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100+ Free AHIP PHIAS Practice Questions
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Sample AHIP PHIAS Practice Questions
Try these sample questions to test your AHIP PHIAS exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.
1Which managed care model requires members to select a primary care physician (PCP) who acts as a gatekeeper and generally provides NO coverage for out-of-network care except in emergencies?
A.HMO
B.PPO
C.POS
D.Indemnity plan
Explanation: A traditional Health Maintenance Organization (HMO) requires members to choose a PCP who coordinates and authorizes specialist care, and it generally covers only in-network services except in emergencies. This tight network control is the defining feature distinguishing HMOs from looser models.
2A key distinguishing feature of a Preferred Provider Organization (PPO) compared with an HMO is that a PPO:
A.Provides coverage for out-of-network providers at higher cost sharing
B.Requires a PCP referral for all specialist visits
C.Pays providers exclusively through capitation
D.Excludes all out-of-network care except emergencies
Explanation: PPOs let members see out-of-network providers but apply higher deductibles and coinsurance for doing so, and they typically do not require referrals. This flexibility is the core trade-off versus the lower premiums of an HMO.
3An Exclusive Provider Organization (EPO) is best described as a plan that:
A.Requires referrals but covers out-of-network care
B.Has no network and pays any licensed provider
C.Covers only in-network providers but typically does not require PCP referrals
D.Pays providers solely through global capitation
Explanation: An EPO restricts coverage to in-network providers (no out-of-network benefit except emergencies) like an HMO, but unlike an HMO it usually does not require referrals to see specialists. It sits between HMO and PPO designs.
4A Point-of-Service (POS) plan is characterized by which combination of features?
A.A PCP gatekeeper plus the option to use out-of-network providers at higher cost
B.No PCP, no out-of-network coverage
C.Only out-of-network coverage
D.Mandatory capitation and no member choice
Explanation: A POS plan combines HMO and PPO elements: members select a PCP who manages referrals (HMO-like) but may go out of network at higher cost sharing (PPO-like). This hybrid gives members a coordinated yet flexible option.
5To be qualified to pair with a Health Savings Account (HSA), a High Deductible Health Plan (HDHP) must:
A.Meet IRS minimum deductible and maximum out-of-pocket limits
B.Cover all services at 100% before the deductible
C.Be sold only on the ACA marketplace
D.Use a closed HMO network
Explanation: An HSA-qualified HDHP must satisfy annually indexed IRS rules for a minimum deductible and a maximum out-of-pocket limit, and it generally cannot pay non-preventive benefits before the deductible is met. These thresholds define HSA eligibility.
6Which term describes a fixed dollar amount a member pays for a covered service, such as $30 for an office visit?
A.Coinsurance
B.Deductible
C.Copayment
D.Premium
Explanation: A copayment is a flat, fixed dollar amount the member pays at the point of service for a specific benefit. It differs from coinsurance, which is a percentage of the allowed charge.
7The maximum amount a member must pay for covered in-network essential health benefits during a plan year, after which the plan pays 100%, is the:
A.Out-of-pocket maximum
B.Deductible
C.Coinsurance ceiling
D.Lifetime maximum
Explanation: The out-of-pocket maximum caps a member's total cost sharing (deductible, copays, coinsurance) for covered in-network essential benefits in a year; once reached, the plan pays 100%. The ACA prohibits annual and lifetime dollar limits on essential health benefits.
8In a capitation arrangement, a provider is paid:
A.A fixed amount per member per month regardless of services used
B.A percentage of billed charges
C.A negotiated fee for each service rendered
D.A bonus only when quality targets are met
Explanation: Capitation pays a provider a fixed per-member-per-month (PMPM) amount to cover defined services, shifting utilization risk to the provider. The provider profits if costs run below the capitation and loses if they exceed it.
9A narrow network plan is primarily designed to:
A.Lower premiums by contracting with a smaller set of providers at favorable rates
B.Eliminate all member cost sharing
C.Remove the need for prior authorization
D.Guarantee access to every provider in a region
Explanation: Narrow networks limit the contracted provider set to those who accept lower negotiated rates or demonstrate efficiency, allowing the plan to offer lower premiums. The trade-off is reduced provider choice for members.
10An Accountable Care Organization (ACO) is best described as:
A.A group of providers that voluntarily coordinate care and share accountability for cost and quality of a defined population
B.A standalone insurance carrier licensed by the state
C.A federal agency that regulates Medicare Advantage
D.A type of pharmacy benefit manager
Explanation: An ACO is a network of doctors, hospitals, and other providers who voluntarily join to coordinate care for an attributed population and share in savings (and sometimes losses) tied to cost and quality benchmarks. The Medicare Shared Savings Program is the best-known example.
About the AHIP PHIAS Practice Questions
Verified exam format metadata for Professional, Health Insurance Advanced Studies is pending. The practice questions above remain available while official exam length, timing, passing score, fee, and administrator details are reviewed.