CCM Healthcare Regulations and Compliance 3 — Questions and Answers
Question 1: Under the ACA's essential health benefits (EHB) requirement, which of the following must be covered by individual and small group market plans?
- Cosmetic surgery and elective procedures
- Mental health and substance use disorder services (Correct answer)
- All experimental treatments approved by the FDA
- Unlimited outpatient visits without cost-sharing
Correct answer: Mental health and substance use disorder services
Mental health and substance use disorder services are one of the ten categories of essential health benefits that must be covered by non-grandfathered individual and small group market plans.
Question 2: The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that financial requirements and treatment limitations for mental health benefits be no more restrictive than those for medical/surgical benefits. This requirement applies to which type of limitation?
- Only annual dollar limits
- Both quantitative limits (like visit caps) and non-quantitative limits (like prior authorization requirements) (Correct answer)
- Only lifetime benefit maximums
- Only inpatient treatment restrictions
Correct answer: Both quantitative limits (like visit caps) and non-quantitative limits (like prior authorization requirements)
MHPAEA applies to both quantitative treatment limitations such as day or visit caps, and non-quantitative limitations such as prior authorization, step therapy, and network composition standards.
Question 3: A case manager is helping a patient navigate a denial of post-acute care. The insurance plan is employer-sponsored and self-funded. Which federal law governs appeals rights and fiduciary responsibilities for this plan?
- ACA marketplace rules
- ERISA (Employee Retirement Income Security Act) (Correct answer)
- Medicaid managed care regulations
- COBRA continuation rules
Correct answer: ERISA (Employee Retirement Income Security Act)
ERISA governs self-funded employer-sponsored plans, establishing fiduciary duties, appeals requirements, and participant rights including claims and appeals procedures.
Question 4: A patient is transitioning from a hospital to home care. The case manager must ensure the discharge plan meets CMS requirements. Which CoP mandates that hospitals have a discharge planning process for all patients?
- CoP – Medical Records
- CoP – Discharge Planning (Correct answer)
- CoP – Pharmaceutical Services
- CoP – Governing Body
Correct answer: CoP – Discharge Planning
The CMS Discharge Planning Condition of Participation requires hospitals to identify patients needing post-discharge services and develop a discharge plan meeting each patient's goals and treatment preferences.
Question 5: The IMPACT Act of 2014 requires post-acute care providers to report standardized patient assessment data. Which of the following is a primary goal of the IMPACT Act?
- To eliminate Medicare Advantage plans
- To enable quality comparisons and care coordination across post-acute settings (Correct answer)
- To restrict access to skilled nursing facilities
- To mandate electronic health records for all providers
Correct answer: To enable quality comparisons and care coordination across post-acute settings
The IMPACT Act requires standardized assessment data across PAC settings to enable cross-setting quality comparisons and support improved discharge planning and care coordination.
Question 6: Under Medicare's Two-Midnight Rule, inpatient hospital admission is generally appropriate when the treating physician expects the patient to require care spanning at least two midnights. What happens if a patient is admitted as inpatient but the stay does not meet this benchmark?
- The patient is automatically transferred to a long-term care facility
- CMS may deny payment and the hospital may need to reclassify the stay as observation (Correct answer)
- The physician loses Medicare billing privileges immediately
- The patient must be discharged within 24 hours by regulation
Correct answer: CMS may deny payment and the hospital may need to reclassify the stay as observation
When an inpatient stay does not meet the two-midnight benchmark, Medicare may deny the inpatient claim and the hospital may reclassify the stay to outpatient observation status.
Question 7: A case manager is reviewing a Medicare Advantage plan's prior authorization requirements. Under CMS regulations, Medicare Advantage plans must conduct prior authorization reviews based on what standard?
- The plan's proprietary clinical criteria only
- Medically accepted clinical criteria consistent with Medicare coverage rules (Correct answer)
- State Medicaid guidelines
- The referring physician's written request alone
Correct answer: Medically accepted clinical criteria consistent with Medicare coverage rules
CMS requires Medicare Advantage plans to use medically accepted clinical criteria that are consistent with Medicare coverage rules and evidence-based guidelines when conducting prior authorization reviews.
CCM Healthcare Regulations and Compliance 3
Under the ACA's essential health benefits (EHB) requirement, which of the following must be covered by individual and small group market plans?