UHC Certification Flashcards

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Questions and Answers

What part of Medicare helps cover the costs of Joseph's inpatient hospital stay?

Part A

The consumer must be in a valid ___ election or disenrollment period.

Which of the following consumers would be eligible for Medicare?

Consumers age 65 or older

Consumers under 65 years of age with certain disabilities for more than 24 months

Consumers of all ages with ESRD or ALS

All of the above (correct)

What defines a Medicare Advantage (MA) Plan?

MA Plans are health plan options approved by Medicare and offered by private insurance companies. Signup and view all the answers

What eligibility requirements must Janice meet to enroll in a 2021 Medicare Advantage plan? (Select the two answers that apply)

Reside in the plan's service area Signup and view all the answers

What must be explained to consumers enrolling in an HMO (Health Maintenance Organization) MA Plan?

Explanation of network providers, referrals, and coverage limits. Signup and view all the answers

Which of the following are MA Plans that focus on using network providers?

All of the above Signup and view all the answers

What is true about Medicare Supplement Open Enrollment?

It is the first 6 months a consumer is 65 or older and enrolled in Medicare Part B. Signup and view all the answers

How does the Medicare Advantage Out-of-Pocket (OOP) maximum work?

It limits the amount of money a consumer will have to spend on Medicare-covered health care services each year. Signup and view all the answers

What happens if a consumer enrolls in an MA Plan with integrated prescription drug coverage?

The consumer will be automatically disenrolled from their stand-alone PDP. Signup and view all the answers

What describes a government program that provides prescription drug coverage?

Medicare Parts A and B. Signup and view all the answers

What is required for eligibility in Medicare Prescription Drug Plans?

A consumer must be entitled to Medicare Part A and/or enrolled in Medicare Part B. Signup and view all the answers

What are two options for Medicare consumers to get Part D prescription drug coverage? (Select 2)

Medicare Advantage Plan with drug coverage Signup and view all the answers

Which statement is not true about the Coverage Gap?

All members reach the Coverage Gap. Signup and view all the answers

Which of the following options are drug utilization management (UM) rules? (Select 3)

Prior authorization Signup and view all the answers

What best describes the Late Enrollment Penalty (LEP)?

The amount added to the member's monthly plan premium if they did not enroll when first eligible. Signup and view all the answers

How is financial assistance offered for consumers who qualify for Low Income Subsidy for Medicare Part D costs?

Through subsidies such as lower or no monthly plan premiums and lower or no copayments. Signup and view all the answers

What are the drug levels called that are associated with member cost-sharing?

Drug tiers. Signup and view all the answers

In states where Medicare Supplement Insurance underwriting criteria apply, which of the following does NOT apply?

Consumers are guaranteed acceptance without underwriting. Signup and view all the answers

The new MACRA legislation applies to all carriers offering Medicare supplement plans.

True Signup and view all the answers

Which of the following is NOT true of Medicare Supplement Insurance Plans?

They cover all medical expenses. Signup and view all the answers

Study Notes

Medicare Parts Overview

Part A: Covers inpatient hospital stays, skilled nursing facility stays, hospice care, and some home health care services.
Eligibility for Medicare: Consumers aged 65 or older, those under 65 with disabilities for over 24 months, and individuals with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS) qualify.

Medicare Advantage Plans

MA Plans: Health plans approved by Medicare, provided by private insurance companies, offering additional benefits beyond Original Medicare.
Enrollment Requirements: Eligible consumers must reside in the plan's service area and cannot have ESRD.
Types of MA Plans: Include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Point of Service (POS) plans that primarily use network providers.

Medicare Supplements and Open Enrollment

Medicare Supplement Open Enrollment: Begins when a consumer turns 65 and enrolls in Medicare Part B, lasting for six months.
Coverage Updates: Medicare Supplement Insurance plans do not automatically update benefit amounts when Medicare changes costs.

Prescription Drug Coverage (Part D)

Eligibility for Part D: Consumers must be enrolled in Medicare Part A and/or Part B to qualify for Medicare Prescription Drug Plans.
Enrollment in MA with Drug Coverage: Consumers will be automatically disenrolled from stand-alone Prescription Drug Plans upon joining an MA Plan with integrated drug coverage.
Low Income Subsidy: Provides financial assistance for eligible consumers, including reduced premiums and copayments.

Cost Management and Drug Tiers

Out-of-Pocket Maximum: Limits annual expenses on Medicare-covered health care services within Medicare Advantage plans.
Drug Tiers: Represent various levels of cost-sharing in a plan’s formulary, dictating member copayments or coinsurance.
Late Enrollment Penalty (LEP): Added to monthly premiums for consumers who do not enroll in a Medicare Part D plan when first eligible or if they lack creditable prescription coverage for 63 days or more.

Underwriting and Legislation

MACRA Impact: The legislation affects all carriers providing Medicare supplement plans effective January 1, 2020.
Underwriting Criteria: In states with specific criteria, consumers may face underwriting to determine acceptance and applicable rates.

Coverage Gaps and Drug Management

Coverage Gap (Donut Hole): Not all members face this gap in coverage; eligibility varies.
Drug Utilization Management (UM): Rules designed to oversee and control medication use within the plan.

These notes encapsulate essential concepts and guidelines for understanding how Medicare, Medicare Advantage, and related prescription drug plans operate.

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Test your knowledge on Medicare and its components with these flashcards. Each card presents questions related to Original Medicare, coverage specifics, and eligibility criteria. Perfect for anyone preparing for their UHC certification.