AHIP Final Test UPDATED ACTUAL Exam Questions and
CORRECT Answers (Complete Verified Answers)
Question 1.
Insurer vs Insured
Correct Answer: - insurer is a company that provides plan - insured are the
people that buy into the plan
Question 2.
Group health insurance
Correct Answer: Health coverage provided by employers to members of a
group.
Question 3.
Group health insurance - types of coverage
Correct Answer: You can choose among several or just one depending on your
employer * dental, vision, medical benefits, managed care, fee-for-service
insurance - dental: * basic/preventative services, restorative services,
comprehensive or stand-alone, ACA (children, some adults) - vision: * basic
exams and prescription glasses, ACA (children, some adults)
^ both are employer-sponsored voluntary group plans
Question 4.
Premium tax-credit
Correct Answer: a subsidy that reduces the amount that consumers must pay *
tax credit that will lower monthly premium based on income and household
info * advanced premium tax-credit (aptc)
Question 5.
self employed workers
Correct Answer: can deduct health insurance premiums from their federal
taxable income - important tax savings
Question 6.
contracts/health insurance policy
Correct Answer: between insurer and insured - consideration: specifically
termed agreement w/ promise to do something in return for a valuable benefit
(employer/insured premium payments to the insurer)
,Question 7.
Covered services
Correct Answer: insurance policy will clearly state their covered services and
their exlusions - proactive, preventative, and reactive services
Question 8.
cost-sharing
Correct Answer: a situation where insured individuals pay a portion of the
healthcare costs, such as deductibles, coinsurance or co-payments - insured is
reimbursed for some but not all of the costs - reimbursement depends on
policy
Question 9.
Deductible/coinsurance
Correct Answer: Money paid out of pocket before insurance covers the
remaining costs. % of medical bill that insured pays out of pocket
Question 10.
copay
Correct Answer: a fixed fee you pay for specific medical services
Question 11.
government sponsored plans
Correct Answer: federal and state gov * medicare and medicaid - medicare -->
65+ or younger w/ disabilities or severe kidney problems - medicaid -->
low-income individuals
Question 12.
employer sponsored plans
Correct Answer: - employer determines coverage - company's HR dept
answers employee questions
Question 13.
excluded services
Correct Answer: services not covered in a medical insurance contract like
experimental or non-contracted providers, elective or cosmetic surgery
, Question 14.
Health Care Philosophy
Correct Answer: * good quality = cost effective - more expensive does not
mean good healthcare * cost vs care balance - good benefits priced
appropriately * less cost, more quality
triangle --> cost, access, quality
*more medical care does not mean better outcomes
Question 15.
managed care improves cost/access/quality
Correct Answer: cost: limited provider networks, inventing new ways to pay
physicians, requiring referrals for specialty care
quality: credentialing providers, evidence-based medical policies, grading
providers on their quality outcomes, comparing providers to their peers
access: reigning in premium increases and reducing unnecessary care to make
additional provider time available
Question 16.
annual increase in premiums
Correct Answer: - result from consumer/government limitations placed on
managed care - other factors: higher provider fees, increased use of tech in
delivery of care, health care fraud and other admin costs
Question 17.
Provider network
Correct Answer: * to assure quality/cost control and addressing population
health issues
1. closed network (specific providers)
2. open network (not set of providers)
3. defined network w/ out-of-network coverage (specific providers but any
out-of-network services = larger portion of costs)
quality control - credentialing providers (Verify and review licenses to avoid
malpractices)
cost control - negotiate fee payments w/ in-network providers = high patient
volume for lower per-unit costs * makes costs of plans more predictable
addressing population health issues - focus network on certain population
issues such as obesity - providers do this w/ communication or w/
action/outcome based payment incentives
Question 18.
4 most common functions preformed by health plan medical departments
CORRECT Answers (Complete Verified Answers)
Question 1.
Insurer vs Insured
Correct Answer: - insurer is a company that provides plan - insured are the
people that buy into the plan
Question 2.
Group health insurance
Correct Answer: Health coverage provided by employers to members of a
group.
Question 3.
Group health insurance - types of coverage
Correct Answer: You can choose among several or just one depending on your
employer * dental, vision, medical benefits, managed care, fee-for-service
insurance - dental: * basic/preventative services, restorative services,
comprehensive or stand-alone, ACA (children, some adults) - vision: * basic
exams and prescription glasses, ACA (children, some adults)
^ both are employer-sponsored voluntary group plans
Question 4.
Premium tax-credit
Correct Answer: a subsidy that reduces the amount that consumers must pay *
tax credit that will lower monthly premium based on income and household
info * advanced premium tax-credit (aptc)
Question 5.
self employed workers
Correct Answer: can deduct health insurance premiums from their federal
taxable income - important tax savings
Question 6.
contracts/health insurance policy
Correct Answer: between insurer and insured - consideration: specifically
termed agreement w/ promise to do something in return for a valuable benefit
(employer/insured premium payments to the insurer)
,Question 7.
Covered services
Correct Answer: insurance policy will clearly state their covered services and
their exlusions - proactive, preventative, and reactive services
Question 8.
cost-sharing
Correct Answer: a situation where insured individuals pay a portion of the
healthcare costs, such as deductibles, coinsurance or co-payments - insured is
reimbursed for some but not all of the costs - reimbursement depends on
policy
Question 9.
Deductible/coinsurance
Correct Answer: Money paid out of pocket before insurance covers the
remaining costs. % of medical bill that insured pays out of pocket
Question 10.
copay
Correct Answer: a fixed fee you pay for specific medical services
Question 11.
government sponsored plans
Correct Answer: federal and state gov * medicare and medicaid - medicare -->
65+ or younger w/ disabilities or severe kidney problems - medicaid -->
low-income individuals
Question 12.
employer sponsored plans
Correct Answer: - employer determines coverage - company's HR dept
answers employee questions
Question 13.
excluded services
Correct Answer: services not covered in a medical insurance contract like
experimental or non-contracted providers, elective or cosmetic surgery
, Question 14.
Health Care Philosophy
Correct Answer: * good quality = cost effective - more expensive does not
mean good healthcare * cost vs care balance - good benefits priced
appropriately * less cost, more quality
triangle --> cost, access, quality
*more medical care does not mean better outcomes
Question 15.
managed care improves cost/access/quality
Correct Answer: cost: limited provider networks, inventing new ways to pay
physicians, requiring referrals for specialty care
quality: credentialing providers, evidence-based medical policies, grading
providers on their quality outcomes, comparing providers to their peers
access: reigning in premium increases and reducing unnecessary care to make
additional provider time available
Question 16.
annual increase in premiums
Correct Answer: - result from consumer/government limitations placed on
managed care - other factors: higher provider fees, increased use of tech in
delivery of care, health care fraud and other admin costs
Question 17.
Provider network
Correct Answer: * to assure quality/cost control and addressing population
health issues
1. closed network (specific providers)
2. open network (not set of providers)
3. defined network w/ out-of-network coverage (specific providers but any
out-of-network services = larger portion of costs)
quality control - credentialing providers (Verify and review licenses to avoid
malpractices)
cost control - negotiate fee payments w/ in-network providers = high patient
volume for lower per-unit costs * makes costs of plans more predictable
addressing population health issues - focus network on certain population
issues such as obesity - providers do this w/ communication or w/
action/outcome based payment incentives
Question 18.
4 most common functions preformed by health plan medical departments
