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

Options :

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

Question 2

Health plans arrange for the delivery of various levels of healthcare, including

1. Emergency care

2. Urgent care

3. Primary care delivered in a provider’s office

In a ranking of these levels of care according to cost, beginning with the least expensive level of

care and ending with the most expensive level of care, the correct order would be

Options :

A : 1—2—3

B : 2—3—1

C : 3—1—2

D : 3—2—1

Answer: D

Question 3

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to

Options :

A : standard medical-surgical services

B : mental health and substance abuse services

C : services offered to Medicare enrollees as optional supplementary benefits

D : all of the above

Answer: D

Question 4

Benchmarking is a quality improvement strategy used by some health plans. With regard to benchmarking, it is correct to say that

Options :

A :

cost-based benchmarking reveals why some areas of a health plan perform better or worse than comparable areas of other organizations

B :

diagnosis-related groups (DRGs) are a source of benchmarking data that describe individual procedures and cover both inpatient and outpatient care

C :

patient billing records provide a much more accurate account of procedure costs for benchmarking than do current procedural terminology (CPT) codes

D : the focus of benchmarking for health plan has shifted from identifying the lowest cost practices to identifying best practices

Answer: D

Question 5

The following statement(s) can correctly be made about the scope of case management:

1. Case management incorporates activities that may fall outside a health plan’s typical

responsibilities, such as assessing a member’s financial situation

2. Case management generally requires a less comprehensive and complex approach to a course

of care than does utilization review

3. Case management is currently applicable only to medical conditions that require inpatient

hospital care and are categorized as catastrophic in terms of health and/or costs

Options :

A : All of the above

B : 1 and 2 only

C : 2 and 3 only

D : 1 only

Answer: D

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