UHC Certification Exam: Medicare Coverage & Plans (2024), Exams of Nursing

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Questions With Solution 2024 Graded

A

Medicare - answer Federal health insurance program Medicare is administered by whom? - answer CMS ( Centers for medicare and medicaid services) Parts A & B of medicare are - answer federal health insurance program referred to as original medicare Part A? - answer Hospital insurance Part B? - answer Medical insurance What doesnt medicare cover? - answer routine dental, eye care hearing exam,deductibles, coinsurance and copayments Part C? - answer Medicare Advantage Plans MA covers? - answer Part A &B coverage, and some part D coverage

MA plans are not? - answer Medicare supplement insurance plans What offers lower monthly premiums MADP or supplement? - answer MADP do MAP's have a annual maximum OOP maximum that limits the amount of money a member must spend every year for covered services? - answer YES MA plans integrate what type of additonal coverage? - answer part D prescription drug coverage If a customer wants to keep their stand alone prescription drug plan, what may the customer want to enroll in? - answer MA-only PFFS plan What is a stand alone drug plan called? - answer PDP WHat is PFFS? - answer Private 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? - answer PFFS plan

Medicare supplement insurance policies cannot be used in conjunction with what type of plan? - answer MA plan A medicare supplement insurance plan helps to cover some of the OOP costs associated with? - answer original medicare. A medicare supplement insurance plan does NOT pay the cost-sharing of what type of plan? - answer MA plan when a client enrolls in a MA plan, will it automatically terminate their MA plan? - answer NO Can a customer call to terminate their Med Sup plan? - answer no it must be done in writing What are the different types of MA plans? - answer HMO, POS, PPO, RPPO, PFFS, SNP, and MSA For an HMO, they customer must us IN network providers, what are the exceptions to their rule? - answer Emergencies, 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? - answer Yes

In a POS plan, does a member need a referral from their PCP to see a specialist? - answer yes Can a member with a POS plan see a specialist? - answer Yes, but they may have to pay a higher cost, and there coverage limits With a PFFS plan, can a member seek treatment from any medicare eligible provider who agrees to accept the plans conditions and payment rates? - answer Yes Does a PCP need to be selected with a PFFS plan? - answer No What is the only plan to offer non-network PFFS plans? - answer UHC What are SNP's for? ( Dual SNP) - answer People who have both medicare and Medicaid Institutional SNP? - answer Nursing homes Chronic condition SNP? - answer people who have certain chronic medical conditions MSA? - answer Medical savings account

most MA plans require a what? although not all plans require that the chosen____ cordinate the members care - answer PCP selection If a PCP is required and the customer does not indicate one on the enrollment application, a _____ will automatically assigned - answer PCP To avoid member complaints, encourage customers to select a ____and make sure the _____ is accepting new patients - answer PCP In which plan ( HMO/POS) are out of network benefits available at a higher cost? - answer POS With a PFFS plan, does a PCP need to be selected? and are prior authorizations or referrals from a PCP required? - answer No, NO once a member with a MAP reaches the maximum OOP expenses, is there cost sharing for any additional services? - answer no MA plans with an OON component may or may not have an? - answer OOP maximum for OON services depending on the plan All medicare covered ( part A and part B) services count torward the? - answer OOP maxium with MAP's

Services and deatures that do not count toward the maxium OOP in a MAP include? - answer plan premium, part D prescription drugs and any non-medicare covered services such as eyewear and hearing aids Is the OOP maximum amount different between MA plans? - answer Yes UHC strongly discourages Dual-eligible customers, from enrolling into a PFFS plan due to? - answer having potential negative impacts to the customer What does dual eligible customers mean? - answer having both medicare and medicaid Before enrolling any customer into a PFFS plan, ask if they are enrolled in a state _____ program? - answer medicaid If a customer is enrolled in a state medicaid program, explain to them that a PFFS plan may - answer Impact 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? - answer cost sharing

