CCM Financial Management & Reimbursement Flashcards

Which government program provides health coverage to children in families with incomes too high for Medicaid but too low for private insurance?

Answer: CHIP

The Children's Health Insurance Program (CHIP) covers children in low-to-moderate income families who do not qualify for Medicaid.

A CCM must understand DRGs (Diagnosis-Related Groups) because they determine:

Answer: Inpatient hospital reimbursement rates under Medicare

DRGs are a classification system used by Medicare to set fixed reimbursement rates for inpatient hospital stays based on diagnosis and procedures.

What does the term 'dual eligible' refer to in the context of care management?

Answer: Clients who qualify for both Medicare and Medicaid

Dual eligible individuals qualify for both Medicare and Medicaid, receiving benefits from both programs, often requiring complex care coordination.

A care manager is helping a client utilize a Health Savings Account (HSA). Which plan type is required for HSA eligibility?

Answer: High-Deductible Health Plan (HDHP)

HSAs are only available to individuals enrolled in a qualifying High-Deductible Health Plan (HDHP) and allow pre-tax savings for medical expenses.

Which federal law allows workers to continue employer-sponsored health coverage for a limited period after leaving a job?

Answer: COBRA

COBRA (Consolidated Omnibus Budget Reconciliation Act) allows employees and dependents to continue group health coverage for up to 18-36 months after qualifying events.

A CCM notices a client is at risk of falling into the Medicare Part D 'coverage gap.' What should the care manager primarily do?

Answer: Explore Extra Help (Low Income Subsidy) eligibility and manufacturer assistance programs

Care managers should assess eligibility for Medicare Extra Help (LIS) and pharmaceutical assistance programs to reduce costs when clients face the Part D coverage gap.