Understanding Medicare Parts A & B and Medicare Advantage Plans, Exams of Nursing

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UHC Certification 2023/2024 Questions With Complete Solutions Medicare - CORRECT ANSWERFederal health insurance program Medicare is administered by whom? - CORRECT ANSWERCMS ( Centers for medicare and medicaid services) Parts A & B of medicare are - CORRECT ANSWERfederal health insurance program referred to as original medicare Part A? - CORRECT ANSWERHospital insurance Part B? - CORRECT ANSWERMedical insurance What doesnt medicare cover? - CORRECT ANSWERroutine dental, eye care hearing exam,deductibles, coinsurance and copayments Part C? - CORRECT ANSWERMedicare Advantage Plans MA covers? - CORRECT ANSWERPart A &B coverage, and some part D coverage MA plans are not? - CORRECT ANSWERMedicare supplement insurance plans What offers lower monthly premiums MADP or supplement? - CORRECT ANSWERMADP do MAP's have a annual maximum OOP maximum that limits the amount of money a member must spend every year for covered services? - CORRECT ANSWERYES MA plans integrate what type of additonal coverage? - CORRECT ANSWERpart D prescription drug coverage If a customer wants to keep their stand alone prescription drug plan, what may the customer want to enroll in? - CORRECT ANSWERMA-only PFFS plan What is a stand alone drug plan called? - CORRECT ANSWERPDP WHat is PFFS? - CORRECT ANSWERPrivate Fee for Service (PFFS) - Plans that allow you to go to any doctor or hospital that accepts their terms If a customer lives in a rural area, what type of plan may they want because it gives them freedom to access doctors that may not be in their network? - CORRECT ANSWERPFFS plan Do HMO's require referals? - CORRECT ANSWERYes Do PPO's require a referal? - CORRECT ANSWERNo UHC Certification 2023/2024 Questions With Complete Solutions When a member enrolls in a MA plan, they receive their coverage from medicare or the MA plan? - CORRECT ANSWERMA plan When a customer is enrolled in a MA plan, they must continue paying their premiums for what other plan? - CORRECT ANSWERPart B MA plans have a maxium annual limit on OOP costs called a? - CORRECT ANSWERMOOP amount ( Maxium out of pocket) When a member is enrolled in a MA plan, they are automatically disenrolled from any other MA plan or PDP( prescription drug plan) in which they are enrolled as of the new plans_____? - CORRECT ANSWEReffective date An exception exisits for MA-only PFFS plans as a member can also be enrolled in a what? - CORRECT ANSWERStand alone PDP If a member enrolls in a MA plan, what must the member do? - CORRECT ANSWERCancel in writing their medicare supplement insurance policy with the carrier after their request to enroll in MA plan has been approved. Medicare supplement insurance policies cannot be used in conjunction with what type of plan? - CORRECT ANSWERMA plan A medicare supplement insurance plan helps to cover some of the OOP costs associated with? - CORRECT ANSWERoriginal medicare. A medicare supplement insurance plan does NOT pay the cost-sharing of what type of plan? - CORRECT ANSWERMA plan when a client enrolls in a MA plan, will it automatically terminate their MA plan? - CORRECT ANSWERNO Can a customer call to terminate their Med Sup plan? - CORRECT ANSWERno it must be done in writing What are the different types of MA plans? - CORRECT ANSWERHMO, POS, PPO, RPPO, PFFS, SNP, and MSA For an HMO, they customer must us IN network providers, what are the exceptions to their rule? - CORRECT ANSWEREmergencies, Urgent care, and renal dialysis services. In a HMO plan, does a member have to choose a PCP? and do they require referrals to see a specialist? - CORRECT ANSWERYes UHC Certification 2023/2024 Questions With Complete Solutions If a customer is enrolled in a state medicaid program, explain to them that a PFFS plan may - CORRECT ANSWERImpact their ability to continue seeing their current providers, and may create OOP expenses they may not be able to afford. If a customer on medicaid applies for a PFFS plan, the customer may be responsible for? - CORRECT ANSWERcost sharing Only enroll a dual eligible customer into a PFFS plan if the customer insists on enrolling and disclose the potential impacts of - CORRECT ANSWERenrolling What type of plan can be network based or non-network based? - CORRECT ANSWERPFFS UHC does not offer network-based ___ plans? - CORRECT ANSWERPFFS what is deeming? - CORRECT ANSWERa key feature of a PFFS plan is that the member can choose their health care provider both at home and when they travel in the US What us a deemed provider? - CORRECT ANSWERone that is A) aware in advance of furnishing health care services that the individual receiving the services is enrolled in a PFFS plan B) Has reasonable access to the plans terms and conditions of payment in advance of furnishing services C) furnishes services that are covered by the plan What is a deemed provider - CORRECT ANSWERmust participate in medicare and agree to the plans terms and conditions of payment PFFS member responsibilities? - CORRECT ANSWERthe member must choose to use medicare-eligible provides who agree to the plan's terms and conditions of payment in order to receive coverage under the plan present the member ID and inform provider of the PFFS membership prior to each visit and before receiving covered services CMS allows the PFFS plan to decide if balance ____ is permitted - CORRECT ANSWERbalance Plans must ___ what is permitted