CCM CCM Financial & Benefits Navigation 2 — Questions and Answers
Question 1: Which government program provides health coverage to low-income children, pregnant women, elderly adults, and people with disabilities in the US?
- Medicare
- CHIP
- Medicaid (Correct answer)
- VA Health Benefits
Correct answer: Medicaid
Medicaid is a joint federal-state program providing health coverage to eligible low-income populations including children, pregnant women, elderly, and disabled individuals.
Question 2: The Children's Health Insurance Program (CHIP) is designed to cover:
- Adults without employer coverage
- Children in families with incomes too high for Medicaid but who cannot afford private insurance (Correct answer)
- Elderly individuals with limited income
- Veterans and their dependents
Correct answer: Children in families with incomes too high for Medicaid but who cannot afford private insurance
CHIP fills the gap for children whose family incomes exceed Medicaid limits but are still too low to afford private coverage.
Question 3: A CCM case manager is helping a client navigate a prior authorization denial. The appropriate next step is to:
- Accept the denial and seek an alternative treatment
- File an appeal using clinical documentation supporting medical necessity (Correct answer)
- Contact the state insurance commissioner directly
- Advise the client to pay out-of-pocket
Correct answer: File an appeal using clinical documentation supporting medical necessity
Appealing with supporting clinical documentation to establish medical necessity is the standard process for challenging prior authorization denials.
Question 4: The Affordable Care Act (ACA) marketplace special enrollment period (SEP) is triggered by which of the following?
- Annual income tax filing
- A qualifying life event such as job loss, marriage, or having a baby (Correct answer)
- Turning 26 years old only
- Moving to a new state only
Correct answer: A qualifying life event such as job loss, marriage, or having a baby
Qualifying life events — including loss of coverage, marriage, birth/adoption, or moving — trigger a Special Enrollment Period outside the annual open enrollment window.
Question 5: Pharmaceutical patient assistance programs (PAPs) are primarily offered by:
- Federal government agencies
- Drug manufacturers to provide free or reduced-cost medications to qualifying patients (Correct answer)
- State Medicaid programs only
- Private insurance companies
Correct answer: Drug manufacturers to provide free or reduced-cost medications to qualifying patients
Pharmaceutical manufacturers operate PAPs to provide medications at no or low cost to uninsured or underinsured patients who meet eligibility criteria.
Question 6: When a client is hospitalized, the case manager's financial navigation role includes:
- Negotiating surgical fees directly with the surgeon
- Screening for financial assistance programs and coordinating discharge to prevent unplanned readmissions driven by cost (Correct answer)
- Approving or denying insurance claims
- Setting hospital billing rates
Correct answer: Screening for financial assistance programs and coordinating discharge to prevent unplanned readmissions driven by cost
Case managers identify financial barriers to discharge and connect clients with assistance programs to support safe, sustainable transitions home.
CCM CCM Financial & Benefits Navigation 2
Which government program provides health coverage to low-income children, pregnant women, elderly adults, and people with disabilities in the US?