AHM-540 : AHM Medical Management Exam

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Medical
AHM-540
AHM Medical Management
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QUESTION: 155
The following statements are about chronic and disabling conditions among children eligible
for Medicaid. Three of the statements are true and one is false. Select the answer choice
containing the FALSE statement.
A. Children with chronic conditions use more physician and nonphysician professional
services than do children in the general population.
B. The majority of chronic conditions affecting children in Medicaid programs are the same
as those affecting children in the general population.
C. Medicaid-eligible children are at risk for seriousmental and physical conditions.
D. Children in Medicaid programs have a higher incidence of chronic disabling conditions
than do children in the general population.
Answer: B
QUESTION: 156
Determine whether the following statement is true or false:
The key to successfully managing the quality and cost-effectiveness of healthcare services
for Medicaid enrollees is to merge Medicaid recipients into existing plans.
A. True
B. False
Answer: B
QUESTION: 157
Access to services is an important issue for both fee-for-service (FFS) Medicaid and
managed Medicaid programs. Access to services under managed Medicaid is affected by the
A. lack of qualified providers in provider networks
B. lack of resources necessary to establish case management programs for patients with
complex conditions
C. unstable eligibility status of Medicaid recipients
D. inability of Medicaid recipients to change health plans or PCPs
Answer: C
QUESTION: 158
The following statement(s) can correctly be made about medical management considerations
for the Federal Employee Health Benefits Program (FEHBP):
1. FEHBP plan members who have exhausted the health plan’s usual appeals process for a
disputed decision can request an independent review by the Office of Personnel Management
(OPM)
2. All health plans that cover federal employees are required to develop and implement
patient safety initiatives
A. Both 1 and 2
B. 1 only
C. 2 only
D. Neither 1 nor 2
Answer: A
QUESTION: 159
Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located
at a military installation. Ms. Wilson serves as a primary point of contact between enrollees
and the TRICARE system and answers enrollees’ questions about plan options, eligibility,
provider selection, and claims. This information indicates that Ms. Wilson serves as a
A. lead agent
B. beneficiary services representative
C. health plan support contractor
D. primary care manager (PCM)
Answer: B
QUESTION: 160
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Select
the term or phrase in each pair that correctly completes the paragraph. Then select the answer
choice containing the two terms or phrases you have chosen.
TRICARE enrollees have the right to challenge authorization and coverage decisions. Such
challenges are referred to as (appeals / grievances) and are typically handled by the
(TRICARE contractor / Area Field Office).
A. appeals / TRICARE contractor
B. appeals / Area Field Office
C. grievances / TRICARE contractor
D. grievances / Area Field Office
Answer: A
QUESTION: 161
The delivery of quality, cost-effective healthcare is a primary goal of both group healthcare
and workers’ compensation programs. One difference between group healthcare and
workers’ compensation is that workers’ compensation
A. provides health and disability benefits to employees injured on the job only if the
employer is at fault for the injury
B. provides coverage for a variety of direct and indirect healthcare, disability, and workplace
costs
C. manages costs by including employee cost-sharing features in its benefit design
D. places limits on benefits by restricting the amount of benefit payments or the number of
covered hospital days or provider office visits
Answer: B
QUESTION: 162
For this question, if answer choices (A) through (C) are all correct, select answer choice (D).
Otherwise, select the one correct answer choice.
Ways that workers’ compensation health plans can help control the costs of job-related
injuries and illnesses include
A. applying strict definitions of medical necessity
B. developing prevention and recovery programs
C. applying out-of-network benefit reductions
D. all of the above
Answer: B
QUESTION: 163
Occasionally, employers combine workers’ compensation, group healthcare, and disability
programs into an integrated product known as 24-hour coverage. One true statement about
24- hour coverage is that it typically
A. increases administrative costs
B. requires plans to maintain separate databases of patient care information
C. exempts plans from complying with state workers’ compensation regulations
D. allows plans to apply disability management and return-to-work techniques to
nonoccupational conditions
Answer: D

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