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AHM-520 – Health Plan Finance and Risk Management

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Showing 10–12 of 15 questions

Question 10 (Volume A)

In order to calculate a simple monthly capitation payment, the Argyle Health Plan used the following information:

 The average number of office visits each member makes in a year is two

 The FFS rate per office visit is $55

 The member copayment is $5 per office visit

 The reimbursement period is one month

Given this information, Argyle would correctly calculate that the per member per month (PMPM) capitation rate should be

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  • ○

    $4.17
  • ○

    $8.33
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    $9.17
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    $10.00
Question 11 (Volume B)

The Coral Health Plan, a for-profit health plan, has two sources of capital:

Debt and equity. With regard to these sources of capital, it can correctly be stated that

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  • ○

    Coral's equity holders have an ownership interest in the health plan
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    The interest that Coral pays on its debt most likely is not tax deductible to Coral
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    Coral's debt holders have no legal claim to Coral's assets
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    Equity is a more risky source of capital, from Coral's perspective, than is debt
Question 12 (Volume A)

The following statements are about the new methodology authorized under the Balanced Budget Act of 1997 (BBA) for payments by the Centers for Medicaid & Medicare Services (CMS) to Medicare-contracting health plans.

Select the answer choice containing the correct statement.

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  • ○

    Under this new methodology, Medicare-contracting health plans are paid the lower of (a) a floor payment amount per enrollee covered or (b) the health plan's payment rate increased by 2% from the previous year.
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    The new methodology has decreased the rate of growth in payments from CMS to Medicare-contracting health plans.
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    Under this new methodology, Medicare-contracting health plans are paid 90% of the adjusted average per capita cost (AAPCC) of providing a service to a beneficiary.
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    Under the principal inpatient diagnostic cost group (PIP-DCG), a new risk adjustment methodology, Medicare-contracting health plans will no longer be required to calculate and submit to CMS a Medicare adjusted community rate (ACR).