A Review Of Breathing AHM-540 Test Question

NEW QUESTION 1
Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray’s condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace’s medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.
In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an example of

• A. a cosmetic service
• B. an investigational service
• C. an off-label use
• D. a quality-of-life service

Answer: C

NEW QUESTION 2
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 3
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 4
Vision care is typically separated into two categories: routine eye care and clinical eye care. The standard benefit plans offered by most health plans include coverage for
* 1. Routine eye care
* 2. Clinical eye care

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

Answer: C

NEW QUESTION 5
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 6
The delivery of quality, cost-effective healthcare is a primary goal of both group healthcare and workers’ compensation programs. One difference between group healthcare and workers’ compensation is that workers’ compensation

• A. provides health and disability benefits to employees injured on the job only if the employer is at fault for the injury
• B. provides coverage for a variety of direct and indirect healthcare, disability, and workplace costs
• C. manages costs by including employee cost-sharing features in its benefit design
• D. places limits on benefits by restricting the amount of benefit payments or the number of covered hospital days or provider office visits

Answer: B

NEW QUESTION 7
In order to provide a true measure of quality, the data collected by a quality indicator should accurately represent the service dimension being measured. This information indicates that the indicator should exhibit the characteristic known as

• A. clarity
• B. reliability
• C. validity
• D. feasibility

Answer: C

NEW QUESTION 8
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the two terms or phrases that you have selected.
The process for collecting and analyzing data differs for quality assessment (QA) and quality improvement (QI). For QA, data collection focuses on (objective / both objective and subjective) data, and data analysis identifies the (degree / cause) of variance.

• A. objective / degree
• B. objective / cause
• C. both objective and subjective / degree
• D. both objective and subjective / cause

Answer: A

NEW QUESTION 9
The following statements are about medical management considerations for dental care. Select the answer choice containing the correct statement.

• A. Managed dental care organizations are regulated at the state rather than the federal level.
• B. Dental care differs from medical care in that most dental care is provided by specialists.
• C. Dental preferred provider organizations (Dental PPOs) are subject to more regulation than are dental health maintenance organizations (DHMOs).
• D. Managed dental plans are accredited by the National Association of Dental Plans (NADP).

Answer: A

NEW QUESTION 10
The Noble Health Plan conducted a cost/benefit analysis of the following four prescription drugs:
BenefitCost Drug A$525$350 Drug B$450$250
Drug C$400$200 Drug D$350$100
According to this analysis, the drug that represents the most efficient use of resources is

• A. Drug A
• B. Drug B
• C. Drug C
• D. Drug D

Answer: D

NEW QUESTION 11
One way that health plans evaluate their UR programs is by monitoring utilization rates. By definition, utilization rates typically

• A. indicate changes in the total amount of medical expenses or claim dollars paid for particular procedures
• B. measure the number of services provided per 1,000 members per year
• C. indicate standard approaches to care for many common, uncomplicated healthcare services
• D. report the number of times that a particular provider performs or recommends a service excluded from the benefit plan

Answer: B

NEW QUESTION 12
Occasionally, employers combine workers’ compensation, group healthcare, and disability programs into an integrated product known as 24-hour coverage. One true statement about 24-hour coverage is that it typically

• A. increases administrative costs
• B. requires plans to maintain separate databases of patient care information
• C. exempts plans from complying with state workers’ compensation regulations
• D. allows plans to apply disability management and return-to-work techniques to nonoccupational conditions

Answer: D

NEW QUESTION 13
The Strathmore Health Plan uses clinical pathways to manage its acute care services. In order to reduce the risk of financial liability associated with the use of clinical pathways, Strathmore and its network hospitals should

• A. base pathways on relevant evidence reported in medical literature
• B. restrict each pathway to a single medical condition
• C. use pathways to establish a new standard of care
• D. allow providers to use only those interventions listed in the pathways

Answer: A

NEW QUESTION 14
Private employers are key purchasers of health plan services. The following statement(s) can correctly be made about employer expectations about the quality and cost- effectiveness of healthcare services:
* 1. For both health maintenance organizations (HMOs) and non-HMO plans, employers typically have access to accreditation results and performance measurement reports to help them evaluate the quality of healthcare and service
* 2. Because of employers’ concern about the quality and costs of healthcare services available through health plans, direct contracting has become a dominant model among employers who sponsor health benefit programs for their employees

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

Answer: D

NEW QUESTION 15
The Quality Assessment Performance Improvement (QAPI) is a quality initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare and Medicaid health plan enrollees. The Centers for Medicare and Medicaid Services (CMS) requires compliance with QAPI from

• A. both Medicare+Choice plans and Medicaid health plans
• B. Medicare+Choice plans only
• C. Medicaid health plans only
• D. neither Medicare+Choice plans nor Medicaid health plans

Answer: B

NEW QUESTION 16
PBMs are accredited by the same organizations that accredit health plans.

• A. True
• B. False

Answer: B

NEW QUESTION 17
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