The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph.
To manage the delivery of healthcare services to their members, health plans use clinical practice parameters. _________ is the type of clinical practice parameter that a health plan uses to make coverage decisions concerning medical necessity and appropriateness.
Correct Answer:
B
Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray’s condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace’s medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.
In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an example of
Correct Answer:
C
PBMs are accredited by the same organizations that accredit health plans.
Correct Answer:
B
Determine whether the following statement is true or false:
Under a carve-out arrangement for disease management, patients typically maintain their existing relationships with primary care providers (PCPs) for all care, including disease management.
Correct Answer:
B
Recent laws and regulations have established new requirements for Medicaid eligibility. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 affected Medicaid eligibility by
Correct Answer:
A
