Medical Management Exam Answer Key

Medical Management Exam These comprehensive responses to AHIP exam questions, complete with explanations and 100% accurate answers, will aid in your preparation for the 2025 exam. We hope this may be helpful to you. Question #1 The paragraph below contains an incomplete statement. Select the answer choice containing the term that correctly completes the paragraph. Medical management programs often require the analysis of many types of data and information. _____________ is an automated process that analyzes variables to help detect patterns and relationships in the data. A. Unbundling B. Outsourcing C. Data mining D. Drilling down The correct option is C. Data mining. Here is an explanation of why that is the correct answer: Data mining is the precise term for the process of using automated software and statistical techniques to search through large amounts of data to identify meaningful patterns, trends, and relationships that might not be apparent through simple analysis. This is exactly what the paragraph describes. In medical management, a health plan might use data mining to identify which members are at high risk for developing a chronic condition or to find patterns of fraud in claims data. Question #2 Since its inception, Medicare has undergone a number of changes because of legal and regulatory action. One result of the Balanced Budget Act (BBA) of 1997 has been to A. expand Medicare benefits by mandating coverage for certain preventive services B. reduce the number of organizations that can deliver covered services C. encourage growth of managed Medicare programs in all markets D. increase the number of "zero premium" plans available to Medicare beneficiaries The correct option is C. encourage growth of managed Medicare programs in all markets. Here is an explanation of why that is the correct answer: The Balanced Budget Act (BBA) of 1997 was a landmark piece of legislation that made significant changes to the Medicare program. Its most notable and far-reaching impact was the creation of the Medicare+Choice program, which is now known as Medicare Advantage. The primary goals of creating the Medicare+Choice program were to:  Provide Medicare beneficiaries with more health plan choices beyond the traditional fee-forservice model.  Encourage private, managed care organizations (like HMOs and PPOs) to enter the Medicare market and compete for members.  Control the growth of Medicare spending through the efficiencies of managed care. Essentially, the BBA created a new structure and new payment rules designed to make it more attractive for private health plans to offer services to Medicare beneficiaries, thereby encouraging the growth of managed care within the Medicare program. Question #3 To measure performance for quality management, health plans collect and analyze three types of data: financial data, clinical data, and customer satisfaction data. The following statement(s) can correctly be made about the sources of clinical data: 1.Patient surveys are the most widely used source of disease-specific clinical information 2.Outcomes research studies sponsored by academic institutions and professional organizations have limited usefulness for particular health plans or individual providers 3.The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mental health status A. All of the above B. 1 and 2 only C. 2 and 3 only D. 3 only The correct option is D. 3 only. Here is a breakdown of why statement 3 is correct and why statements 1 and 2 are incorrect:  Statement 3: The SF-36 and the HSQ-39 (Health Status Questionnaire) surveys address both physical and mental health status. o This statement is correct. The SF-36 (Short Form 36) is one of the most widely used survey instruments for measuring a patient's overall health status and quality of life. It is specifically designed to measure eight health concepts which are then aggregated into two summary scores: a Physical Component Summary (PCS) and a Mental Component Summary (MCS) This confirms that it addresses both physical and mental health. The Health Status Questionnaire (HSQ) is a family of related surveys, including the SF-36, that serve the same purpose.  Statement 1: Patient surveys are the most widely used source of disease-specific clinical information. o This statement is incorrect. While patient surveys are valuable for gathering data on symptoms, satisfaction, and a patient's perception of their health (patient-reported outcomes), they are not the most widely used source for disease-specific clinical information. The most heavily used sources for this type of detailed clinical data are claims data (which contain diagnosis and procedure codes), electronic health records (EHRs), pharmacy data, and laboratory results.  