PFFS member responsibilities? - answer the 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 - answer balance Plans must ___ what is permitted in the terms and conditions of payment - answer decide MA plan should not be referred to as a - answer supplement replacement, supplement, replacement no cost, free plan or zero cost plan Medicare part D is a state program or a federal program - answer federal program In order for a customer to obtain medicare part D, what must they have to do? - answer they 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? - answer Part 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? - answer Initial enrollment period consumers can also enroll, disenroll or change coverage each year between when? - answer october 15 - dec 15th during the annual election period( AEP) AEP? - answer annual enrollment period OEP? - answer Open 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? - answer part D plan ____ does not allow for PDP enrollment changes? - answer PDP What is a PDP? - answer a stand alone medicare prescription drug plan What do PDP's do? - answer add prescription drug coverage to original medicare, MSA's, some medicare cost plans, and some medicare private fee for service PFFS plans

In a Medicare prescription drug coverage plan, the member pays (all/some) of the yearly deductible? - answer all- the plan pays nothing is the initial coverage for the medicare prescription drug coverage plan covered entirely by the customer or plan? - answer member 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? - answer $3, for the coverage gap in a medicare drug coverage plan, who pays what?

• answer the member pays most, and the plan pays a little in the coverage gap, member pays up to what percent of most brand named drugs - answer 25% In the coverage gap, the member pays what percent for generic drugs? - answer 37% When OOP costs for the coverage gap reaches what amount, they will move onto the catastrophic coverage? - answer $5, Catastrophic coverage is what in the order of medicare prescription drug plan - answer last

In catastrophic coverage, who pays what? - answer The member pays a little while the plan pays most In catastrophic coverage, the member pays what? - answer a small copay or coinsurance for drugs PDP break down for 2019 - answer Annual deductible= $ Initial coverage- $ Coverage gap- $5, What is the coverage gap for medicare prescription drug coverage? - answer Its a temporary limit on what the medicare prescription drug plan will cover When a customer reaches the ____ They will pay 25% for most brand named drugs and 37% for generic drugs - answer coverage gap consumers with limited _____ may qualify for extra help from medicare to cover their part D premiums and Part D related OOP costs - answer income and resources TO qualify for low income subsidy on part D, the consumers income must be at or below - answer 150% of the FPL ( federal poverty level)

The organization providing the prescription drug coverage MUST inform the consumer annually if the prescription drug coverage is ________ - answer creditable coverage how many days does medicare allow before a customer accrues a penalty - answer 63 days if a customer accrues a late penalty for not accepting medicare before the 63 day limit, the late enrollment penalty is added to what? - answer the monthly plan premium What is the late enrollment penalty? - answer 1% x 35.02(2018 NBBP or national base beneficiary premium) x # of months= penalty Can the pharmacy used impact OOP costs for covered drugs? - answer yes. The customer should use a preferred or standard in network pharmacy Under the part D benefit, drugs filled at an OON pharmacy are covered only when the member is not able to use an in-network pharmacies for covered medications, generally at a higher ________ - answer OOP cost What is a preferred pharmacy? - answer A contracted network pharmacy that offers medicare part D members covered Part D drugs at negotiated prices. The prices are lower levels of cost-sharing than apply at a non-preferred (standard) pharmacy

What is a formulary drug list? - answer A list of covered drugs selected by the plan with the help of a team of doctors and pharmacists The drug list often represents the level of cost-sharing associated with various groupings of medications(preferred generics, generics, preferred brands, non preferred drugs) The list must meet requirements set by medicare ( CMS) Medicare approved the plan's drug list How many tiers are there for medicare prescription drug coverage? - answer 5 What are the 5 tiers for medicare prescription drug coverage? - answer Tier 1, 2,3,4, Tier 1? - answer Member pays lowest copayment and lower cost commonly used generic drugs are covered Tier 2? - answer Member pays a low copayment, many generic drugs are covered

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? - answer members 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? - answer it helps physicians and members ensure their medications are working to help improve their health To be enrolled in a MTM, a customer MUST - answer 1) have a chronic health condition

2. member takes several different medications
3. Member's medications have a combined cost of more than $3, per year to be enrolled in the MTM program ( medication therapy program) the enrolled member must meet all of the following - answer 1) member has more than one chronic health condition
4. Member takes several different medications

3. Member's medications have a combined cost of more than $3, per year ( 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 - answer formulary 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 - answer TrOOP The stage in Medicare part D prescription drug coverage in which there is a temporary limit on what the plan will cover for drugs - answer coverage gap A drug may require this type of approval by the plan prior to a member receiving it? - answer prior authorization Extra help for customers with limited income and resources from Medicare to cover their part D premiums and Part D related OOP costs answer low income subsidy