CCM CCM Financial Management & Reimbursement 1 — Questions and Answers
Question 1: Which federal program provides health coverage primarily to individuals aged 65 and older, directly impacting reimbursement decisions in care management?
- Medicaid
- Medicare (Correct answer)
- CHIP
- TRICARE
Correct answer: Medicare
Medicare is the federal health insurance program for individuals aged 65 and older, and understanding its reimbursement structures is essential for care managers.
Question 2: A care manager is helping a client navigate out-of-pocket costs. Which term describes the fixed amount a patient pays for a covered health care service after meeting their deductible?
- Premium
- Copayment (Correct answer)
- Coinsurance
- Deductible
Correct answer: Copayment
A copayment is a fixed dollar amount paid by the patient for a specific covered service, separate from the deductible.
Question 3: Which reimbursement model pays providers a set amount per patient per month regardless of services rendered, incentivizing preventive care?
- Fee-for-service
- Capitation (Correct answer)
- Per diem
- Bundled payment
Correct answer: Capitation
Capitation pays a fixed monthly rate per enrolled patient, encouraging cost-effective and preventive care delivery.
Question 4: A CCM is reviewing a client's Explanation of Benefits (EOB). What is the primary purpose of this document?
- It is a bill from the provider
- It explains what the insurance paid and what the patient owes (Correct answer)
- It lists the client's upcoming appointments
- It outlines the client's care plan goals
Correct answer: It explains what the insurance paid and what the patient owes
An EOB is a statement from the insurer detailing what was billed, what the plan covered, and what the patient is responsible for paying.
Question 5: Which term refers to the negotiated maximum amount a health insurance plan will pay for a covered service from an in-network provider?
- Usual and customary rate
- Allowable amount (Correct answer)
- Billed charge
- Balance billing
Correct answer: Allowable amount
The allowable amount is the maximum negotiated rate the insurer will pay for a service, with the patient responsible for their share of that amount.
Question 6: Under the Affordable Care Act (ACA), what is the term for the annual cap on out-of-pocket expenses a patient must pay for covered in-network services?
- Lifetime benefit maximum
- Out-of-pocket maximum (Correct answer)
- Annual deductible cap
- Coinsurance ceiling
Correct answer: Out-of-pocket maximum
The out-of-pocket maximum is the most a patient will pay in a year for covered services; after reaching it, the insurer covers 100% of covered costs.
CCM CCM Financial Management & Reimbursement 1
Which federal program provides health coverage primarily to individuals aged 65 and older, directly impacting reimbursement decisions in care management?