AHIP AHM-510 問題集

質問 1：
Several states have adopted clinical practice guidelines for treating workers' compensation injuries. Clinical practice guidelines can best be described as
A. Detailed plans of medical treatment designed to facilitate a patient's return to the workplace
B. Fee schedules that specify the maximum amount providers may charge for treating workers' compensation patients
C. A utilization management and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific case
D. Payment practices that might technically violate the provisions of the anti-kickback statute but that will not be considered illegal and for which providers and health plans will not be subject to penalties
正解：C

質問 2：
After conducting a business portfolio analysis, the Acorn Health Plan decided to pursue a harvest strategy with one of its strategic business units (SBUs)-Guest Behavioral Healthcare. By following a harvest strategy with Guest, Acorn most likely is seeking to
A. Maintain Guest's market position
B. Sacrifice immediate earnings in order to fund Guest's growth
C. Increase Guest's market share
D. Maximize Guest's short-term earnings and cash flow
正解：D

質問 3：
Indigo Health Plan advertised a specific individual health insurance policy through a direct mail advertisement that provided detailed information about the product. In order to comply with theNAIC Model Rules Governing Advertisements of Accident and Sickness Insurance, Indigo must disclose whether the advertised policy contains any exceptions, reductions, or
limitations. Thus, Indigo disclosed in the advertisement that one policy provision limits coverage for dental exams to $50 per exam and to one exam per calendar year. This information indicates that, with respect to the definitions in the NAIC Model Rules, Indigo's advertisement is an example of an
A. Invitation to contract, and it discloses a policy provision known as a reduction
B. Invitation to contract, and it discloses a policy provision known as an exception
C. Invitation to inquire, and it discloses a policy provision known as an exception
D. Invitation to inquire, and it discloses a policy provision known as a reduction
正解：A

質問 4：
Greenpath Health Services, Inc., an HMO, recently terminated some providers from its network in response to the changing enrollment and geographic needs of the plan. A provision in Greenpath's contracts with its healthcare providers states that Greenpath can terminate the contract at any time, without providing any reason for the termination, by giving the other party a specified period of notice.
The state in which Greenpath operates has an HMO statute that is patterned on the NAIC HMO Model Act, which requires Greenpath to notify enrollees of any material change in its provider network. As required by the HMO Model Act, the state insurance department is conducting an examination of Greenpath's operations. The scope of the on-site examination covers all aspects of Greenpath's market conduct operations, including its compliance with regulatory requirements.
The contracts between Greenpath and its healthcare providers contain a termination provision known as
A. A 'without cause' termination provision
B. An 'economic credentialing' termination provision
C. A 'fair procedure' termination provision
D. A 'breach of contract' termination provision
正解：A

質問 5：
Some health plans qualify as tax-exempt organizations under Sections 501(c)(3) and 501(c)(4) of the Internal Revenue Code. One true statement regarding a health plan that qualifies as a 501(c)(4) social welfare organization, in comparison to a health plan that qualifies as a 501(c)(3) charitable organization, is that a
A. 501(c)(4) social welfare organization is allowed to distribute profits for the benefit of individuals, whereas a 501(c)(3) charitable organization can use surplus only for the benefit of the organization, the community, or a charity
B. 501(c)(4) social welfare organization can raise operating funds through the sale of tax-exempt bonds, whereas a 501(c)(3) charitable organization does not have this advantage
C. 501(c)(4) exemption is easier to obtain than a 501(c)(3) exemption, because 501(c)(4) social welfare organizations are allowed to benefit a comparatively smaller group of individuals
D. 501(c)(4) social welfare organization has less flexibility in determining use of funds for social or political activities than does a 501(c)(3) charitable organization
正解：C

質問 6：
Third party administrators (TPAs) provide various administrative services to health plans or groups that provide health benefit plans to their employees or members. Many state laws that regulate TPAs are based on the NAIC Third Party Administrator Model Statute. One provision of the TPA Model Law is that it
A. Requires TPAs to notify the state insurance department immediately following any material change in the TPA's ownership or control
B. Prohibits TPAs from entering into an agreement under which the amount of the TPA's compensation is based on the amount of premium or charges the TPA collects
C. Requires TPAs, upon the termination of a TPA agreement with a group, to immediately transfer all its records relating to the group to the new administrator
D. Prohibits TPAs from performing insurance functions such as underwriting and claims processing
正解：A