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  • Exam Name: Governance and Regulation
  • Last Update: 18-May-2024
  • Questions and Answers: 76
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AHM-510 Questions and Answers

Question # 1

Health plans should monitor changes in the environment and emerging trends, because changes in society will affect the managed care industry. One true statement regarding recent changes in the environment in which health plans operate is that

A.

Women as a group receive more healthcare and interact more often with health plans than do men over the course of a lifetime

B.

The focus of healthcare during the past decade has shifted away from outpatient care to inpatient hospital treatment

C.

The uninsured population in the United States has been decreasing in recent years

D.

The decline in overall inflation in the 1990s failed to slow the growth in healthcare inflation

Question # 2

There are several approaches to the interagency division of responsibility for managed care entity (MCE) oversight. In State M, the state Medicaid agency, the state department of health, and the state insurance department are all responsible for ensuring that quality improvement programs are in place among the same group of MCEs and that these programs meet each agency's rules and regulations for such programs. This information indicates that State M uses the approach known as the

A.

Parallel model

B.

Shared model

C.

Concurrent model

D.

PACE model

Question # 3

The Opal Health Plan complies with all of the provisions of the Newborns' and Mothers' Health Protection Act of 1996 (NMHPA). Samantha Hill and Debra Chao are Opal enrollees. Ms. Hill was hospitalized for a cesarean birth, and Ms. Chao was hospitalized for a normal delivery. From the following answer choices, select the response that indicates the minimum hospital stay for which Opal, under NMHPA, must provide benefits for Ms. Hill and Ms. Chao.

A.

Ms. Hill: 72 hours; Ms. Chao: 24 hours

B.

Ms. Hill: 72 hours; Ms. Chao: 48 hours

C.

Ms. Hill: 96 hours; Ms. Chao: 24 hours

D.

Ms. Hill: 96 hours; Ms. Chao: 48 hours

Question # 4

Health maintenance organizations (HMOs) seeking federal qualification under the HMO Act of 1973 and its amendments must meet requirements in four basic operational areas. One operational requirement for qualification is that an HMO must

A.

Ensure that at least 1/3 of its policy-making body is comprised of HMO members

B.

Ensure that there is adequate representation of underserved communities on its policy-making body

C.

Have an ongoing quality assurance program that meets the requirements of the Centers for Medicaid & Medicare Services (CMS), stresses health outcomes, and provides for review by health professionals

D.

Test, safeguard, and promote quality of care by following detailed programmatic techniques that are explained in CMS's Federally Qualified HMO (FQHMO) Manual

Question # 5

Antitrust laws can affect the formation, merger activities, or acquisition initiatives of a health plan. In the United States, the two federal agencies that have the primary responsibility for enforcing antitrust laws are the

A.

Internal Revenue Service (IRS) and the Department of Justice (DOJ)

B.

Office of Inspector General (OIG) and the Department of Defense (DOD)

C.

Federal Trade Commission (FTC) and the Department of Labor (DOL)

D.

Federal Trade Commission (FTC) and the Department of Justice (DOJ)

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