Free AHM-530 Exam Braindumps

- (Topic 2)
As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must

1. A. Allow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider
2. B. Base a provider’s participation in the network, reimbursement, and indemnification levels on the provider’s license or certification
3. C. Define its service area according to community patterns of care
4. D. Require enrollees to obtain prior authorization for all emergency or urgently needed services

Correct Answer: C

- (Topic 2)
There are several approaches to providing Medicaid health plan. One such approach involves the use of organizations who contract with the state’s Medicaid agency to provide primary care as well as administrative services. These organizations are known as

1. A. Enrollment brokers
2. B. Primary care case managers (PCCMs)
3. C. Certified medical assistants (CMAs)
4. D. Prepaid health plans (PHPs)

Correct Answer: B

- (Topic 2)
The following statements are about the organization of network management functions of health plans. Select the answer choice containing the correct response:

1. A. Compared to a large health plan, a small health plan typically has more integration among its network management activities and less specialization of roles.
2. B. It is usually more efficient to have a large health plan's provider relations representatives located in the health plan's corporate headquarters rather than based in regional locations that are close to the provider offices the representatives cover.
3. C. An health plan's provider relations representatives are usually responsible for conducting an initial orientation of providers and educating providers about health plan developments, rather than recruiting and assisting with the selection of new providers.
4. D. In general, a health plan that uses a centralized approach for some of its network management activities should not use a decentralized approach for other network management activities.

Correct Answer: A

- (Topic 2)
Partial capitation is one common approach to capitation. One typical characteristic of partial capitation is that it:

1. A. Includes only primary care services
2. B. Covers such services as immunizations and laboratory tests
3. C. Can be used only if the provider's panel size is less than 50 providers
4. D. Covers such services as cardiology and orthopedics

Correct Answer: A

- (Topic 1)
In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which increased the continuity and portability of health insurance coverage. One statement that can correctly be made about HIPAA is that it

1. A. Applies to group health insurance plans only
2. B. Limits the length of a health plan’s pre-existing condition exclusion period for a previously covered individual to a maximum of six months after enrollment.
3. C. Guarantees access to healthcare coverage for small businesses and previously covered individuals who meet specified eligibility requirements.
4. D. Guarantees renewability of group and individual health coverage, provided the insureds are still in good health

Correct Answer: C