MEDICARE & MEDICAID FOR LINE 2-40 HEALTH INSURANCE AGENT LICENSE
What are the two main coverage options for Medicare coverage?
1- Original Medicare (Parts A & B) 2- Medicare Advantage
What are the four parts of Medicare Part D coverage?
1. Deductible 2. Initial Coverage Limit 3. Coverage Gap 4. Catastrophic
What are the 6 key drug categories, as listed in the formulary?
1. antidepressants 2. Antipsychotic 3. Anticonvulsant 4. Antiretroviral (HIV) 5. Antineoplastics (Cancer) 6. Immunosuppresants (Transplant)
Which of the following answers describes the possible dates for the IEP?
3 months before, the month of, and 3 months after the 65th birth month
If an individual does not have to pay any co-payments/co-insurance, or a Part B premium, the best plan for them would be?
A DSNP if one is available because it is specifically designed to fit the needs of this type of person
What is a Low-Income-subsidy?
A Medicare low income subsidy program to help members who need financial assistance in paying for their Medicare Prescription Drug costs. Administered by the SSA Eligibility is based on: -Income & Assets Payments made on behalf of LIS counts towards the members TrOOP (True-Out-of-Pocket costs) Individuals who are full or partial dual eligible for Medicare & Medicaid, or SSI receipients automatically qualify for LIS Apply on SocialSecurity.gov or call the SSA office LIS members have the ability to change plans *quarter to quarter* through a standing *Special Enrollment Period* (SEP) LIS benefits may include: -Reduction/elimination of Plan D's deductible -Reduction/elimination of co-pays/co-insurance for all Part D covered drugs -No coverage gap phase -Litle to no co-payment in the catastrophic phase
What is Medicare?
A federal insurance program
If someone enrolls into a MA-PD Plan, they are no longer covered for Medicare Parts A and B benefits?
False
True or False: Formulary lists are the same in every Medicare-approved plan
False
True or False: If a person qualifies for Medicaid, they are no loner eligible for any MA Plan?
False
True or False: Individuals who receive LIS and who delayed enrollment in Part D may have to pay a late enrollment penalty?
False
True or False: Medicare Advantage Plans are required to offer the same basic benefits and cover them the same, with the same costs as Original Medicare. The only variation may be the premium cost of the plan?
False
True or False: Medicare Part C and Medicare Supplemental Policies are essentially the same thing and should be described as virtually the same to prospects?
False
True or False: To join a Medicare Advantage Plan, you do not have to live in the county served by the plan?
False
True or False: A Preferred Provider Organization (PPO) requires a member to see a in-network provider
False Members can see in-network or out-of-network providers. However, utilizing out-of-network providers can result in higher co-pays/co-insurance
Copayments are:
Fixed dollar amounts that are payable to covered services
True or False: "Extra Help" is administered through the Social Security Administration
True
True or False: A beneficiary can only use their permanent address when enrolling in a Medicare Part C or D plan.
True
True or False: An authorized representative (meaning a person who has power of attorney or legal authority) can complete an enrollment on behalf of a Medicare beneficiary.
True
True or False: In a Medicare Part D drug Plan, if a drug is not covered by the plan or the beneficiary gets it from a out-of-network pharmacy, they may be required to pay the full-cost of the drug?
True
True or False: Medicare Supplemental policies only work with 'Original Medicare'?
True
True or False: Medicare beneficiaries may have to pay a penalty if they chose to delay enrollment in Medicare Part D and they do not maintain creditable coverage?
True
True or False: Medicare beneficiaries qualify for an SEP to change MA Plans one time per quarter of the year, except for the last quarter of the year?
True
True or False: Members enrolled in MA Plans must continue to pay their Part B premium.
True
True or False: People with Medicare may be enrolled in only one PDP plan at a time?
True
True or False: The "Coverage Gap" is also known as the "Donut Hole"?
True
Low-Income Subsidy (LIS) is also known as...?
"Extra Help"
Formularies
A list of covered drugs CMS creates the Medicare Part D formulary which identifies medications covered under Part D; Insurance companies make their own formularies based off the CMS Part D formulary All Part D formularies must: -Include drugs based on widely accepted treatment guidelines -Include at least 2 drugs from each category or class, at least one of which is on a "preferred" tier -Include enough commonly used drugs -Provide clinical justification if a drug requires step therapy or pre-certification -Be submitted monthly to CMS for approval
Medicare Advantage Plans
A way to get Medicare Part A and Part B coverage combined under one plan; most MA Plans include Part D as well These coverages together are called Medicare Part C or "MA Plans" These plans set a limit on out-of-pocket anual costs When enrolled in an MA Plan, you must show your MA card to the provider to have services covered Some of the most common types of MA Plans are: -(*HMO*): Health Maintenance Organization Plans -(*PPO*): Preferred Provider Organization Plans -(*PFFS*): Private Fee-for-Service Plans -(*SNPs*): Special Needs Plans -(*HMO-POS*): Health Maintenance Organization-Proint of Service Plans -(*MSA*): Medicare Savings Account
Which of the following is a requirement to enroll in a MA Plan?
