NEW QUESTION 1
In most health plans, the formulary system is developed and managed by a P&T committee. The P&T committee is responsible for

• A. evaluating and selecting drugs for inclusion in the formulary
• B. overseeing the manufacture, distribution, and marketing of prescription drugs
• C. certifying the medical necessity of expensive, potentially toxic, or nonformulary drugs
• D. all of the above

Answer: A

NEW QUESTION 2
CMS has developed two prototype programs—Programs of All-inclusive Care for the Elderly (PACE) and the Social Health Maintenance Organization (SHMO) demonstration project—to deliver healthcare services to Medicare beneficiaries. From the answer choices below, select the response that correctly identifies the features of these programs.

• A. PACE-annual limits on benefits for nursing home and community-based care SHMO-no limits on long-term care benefits
• B. PACE-provide long-term care only SHMO-provide acute and long-term care
• C. PACE-enrollees must be age 65 or older SHMO-enrollees must be age 55 or older
• D. PACE-enrollment open to nursing home certifiable Medicare beneficiaries only SHMO- enrollment open to all Medicare beneficiaries

Answer: D

NEW QUESTION 3
Outcomes management is a tool that health plans use to maximize all the results
associated with healthcare processes. The following statement(s) can correctly be made about outcomes management:
* 1. The goal of outcomes management is to identify and implement treatments that are cost- effective and deliver the greatest value
* 2. Outcomes management introduces performance as a critical factor in the assessment and improvement of outcomes

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

Answer: A

NEW QUESTION 4
The following statements are about chronic and disabling conditions among children eligible for Medicaid. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. Children with chronic conditions use more physician and nonphysician professional services than do children in the general population.
• B. The majority of chronic conditions affecting children in Medicaid programs are the same as those affecting children in the general population.
• C. Medicaid-eligible children are at risk for seriousmental and physical conditions.
• D. Children in Medicaid programs have a higher incidence of chronic disabling conditions than do children in the general population.

Answer: B

NEW QUESTION 5
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 6
The following statements are about disease management programs. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. The focus of disease management is on responding to the needs of individual members for extensive, customized healthcare supervision.
• B. Disease management programs serve to improve both clinical and financial outcomes for healthcare services related to chronic conditions.
• C. Tools such as preventive care, self-care, and decision support programs are used to support both case management and disease management.
• D. Disease management programs apply to both diseases and medical conditions that are not diseases, such as high-risk pregnancy, severe burns, and trauma.

Answer: A

NEW QUESTION 7
Comorbidity can have a significant impact on the effective implementation of disease management programs. Comorbidity can correctly be defined as the

• A. degree to which the progression of a disease or condition is understood
• B. prevalence or rate of a sickness or injury within a given population
• C. degree of severity of a particular disease or condition
• D. presence of a chronic condition or added complication other than the condition that requires medical treatment

Answer: D

NEW QUESTION 8
With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT

• A. maintaining clinical practices
• B. delivering performance feedback to providers
• C. participating in utilization management (UM) activities
• D. educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management

Answer: A

NEW QUESTION 9
The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
The Balanced Budget Act (BBA) of 1997 established the use of _______ to determine coverage of emergency services for Medicare and Medicaid enrollees in health plans.

• A. utilization management standards
• B. the prudent layperson standard
• C. preauthorization
• D. diagnosis-based retrospective review

Answer: B

NEW QUESTION 10
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
In most commercial health plans, the case management process is directed by a case manager whose responsibilities typically include

• A. focusing on a disabled member’s vocational rehabilitation and training
• B. approving all care decisions for patients under case management
• C. reducing the fragmentation of care that often results when individuals obtain services from several different providers
• D. all of the above

Answer: C

NEW QUESTION 11
When analyzing and applying HRA results, the Multistate Health Plan noted sampling bias. This information indicates that the HRA results

• A. do not accurately depict the characteristics of the Multistate member population under study because of errors in data collection
• B. are more accurate for individual Multistate members than they are for the total population
• C. cannot be stated in numerical terms
• D. indicate variation in the number, types, and severity of behavioral risks presented by Multistate’s members

Answer: A

NEW QUESTION 12
Determine whether the following statement is true or false: Participation in disease management programs is currently voluntary.