Statement 2: Outcomes research studies sponsored by academic institutions and professional organizations have limited usefulness for particular health plans or individual providers. o This statement is incorrect. The opposite is true. These large-scale outcomes studies are the foundation of evidence-based medicine. Health plans rely heavily on this research to develop their clinical practice guidelines, create medical policies, and design their disease management programs. Individual providers use the findings from these studies to stay current and make informed treatment decisions for their patients. They have very high, not limited, usefulness. Question #4 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. A. This questionnaire was designed specifically for use by health plans. B. Each health plan must use the same form of the questionnaire, with no additions or modifications. C. This questionnaire monitors the prevalence of the major behavioral risks associated with illness and injury among adults. D. All of the above statements are correct. The correct option is C. This questionnaire monitors the prevalence of the major behavioral risks associated with illness and injury among adults. Here is an explanation of why that is the correct answer:  Statement C is the definition and purpose of the BRFSS. The Behavioral Risk Factor Surveillance System (BRFSS) is a national public health survey system coordinated by the Centers for Disease Control and Prevention (CDC). Its primary function is to collect statelevel data on the health-related risk behaviors (like smoking, alcohol use, physical inactivity, and poor diet), chronic health conditions, and the use of preventive services among the U.S. adult population. This is a perfect description of its role. Question #5 Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements. A. The proportion of adult members who are screened for hypertension will increase by ten percent. B. Primary care providers (PCPs) will increase the proportion of children under the age of two who are up-to-date on immunizations by seven percent within one year. C. The QM program director will evaluate the level of provider compliance with clinical practice guidelines (CPGs). D. The disease management program director will increase participation by asthmatic children in the health plan's pediatric asthma disease management program. The correct option is B. Primary care providers (PCPs) will increase the proportion of children under the age of two who are up-to-date on immunizations by seven percent within one year. Here is an explanation of why that is the correct answer: A complete and effective action statement for performance improvement should be "SMART" (Specific, Measurable, Achievable, Relevant, Time-bound). At a minimum, it must clearly define: 1. Who is responsible for the action. 2. What the specific action or goal is. 3. How much change is expected (a measurable target). 4. By when the goal should be accomplished (a timeframe). Let's analyze the options based on these required elements:  A. The proportion of adult members who are screened for hypertension will increase by ten percent. o What: Increase hypertension screening. o How much: By 10%. o Who: Missing. o By when: Missing.    B. Primary care providers (PCPs) will increase the proportion of children under the age of two who are up-to-date on immunizations by seven percent within one year. o Who: Primary care providers (PCPs). o What: Increase immunization rates for children under two. o How much: By 7%. o By when: Within one year. o This statement includes all four required elements. C. The QM program director will evaluate the level of provider compliance with clinical practice guidelines (CPGs). o Who: The QM program director. o What: Evaluate provider compliance. (This is a task, not a performance improvement goal). o How much: Missing. o By when: Missing. D. The disease management program director will increase participation by asthmatic children in the health plan's pediatric asthma disease management program. o Who: The disease management program director. o What: Increase participation in the asthma program. o How much: Missing. o By when: Missing. Question #6 In most health plans, the formulary system is developed and managed by a P&T committee. The P&T committee is responsible for A. evaluating and selecting drugs for inclusion in the formulary B. overseeing the manufacture, distribution, and marketing of prescription drugs C. certifying the medical necessity of expensive, potentially toxic, or nonformulary drugs D. all of the above The correct option is A. evaluating and selecting drugs for inclusion in the formulary. Here is an explanation of why that is the correct answer: The primary and most fundamental responsibility of a Pharmacy & Therapeutics (P&T) committee is to manage the health plan's formulary. This involves a rigorous, evidence-based process where the committee:  Evaluates the safety, clinical efficacy, and cost-effectiveness of new and existing drugs.  Selects which drugs will be included on the formulary (the list of covered medications).  Determines the formulary status of drugs (e.g., which tier a drug is on, whether it requires prior authorization). Question #7 With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT A. maintaining clinical practices B. delivering performance feedback to providers C. participating in utilization management (UM) activities D. educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management The correct option is A. maintaining clinical practices. Here is an explanation of why that is the correct answer: The role of a medical director at a Managed Care Organization (MCO) is a senior administrative and executive position. It requires a full-time commitment to overseeing the clinical aspects of the health plan. While medical directors must maintain their medical licenses, they are typically not engaged in the active, day-to-day clinical practice of seeing and treating their own patients. Their focus is on population health, policy, and management, not individual patient care. Question #8 The following statements describe situations in which health plan members have medical problems that require care. Select the statement that describes a situation in which self-care most likely would not be appropriate. A. Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area. B. Calvin Dodd has Type II diabetes and requires blood glucose monitoring tests several times each day. C. Caroline Evans has severe arthritis that requires regular exercise and oral medication to reduce pain and help her maintain mobility. D. Oscar Gracken is recovering from a heart attack and requires ongoing cardiac rehabilitation. The correct option is A. Two days after bruising her leg, Avis Bennet notices that the pain from the bruise has increased and that there are red streaks and swelling around the bruised area. Here is an explanation of why that is the correct answer: The situation described in option A presents clear signs of a potentially serious medical problem that requires immediate professional evaluation. The key symptoms are:  Increased pain: Pain worsening over time instead of improving is a red flag.  Red streaks: This is a classic sign of lymphangitis, which is an infection spreading through the lymphatic system.  Swelling: This, combined with the other symptoms, points to a significant inflammatory response, likely from an infection like cellulitis. These symptoms indicate that a simple bruise has likely developed a secondary bacterial infection. This is an acute, urgent condition that cannot be managed with self-care and requires prompt medical attention, very likely including prescription antibiotics. Question #9 The following statements are about risk management for case management. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement. A. The use of a signed consent authorization form is consistent with accrediting agency standards for patient privacy and confidentiality of medical information. B. Case management that is initiated after a member has incurred substantial medical expenses is more likely to be viewed as a tool to cut costs rather than to improve outcomes. C. Health plan documents indicating that any case management delegates are separate, independent entities may reduce an health plan's exposure to risk. D. A case management file cannot be used to support the health plan's position in the event of a lawsuit. The correct option is D. A case management file cannot be used to support the health plan's position in the event of a lawsuit. This statement is FALSE. Here is an explanation of why: The case management file is a critical legal and business record. Meticulous and contemporaneous documentation is a cornerstone of risk management in case management. In the event of a lawsuit, the case management file is often a primary piece of evidence. If the documentation is thorough, accurate, and objective, it can be the most powerful tool to support the health plan's position. It can demonstrate that the case manager acted reasonably, followed established protocols, communicated effectively with the member and providers, and made decisions based on appropriate clinical information. Conversely, poor or missing documentation can be used against the health plan. Therefore, the idea that the file cannot be used to support the plan's position is incorrect. Question #10 PBMs are accredited by the same organizations that accredit health plans. A. True B. False The correct option is A. True. Here is an explanation of why that is the correct answer: The leading independent organizations that accredit health plans in the United States, such as URAC (Utilization Review Accreditation Commission) and the NCQA (National Committee for Quality Assurance), also offer accreditation and certification programs for Pharmacy Benefit Managers (PBMs).  URAC offers a specific Pharmacy Benefit Management Accreditation. By achieving this, a PBM demonstrates a comprehensive commitment to quality care, improved processes, and better patient outcomes.  NCQA, a primary accreditor of health plans, also accredits and certifies PBMs in areas such as Utilization Management and Health Information Products. Since a health plan's pharmacy benefits are a critical part of their overall service, NCQA's standards for health plans often require a close evaluation of their PBM partners. Question #11 The Westchester Health Plan classifies its key processes into the following categories: high-risk, high-volume, problem-prone, and high-cost. Westchester also prioritizes the categories in terms of importance. The process category that Westchester most likely ranks highest in importance is A. High-risk processes B. High-volume processes C. Problem-prone processes D. High-cost processes The correct option is A. High-risk processes. Here is an explanation of why that is the correct answer: While all of these categories are important for a health plan to monitor and manage, high-risk processes are ranked as the most critical. This is because a failure in a high-risk process has the most severe potential consequences.  