The case management team at the Hightower Health Plan reviewed the medical records of the following two plan members to determine the type of care each one needs and the most appropriate setting for that care:

Ira Morton was hospitalized for a severe stroke. Although his medical condition is stable, the stroke left him partially paralyzed and he will require extensive rehabilitation and 24-hour medical care.

Theresa Finley is recovering from a total hip replacement and is in need of short-term physical therapy and twice-weekly visits from a licensed nurse to check her blood pressure and the healing of her incision.

From the answer choices below, select the response that correctly identifies the level of care that would be most appropriate for Mr. Morton and Ms. Finley.

The following statements are about QAPI as it applies to Medicare+Choice plans and Medicaid health plan entities. Select the answer choice containing the correct statement.

This agency oversees fraud and abuse matters as they relate to medical management.

The following statements are about the use of hospitalists to manage inpatient care. Select the answer choice containing the correct statement.

The following statement(s) can correctly be made about performance measurement systems:

1. The most difficult purpose for a performance measurement system to address is to measure changes in outcomes caused by modifications in administrative or clinical treatment processes

2. A health plan needs different performance measurement systems to evaluate its administrative services and the clinical performance of its providers

A health plan’s coverage policies are linked to its purchaser contracts. The following statement(s) can correctly be made about the purchaser contract and coverage decisions:

1. In case of conflict between the purchaser contract and a health plan’s medical policy or benefits administration policy, the contract takes precedence

2. Purchaser contracts commonly exclude custodial care from their coverage of services and supplies

3. All of the criteria for coverage decisions must be included in the purchaser contract

State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on

Some health plans administer a questionnaire known as the Behavioral Risk Factor Surveillance System (BRFSS) as part of their health risk assessment (HRA) processes. The following statements are about the BRFSS. If statements (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct statement.

Step-therapy is a form of prior authorization that reserves the use of more expensive medications for cases in which the use of less expensive medications has been unsuccessful. Step-therapy is appropriate for situations in which

1. A significant percentage of those treated with the initial therapy will require the second therapy

2. The delay created when a patient moves from one therapy to the next therapy will not cause serious or permanent effects

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.

The following statement(s) can correctly be made about Harbrace’s use of extra-contractual coverage:

1. Harbrace’s medical policy most likely establishes the procedure that Harbrace used to evaluate the value of Upzil for treating Ms. Ray

2. One way for Harbrace to reduce the risk associated with extra-contractual coverage is by including an alternative care provision in its contracts with purchasers