AHIP Exam AHM-530 Topic 3 Question 92 Discussion

Actual exam question for AHIP's AHM-530 exam

Question #: 92
Topic #: 3

To protect providers against business losses, many health plan-provider contracts include carve-out provisions to help providers manage financial risk. The following statements are examples of such provisions:

The Apex Health Plan carves out immunizations from PCP capitations. Apex compensates PCPs for immunizations on a case rate basis.

The Bengal Health Plan carves out behavioral healthcare services from the scope of PCP services because these services require specialized knowledge and skills that most PCPs do not possess.

From the answer choices below, select the response that best identifies the types of carve-outs used by Apex and Bengal.

AApex: disease-specific carve-out Bengal: specialty services carve-out

BApex: disease-specific carve-out Bengal: specific-service carve-out

CApex: specific-service carve-out Bengal: specialty services carve-out

DApex: specific-service carve-out Bengal: disease-specific carve-out

Show Suggested Answer

Suggested Answer: B

by Antonio at Jul 08, 2024, 01:10 AM

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Willetta

8 months ago

Hmm, I'm stumped. Maybe I should have paid more attention in that Medicaid lecture. *laughs* Guess I'll just have to wing it on this one.

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Arthur

7 months ago

C) Receives no payments directly from Medicaid for services rendered but rather receives a portion of the capitation payment that Medicaid makes to the health plans with which Preamble contracts.

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Josephine

7 months ago

B) Is at a higher risk of operating at a loss than are most other hospitals.

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Jerry

8 months ago

A) Receives financial assistance from the federal government but not a state government.

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Lashon

8 months ago

This is a tough one, but I'm going to go with C. Preamble probably gets a cut of the capitation payment rather than direct Medicaid reimbursement.

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Mindy

7 months ago

Yeah, it makes sense that they don't receive direct payments from Medicaid.

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Allene

7 months ago

I agree, they probably get a portion of the capitation payment.

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Janessa

7 months ago

I think Preamble is eligible for higher capitation rates.

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Lezlie

7 months ago

I agree, it seems like C is the most likely option for a DSH like Preamble.

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Aron

8 months ago

Yeah, that makes sense. They contract with health plans, so they might not get direct Medicaid payments.

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Alpha

8 months ago

I think Preamble Hospital probably gets a cut of the capitation payment.

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Keshia

8 months ago

Hmm, that's a good point. I see where you're coming from.

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Domonique

8 months ago

I don't know, this question seems a bit tricky. I'm leaning towards D, but I'm not totally sure.

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Dana

8 months ago

B) Is at a higher risk of operating at a loss than are most other hospitals.

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Felicitas

8 months ago

A) Receives financial assistance from the federal government but not a state government.

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Augustine

9 months ago

I disagree, I believe the answer is D. DSHs are eligible for higher capitation rates for Medicaid services.

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Serina

9 months ago

Option B seems the most likely. DSHs typically operate with higher costs due to the population they serve, so they are at a higher risk of losses.

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Jestine

8 months ago

It's important for DSHs to receive support to continue providing care to indigent populations.

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Wai

8 months ago

It makes sense that they would need financial assistance to cover those costs.

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Christiane

8 months ago

DSHs definitely have higher costs, so operating at a loss is a real risk.

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Roxane

8 months ago

I agree, option B does seem like the most likely choice.

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Keshia

9 months ago

I think the answer is B. DSHs are usually at a higher risk of operating at a loss.

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