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NEW QUESTION 1
Medicare beneficiaries can obtain healthcare benefits through fee-for-service (FFS) Medicare programs, Medicare medical savings account (MSA) plans, Medigap insurance, or coordinated care plans (CCPs). Unlike other coverage options, CCPs

  • A. provide only those benefits covered by Medicare Part A and Part B
  • B. are not subject to federal or state regulation
  • C. place primary care at the center of the delivery system
  • D. are structured as indemnity plans

Answer: C

NEW QUESTION 2
The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through
* 1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
* 2.The National Committee for Quality Assurance (NCQA)
* 3.The American Accreditation HealthCare Commission/URAC (URAC)

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

Answer: B

NEW QUESTION 3
The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self- care most likely would not be appropriate.

  • A. Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area.
  • B. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day.
  • C. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility.
  • D. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation.

Answer: A

NEW QUESTION 4
The BBA of 1997 allows states to provide Medicaid benefits to children through the State Children’s Health Insurance Program (SCHIP). Under the terms of the BBA, states can implement SCHIP as
* 1. Part of their existing Medicaid programs
* 2.Separate commercial insurance programs

  • A. Both 1 and 2
  • B. 1 only
  • C. 2 only
  • D. Neither 1 nor 2

Answer: A

NEW QUESTION 5
Emilio Martinez, a member of the Bloom Health Plan, has recently been diagnosed with prostate cancer by his physician, Dr. Robert Cohen. Mr. Martinez has decided to participate in Bloom’s shared decision-making program for prostate cancer. On the basis of this information, it is most likely correct to say
* 1. That verification of Mr. Martinez’s understanding about his care options protects both Dr. Cohen and Bloom against charges of malpractice
* 2. That Mr. Martinez and Dr. Cohen will discuss the care options available to Mr. Martinez, but the ultimate decision about care is up to Dr. Cohen

  • A. Both 1 and 2
  • B. 1 only
  • C. 2 only
  • D. Neither 1 nor 2

Answer: D

NEW QUESTION 6
The Glenway Health Plan’s pharmacy and therapeutics (P&T) committee conducted pharmacoeconomic research to measure both the clinical outcomes and costs of two new cholesterol-reducing drugs. Results were presented as a ratio showing the cost required to produce a 1 mcg/l decrease in cholesterol levels. The type of pharmacoeconomic research that Glenway conducted in this situation was most likely

  • A. cost-effectiveness analysis (CEA)
  • B. cost-minimization analysis (CMA)
  • C. cost-utility analysis (CUA)
  • D. cost of illness analysis (COI)

Answer: A

NEW QUESTION 7
Most health plans require a PCP referral or precertification for CAM benefits.

  • A. True
  • B. False

Answer: B

NEW QUESTION 8
Accreditation is intended to help purchasers and consumers make decisions about healthcare coverage.
The following statements are about accreditation. Select the answer choice containing the correct statement.

  • A. At the request of health plans, accrediting agencies gather the data needed for accreditation.
  • B. Most purchasers and consumers review accreditation results when making decisions to purchase or enroll in a specific health plan.
  • C. Accreditation is typically conducted by independent, not-for-profit organizations.
  • D. All health plans are required to participate in the accreditation process.

Answer: C

NEW QUESTION 9
DUR can be conducted prospectively, concurrently, or retrospectively. One true statement about prospective DUR is that it

  • A. involves periodic audits of the medical records of a certain group of patients
  • B. is based on historical data
  • C. focuses on the drug therapy for a single patient rather than overall usage patterns
  • D. is conducted by physicians, without input from pharmacists

Answer: C

NEW QUESTION 10
Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare practitioners are those available from NCQA. These NCQA credentialing standards apply to

  • A. chiropractors
  • B. naturopaths
  • C. acupuncturists
  • D. all of the above

Answer: A

NEW QUESTION 11
Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they

  • A. determine which healthcare services are medically necessary and appropriate for a particular patient in a particular situation
  • B. outline the services that will be delivered, the providers responsible for delivering the services, the timing of delivery, the setting in which services are delivered, and the expected outcomes of the interventions
  • C. cover only services delivered in an acute inpatient setting
  • D. address medical conditions that affect a small segment of a given population and with which the majority of providers are unfamiliar

Answer: B

NEW QUESTION 12
The Mental Health Parity Act (MHPA) of 1996 is a federal law that establishes requirements for behavioral healthcare coverage for group plan members. The MHPA

  • A. requires health plans to offer mental health benefits to all eligible members
  • B. prohibits health plans that offer mental health benefits from imposing lower annual or lifetime dollar limits on mental illnesses than they do on physical illnesses
  • C. provides an exemption for health plans that can demonstrate cost savings of more than 1 percent
  • D. prohibits health plans from limiting the number of outpatient visits or inpatient dayscovered under the plan

Answer: B

NEW QUESTION 13
The following statement(s) can correctly be made about utilization guidelines:
* 1. When developing utilization guidelines, health plans balance evidence-based criteria with experience-based criteria
* 2. Utilization guidelines indicate when a UR nurse should refer a decision to a physician reviewer

  • A. Both 1 and 2
  • B. 1 only
  • C. 2 only
  • D. Neither 1 nor 2

Answer: A

NEW QUESTION 14
Health plans that choose to contract with external organizations for pharmacy services typically contract with pharmacy benefit managers (PBMs). Functions that a PBM typically performs for a health plan include
* 1.Managing the costs of prescription drugs
* 2.Promoting efficient and safe drug use
* 3.Determining the health plan’s internal management responsibilities for pharmacy services

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

Answer: B

NEW QUESTION 15
The Carlyle Health Plan uses the following clinical outcome measures to evaluate its diabetes and asthma disease management programs:
Measure 1: The percentage of diabetic patients who receive foot exams from their providers according to the program’s recommended guidelines Measure 2: The number of asthma patients who visited emergency departments for acute asthma attacks
From the answer choices below, select the response that correctly identifies whether these measures are true outcome measures or intermediate outcome measures. Measure 1- Measure 2-

  • A. Measure 1-true outcome measure Measure 2-true outcome measure
  • B. Measure 1-true outcome measure Measure 2-intermediate outcome measure
  • C. Measure 1-intermediate outcome measure Measure 2-true outcome measure
  • D. Measure 1-intermediate outcome measure Measure 2-intermediate outcome measure

Answer: C

NEW QUESTION 16
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