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NEW QUESTION 1
Health plans that offer healthcare programs for Medicare beneficiaries have a strong financial incentive for identifying high-risk seniors as early as possible. The identification of high-risk seniors is typically accomplished through the use of

  • A. case management
  • B. geriatric evaluation and management (GEM)
  • C. intervention identification
  • D. interdisciplinary home care (IHC)

Answer: C

NEW QUESTION 2
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
Definitions of quality healthcare vary; however, four dimensions are essential to quality healthcare services. _____ is the quality dimension indicating that services result in the best care for a given cost or the lowest cost for a given level of care.

  • A. Accessibility
  • B. Effectiveness
  • C. Acceptability
  • D. Efficiency

Answer: D

NEW QUESTION 3
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

NEW QUESTION 4
Designing effective medical management programs for Medicare beneficiaries requires an understanding of the unique health needs of the Medicare population. One characteristic of Medicare beneficiaries is that they typically

  • A. do not experience mental health problems
  • B. consume more than half of all prescription drugs
  • C. are likely to equate quality with the technical aspects of clinical procedures
  • D. require longer and more costly recovery periods following acute illnesses or injuries than does the general population

Answer: D

NEW QUESTION 5
This agency’s accreditation decisions are based on the results of an on-site survey of clinical and administrative systems and processes, as well as the health plan’s performance on selected effectiveness of care and member satisfaction measures.

  • A. American Accreditation HealthCare Commission/URAC (URAC)
  • B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • C. Community Health Accreditation Program (CHAP)
  • D. National Committee for Quality Assurance (NCQA)

Answer: D

NEW QUESTION 6
In order to achieve changes in outcomes, health plans make changes to existing structures and processes. The introduction of preauthorization as an attempt to control overuse of services is an example of a reactive change. Reactive changes are typically

  • A. both planned and controlled
  • B. planned, but they are rarely controlled
  • C. controlled, but they are rarely planned
  • D. neither planned nor controlled

Answer: C

NEW QUESTION 7
Health plans that offer complementary and alternative medicine (CAM) services face potential liability because many types of CAM services

  • A. must be offered as separate supplemental benefits or separate products
  • B. lack clinical trials to evaluate their safety and effectiveness
  • C. are not covered by state or federal consumer protection statutes
  • D. focus on a specific illness, injury, or symptom rather than on the whole body

Answer: B

NEW QUESTION 8
The following statements are about QAPI as it applies to Medicare+Choice plans and Medicaid health plan entities. Select the answer choice containing the correct statement.

  • A. QAPI provides separate sets of standards for Medicaid MCEs and Medicare+Choice plans.
  • B. Medicaid primary care case management (PCCM) programs are required to comply with all QAPI standards.
  • C. QISMC standards for quality measurement and improvement apply only to clinical services delivered to Medicare and Medicaid enrollees.
  • D. States that require Medicaid MCEs to comply with QAPI standards are considered to be in compliance with CMS quality assessment and improvement regulations.

Answer: D

NEW QUESTION 9
Determine whether the following statement is true or false:
With respect to the size of a managed care organization (MCO) and its medical management operations, it is correct to say that large health plans typically have more integration among activities and less specialization of roles than do small MCOs.

  • A. True
  • B. False

Answer: B

NEW QUESTION 10
The following statements are about health plans' complaint resolution procedures (CRPs). Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

  • A. An health plan's CRPs reduce the likelihood of errors in decision making.
  • B. CRPs typically provide for at least two levels of appeal for formal appeals.
  • C. CRPs include only formal appeals and do not apply to informal complaints.
  • D. Most complaints are resolved without proceeding through the entire CRP process.

Answer: C

NEW QUESTION 11
The paragraph below contains two pairs of terms enclosed in parentheses. Select the term in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms that you have chosen.
Under a delegation arrangement, the (delegate / delegator) is responsible for performing the delegated function according to established standards, and the (delegate / delegator) is ultimately accountable for any deficiencies in the performance of the function.

  • A. delegate / delegate
  • B. delegate / delegator
  • C. delegator / delegate
  • D. delegator / delegator

Answer: B

NEW QUESTION 12
Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should Mr. Farrell become incapacitated.
The document that Mr. Farrell is using to communicate his end-of-life healthcare wishes to his family is known as a

  • A. medical power of attorney
  • B. patient assessment and care plan
  • C. living will
  • D. healthcare proxy

Answer: C

NEW QUESTION 13
All states have laws describing the conditions under which pharmacists can substitute a generic drug for a brand-name drug. With respect to these laws, it is correct to say that in every state,

  • A. pharmacists must obtain physician approval before substituting generics for brand-name drugs
  • B. pharmacists must obtain authorization from the health plan before substituting generics for brand-name drugs
  • C. prescribers must obtain authorization from the health plan before prescribing a brand- name drug
  • D. prescribers have some mechanism that allows them to prevent pharmacists from substituting generics for brand-name drugs

Answer: D

NEW QUESTION 14
A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions:
* 1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence
* 2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies
* 3. All of the criteria for coverage decisions must be included in the purchaser contract

  • A. All of the above
  • B. 1 and 2 only
  • C. 2 only
  • D. 3 only

Answer: B

NEW QUESTION 15
Determine whether the following statement is true or false:
All health plans participating in the Federal Employee Health Benefits Program (FEHBP) are required to use the Consumer Assessment of Health Plans (CAHPS) to measure customer satisfaction.

  • A. True
  • B. False

Answer: A

NEW QUESTION 16
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