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AHM-520 Exam Dumps - Health Plan Finance and Risk Management

Question # 4

The following statements are about 501(c)(9) trusts. Select the answer choice containing the correct statement:

A.

In the event a 501(c)(9) trust is terminated, any funds remaining in the trust revert back to the employer.

B.

In order to satisfy Internal Revenue Code (IRC) requirements, membership in a 501(c)(9) trust is mandatory for all employees.

C.

Contributions made by an employer to a 501(c)(9) trust are deductible for federal income tax purposes.

D.

Typically, a 501(c)(9) trust is controlled solely by the employer that established the trust.

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Question # 5

Juan Ramirez, a licensed social worker, and Dr. Laura Lui, a licensed psychiatrist, are under contract to the Peninsula Health Plan. Peninsula has contracted with CMS to provide services to Medicare and Medicaid beneficiaries. Both Mr. Ramirez and Dr. Lui provide the same type of counseling services to Peninsula's enrollees. With respect to amendments made to the Balanced Budget Act (BBA) of 1997 that impact provider reimbursement, the amount by which Peninsula will reimburse Mr. Ramirez will be equal to:

A.

50% of Dr. Lui's reimbursement

B.

75% of Dr. Lui's reimbursement

C.

90% of Dr. Lui's reimbursement

D.

100% of Dr. Lui's reimbursement

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Question # 6

Mandated benefit laws are state or federal laws that require health plans to arrange for the financing and delivery of particular benefits. Ways that mandated benefits have the potential to influence health plans include:

1. Causing a lower degree of uniformity among health plans of competing health plans in a given market

2. Increasing the cost of the benefit plan to the extent that the plan must cover mandated benefits that would not have been included in the plan in the absence of the law or regulation that mandates the benefits

A.

Both 1 and 2

B.

1 only

C.

2 only

D.

Neither 1 nor 2

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Question # 7

Dr. Martin Cassini is an obstetrician who is under contract with the Bellerby Health Plan. Bellerby compensates Dr. Cassini for each obstetrical patient he sees in the form of a single amount that covers the costs of prenatal visits, the delivery itself, and post-delivery care . This information indicates that Dr. Cassini is compensated under the provider reimbursement method known as a:

A.

global fee

B.

relative value scale

C.

unbundling

D.

discounted fee-for-service

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Question # 8

The Column health plan is in the process of developing a strategic plan.

The following statements are about this strategic plan. Three of the statements are true, and one statement is false. Select the answer choice containing the FALSE statement.

A.

Human resources most likely will be a critical component of Column's strategic plan because, in health plan markets, the size and the quality of a health plan's provider network is often more important to customers than are the details of a product's benefit design.

B.

Column's strategic plan should only address how the health plan will differentiate its products, rather than where and how it will sell these products.

C.

Column most likely will need to develop contingency plans to address the need to make adjustments to its original strategic plan.

D.

Column's information technology (IT) strategy most likely will be a critical element in successfully implementing the health plan's strategic plan.

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Question # 9

The Longview Hospital contracted with the Carlyle Health Plan to provide inpatient services to Carlyle’s enrolled members. Carlyle provides Longview with a type of stop-loss coverage that protects, on a claims incurred and paid basis, against losses arising from significantly higher than anticipated utilization rates among Carlyle’s covered population. The stop-loss coverage specifies an attachment point of 130% of Longview’s projected $2,000,000 costs of treating Carlyle plan members and requires Longview to pay 15% of any costs above the attachment point. In a given plan year, Longview incurred covered costs totaling $3,000,000.

With regard to the type of stop-loss coverage provided to Longview by Carlyle and to whether this coverage is classified as insurance or reinsurance, the risk transfer approach used in this situation can be described as:

A.

aggregate stop-loss reinsurance

B.

aggregate stop-loss insurance

C.

specific stop-loss reinsurance

D.

specific stop-loss insurance

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Question # 10

The types of financial risks and costs to which a health plan is subject depends on whether the health plan provides services to the Medicare and/or Medicaid populations or to the commercial population. One distinction between providing services to the Medicare and Medicaid populations and to the commercial population is that Medicare and Medicaid enrollees typically:

A.

Are locked into a plan for a 12-month period, whereas enrollees from the commercial population may disenroll from a plan on a monthly basis

B.

Require less enrollee education than do enrollees from the commercial population

C.

Have higher incidences of chronic illness than do enrollees from the commercial population

D.

Are enrolled in a health plan through a group situation, whereas the commercial population typically enrolls in a health plan on an individual basis

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Question # 11

The following statements are about a health plan's underwriting of small groups. Select the answer choice containing the correct statement.

A.

Almost all states prohibit health plan s from rejecting a small group because of the nature of the business in which the small business is engaged.

B.

Most states prohibit health plans from setting participation levels as a requirement for coverage, even when coverage is otherwise guaranteed issue.

C.

In underwriting small groups, a health plan's underwriters typically consider both the characteristics of the group members and of the employer.