High-risk processes are those that, if not performed correctly, could directly result in significant harm to a patient's health or safety. Examples include utilization management for critical procedures, credentialing of surgeons, or medication management for complex conditions. A failure in these areas can lead to dire health outcomes, major malpractice lawsuits, severe regulatory penalties, loss of accreditation, and irreparable damage to the health plan's reputation. The primary mission of a health plan is to manage care, making the risk of patient harm the paramount concern. Question #12 With respect to the activities of MCO medical directors, it is correct to say that medical directors typically perform all of the following activities EXCEPT A. maintaining clinical practices B. delivering performance feedback to providers C. participating in utilization management (UM) activities D. educating other MCO staff about new clinical developments or provider innovations that might impact clinical practice management The correct option is A. maintaining clinical practices. Here is an explanation of why that is the correct answer: The role of a medical director at a Managed Care Organization (MCO) is a senior administrative and executive position. It requires a full-time commitment to overseeing the clinical aspects of the health plan. While medical directors must maintain their medical licenses, they are typically not engaged in the active, day-to-day clinical practice of seeing and treating their own patients. Their focus is on population health, policy, and management, not individual patient care Question #13 Federal laws, such as the Employee Retirement Income Security Act (ERISA), the Balanced Budget Act (BBA) of 1997, and the Health Insurance Portability and Accountability Act (HIPAA), have affected medical management activities by health plans. Consider the following provisions of federal regulations: Provision 1 Limits damage awards in lawsuits related to noncoverage of benefits based on medical necessity decisions to the cost of noncovered treatment and does not allow health plan members to obtain compensatory or punitive damages Provision 2 Establishes electronic data security standards, which define the security measures that healthcare organizations must take to protect the confidentiality of electronically stored and transmitted patient information From the answer choices below, select the response that correctly identifies the federal laws that include Provision 1 and Provision 2, respectively. A. Provision 1- ERISA Provision 2- HIPAA B. Provision 1- HIPAA Provision 2- ERISA C. Provision 1- BBA of 1997 Provision 2- HIPAA D. Provision 1- ERISA Provision 2- BBA of 1997 The correct option is A. Provision 1- ERISA Provision 2- HIPAA. Here is an explanation of why that is the correct answer:  Provision 1 is from ERISA: The Employee Retirement Income Security Act (ERISA) is a broad federal law that governs employee benefit plans, including most employer-sponsored health plans. A key aspect of ERISA is that it preempts, or overrides, many state-level laws. When a health plan member sues the plan over a denial of benefits under an ERISAgoverned plan, the remedies are typically limited by federal law. The U.S. Supreme Court has interpreted ERISA to mean that a member can generally only sue to recover the value of the denied benefit itself. State-law claims that would allow for compensatory (e.g., for pain and suffering) or punitive damages are usually not permitted in these cases. This matches the description in Provision 1 perfectly.  Provision 2 is from HIPAA: The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is the landmark federal law dealing with patient privacy and data security. The HIPAA Security Rule specifically establishes a national set of security standards for protecting certain health information that is held or transferred in electronic form. It requires covered entities to implement administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and security of electronically stored and transmitted patient information, which is precisely what Provision 2 describes. Question #14 For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice. Many health plans use data warehouses to assist with the performance of medical management activities. With respect to the characteristics of data warehouses, it is generally correct to say A. that the construction of a data warehouse is quick and simple B. that a data warehouse addresses the problems associated with multiple data management systems C. that a data warehouse stores only current data D. all of the above The correct option is B. that a data warehouse addresses the problems associated with multiple data management systems. Here is an explanation of why that is the correct answer: A primary purpose of a data warehouse is to solve the problem of "data silos." A typical health plan has numerous separate, and often incompatible, computer systems for different functions—a claims system, an enrollment system, a provider database, a pharmacy benefits system, a care management system, etc. A data warehouse integrates the data from these disparate sources into a single, unified, and consistent repository. This allows the health plan to perform complex analysis and get a holistic view of its members, providers, and operations, which would be impossible if the data remained locked in separate systems. Question #15 Performance variance can be classified as either common cause variance or special cause variance. The following statement(s) can correctly be made about special cause variance: 1.Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance 2.Special cause variance is typically more difficult to detect and correct than is common cause variance A. Both 1 and 2 B. 1 only C. 2 only D. Neither 1 nor 2 The correct option is B. 1 only. Here is an explanation of why:  Statement 1: "Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance." This statement is correct. Special cause variance (also known as assignable cause variance) is a variation in a process that is caused by specific, identifiable, and often unpredictable events that are not an inherent part of the process. The examples given—a sudden staff shortage, a specific error made by an employee, or a machine breaking down—are all classic examples of special causes that disrupt the normal, stable functioning of a process.  Statement 2: "Special cause variance is typically more difficult to detect and correct than is common cause variance." This statement is incorrect. The opposite is generally true. o Detection: Special cause variance is often easier to detect because it usually results in a data point or a pattern that falls outside the statistically normal operating range (i.e., outside the upper or lower control limits on a control chart). It creates a clear signal that something unusual has happened. o Correction: Special cause variance is also easier to correct. Because it has a specific, assignable cause, you can investigate, find the root of the problem (e.g., fix the broken equipment, retrain the employee), and correct it. o Common cause variance, on the other hand, is the inherent, random "noise" within a stable process. It is much more difficult to detect (as it falls within the expected range) and far more difficult to reduce, as doing so requires a fundamental redesign and improvement of the entire process, not just fixing a single problem. Question #16 The Quality Assessment Performance Improvement (QAPI) is a quality initiative designed to strengthen health plans efforts to protect and improve the health and satisfaction of Medicare and Medicaid health plan enrollees. The Centers for Medicare and Medicaid Services (CMS) requires compliance with QAPI from A. both Medicare+Choice plans and Medicaid health plans B. Medicare+Choice plans only C. Medicaid health plans only D. neither Medicare+Choice plans nor Medicaid health plans The correct option is A. both Medicare+Choice plans and Medicaid health plans. Here is an explanation of why that is the correct answer: The Centers for Medicare and Medicaid Services (CMS) mandates that health plans participating in its major programs establish and maintain a Quality Assessment and Performance Improvement (QAPI) program. This requirement applies to both of the plan types mentioned in the question.  Medicare+Choice Plans: The term "Medicare+Choice" is the former name for what is now known as the Medicare Advantage (MA) program. Federal regulations, specifically under 42 CFR Part 422, Subpart D, require Medicare Advantage organizations to have an ongoing quality improvement program. This program is designed to objectively measure health outcomes and other indicators of quality to drive sustained improvement.  Medicaid Health Plans: States are required to ensure that the Medicaid managed care organizations (MCOs) they contract with establish and implement a comprehensive QAPI program. These QAPI programs are a core component of federal and state oversight of Medicaid managed care and are designed to stimulate significant, sustained improvements in health outcomes and enrollee satisfaction. Because CMS requires these quality initiatives for both Medicare Advantage (formerly Medicare+Choice) and Medicaid managed care plans, option A is the correct answer. Question #17 A health plan's preventive care initiatives may be classified into three main categories: primary prevention, secondary prevention, and tertiary prevention. Secondary prevention refers to activities designed to A. develop an appropriate treatment strategy for patients whose conditions require extensive, complex healthcare B. educate and motivate members to prevent illness through their lifestyle choices C. prevent the occurrence of illness or injury D. detect a medical condition in its early stages and prevent or at least delay disease progression and complications The correct option is D. detect a medical condition in its early stages and prevent or at least delay disease progression and complications. Here is an explanation of the three categories of prevention and why D is the correct answer:    Primary Prevention: This is the most proactive form of prevention. Its goal is to prevent a disease or injury from ever occurring. This involves promoting healthy behaviors and creating safe environments. o Examples: Immunizations, health education on nutrition and exercise, smoking cessation programs, and wearing seatbelts. o Answer choices B and C describe primary prevention. Secondary Prevention: This category focuses on a disease that is already present but may not yet be causing symptoms. The goal is to find and treat the disease at its earliest stage to slow its progress, prevent complications, or cure it. The key is early detection. o Examples: Regular screenings like mammograms, Pap smears, and blood pressure checks; daily low-dose aspirin to prevent a second heart attack. o Answer choice D perfectly describes this level of prevention. Tertiary Prevention: This level of