AHM-530 Free Practice Test

- (Topic 1)
Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be

1. A. $42,857
2. B. $56,700
3. C. $272,160
4. D. $680,400

Correct Answer: C

- (Topic 1)
The actual number of providers included in a provider network may be based on staffing ratios. Staffing ratios relate the number of

1. A. Potential providers in a plan’s network to the number of individuals in the area to be served by the plan
2. B. Providers in a plan’s network to the number of enrollees in the plan
3. C. Providers outside a plan’s network to the number of providers in the plan’s network
4. D. Support staff in a plan’s network to the number of medical practitioners in the plan’s network

Correct Answer: B

- (Topic 1)
Health plans are required to follow several regulations and guidelines regarding the access and adequacy of their provider networks. The Federal Employee Health Benefits Program (FEHBP) regulations, for example, require that health plans

1. A. Allow members direct access to OB/GYN services
2. B. Allow members direct access to prescription drug services
3. C. Provide access to Title X family-planning clinics
4. D. Provide average office waiting times of no more than 30 minutes for appointments with plan providers

Correct Answer: D

- (Topic 1)
The following statements are about the inclusion of unified pharmacy benefits in health plan healthcare packages. Select the answer choice containing the correct statement.

1. A. When pharmacy benefits management is incorporated into an health plan’s operations as a unified benefit, the health plan establishes pharmacy networks, but a pharmacy benefits management (PBM) company manages their operations.
2. B. Under a unified pharmacy benefit, an health plan cannot use mail-order services to provide drugs to its members.
3. C. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs typically give health plans more control over patient access to prescription drugs.
4. D. Compared to programs that do not manage pharmacy benefits in-house, unified pharmacy benefits programs make drug therapy interventions for plan members more difficult.

Correct Answer: C

- (Topic 1)
The method that the Autumn Health Plan uses for reimbursing dermatologists in its provider network involves paying them out of a fixed pool of funds that is actuarially determined for this specialty. The amount of funds that Autumn allocates to dermatologists is based on utilization and costs of services for that discipline.
Under this reimbursement method, a dermatologist who is under contract to Autumn accumulates one point for each new referral made to the specialist by Autumn’s PCPs. If the referral is classified as complicated, then the dermatologist receives 1.5 points. The value of Autumn’s dermatology services fund for the first quarter was $15,000. During the quarter, Autumn’s PCPs made 90 referrals, and 20 of these referrals were classified as complicated.
Autumn’s method of reimbursing specialty providers can best be described as a

1. A. Disease-specific arrangement
2. B. Contact capitation arrangement
3. C. Risk adjustment arrangement
4. D. Withhold arrangement

Correct Answer: B