NEW QUESTION 1
Many health plans use HRA to target their preventive care programs to the healthcare needs of their members. With regard to HRA, it is correct to say that

• A. Health plans rarely delegate HRA activities to external entities
• B. Health plans typically focus their HRA efforts on newly enrolled members
• C. HRA focuses on clinical data for an entire population and does not include demographic information that might identify individual members
• D. HRA is generally a reliable predictor of medical resource utilization

Answer: B

NEW QUESTION 2
Determine whether the following statement is true or false:
Under a carve-out arrangement for disease management, patients typically maintain their existing relationships with primary care providers (PCPs) for all care, including disease management.

• A. True
• B. False

Answer: B

NEW QUESTION 3
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 4
The case management program director at the Nova Health Plan calculated the program’s ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:
Administrative costs for case management ..........$40,000
Actual medical care expenses for patients under case management ..........$680,000
Projected medical care expenses for the same patients without case management
..........$900,000
This information indicates that, for the previous quarter, Nova’s ratio of medical expense savings to case management administrative costs was

• A. 0.71/1
• B. 0.80/1
• C. 5.50/1
• D. 1.25/1

Answer: C

NEW QUESTION 5
The following statements are about the characteristics of a utilization review (UR) program. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. A primary goal of UR is to address practice variations through the application of uniform standards and guidelines.
• B. UR evaluates whether the services recommended by a member’s provider are covered under the benefit plan.
• C. UR recommends the procedures that providers should perform for plan members.
• D. A health plan’s UR program is usually subject to review and approval by the state insurance and/or health departments.

Answer: C

NEW QUESTION 6
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 7
PBMs are accredited by the same organizations that accredit health plans.

• A. True
• B. False

Answer: B

NEW QUESTION 8
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 9
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 10
This agency has authority over Programs of All-inclusive Care for the Elderly (PACE) and the State Children’s Health Insurance Program (SCHIP).

• 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: C

NEW QUESTION 11
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 12
To facilitate electronic commerce (eCommerce), a health plan may establish a secured extranet. One true statement about a secured extranet is that it is

• A. based on Web-based technologies
• B. available only to the employees of the health plan
• C. publicly available, so the potential exists for unauthorized access to a health plan’s proprietary systems
• D. used to handle the majority of health plan eCommerce

Answer: A

NEW QUESTION 13
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 14
To improve members’ abilities to make appropriate care decisions about specific medical problems, some health plans use a form of decision support known as telephone triage programs. The following statements are about telephone triage programs. Select the answer choice containing the correct statement.

• A. The primary role of telephone triage clinical staff is to diagnose the caller’s condition and give medical advice.
• B. Quality management (QM) for telephone triage programs typically focuses on the clinical information provided rather than on the quality of service.
• C. Currently, none of the major accrediting agencies offers an accreditation program specifically for telephone triage programs.
• D. A telephone triage program may also include a self-care component.

Answer: B

NEW QUESTION 15
Elaine Newman suffered an acute asthma attack and was taken to a hospital emergency department for treatment. Because Ms. Newman’s condition had not improved enough following treatment to warrant immediate release, she was transferred to an observation care unit. Transferring Ms. Newman to the observation care unit most likely

• A. resulted in unnecessarily expensive charges for treatment
• B. prevented M
• C. Newman from receiving immediate attention for her condition
• D. gave M
• E. Newman access to more effective and efficient treatment than she could have obtained from other providers in the same region
• F. allowed clinical staff an opportunity to determine whether M
• G. Newman required hospitalization without actually admitting her

Answer: D

NEW QUESTION 16
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 17
In order for a health plan’s performance-based quality improvement programs to be effective, the desired outcomes must be

• A. achievable within a specified timeframe
• B. defined in terms of multiple results
• C. expressed in subjective, qualitative terms
• D. all of the above

Answer: A

NEW QUESTION 18
The following statements are about the use of provider profiling for pharmacy benefits. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

• A. Health plans typically use provider profiles to improve the quality of care associated with the use of prescription drugs.
• B. Provider profiles identify prescribing patterns that fall outside normal ranges.
• C. Health plans can motivate providers to change their prescribing patterns by sharing profile information with plan members and the general public.
• D. Provider profiles are effective in modifying individual prescribing patterns, but they have little effect on group prescribing patterns.

Answer: D

NEW QUESTION 19
The case management team at the Hightower Health Plan reviewed the medical records of the following two plan members to determine the type of care each one needs and the most appropriate setting for that care:
Ira Morton was hospitalized for a severe stroke. Although his medical condition is stable, the stroke left him partially paralyzed and he will require extensive rehabilitation and 24- hour medical care.
Theresa Finley is recovering from a total hip replacement and is in need of short-term physical therapy and twice-weekly visits from a licensed nurse to check her blood pressure and the healing of her incision.
From the answer choices below, select the response that correctly identifies the level of care that would be most appropriate for Mr. Morton and Ms. Finley.

• A. M
• B. Morton-acute care M
• C. Finley-subacute care
• D. M
• E. Morton-palliative care M
• F. Finley-acute care
• G. M
• H. Morton-subacute care M
• I. Finley-skilled care
• J. M
• K. Morton-skilled care M
• L. Finley-palliative care

Answer: C

NEW QUESTION 20
One of the steps in drug utilization review (DUR) is defining optimal drug use, which can be accomplished by applying diagnosis criteria and drug-specific criteria. Drug-specific criteria are standards that identify the

• A. appropriate dosages, duration of treatment, and other elements related to the use of a particular drug
• B. actual prescribing and dispensing patterns for a particular drug
• C. types of diseases, conditions, or patients for which a drug should be used
• D. cost-effectiveness of all possible drug treatments for a particular condition

Answer: A

NEW QUESTION 21
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