D.

Generally, a health plan's underwriters require small employers to contribute at least 80% of the cost of the healthcare coverage.

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Question # 12

The Caribou health plan is a for-profit organization. The financial statements that Caribou prepares include balance sheets, income statements, and cash flow statements. To prepare its cash flow statement, Caribou begins with the net income figure as reported on its income statement and then reconciles this amount to operating cash flows through a series of adjustments. Changes in Caribou's cash flow occur as a result of the health plan's operating activities, investing activities, and financing activities.

The basic formula for Caribou's income statement is

A.

Cash Inflows – Cash Outflows = Net Cash Inflow (Outflow)

B.

Revenues – Expenses = Net Income (Net Loss)

C.

Sources of Funds – Uses of Funds = Net Change in Cash

D.

Assets = Liabilities + Owners' Equity

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Question # 13

A key factor that distinguishes the various types of health plans is the type and amount of risk that a health plan assumes with respect to the delivery and financing of healthcare benefits. An example of a type of health plan that typically assumes the financial risk of delivering and financing healthcare benefits is a

A.

Third party administrator (TPA)

B.

Utilization review organization (URO)

C.

Preferred provider organization (PPO)

D.

Pharmacy benefit management (PBM) plan

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Question # 14

The Newfeld Hospital has contracted with the Azalea Health Plan to provide inpatient services to Azalea's enrolled members. The contract calls for Azalea to provide specific stop-loss coverage to Newfeld once Newfeld's treatment costs reach $20,000 per case and for Newfeld to pay 20% of the next $50,000 of expenses for this case. After Newfeld's treatment costs on a case reach $70,000, Azalea reimburses the hospital for all subsequent treatment costs.

The maximum amount for which Newfeld is at risk for any one Azalea plan member's treatment costs is

A.

$10,000

B.

$14,000

C.

$30,000

D.

$34,000

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Question # 15

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

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Question # 16

The following statements illustrate common forms of capitation:

1. The Antler Health Plan pays the Epsilon Group, an integrated delivery system (IDS), a capitated amount to provide substantially all of the inpatient and outpatient services that Antler offers. Under this arrangement, Epsilon accepts much of the risk that utilization rates will be higher than expected. Antler retains responsibility for the plan's marketing, enrollment, premium billing, actuarial, underwriting, and member services functions.

2. The Bengal Health Plan pays an independent physician association (IPA) a capitated amount to provide both primary and specialty care to Bengal's plan members. The payments cover all physician services and associated diagnostic tests and laboratory work. The physicians in the IPA determine as a group how the individual physicians will be paid for their services.

From the following answer choices, select the response that best indicates the form of capitation used by Antler and Bengal.

A.

Antler = subcapitation

Bengal = full-risk capitation

B.

Antler = subcapitation

Bengal = full professional capitation

C.

Antler = global capitation

Bengal = subcapitation

D.

Antler = global capitation

Bengal = full professional capitation

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Question # 17

For each of its products, the Wisteria Health Plan monitors the provider reimbursement trend and the residual trend. One true statement about these trends is that

A.

The provider reimbursement trend probably is more difficult for Wisteria to quantify than is the residual trend

B.

Wisteria's residual trend is the difference between the total trend and the portion of the total trend caused by changes in Wisteria's provider reimbursement levels

C.

The residual trend most likely has more impact on Wisteria's total trend than does the provider reimbursement trend

D.

An example of a residual trend would be a 5% increase in the capitation rate paid to a PCP by Wisteria

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Question # 18

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

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Question # 19

The Cardinal health plan complies with all of the provisions of HIPAA.

Cardinal has received requests for healthcare coverage from the following companies that meet the statutory definition of a small group:

  • The Xavier Company has excellent claims experience
  • The Youngblood Company has not previously offered group healthcare coverage to its employees
  • The Zebulon Company has poor claims experience

According to HIPAA's provisions, Cardinal must issue a healthcare contract to

A.

Xavier, Youngblood, and Zebulon

B.

Xavier and Youngblood only

C.

Xavier only

D.

None of these companies

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Question # 20

The accounting department of the Enterprise health plan adheres to the following policies:

  • Policy A—Report gains only after they actually occur
  • Policy B—Report losses immediately
  • Policy C—Record expenses only when they are certain
  • Policy D—Record revenues only when they are certain

Of these Enterprise policies, the ones that are consistent with the accounting principle of conservatism are Policies

A.

A, B, C, and D

B.

A, B, and D only

C.

A and B only

D.

C and D only

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Question # 21

Kevin Olin applied for individual healthcare coverage from the Mercury health plan. Before issuing the policy, Mercury's underwriters attached a rider that excludes from coverage any loss that results from Mr. Olin's chronic knee problem. This information indicates that Mr. Olin's policy includes

A.

a moral hazard rider

B.

an essential plan rider

C.

an impairment rider

D.

an insurable interest rider

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Question # 22

This concept, which is an extension of the going-concern concept, holds that the value of an asset that a company reports in its accounting records should be the asset's historical cost, not its current market value. Although this concept offers objectivity and reliability, it may lack relevance, particularly for assets held for a long period of time.

