Medicare Part D Eligibility

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Questions and Answers

What is a requirement to join a Medicare Part C plan?

Being a United States citizen or lawfully present in the U.S.

What type of Medicare plan provides hospital insurance?

Part A

How do Medicare Prescription Drug Plans (PDPs) work?

They are run by private companies that contract with Medicare

What is a requirement to enroll in a Medicare Part D plan?

Being enrolled in Medicare Part A and Part B Signup and view all the answers

What type of plan provides medical insurance?

Part B Signup and view all the answers

What is NOT a requirement to join a Medicare Part C plan?

Having a high income Signup and view all the answers

What type of plan provides Medicare prescription drug coverage?

Medicare Prescription Drug Plans (PDPs) Signup and view all the answers

What is a requirement to join a Medicare plan?

Not being incarcerated Signup and view all the answers

What is required to join a Medicare Prescription Drug Plan (PDP)?

Having Medicare Part A and Part B Signup and view all the answers

What is a requirement to join a Medicare Advantage Plan with drug coverage (MA-PD)?

Having Medicare Part A and Part B Signup and view all the answers

What is not a requirement to join a Medicare Cost Plan with Part D coverage?

Living outside the U.S. Signup and view all the answers

What is a right you have under Medicare?

To have a claim for payment filed with Medicare Signup and view all the answers

What type of decisions can you get an appeal (review) of under Medicare?

Health care payment, coverage of services, and prescription drug coverage Signup and view all the answers

Who can you call to file complaints about services you got in Original Medicare?

QIO Signup and view all the answers

What is the purpose of the QIO Program?

To improve the quality of health care for all Medicare beneficiaries Signup and view all the answers

What is required under the Social Security Act for Medicare?

QIOs to improve the quality of health care Signup and view all the answers

What type of complaint can a Medicare member file against a healthplan's decision?

Part C appeal Signup and view all the answers

What happens when a Medicare Advantage plan makes a decision about whether items or services are covered?

An organization determination is made Signup and view all the answers

What is the reason for a small number of appeals and grievances in an organization?

Members are unaware of their rights to file an appeal or grievance Signup and view all the answers

What is an example of a situation where a member might appeal a healthplan's decision?

The healthplan stops physical therapy Signup and view all the answers

What is the term for the Medicare Advantage plan's decision about whether items or services are covered or how much you have to pay for covered items or services?

Organization determination Signup and view all the answers

What is a Member grievance related to?

Quality of care issues Signup and view all the answers

Who can also make an organization determination?

The Medicare Advantage plan's network provider or facility Signup and view all the answers

What can a member do if they cannot get an item or service they feel they need?

Appeal the healthplan's decision Signup and view all the answers

What is the primary purpose of Medicare?

To provide health insurance for people 65 and older, and those with certain disabilities Signup and view all the answers

Which agency is responsible for enrolling most people in Medicare?

Social Security Administration (SSA) Signup and view all the answers

What does Medicare Part A cover?

Inpatient hospital care and skilled nursing facility care Signup and view all the answers

What is the main difference between Original Medicare and Medicare Advantage Plans?

Original Medicare is a government program, while Medicare Advantage Plans are private insurance plans Signup and view all the answers

What type of Medicare Advantage Plan requires you to use plan doctors, hospitals, and other providers or pay more or all of the costs?

Medicare Health Maintenance Organization (HMO) Plan Signup and view all the answers

Which of the following is NOT a type of Medicare Advantage Plan?

Medicare Supplement Insurance Plan Signup and view all the answers

What is the primary purpose of Medicaid?

To provide health insurance for people with low incomes and limited resources Signup and view all the answers

What is the main difference between Medicare and Medicare-Medicaid Plan (MMP)?

Medicare only covers hospital insurance, while Medicare-Medicaid Plan covers medical and hospital insurance Signup and view all the answers

Who is eligible to join a Medicare Advantage Plan?

