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UHC certification
Medicare - correct answer Federal health insurance program Medicare is administered by whom? - correct answer CMS ( Centers for Medicare and Medicaid services) Parts A & B of Medicare are - correct answer federal health insurance program referred to as original medicare Part A? - correct answer Hospital insurance Part B? - correct answer Medical insurance What doesnt medicare cover? - correct answer routine dental, eye care hearing exam,deductibles, coinsurance and copayments Part C? - correct answer Medicare Advantage Plans MA covers? - correct answer Part A &B coverage, and some part D coverage MA plans are not? - correct answer Medicare supplement insurance plans What offers lower monthly premiums MADP or supplement? - correct 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? - correct answer YES MA plans integrate what type of additonal coverage? - correct 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? - correct answer MA-only PFFS plan What is a stand alone drug plan called? - correct answer PDP WHat is PFFS? - correct 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? - correct answer PFFS plan Do HMO's require referals? - correct answer Yes Do PPO's require a referal? - correct answer No When a member enrolls in a MA plan, they receive their coverage from medicare or the MA plan? - correct answer MA plan When a customer is enrolled in a MA plan, they must continue paying their premiums for what other plan? - correct answer Part B MA plans have a maxium annual limit on OOP costs called a? - correct answer MOOP 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 answer effective date An exception exisits for MA-only PFFS plans as a member can also be enrolled in a what? - correct answer Stand alone PDP
With a PFFS plan, can a member seek treatment from any medicare eligible provider who agrees to accept the plans conditions and payment rates? - correct answer Yes Does a PCP need to be selected with a PFFS plan? - correct answer No What is the only plan to offer non-network PFFS plans? - correct answer UHC What are SNP's for? ( Dual SNP) - correct answer People who have both medicare and Medicaid Institutional SNP? - correct answer Nursing homes Chronic condition SNP? - correct answer people who have certain chronic medical conditions MSA? - correct answer Medical savings account What does a MSA do? - correct answer Combines a high deductible medicare advantage plan and a bank account How does MSA plans work? - correct answer the plan deposits money from emdicare in the account which can then be used to pay for medical expenses until their deductible is met Does UHC currently offer a MSA? - correct answer no MA plans include some key features such as? - correct answer Prescription drug coverage, PCPs and a OOP maxium In a MA-Part D plan, A member will be disenrolled from their stand alone PDP upon enrollment in a? - correct answer MA-PD
in a MA-part D plan, A member will be disenrolled from their MA-PD upon enrollment in? - correct answer a stand-alone PDP With MA only, a member will be disenrolled from their stand alone PDP upon enrolling in a? - correct answer Non-PFFS MA-only plan in MA-only, a member will be disenrolled from their non-PFFS MA-only plan upon enrolling in a? - correct answer Stand alone PDP most MA plans require a what? although not all plans require that the chosen____ cordinate the members care - correct answer PCP selection If a PCP is required and the customer does not indicate one on the enrollment application, a _____ will automatically assigned - correct answer PCP To avoid member complaints, encourage customers to select a ____and make sure the _____ is accepting new patients - correct answer PCP In which plan ( HMO/POS) are out of network benefits available at a higher cost? - correct answer POS With a PFFS plan, does a PCP need to be selected? and are prior authorizations or referrals from a PCP required? - correct answer No, NO once a member with a MAP reaches the maximum OOP expenses, is there cost sharing for any additional services? - correct answer no MA plans with an OON component may or may not have an? - correct answer OOP maximum for OON services depending on the plan All medicare covered ( part A and part B) services count torward the? - correct answer OOP maxium with MAP's
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 answer must participate in medicare and agree to the plans terms and conditions of payment PFFS member responsibilities? - correct 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 - correct answer balance Plans must ___ what is permitted in the terms and conditions of payment - correct answer decide MA plan should not be referred to as a - correct answer supplement replacement, supplement, replacement no cost, free plan or zero cost plan Medicare part D is a state program or a federal program - correct answer federal program In order for a customer to obtain medicare part D, what must they have to do? - correct 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? - correct 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? - correct answer Initial enrollment period consumers can also enroll, disenroll or change coverage each year between when? - correct answer october 15- dec 15th during the annual election period( AEP) AEP? - correct answer annual enrollment period OEP? - correct 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? - correct answer part D plan ____ does not allow for PDP enrollment changes? - correct answer PDP What is a PDP? - correct answer a stand alone medicare prescription drug plan What do PDP's do? - correct answer add 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 answer A+B+D C+D When a consumer has original medicare and a prescription drug plan, they can also have a medicare________ insurance plan - correct answer medicare supplement insurance plan There are 4 stages to medicare part standard prescription drug coverage; what are they? - correct answer 1) yearly deductible
