Healthcare Regulations and Compliance Flashcards
7 cards from real CCM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Healthcare Regulations and Compliance flashcards as text
Under the ACA's essential health benefits (EHB) requirement, which of the following must be covered by individual and small group market plans?
Answer: Mental health and substance use disorder services
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.
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?
Answer: Both quantitative limits (like visit caps) and non-quantitative limits (like prior authorization requirements)
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.
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?
Answer: ERISA (Employee Retirement Income Security Act)
ERISA governs self-funded employer-sponsored plans, establishing fiduciary duties, appeals requirements, and participant rights including claims and appeals procedures.
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?
Answer: CoP – Discharge Planning
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.
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?
Answer: To enable quality comparisons and care coordination across post-acute settings
The IMPACT Act requires standardized assessment data across PAC settings to enable cross-setting quality comparisons and support improved discharge planning and care coordination.
Under Medicare's Two-Midnight Rule, inpatient hospital admission is generally appropriate when the treating physician expects the patient to require care spanning at least two midnights. What happens if a patient is admitted as inpatient but the stay does not meet this benchmark?
Answer: CMS may deny payment and the hospital may need to reclassify the stay as observation
When an inpatient stay does not meet the two-midnight benchmark, Medicare may deny the inpatient claim and the hospital may reclassify the stay to outpatient observation status.
A case manager is reviewing a Medicare Advantage plan's prior authorization requirements. Under CMS regulations, Medicare Advantage plans must conduct prior authorization reviews based on what standard?
Answer: Medically accepted clinical criteria consistent with Medicare coverage rules
CMS requires Medicare Advantage plans to use medically accepted clinical criteria that are consistent with Medicare coverage rules and evidence-based guidelines when conducting prior authorization reviews.