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AHM Medical Management
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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.
Children with chronic conditions use more physician and nonphysician professional services than do children in the general population.
The majority of chronic conditions affecting children in Medicaid programs are the same as those affecting children in the general population.
Medicaid-eligible children are at risk for seriousmental and physical conditions.
Children in Medicaid programs have a higher incidence of chronic disabling conditions than do children in the general population.
Determine whether the following statement is true or false:
The key to successfully managing the quality and cost-effectiveness of healthcare services for Medicaid enrollees is to merge Medicaid recipients into existing plans.
True
False
Access to services is an important issue for both fee-for-service (FFS) Medicaid and managed Medicaid programs. Access to services under managed Medicaid is affected by the
lack of qualified providers in provider networks
lack of resources necessary to establish case management programs for patients with complex conditions
unstable eligibility status of Medicaid recipients
inability of Medicaid recipients to change health plans or PCPs
The following statement(s) can correctly be made about medical management considerations for the Federal Employee Health Benefits Program (FEHBP):
FEHBP plan members who have exhausted the health plan’s usual appeals process for a disputed decision can request an independent review by the Office of Personnel Management (OPM)
All health plans that cover federal employees are required to develop and implement patient safety initiatives
Both 1 and 2
1 only
2 only
Neither 1 nor 2
Serena Wilson, a registered nurse, is employed at a TRICARE Service Center (TSC) located at a military installation. Ms. Wilson serves as a primary point of contact between enrollees and the TRICARE system and answers enrollees’ questions about plan options, eligibility, provider selection, and claims. This information indicates that Ms. Wilson serves as a
lead agent
beneficiary services representative
health plan support contractor
primary care manager (PCM)
The paragraph below contains two pairs of terms or phrases enclosed in parentheses. Select the term or phrase in each pair that correctly completes the paragraph. Then select the answer choice containing the two terms or phrases you have chosen.
TRICARE enrollees have the right to challenge authorization and coverage decisions. Such challenges are referred to as (appeals / grievances) and are typically handled by the (TRICARE contractor / Area Field Office).
appeals / TRICARE contractor
appeals / Area Field Office
grievances / TRICARE contractor
grievances / Area Field Office
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
provides health and disability benefits to employees injured on the job only if the employer is at fault for the injury
provides coverage for a variety of direct and indirect healthcare, disability, and workplace costs
manages costs by including employee cost-sharing features in its benefit design
places limits on benefits by restricting the amount of benefit payments or the number of covered hospital days or provider office visits
For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.
Ways that workers’ compensation health plans can help control the costs of job-related injuries and illnesses include
applying strict definitions of medical necessity
developing prevention and recovery programs
applying out-of-network benefit reductions
all of the above
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
increases administrative costs
requires plans to maintain separate databases of patient care information
exempts plans from complying with state workers’ compensation regulations
allows plans to apply disability management and return-to-work techniques to nonoccupational conditions
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