AHIP AHM-250 問題集

質問 1：
The following statements are about the various Health Plan Accountability Models adopted by the NAIC.
A. According to the Health Care Professional Credentialing Verification Model Act, a health plan must select all providers who meet the plan's credentialing criteria
B. The Health Carrier Grievance Procedure Model Act requires all health carriers to maintain a first-level grievance review, but it does not require any second-level review
C. Under the terms of the Health Plan Network Adequacy Model Act, all health plans would be required to hold covered persons harmless against provider collections and provide continued coverage for uncompleted treatment in the event of plan insolvency
D. The Quality Assessment and Improvement Model Act exempts closed plans from implementing a quality improvement program.
正解：C

質問 2：
Although the process is voluntary for health plans, external accreditation is becoming more and more important as states and purchasers require health plans undergo as many states and purchasers require health plans undergo some type of external review pr
A. Cannot assure that a health plan meets a specified level of quality.
B. Is voluntary for health plans.
C. Typically requires the accrediting organization to conduct a medical record review and a review of a health plan's credentialing processes, but not an evaluation of the health plans' member service systems processes.
D. Requires all change accreditation organizations to use the same standards of accreditation.
正解：B

質問 3：
For this question, select the answer choice containing the terms that correctly complete the blanks labeled A and B in the paragraph below.
NCQA offers Quality Compass, a national database of performance and accreditation information submitted by managed
A. Health Plan Employer Data and Information Set (HEDIS) mandatory
B. ORYX voluntary
C. Health Plan Employer Data and Information Set (HEDIS) voluntary
D. ORYX mandatory
正解：C

質問 4：
Calculate the hospital bed days per 1000 members for the Month to date (MTD) on 25 April, with plan membership of 25,000 and total gross hospital bed days in MTD is 300 for an XYZ Health plan?
A. 1000
B. 365
C. 480
D. 175
正解：D

質問 5：
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. The Centers for Medicare and Medicaid Services (CMS) prohibits health plans that assume Medicare risk from using the adjusted community rating (ACR) me
B. 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.
C. Standard (pure) community rating is typically used for large groups because it is the most competitive rating method for large groups.
D. 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.
正解：D

質問 6：
In order to cover some of the gap between FFS Medicare coverage and the actual cost of services, beneficiaries often rely on Medicare supplements. Which of the following statements about Medicare supplements is correct?
A. The initial ten (A-J) Medigap policies offer a basic benefit package that includes coverage for Medicare Part A and Medicare Part B coinsurance.
B. Medigap benefits vary by plan type (A through L), and are not uniform nationally.
C. Each insurance company selling Medigap must sell all the different Medigap policies.
D. Medicare SELECT is a Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part A coverage.
正解：A

質問 7：
The prudent layperson standard described in the Balanced Budget Act (BBA) of 1997 requires all hospitals that receive Medicare or Medicaid reimbursement to screen and, if necessary, stabilize all patients who come to their emergency departments.
A. False
B. True
正解：A