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Exam Code: AHM-510
Exam Name: Governance and Regulation
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Exam Code: AHM-520
Exam Name: Health Plan Finance and Risk Management
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Exam Code: AHM-530
Exam Name: Network Management
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NO.1 Federal law addresses the relationship between Medicare- or Medicaidcontracting health plans
and providers who are at "substantial financial risk."
Under federal law, Medicare- or Medicaid-contracting health plans
A. Place a provider at "substantial risk" whenever incentive arrangements put the provider at risk for
amounts in excess of 10% of his or her total potential reimbursement for providing services to
Medicare and Medicaid enrollees
B. Must provide stop-loss coverage to a provider who is placed at "substantial financial risk" for
services that the provider does not directly provide to Medicare or Medicaid enrollees
C. Both A and B
D. A only
E. B only
F. Neither A nor B
Answer: C
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NO.2 The Acorn Health Plan uses a resource-based relative value scale (RBRVS) to help determine the
reimbursement amounts that Acorn should make to providers who are compensated under an FFS
system. With regard to the advantages and disadvantages to Acorn of using RBRVS, it can correctly be
stated that
A. An advantage of using RBRVS is that it can assist Acorn in developing reimbursement schedules for
various types of providers in a comprehensive healthcare plan
B. An advantage of using RBRVS is that it puts providers who render more medical services than
necessary at financial risk for this overutilization
C. A disadvantage of using RBRVS is that it will be difficult for Acorn to track treatment rates for the
health plan's quality and cost management functions
D. A disadvantage of using RBRVS is that it rewards procedural healthcare services more than
cognitive healthcare services
Answer: A
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NO.3 The Fiesta Health Plan prices its products in such a way that the rates for its products are
reasonable, adequate, equitable, and competitive. Fiesta is using blended rating to calculate a
premium rate for the Murdock Company, a large employer. Fiesta has assigned a credibility factor of
0.6 to Murdock. Fiesta has also determined that Murdock's manual rate is $200 PMPM and that
Murdock's experience rate is $180 PMPM. Fiesta would correctly calculate that its blended rate
PMPM for Murdock should be Fiesta's retention charge plus
A. $152
B. $188
C. $192
D. $228
Answer: B
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NO.4 One true statement about cash-basis accounting is that
A. Cash receipt, but not cash disbursement, is an important component of cash-basis accounting
B. Most companies use a pure cash-basis accounting system
C. Cash-basis accounting records revenue according to the realization principle and expenses
according to the matching principle
D. Health insurance companies and health plans that fall under the jurisdiction of state insurance
commissioners must report some items on a cash basis for statutory reporting purposes
Answer: D
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NO.5 Several federal agencies establish rules and requirements that affect health plans. One of these
agencies is the Department of Labor (DOL), which is primarily responsible for _________.
A. Issuing regulations pertaining to the Health Insurance Portability and Accountability Act (HIPAA) of
1996
B. Administering the Medicare and Medicaid programs
C. Administering ERISA, which imposes various documentation, appeals, reporting, and disclosure
requirements on employer group health plans
D. Administering the Federal Employees Health BenefitsProgram (FEHBP), which providesvoluntary
health insurance coverage to federal employees, retirees, and dependents
Answer: C
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NO.6 The following information was presented on one of the financial statements prepared by the
Rouge health plan as of December 31, 1998:
When calculating its cash-to-claims payable ratio, Rouge would correctly divide its:
A. Cash by its reported claims only
B. Cash by its reported claims and its incurred but not reported claims (IBNR)
C. Reported claims by its cash
D. Reported claims and its incurred but not reported claims (IBNR) by its cash
Answer: B
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NO.7 The sentence below contains two pairs of words enclosed in parentheses. Determine which
word in each pair correctly completes the statement. Then select the answer choice containing the
two words that you have chosen. Purchasing stop-loss coverage most likely (increases / reduces) a
health plan's underwriting risk and (increases / reduces) the health plan's affiliate risk.
A. increases / increases
B. increases / reduces
C. reduces / increases
D. reduces / reduces
Answer: C
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NO.8 The Lindberg Company has decided to terminate its group healthcare coverage with the Benson
Health Plan. Lindberg has several former employees who previously experienced qualifying events
that caused them to lose their group coverage. One federal law allows these former employees to
continue their group healthcare coverage. From the answer choices below, select the response that
correctly identifies the federal law that grants these individuals with the right to continue group
healthcare coverage, as well as the entity which is responsible for continuing this coverage:
A. Federal law: Consolidated Omnibus Budget Reconciliation Act (COBRA) Entity: Lindberg
B. Federal law: Consolidated Omnibus Budget Reconciliation Act (COBRA) Entity: Benson
C. Federal law: Employee Retirement Income Security Act (ERISA) Entity: Lindberg
D. Federal law: Employee Retirement Income Security Act (ERISA) Entity: Benson
Answer: A
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