prevention applies when a disease is already established and has caused some level of impairment. The goal is to soften the impact of the ongoing illness, manage its long-term effects, and improve the patient's quality of life. This involves rehabilitation and chronic disease management. o Examples: Cardiac rehab programs after a heart attack, diabetes management programs, and physical therapy after an injury. o Answer choice A describes tertiary prevention. Question #18 Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Rays 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 Harbraces medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extracontractual coverage of Upzil for Ms. Ray. The following statement(s) can correctly be made about Harbraces use of extra- contractual coverage: 1.Harbraces 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 A. Both 1 and 2 B. 1 only C. 2 only D. Neither 1 nor 2 The correct option is C. 2 only. Here is an explanation of why:  Statement 1 is incorrect. A health plan's medical policy outlines what is considered medically necessary and therefore covered under the standard terms of the contract. In this case, Harbrace's medical policy for migraines does not include Upzil, likely because its use for migraines is considered experimental or investigational. Therefore, the medical policy would be the basis for denying the claim, not for evaluating it for an exception. The decision to grant extra-contractual coverage is an administrative one that occurs outside of or in spite of the established medical policy, often through a case management or appeals process.  Statement 2 is correct. An alternative care provision is a clause included in a health plan's contracts (with employers or other purchasers) that gives the plan the discretion to cover services that are not explicitly listed as covered benefits. This provision is specifically designed to handle unique situations like Ms. Ray's. It allows the health plan to approve a non-covered, potentially cost-effective, or compassionate-use treatment on a case-by-case basis without setting a precedent that the treatment is now a standard covered benefit for all members. This provision is a key risk management tool because it provides a contractual framework for making these exceptions, which can reduce legal challenges and clarify that such decisions are made at the plan's discretion. Question #19 Determine whether the following statement is true or false: Independent review organizations (IROs) can mediate disputes and offer advisory opinions to health plans on UR issues, but they cannot render binding decisions on appeals. A. True B. False The correct option is B. False. Here is an explanation of why the statement is false: The primary and most critical function of an Independent Review Organization (IRO) in the context of healthcare appeals is precisely to render a final, binding decision. When a health plan member has exhausted the internal appeals process and still disagrees with a denial of coverage (especially one based on medical necessity), they have the right, under the Affordable Care Act (ACA) and many state laws, to an external review by an IRO. The decision made by this independent, third-party organization is legally binding on the health plan. If the IRO overturns the health plan's denial, the health plan is required by law to cover the service. The statement's claim that IROs "cannot render binding decisions" is a direct contradiction of their fundamental purpose in the member appeals process. Question #20 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 A. standard medical-surgical services B. mental health and substance abuse services C. services offered to Medicare enrollees as optional supplementary benefits D. all of the above The correct option is D. all of the above. Here is an explanation of why that is the correct answer: The Quality Assessment and Performance Improvement (QAPI) program, as mandated by the Centers for Medicare and Medicaid Services (CMS) for Medicare Advantage (formerly Medicare+Choice) plans, is designed to be comprehensive and all-encompassing. The regulations require the QAPI program to address the full spectrum of care and services that a health plan provides to its Medicare enrollees. Let's look at each option:  A. standard medical-surgical services: These are the core healthcare services and are unquestionably a primary focus of any quality improvement program.  B. mental health and substance abuse services: These services are critical components of a member's overall health. CMS requires Medicare Advantage plans to cover these services, and they must be included within the scope of the QAPI program to ensure quality of care and integration with physical health services.  C. services offered to Medicare enrollees as optional supplementary benefits: When a Medicare Advantage plan chooses to offer supplemental benefits (such as dental, vision, or hearing services) as part of its benefit package, it is responsible for the quality of those services. The QAPI program's oversight extends to all services the plan provides to its members, including these supplemental benefits. Because the QAPI standards are intended to be broad and cover all aspects of the care and services a member receives through their health plan, all three of the listed categories are included. Therefore, the correct answer is D.