From the following answer choices, choose the name of the accounting concept that matches the description.

A.

Measuring-unit concept

B.

Full-disclosure concept

C.

Cost concept

D.

Time-period concept

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Question # 23

As part of the first step in its strategic planning process, the Trout health plan developed the following statements:

  • Statement A—Trout will deliver quality healthcare to our customers at a reasonable cost.
  • Statement B—Within five years, Trout will be recognized as the industry leader in all of our markets.

Statement A can best be described as a

A.

Vision statement, and Statement B also can best be described as a vision statement

B.

Vision statement, whereas Statement B can best be described as a mission statement

C.

Mission statement, whereas Statement B can best be described as a vision statement

D.

Mission statement, and Statement B also can best be described as a mission statement

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Question # 24

The following statement(s) can correctly be made about a health plan's underwriting of small groups:

A.

Typically, a health plan medically underwrites both the employees of a small group and their dependents, even though small group reform laws prohibit health plans from singling out individuals for rejection or substandard rate-ups.

B.

In the absence of laws mandating otherwise, a health plan's underwriting standards grow stricter as group size gets smaller.

C.

Both A and B

D.

A only

E.

B only

F.

Neither A nor B

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Question # 25

Under the doctrine of corporate negligence, a health plan and its physician administrators may be held directly liable to patients or providers for failing to investigate adequately the competence of healthcare providers whom it employs or with whom it contracts, particularly where the health plan actually provides healthcare services or restricts the patient's/enrollee's choice of physician.

A.

True

B.

False

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Question # 26

Costs that can be defined by behavior are most commonly classified as fixed costs, variable costs and semi-variable costs. Examples of fixed costs include:

A.

Rent, insurance expense, and depreciation on computer equipment

B.

Rent, claims processing costs, and selling expenses

C.

Claims processing costs, telephone expense, and depreciation on computer equipment

D.

Premium processing, rent, and selling expenses

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Question # 27

A financial analyst wants to learn the following information about the

Forest health plan for a given financial period:

A.

Forest's beginning-of-period cash balance

B.

Forest's minimum cash balance

C.

The cash needs of Forest during the period

D.

Forest's end-of-period cash balance

From Forest's cash budget, the analyst most likely can obtain information about

E.

A, B, C, and D

F.

A, B, and C only

G.

A and D only

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Question # 28

The Wallaby Health Plan purchased an asset two years ago for $50,000. At the time of purchase, the asset had an appraised value of $52,000. The asset carries a value on Wallaby’s general ledger of $47,000, and its current market value is $80,000. According to the cost concept, Wallaby would report on its financial statements a value for this asset equal to:

A.

$47,000

B.

$50,000

C.

$52,000

D.

$80,000

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Question # 29

In a comparison of small employer-employee groups to large employer-employee groups, it is correct to say that small employer-employee groups tend to:

A.

More closely follow actuarial predictions with respect to morbidity rates

B.

Generate more administrative expenses as a percentage of the total premium amount the group pays

C.

Have less frequent and smaller claims fluctuations

D.

Expose an health plan to a lower risk of anti selection

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Question # 30

In evaluating the claims experience during a given rating period of the Lucky Company, the Calaway Health Plan determined that the claims incurred by Lucky were lower than Calaway anticipated when it established Lucky’s premium rate for the rating period. Calaway, therefore, refunded a portion of Lucky’s premium to reflect the better-than-anticipated claims experience. This rating method is known as:

A.

durational rating

B.

retrospective experience rating

C.

blended rating

D.

prospective experience rating

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Question # 31

The Sesame health plan uses a method of accumulating cost data that enables the health plan to satisfy financial reporting requirements for compiling financial statements and corporate tax returns. Although this method assists Sesame's managers in studying which types of costs are rising and falling over time, it does not explain which areas of Sesame incur each cost. This method, which is the most basic level of cost accumulation, is known as accumulating costs by

A.

Cost center

B.

Type of cost

C.

Lines of business

D.

Function

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Question # 32

The Poplar Company and a Blue Cross/Blue Shield organization have contracted to provide a typical fully funded health plan for Poplar's employees. One true statement about this health plan for Poplar's employees is that

A.

Poplar bears the entire financial risk if, during a given period, the dollar amount of services rendered to Poplar plan members exceeds the dollar amount of premiums collected for this health plan

B.

Poplar and the Blue Cross/Blue Shield organization share the financial risk of paying for claims under Poplar's health plan

C.

The Blue Cross/Blue Shield organization, upon acceptance of a premium, becomes the group plan sponsor for Poplar's health plan

D.

The Blue Cross/Blue Shield organization, upon acceptance of a premium, bears the entire financial risk of paying for the administrative expenses associated with health plan operations

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