in the terms and conditions of payment - CORRECT ANSWERdecide MA plan should not be referred to as a - CORRECT ANSWERsupplement replacement, supplement, replacement no cost, free plan or zero cost plan UHC Certification 2023/2024 Questions With Complete Solutions Medicare part D is a state program or a federal program - CORRECT ANSWERfederal program In order for a customer to obtain medicare part D, what must they have to do? - CORRECT ANSWERthey must enroll individually in a plan offered by a private insurance company approved by medicare In order to be eligible for part D, what must a client also have? - CORRECT ANSWERPart A and B When a client enrolls in part D prescription drug coverage when they first become eligible, what is that time period often called? - CORRECT ANSWERInitial enrollment period consumers can also enroll, disenroll or change coverage each year between when? - CORRECT ANSWERoctober 15- dec 15th during the annual election period( AEP) AEP? - CORRECT ANSWERannual enrollment period OEP? - CORRECT ANSWEROpen enrollment period MA plan members whop use the OEP to disenroll from their MA plan and obtain coverage from original medicare, may enroll in a stand alone what plan? - CORRECT ANSWERpart D plan ____ does not allow for PDP enrollment changes? - CORRECT ANSWERPDP What is a PDP? - CORRECT ANSWERa stand alone medicare prescription drug plan What do PDP's do? - CORRECT ANSWERadd prescription drug coverage to original medicare, MSA's, some medicare cost plans, and some medicare private fee for service PFFS plans WHat type of stand alone variations to medicare can give extra benefits? - CORRECT ANSWERA+B+D C+D When a consumer has original medicare and a prescription drug plan, they can also have a medicare________ insurance plan - CORRECT ANSWERmedicare supplement insurance plan There are 4 stages to medicare part standard prescription drug coverage; what are they? - CORRECT ANSWER1) yearly deductible 2) initial coverage 3) Coverage gap UHC Certification 2023/2024 Questions With Complete Solutions 4) Catastrophic coverage To determine when a member moves from one stage to the next in medicare prescription drug coverage, the plan keeps track of the members TrOOP costs. What does Troop stand for? - CORRECT ANSWERTrue out of pocket Any money spent during the deductible, initial coverage, and coverage gap stages counts towards the TrOOP costs. What doesn't count toward the TrOOP costs? - CORRECT ANSWERThe monthly premium How much is the yearly deductible for a medicare prescription drug coverage? - CORRECT ANSWER$0-$415 In a Medicare prescription drug coverage plan, the member pays (all/some) of the yearly deductible? - CORRECT ANSWERall- the plan pays nothing is the initial coverage for the medicare prescription drug coverage plan covered entirely by the customer or plan? - CORRECT ANSWERmember pays part, the plan pays part in the initial coverage, drug costs are shared by the member and plan until total drug costs paid by both, including the deductible reaches what amount? - CORRECT ANSWER$3,820 for the coverage gap in a medicare drug coverage plan, who pays what? - CORRECT ANSWERthe member pays most, and the plan pays a little in the coverage gap, member pays up to what percent of most brand named drugs - CORRECT ANSWER25% In the coverage gap, the member pays what percent for generic drugs? - CORRECT ANSWER37% When OOP costs for the coverage gap reaches what amount, they will move onto the catastrophic coverage? - CORRECT ANSWER$5,100 Catastrophic coverage is what in the order of medicare prescription drug plan - CORRECT ANSWERlast In catastrophic coverage, who pays what? - CORRECT ANSWERThe member pays a little while the plan pays most In catastrophic coverage, the member pays what? - CORRECT ANSWERa small copay or coinsurance for drugs PDP break down for 2019 - CORRECT ANSWERAnnual deductible= $415 UHC Certification 2023/2024 Questions With Complete Solutions Tier 4 - CORRECT ANSWERMember pays copayment ( MA-PD) coinsurance (PDP) and non-preferred generic and non-preferred grand name drugs are covered Tier 5 - CORRECT ANSWERMember pays coinsurance, and unique and or very high cost drugs are covered What is strep up therapy? - CORRECT ANSWERits an effective, clinically proven, lower-cost alternative to some drugs that treat the same health condition. A plan may require that a member try an alternate drug before covering the requested drug. if a member has already tried other drugs or a provider thinks other drugs are not right for the situation, a member or their doctor can ask the plan to cover these drugs To ensure safe and efficient use of a drug, the plan and/or medicare sets a quantity limit that defines how much of a medication a member can receive at a time. some drugs require approval from the plan prior to the member filling their prescription. - CORRECT ANSWERif a member is prescribed or requires more of a medication than allows, the member or their doctor can contact the plan and ask for an exception. Some drugs require pre-approval by the plan. A member of their provider can ask a plan to cover the drug. - CORRECT ANSWERthe plan may ask the member or provider for additional information to help ensure the drug is appropriate for medicare-eligible health conditions. A member might be asked to try another drug on the formulary before the plan will cover the drug they are requesting. Who qualifies for a medication therapy management program? - CORRECT ANSWERmembers enrolled