CCM Healthcare Regulations and Compliance 5

Question 1

A case manager is reviewing a patient's care in a long-term acute care hospital (LTACH). Under Medicare criteria, a patient must have an average length of stay of at least how many days to justify LTACH-level care?

Accepted Answer

25 days

Answer

Medicare defines LTACHs as hospitals with an average inpatient length of stay greater than 25 days, and patients must generally meet this clinical acuity threshold for Medicare reimbursement.

Question 2

CMS requires Medicare Advantage organizations to establish a chronic condition special needs plan (C-SNP). What is the primary regulatory purpose of a C-SNP?

Accepted Answer

To tailor benefits and care management to enrollees with specific severe or disabling chronic conditions

Answer

C-SNPs are designed to serve beneficiaries with specific severe or disabling chronic conditions by providing specialized benefits, care coordination, and disease management tailored to those conditions.

Question 3

The No Surprises Act (2022) protects patients from unexpected out-of-network bills. In which care setting did this law PRIMARILY target surprise billing?

Accepted Answer

Emergency services and non-emergency services at in-network facilities provided by out-of-network providers

Answer

The No Surprises Act primarily targets emergency services and non-emergency services provided by out-of-network providers at in-network facilities, limiting patient cost-sharing to in-network amounts.

Question 4

A case manager working with a patient covered by a grandfathered health plan notes limited ACA protections apply. Which ACA provision DOES apply to grandfathered plans?

Accepted Answer

Prohibition on lifetime dollar limits on essential health benefits

Answer

The prohibition on lifetime dollar limits on essential health benefits applies to all plans including grandfathered plans, though many other ACA consumer protections do not.

Question 5

Under CMS rules, a Medicare beneficiary who is placed in observation status rather than admitted as an inpatient faces a significant financial consequence. What is the primary concern?

Accepted Answer

Observation status does not count toward the 3-day inpatient stay required to qualify for Medicare-covered skilled nursing facility care

Answer

Patients in observation status are outpatients and do not accumulate the 3-day qualifying inpatient stay required for Medicare coverage of post-acute SNF care, creating a major out-of-pocket liability.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM Healthcare Regulations and Compliance 5