A. Be entitled to Part A and enrolled in Part B B. Not have ESRD (In 2020: some exceptions apply; For 2021 plans: a person with ESRD can enroll) C. Live in the plans service area D. All the above Answer: D
What is the difference between Medicare's part A and part B?
A. Part A helps pay for in-patient care in hospitals, skilled nursing facilities, hospice care, and some home health care and supplies, while Part B helps pay for out-patient services B. Part B is optional coverage for which Medicare beneficiaries pay a monthly premium, while part A is premium-free for most people C. Part B pays for doctor's services, out-patient care, and other medical services not covered under Part A D. All the above Answer: D
How does Medigap work?
After purchasing a supplemental plan, *First*: Medicare pays its share of the Medicare-approved amount for covered health care costs *Second*: the Medigap policy pays its share *Last*: The beneficiary pays any uncovered costs *Must have both Plan A and B to be eligible for Medigap Plans* The beneficiary pays a private insurance company a monthly premium for the Medigap policy, this is in addition to the monthly Medicare Part B premium (paid to Medicare) Medigap policies only cover *one* individual; for spouses who both want coverage, an additional plan must be purchased so that each member has their own coverage Any standardized Medigap policy is *guaranteed renewable* even if you have health problems. This means the insurance company can't cancel your Medigap policy as long as you pay the premium. Some Medigap policies sold in the past cover prescription drugs. However, policies sold after January 1, 2006 aren't allowed to include prescription drug coverage (Part D must now be purchased for prescription drug coverage) If you buy Medigap and a Medicare Part D drug plan from the same company, you may need to make two separate premium payments. It is illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you're switching back to Original Medicare.
What is NOT true for dual eligible beneficiaries
As long as the beneficiaries provider accepts Medicare, the provider will also accept Medicaid
Medicare is governed by:
CMS which is located in Baltimore, MD
After the "Coverage Gap" phase, beneficiaries go into which Medicare Part D phase?
Catastrophic Coverage
Whic plan generally requires the use of a referral to see a specialist?
HMO
Which Medicare Advantage Plan type will cover you only if you use in-network providers?
HMO
Which types of MA Plans allow members to pay less if they use provider that belong to the network. Members can use proiders outside the network, but that may be at a higher cost.
HMO-POS & PPO
What does Medicare Part A cover?
Hospital Insurance: Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part A is what kind of coverage?
In-patient coverage
How does LIS and Medicaid differ?
LIS is for drug coverage and Medicaid is for health coverage
All the following are true of MA plans except:
MA Plan members do not continue to pay Part B premium since the MA Plan replaces it
What does Medicare Part B cover?
Medical Insurance: Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.
If a dual eligible joins a Medicare Advatage Plan, they must show their Medicaid card to their healthcare provider as well as:
Medicare Advantage Card
A Health Maintenance Organization (HMO) Plan is a ____ that may provide additional benefits to members as a Medicare alternative?
Medicare Advantage Plan
Medigap vs. Medicare Advantage Plan
Medicare Advantage plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits
What is Medicare Part C?
Medicare Part C is both Parts A & B together under one policy
The term "Original Medicare" refers to what?
Part A and Part B
What is Medicare Supplement Insurance?
Medicare Supplemnent Insuance, also called "Medigap" is coverage to help fill in the 'gaps' in Medicare coverage (that Original Medicare does not cover) Medigap can help pay for things like: -Co-payments -Co-insurance -Deductibles -Traveling medical care To be eligible you must have both Part's A & B
How does Medicare Part D work?
Medicare drug coverage helps pay for prescription drugs you need. To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage (this includes Medicare drug plans and Medicare Advantage Plans with drug coverage). Each plan can vary in cost and specific drugs covered, but must give at least a standard level of coverage set by Medicare. Medicare drug coverage includes generic and brand-name drugs. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different "tiers" on their formularies. Plans have different monthly premiums. You'll also have other costs throughout the year in a Medicare drug plan. How much you pay for each drug depends on which plan you choose.
What is the Medicare Part B premium?
Most people will pay the standard Part B premium amount ($144.60 in 2020). For individuals with certain AGI above a certain amount (from the previous 2 years tax returns) you would pay the standard premium amount, plus an Income Related Monthly Adjustment Amount (IRMAA - an extra charge added to your premium)
How does Original Medicare work?
Once enrolled, if an individual chooses Original Medicare they will have coverage for hospital insurance (Part A) and medical insurance (Part B). You will then pay for services as you receive them through a deductible ($1,408) and co-insurance (20%) Most prescriptions are not covered; Part D must be added for prescription drug coverage
What are the parts of Medicare?
