AHIP Certification

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Question 1:

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. Each insurance company selling Medigap must sell all the different Medigap policies.

C. Medicare SELECT is a Medicare supplement that uses a preferred provider organization (PPO) to supplement Medicare Part A coverage.

D. Medigap benefits vary by plan type (A through L), and are not uniform nationally.

Correct Answer: A

Question 2:

From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence

A. Health plans and their providers are obligated not to harm their members

B. Health plans and their providers should treat each member in a manner that respects the member\’s goals and values, and they also have a duty to promote the good of the members as a group

C. Health plans and their providers should allocate resources in a way that fairly distributes benefits and burdens among the members

D. Health plans and their providers have a duty to respect the right of their members to make decisions about the course of their lives

Correct Answer: B

Question 3:

Dr. Julia Phram is a cardiologist under contract to Holcomb HMO, Inc., a typical closed- panel plan. The following statements are about this situation. Select the answer choice containing the correct statement.

A. All members of Holcomb HMO must select Dr. Phram as their primary care physician (PCP).

B. Any physician who meets Holcomb\’s standards of care is eligible to contract with Holcomb HMO as a provider.

C. Dr. Phram is either an employee of Holcomb HMO or belongs to a group of physicians that has contracted with Holcomb HMO

D. Holcomb HMO plan members may self-refer to Dr. Phram at full benefits without first obtaining a referral from their PCPs.

Correct Answer: A

Question 4:

As part of its quality management program, the Lyric Health Plan regularly compares its practices and services with those of its most successful competitor. When Lyric concludes that its competitor\’s practices or services are better than its own, Lyric im

A. Benchmarking.

B. Standard of care.

C. An adverse event.

D. Case-mix adjustment.

Correct Answer: A

Question 5:

Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim

A. A, B, C, and D

B. A and C only

C. A, B, and D only

D. B, C, and D only

Correct Answer: A

Question 6:

During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, fo

A. the angina, the high blood pressure, and the broken ankle

B. the angina and the high blood pressure only

C. none of these conditions D. the broken ankle only

Correct Answer: A

Question 7:

A physician-hospital organization (PHO) may be classified as an open PHO or a closed PHO. With respect to a closed PHO, it is correct to say that

A. the specialists in the PHO are typically compensated on a capitation basis

B. the specialists in the PHO are typically compensated on a capitation basis

C. it typically limits the number of specialists by type of specialty

D. it is available to a hospital\’s entire eligible medical staff

E. physician membership in the PHO is limited to PCPs

Correct Answer: B

Question 8:

All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.

A. True

B. False

Correct Answer: A

Question 9:

Ed O\’Brien has both Medicare Part A and Part B coverage. He also has coverage under a PBM plan that uses a closed formulary to manage the cost and use of pharmaceuticals. Recently, Mr. O\’Brien was hospitalized for an aneurysm. Later, he was transferred by

A. Confinement in the extended-care facility after his hospitalization.

B. Transportation by ambulance from the hospital to the extended-care facility.

C. Physicians\’ professional services while he was hospitalized.

D. physicians\’ professional services while he was at the extended-care facility.

Correct Answer: A

Question 10:

In accounting terminology, the items of value that a company owns–such as cash, cash equivalents, and receivables–are generally known as the company\’s

A. revenue

B. net income

C. surplus

D. assets

Correct Answer: D

Question 11:

In order to help review its institutional utilization rates, the Sahalee Medical Group, a health plan, uses the standard formula to calculate hospital bed days per 1,000 plan members for the month to date (MTD). On April 20, Sahalee used the following inf

A. 67

B. 274

C. 365

D. 1,000

Correct Answer: B

Question 12:

In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member\’s medical care.

A. Such intervention can be based on the results of

B. Prospective review

C. Concurrent review

A. A, B, and C

B. A and B only

C. A and C only

D. B only

Correct Answer: B

Question 13:

Identify the CORRECT statement(s):


Smaller the group, the more likely it is that the group will experience losses similar to the average rate of loss that was predicted.


Gender of the group\’s participants has no effect on the likelihood of loss.


All of the listed options


B and C


None of the listed options


A and C

Correct Answer: C

Question 14:

Beginning in the early 1980s, several factors contributed to increased demand for behavioral healthcare services. These factors included

A. increased stress on individuals and families

B. increased availability of behavioral healthcare services

C. greater awareness and acceptance of behavioral healthcare issues

D. all of the above

Correct Answer: D

Question 15:

In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of anti selection. Anti selection can correctly be defined as the

A. inability of a proposed insured to share with the insurer the financial risks of healthcare coverage

B. possibility that a proposed insured will profit from an illness by receiving benefits that exceed the total amount of his or her eligible medical expenses

C. inability of a proposed insured to provide sufficient evidence that proves he or she is an insurable risk

D. tendency of people who have a greater-than-average likelihood of loss to apply for or continue insurance protection to a greater extent than people who have an average or less than average likelihood of the same loss

Correct Answer: D