CCM Healthcare Regulations and Compliance 3

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?

Accepted Answer

Mental health and substance use disorder services

Answer

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?

Accepted Answer

Both quantitative limits (like visit caps) and non-quantitative limits (like prior authorization requirements)

Answer

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?

Accepted Answer

ERISA (Employee Retirement Income Security Act)

Answer

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?

Accepted Answer

CoP – Discharge Planning

Answer

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?

Accepted Answer

To enable quality comparisons and care coordination across post-acute settings

Answer

The IMPACT Act requires standardized assessment data across PAC settings to enable cross-setting quality comparisons and support improved discharge planning and care coordination.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Healthcare Regulations and Compliance 3