about the health plan system and performs initial health screening to evaluate their health

D.

all of the above

Under the alternative funding method used by the Trilogy Company, the insurer charges Trilogy an initial premium that is based on the assumption that claims will be 93% of the expected claims for the year. If claims exceed 93% of expected claims, then Trilogy must reimburse the insurer for any additional claims paid, up to 112% of expected claims. The insurer bears the responsibility for paying claims in excess of 112% of expected claims.

From the following answer choices, choose the name of the alternative funding method described.

A.

Retrospective-rating arrangement

B.

Premium-delay arrangement

C.

Reserve-reduction arrangement

D.

Minimum-premium plan

With regard to capitation arrangements for hospitals, it can correctly be Back to Top stated that

A.

The most common reimbursement method for hospitals is professional services capitation

B.

Most jurisdictions prohibit hospitals and physicians from joining together to receive global capitations that cover institutional services provided by the hospitals

C.

Ahealth plan typically can capitate a hospital for outpatient laboratory and X-ray services only if the health plan also capitates the hospital for inpatient care

D.

Many hospitals have formed physician hospital organizations (PHOs), hospital systems, or integrated delivery systems (IDSs) that can accept global capitation payments from health plans

A stop-loss contract may provide that claims are settled using a paid claims method or an incurred claims method. The Concord Company provides health coverage to its employees through a self-funded health plan. On March 17, a Concord employee who is enrolled in this plan underwent surgery, and the surgery was sufficiently expensive to trigger Concord's specific stop-loss coverage. On April 10, Concord paid the medical expenses associated with the surgery. The term of the stop-loss contract ended on April 1. This information indicates that the stop-loss carrier is responsible for paying a portion of the cost of the surgery under

A.

both the paid claims method and the incurred claims method

B.

the paid claims method but not the incurred claims method

C.

the incurred claims method but not the paid claims method

D.

neither the paid claims method nor the incurred claims method

Because a health plan cannot decline coverage for individuals who are eligible for conversion of group health coverage to individual health coverage, the bulk of the health plan's underwriting for conversion policies is accomplished through health plan design.

A.

True

B.

False

The provider contract that Dr. Zachery Cogan, an internist, has with the Neptune Health Plan calls for Neptune to reimburse him under a typical PCP capitation arrangement. Dr. Cogan serves as the PCP for Evelyn Pfeiffer, a Neptune plan member. After hospitalizing Ms. Pfeiffer and ordering several expensive diagnostic tests to determine her condition, Dr. Cogan referred her to a specialist for further treatment. In this situation, the compensation that Dr. Cogan receives under the PCP capitation arrangement most likely includes Neptune's payment for

A.

All of the diagnostic tests that he ordered on Ms. Pfeiffer

B.

His visits to Ms. Pfeiffer while she was hospitalized

C.

The cost of the services that the specialist performed for Ms. Pfeiffer

D.

All of the above

Users of the Fulcrum Health Plan financial information include:

    The independent auditors who review Fulcrum's financial statements

    Fulcrum's controller (comptroller)

    Fulcrum's plan members

    The providers that deliver healthcare services to Fulcrum plan members

    Fulcrum's competitors

Of these users, the ones that most likely can correctly be classified as external users with a direct financial interest in Fulcrum are the

A.

Independent auditors, the plan members, the providers, and the

B.

Competitors only

C.

Independent auditors, the controller, and the providers only

D.

Controller and the competitors only

E.

Plan members and the providers only