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AHIP AHM-520 Exam
Health Plan Finance and Risk Management (Page 7 )

Updated On: 7-Feb-2026
Page 7 of 44
PDF with 215 Questions

One true statement about a type of capitation known as a percent-of-premium arrangement is that this arrangement

  1. Is the most common type of capitation
  2. Is less attractive to providers when the arrangement sets provisions to limit risk
  3. Sets provider reimbursement at a specific dollar amount per plan member
  4. Transfers some of the risk associated with underwriting and rating from a health plan to a provider

Answer(s): D



The provider contract that Dr. Zachery Cogan, an internist, has with the Neptune Health Plan calls for Neptune to reimburse him under a typical PCP capitation arrangement. Dr. Cogan serves as the PCP for Evelyn Pfeiffer, a Neptune plan member. After hospitalizing Ms. Pfeiffer and ordering several expensive diagnostic tests to determine her condition, Dr. Cogan referred her to a specialist for further treatment. In this situation, the compensation that Dr. Cogan receives under the PCP capitation arrangement most likely includes Neptune's payment for

  1. All of the diagnostic tests that he ordered on Ms. Pfeiffer
  2. His visits to Ms. Pfeiffer while she was hospitalized
  3. The cost of the services that the specialist performed for Ms. Pfeiffer
  4. All of the above

Answer(s): B



The following statements illustrate common forms of capitation:
1. The Antler Health Plan pays the Epsilon Group, an integrated delivery system (IDS), a capitated amount to provide substantially all of the inpatient and outpatient services that Antler offers. Under this arrangement, Epsilon accepts much of the risk that utilization rates will be higher than expected. Antler retains responsibility for the plan's marketing, enrollment, premium billing, actuarial, underwriting, and member services functions.
2. The Bengal Health Plan pays an independent physician association (IPA) a capitated amount to provide both primary and specialty care to Bengal's plan members. The payments cover all physician services and associated diagnostic tests and laboratory work. The physicians in the IPA determine as a group how the individual physicians will be paid for their services.

From the following answer choices, select the response that best indicates the form of capitation used by Antler and Bengal.

  1. Antler = subcapitation
    Bengal = full-risk capitation
  2. Antler = subcapitation
    Bengal = full professional capitation
  3. Antler = global capitation
    Bengal = subcapitation
  4. Antler = global capitation
    Bengal = full professional capitation

Answer(s): D



The following statements are about carve-out programs. Three of these statements are true, and one statement is false. Select the answer choice containing the FALSE statement.

  1. In the type of carve-out in which entire categories of care are administered by independent organizations, a health plan typically reimburses these organizations under an FFS contract.
  2. Typically, a health plan will offer carved-out services to its enrollees, but will manage these services separately.
  3. Carve-outs are services that are excluded from a capitation payment, a risk pool, or a health benefit plan.
  4. The most rapidly growing area related to carve-outs is disease management (DM).

Answer(s): A



The Marble Health Plan sets aside a PMPM amount for each specialty.

When a PCP in Marble's provider network refers a Marble plan member to a specialist and the specialist provides medical services to the member, the specialist begins to receive a share of those funds on a monthly basis. Marble determines the monthly payment for each specialist by dividing the number of active patients for that specialty by the total specialty pool for that month. This form of payment, which is similar to a case rate, is known as

  1. Referral circle capitation
  2. Risk pod capitation
  3. Contact capitation
  4. Retrospective reimbursement capitation

Answer(s): C






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