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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 extracontractual

coverage of Upzil for Ms. Ray.

In this situation, the prescribing of Upzil for Ms. Ray’s headaches is an example of 

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  

One true statement about state regulation of case management activities is that the majority of states  

Health plans that offer healthcare programs for Medicare beneficiaries have a strong financial incentive for identifying high-risk seniors as early as possible. The identification of high-risk seniors is typically accomplished through the use of 

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. The QAPI (Quality Assessment Performance Improvement Program) is a Centers for Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans’ efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to