Part A Part B Part D
Formulary Exclusions
Part D Formulary exclusions include: -Anorexia, weight loss, or weight gain drugs - Fertility drugs -Cosmetic drugs -Cough & cold drugs -Non-prescription drugs (OTC) -Prescription vitamins & mineral products (except prenatals; some limited, enhanced plans may incude prescription vitamins) - Erectile dysfunction drugs (some limited, enhanced plans may incude these) -Brand medications who do not participate in the coverage discount program -Drugs that the FDA las deemed as less than effective -Medicare Part A or B drugs -drugs obtained outside the US
If an individual does not have to pay their Medicare Part B premium, and they receive a bill after doctor visit's as well as large hospital bill's for a hospital stay, they must have what type of Medicaid status?
Partial-Dual eligible
Who is eligible for Medicare?
Persons aged 65 and over People with certain disabilities of any age People with End Stage Renal Disease (ESRD)
What does Medicare Part D cover?
Prescription Drug Coverage: Helps cover the cost of prescription drugs (including many recommended shots or vaccines).
PCP stands for ____.
Primary Care Physician
CMS contracts with _____ to offer prescription drug coverage?
Private insurance companies (carriers)
Where can someone call to see if they qualify for "Extra Help" paying for their prescription drug plan premiums and costs?
Social Security Administration
How do you enroll in Medicare?
Some people get Medicare automatically and others have to sign up. If you are 65 or older, or almost 65 and not getting Social Security then you may have to sign up yourself. There are only certain times when you can enroll, these options are: -*Initial Enrollment Period*: When you first become eligible for Medicare -*Open Enrollment Period*: October 15th-December 7th, when you can join, switch, or drop a plan and coverage would begin on January 1st -*Medicare Advantage Open Enrollment Period*: January 1st-March 31st, you can make a change one time during this time period.
A doctor who treats only certain parts of the body or certain health problems (i.e. cardiologist who treats heart conditions), is called a ______.
Specialist
State Pharmaceutical Assistance Programs (SPAP):
State programs to assist qualifying individuals with financial payment of their prescription drugs (NOT THE SAME AS LIS) SPAP payments count towards the beneficiaries TrOOP Members can be eligible for both LIS & SPAP LIS pays first (Primary) SPAP pays second (Secondary) SPAP is not available in all states, check Medicare.com for eligibility Eligibility is based on: -Income & Assets -Age -Medical Conditions SPAPs help pay for: -Premiums -Medications not covered on a plan's formulary
The Part D drug phase when a person with Medicare is required to pay 25% of the cost of all brand and generic prescriptions drugs is called what?
The coverage gap
MA Plans may offer all the following except:
The option to enroll without Medicare Parts A and B
What is a spend-down?
The total amount of medical expenses you need to spend to reach Medicaid eligibility
Utilization Management Restrictions
These restrictions are implemented on some drugs listed on the formulary in order to keep members safe, and to keep costs down The UM Restrictions are: -Step Therapy (ST): when a plan requires a member to try certain drugs first to treat their medical condition first, before another drug would be covered for the same condition. (eg. the member must try Ibuproufen (without success) before Percocet can be covered) -Prior Authorization (PA): -Quality Limits (QL):
A beneficiary is eligible for Medicare Part D when _____?
They are enrolled in Medicare A ,or Medicare Part B, or both
How does Medicare Advantage work?
This is an all-in-one bundled plan that usually includes Parts A, B & D Some Medicare Advantage Plans offer additional benefits like: Vision, Hearing, Fitness, Transportation and Dental Each Medicare Advantage Plan has different out-of-pocket costs and their own plan rules that must be followed for obtaining covered services
True or False: The initial Election Period (IEP) for Medicare Part D begins three months before the actual month the beneficiary qualifies for medicare, including the month of for which they qualify, and ends three months after the month for which they qualify?
True
True or False: To enroll in Medicare Part D, one must be enrolled in Medicare Part A, or Medicare Part, B or both, and live in the plan's service area?
True
True or False: While enrolled in a Medicare Part D Plan, a person may qualify for "Extra Help" to pay for Part D expenses?
True
True or False: There are two distinct paths available to a person with Medicare?
True Original Medicare or Medicare Advantage Plan
What is TrOOP?
True Out of Pocket is the money a beneficiary pays out of poket, including their deductible,co-insurance and co-pays, plus any discount the beneficiary receives on brand medications while in the 'Gap'. The total drug spend amount is what takes the beneficiary into the Coverage Gap which changes annually. *Neither amounts include monthly premium costs*
True or False: Those with Medicaid, either Full or Partial, should automatically receive LIS?
Tue
"Creditable Coverage" in Medicare refers to what?
When drug or medical coverage of a retirement plan is equal to or better than Medicare's basic drug or medical benefit
If you do not qualify for premium-free Part A Medicare, can you still have Medicare Part A?
Yes, if you don't qualify for premium-free Part A, you can purchase Part A. ($458) - If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $458. ($252) - If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $252.
What is the Medicare Part A Premium?
You usually don't pay a monthly premium for Part A if you or your spouse paid Medicare taxes for a certain amount of time while working. This is sometimes called "premium-free Part A."