People 65 and older, and those with certain disabilities Signup and view all the answers

What is the purpose of the Centers for Medicare & Medicaid Services (CMS)?

To administer the Medicare program Signup and view all the answers

What is a Part D appeal?

A procedure to review an adverse coverage determination made by a health plan Signup and view all the answers

What is a coverage determination?

A decision about whether a drug is covered by the plan and the amount the enrollee must pay Signup and view all the answers

What is the purpose of an expedited appeal?

To request a review of an appeal quickly if the member's health could be seriously harmed Signup and view all the answers

How long does a health plan have to complete an expedited appeal?

72 hours, with a possible extension of up to 14 calendar days Signup and view all the answers

What is the first step in requesting a Part D appeal?

Calling or writing to the health plan Signup and view all the answers

What happens if a pharmacy tells you a prescription isn't covered under your plan?

You need to call or write to the health plan for a formal decision Signup and view all the answers

What is the purpose of a Standard appeal?

To review an adverse coverage determination made by a health plan Signup and view all the answers

What is the main difference between a Standard appeal and an Expedited appeal?

The urgency of the member's health situation Signup and view all the answers

Study Notes

Medicare Eligibility and Enrollment

To join a Medicare plan, you must have Medicare Part A and/or Part B.
To join a Medicare Advantage Plan with drug coverage (MA-PD), you must have Medicare Part A and Part B.
To join a Medicare Cost Plan with Part D coverage, you must have Medicare Part A and Part B or only Part B.
You must live in the plan's service area.
You must not be incarcerated.
You must not be unlawfully present in the U.S.
You must not live outside the U.S.

Medicare Rights

You have the right to have a claim for payment filed with Medicare.
You have the right to get decisions about healthcare payment, coverage of services, and prescription drug coverage.
You have the right to get an appeal (review) of the decisions above.

Medicare Grievance Rights

You have the right to file complaints (also called grievances) about services you got or other concerns or problems getting healthcare and quality of care.
In Original Medicare, call the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) and Quality Innovation Network (QIN-QIO).
CMS relies on QIOs to improve the quality of healthcare for all Medicare beneficiaries.

Medicare Overview

Medicare is a health insurance program for people 65 and older, under 65 with certain disabilities, and any age with End-Stage Renal Disease.
Medicare has various parts, including Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage), and Part D (Prescription Drug Coverage).
The Social Security Administration (SSA) enrolls most people in Medicare, and the Railroad Retirement Board (RRB) enrolls railroad retirees in Medicare.

Medicare Advantage Plans

Medicare Advantage Plans (Part C) are like HMOs or PPOs and provide Part A and Part B coverage.
Most Medicare Advantage Plans include Part D coverage.
Private insurance companies approved by Medicare provide Medicare coverage.
In most Medicare Advantage Plans, you need to use plan doctors, hospitals, and other providers or pay more or all of the costs (networks).

Medicare Prescription Drug Coverage

Medicare Prescription Drug Coverage (Part D) is available for all people with Medicare.
Part D is run by private companies that contract with Medicare.
You can add Part D to your Original Medicare or Medicare Advantage Plan.
You can also add Medicare Supplement Insurance (Medigap) to your Original Medicare.

Who Can Join Part D?

You can join Part D if you have Medicare Part A and/or Part B.
You can join Part D if you live in the plan's service area.
You can join Part D if you are a U.S. citizen or lawfully present in the U.S.
You cannot join Part D if you are incarcerated.

Medicare Appeals

Part C appeals are formal complaints about the health plan's decision not to pay for, not to provide, or to stop an item or service that a Medicare member believes they need.
Part D appeals are any procedures that deal with the review of adverse coverage determinations made by the health plan on the benefits under the Part D plan.
You can request a standard or expedited appeal.
Expedited appeals must be completed as soon as medically indicated, but not longer than 72 hours, with a possible extension of up to 14 calendar days if the delay is in the enrollee's interest.

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