• A. True
• B. False

Answer: A

NEW QUESTION 13
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 14
Administrative action plans are used when performance problems or opportunities are related to the way the organization itself operates. The following statement(s) can correctly be made about administrative action plans:
* 1.Administrative action plans allow health plans to coordinate management activities
* 2.One function of administrative action plans is to integrate service across all levels of the organization
* 3.Administrative action plans are designed to improve outcomes by helping plan members assume responsibility for their own health

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

Answer: B

NEW QUESTION 15
Adele Stanley, a member of the Greenhouse Health Plan, recently went to a network pharmacy to have a prescription filled. The pharmacist informed Ms. Stanley that the prescribed drug was not in the plan formulary and that reimbursement for the drug was not available except in extraordinary circumstances. The pharmacist asked Ms. Stanley if she would accept a generic substitute.
If Ms. Stanley agrees to the generic substitution, she will receive a drug that

• A. has not been tested for safety and efficacy in large clinical trials
• B. is available without a prescription at a reasonable cost
• C. has been classified by the Food and Drug Administration (FDA) as safe, but that has not been proven fully effective
• D. contains active ingredients that are identical to those of the prescribed brand-name drug

Answer: D

NEW QUESTION 16
Since its inception, Medicare has undergone a number of changes because of legal and regulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to

• A. expand Medicare benefits by mandating coverage for certain preventive services
• B. reduce the number of organizations that can deliver covered services
• C. encourage growth of managed Medicare programs in all markets
• D. increase the number of “zero premium” plans available to Medicare beneficiaries

Answer: A

NEW QUESTION 17
Determine whether the following statement is true or false:
The utilization review (UR) process produces the greatest number of case management referrals.

• A. True
• B. False

Answer: A

NEW QUESTION 18
This agency oversees fraud and abuse matters as they relate to medical management.

• A. Health Resources and Services Administration (HRSA)
• B. Office of Personnel Management (OPM)
• C. Department of Health and Human Services (HHS)
• D. Department of Justice (DOJ)

Answer: D

NEW QUESTION 19
The nature of behavioral healthcare creates unique medical management challenges for health plans. One method health plans have used to support the delivery of appropriate services in a cost-effective manner is to

• A. remove behavioral healthcare services from the primary care setting
• B. shift behavioral healthcare from acute inpatient settings to alternative settings when feasible
• C. reserve the use of psychotherapy for treatment of those conditions that persist over long periods of time or for the life of the patient
• D. offer the same level of compensation to all of the professional disciplines that provide behavioral healthcare services to plan members

Answer: B

NEW QUESTION 20
Patricia McLeod is a member of the Enterprise Health Plan, which operates in State X. Ms. McLeod is scheduled to undergo a unilateral mastectomy for the treatment of breast cancer. The surgical procedure will be performed by Dr. Kim Lee, a surgical oncologist.
Based on Enterprise’s medical policy, the contract with the purchaser, and Ms. McLeod’s medical condition, Enterprise’s UR staff have determined that the appropriate course of care for Ms.
McLeod includes a 24-hour stay in the hospital following her surgery. State X, however, has a benefit mandate specifying health plan coverage for 48 hours of inpatient post- mastectomy care. In this situation, the length of hospital stay for which Enterprise must offer coverage is

• A. the length of stay deemed appropriate by D
• B. Lee
• C. the 24-hour stay determined to be appropriate by Enterprise’s UR staff
• D. the length of stay deemed appropriate by M
• E. McLeod
• F. the 48-hour length of stay specified by State X

Answer: D

NEW QUESTION 21
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