- initial coverage
When OOP costs for the coverage gap reaches what amount, they will move onto the catastrophic coverage? - correct answer $5, Catastrophic coverage is what in the order of medicare prescription drug plan - correct answer last In catastrophic coverage, who pays what? - correct answer The member pays a little while the plan pays most In catastrophic coverage, the member pays what? - correct answer a small copay or coinsurance for drugs PDP break down for 2019 - correct answer Annual deductible= $ Initial coverage- $ Coverage gap- $5, What is the coverage gap for medicare prescription drug coverage? - correct 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 - correct 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 - correct answer income and resources TO qualify for low income subsidy on part D, the consumers income must be at or below - correct answer 150% of the FPL ( federal poverty level) when does approved extra help begin? - correct answer the first day of the month the customer becomes eligible
how does a customer qualify for extra help? - correct answer they receive both medicare and medicaid benefits, receive SSI and meet a certain income, and are a MSP participant( medicare savings program) if a customer who automatically qualifies for extra help doesnt enroll in a prescription drug plan, medicare may automatically enroll them in one so they will be able to use the_____? - correct answer extra help What is creditable coverage? - correct answer its a prescription drug coverage that is expected to pay on average at least as much as medicare's standard prescription drug coverage What are some examples of creditable coverage? - correct answer drug plan from an employer, union, TRICARE, indian health service, or department of veterans affairs consumers with creditable coverage when they become eligible for medicare can generally keep that coverage without paying a ____ if they decide to enroll in medicare prescription drug coverage later? - correct answer penality The organization providing the prescription drug coverage MUST inform the consumer annually if the prescription drug coverage is ________ - correct answer creditable coverage how many days does medicare allow before a customer accrues a penalty - correct 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? - correct answer the monthly plan premium What is the late enrollment penalty? - correct 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? - correct answer yes. The customer should use a preferred or standard in network pharmacy
Teir 3? - correct answer Member pays a medium copayment and many common brand name drugs and some higher cost generic drugs are covered Tier 4 - correct answer Member pays copayment ( MA-PD) coinsurance (PDP) and non-preferred generic and non-preferred grand name drugs are covered Tier 5 - correct answer Member pays coinsurance, and unique and or very high cost drugs are covered What is strep up therapy? - correct answer its 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 answer if 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 answer the 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 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? - correct 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 - correct answer 1) have a chronic health condition
- member takes several different medications
- 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 answer 1) member has more than one chronic health condition
- Member takes several different medications
- Member's medications have a combined cost of more than $3,919 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 - correct 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 - correct 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 - correct answer coverage gap A drug may require this type of approval by the plan prior to a member receiving it?
- correct 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 - correct answer low income subsidy applying for help for medicare prescription drug plan expenses does NOT automatically enroll him in a _______ plan - correct answer prescription drug plan what does MMP stand for? - correct answer Medicare-medicaid plan
Is emergency care covered in a PFFO plan regardless of whether the provider agrees to accept the plans payment? - correct answer yes it is` Who allows the PFFS plan to decide if balance billing is permitted? - correct answer CMS. Plans must disclose what is permitted in the terms and conditions Does the OEP( Open enrollment period) allow for PDP changes? - correct answer No 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 answer disenrolled what happens when a customer is enrolled in a employee or union sponsored health plan and decides to enroll in a PDP? - correct answer the 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 answer does not contribute WHat kind of medicare plan is only available through employer groups? - correct answer employer 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 answer yes. not only that but they have similar coverage as medicare supplement insurance plans and members can go to any provider that accepts medicare