in a medicare prescription drug plan who take medications for multiple medical conditions may qualify at no additional cost, for a medication therapy management program( MTM) How does the MTM program work? - CORRECT ANSWERit helps physicians and members ensure their medications are working to help improve their health To be enrolled in a MTM, a customer MUST - CORRECT ANSWER1) have a chronic health condition 2) member takes several different medications 3) Member's medications have a combined cost of more than $3,919 per year to be enrolled in the MTM program ( medication therapy program) the enrolled member must meet all of the following - CORRECT ANSWER1) member has more than one chronic health condition 2) Member takes several different medications 3) Member's medications have a combined cost of more than $3,919 per year UHC Certification 2023/2024 Questions With Complete Solutions ( the dollar amount can change per year) is estimated based on OOP costs and the costs the plan pays for the medications each calendar year. the plan can help members determine if they may reach this dollar limit. A list of drugs covered within the part D benefit plan - CORRECT ANSWERformulary Money spent ( excluding premiums) during the Deductible, initial coverage and coverage gap stages count toward ____, which determines when a member moves from the drug coverage stage to the next - CORRECT ANSWERTrOOP The stage in Medicare part D prescription drug coverage in which there is a temporary limit on what the plan will cover for drugs - CORRECT ANSWERcoverage gap A drug may require this type of approval by the plan prior to a member receiving it? - CORRECT ANSWERprior authorization Extra help for customers with limited income and resources from Medicare to cover their part D premiums and Part D related OOP costs - CORRECT ANSWERlow income subsidy applying for help for medicare prescription drug plan expenses does NOT automatically enroll him in a _______ plan - CORRECT ANSWERprescription drug plan what does MMP stand for? - CORRECT ANSWERMedicare-medicaid plan What does MMP do? - CORRECT ANSWERindividuals can receive both medicare parts A &B and full medicaid benefits through one health plan Generally, qualified individuals are passively enrolled into the state's coordinated care plan with the ability to opt-out and choose other medicare - CORRECT ANSWERoptions Why would someone want to enroll in a MA-only PFFS plan? - CORRECT ANSWERthey want to keep their stand alone prescription drug plan (PDP) when a member enrolls in a different MA plan offered by the same MA organization, his/her year to date contribution toward the annual OOP maximum plan is what? - CORRECT ANSWERis counted towards his/her MOOP in the new MA plan IF: 1) the new plan is the same type as the previous plan ( eg HMO to HMO) and both plans are on the contract and/or have the same legal entity 2) the new plan is a different type than the previous plan ( eg HMO to PPO) and both plans have the SAME legal entity UHC Certification 2023/2024 Questions With Complete Solutions If a member is switching from one MA plan to another, does the member have to be apart of the same carrier to retain his/her MOOP expenses? - CORRECT ANSWERyes. if the member is from a different carrier, the MOOP expense will NOT carry over to the new plans yearly deductible What type of plans are network based plans? - CORRECT ANSWERHMO's, POS's, and PPO's What type of plan can either be network based or non- network based? - CORRECT ANSWERPFFO Before enrolling a customer in a MA plan, you must verify the network status of each provider the customer currently uses or intends to use by checking what? - CORRECT ANSWERthe plans provider directory or by contacting the plan. If possible, use an online directory over a printed directory as they are more current. Remind the customer to check their providers status before receiving care to ensure that their network status has not changed. ( see provider search job aid on jarvis, UHC's agent portal) Is emergency care covered in a PFFO plan regardless of whether the provider agrees to accept the plans payment? - CORRECT ANSWERyes it is` Who allows the PFFS plan to decide if balance billing is permitted? - CORRECT ANSWERCMS. Plans must disclose what is permitted in the terms and conditions Does the OEP( Open enrollment period) allow for PDP changes? - CORRECT ANSWERNo you cant make changes to PDP during the OEP If a customer enrolled in a MAP( with or without prescription drug coverage), will be automatically ________from that plan and returned to original medicare upon enrolling in a PDP ( except MA-only PFFS plans) - CORRECT ANSWERdisenrolled what happens when a customer is enrolled in a employee or union sponsored health plan and decides to enroll in a PDP? - CORRECT ANSWERthe customer MAY lose coverage for themselves and their dependents upon enrollment in a PDP, and may not be able to re-enroll in the employer or union plan at a later date in an employer/union-sponsored group retiree plan, or more specifically a subsidized plan, the employer contributes to the premium, but with an endorsed plan, the employer _____? - CORRECT ANSWERdoes not contribute WHat kind of medicare plan is only available through employer groups? - CORRECT ANSWERemployer senior supplement group retiree plans does an employer senior supplement group retiree plan help pay for some or all the costs not covered by original medicare? - CORRECT ANSWERyes. not only that but