AHIP Final Exam 2023 with verified questions and answers

Types of Medicare Advantage Plans PPO, HMO, MSA, Cost Plan, PFFS Medicare-Medicaid plans Serve both Medicare and Medicaid individuals. Include Part D coverage. Individuals sometimes referred to as dual eligibles Medicare Cost Plan Type of Medicare health plan. Have Part B to enroll. Can join anytime plan is accepting new members. A non network provider will can charge higher coinsurances and deuctibles. Different enrollment/disenrollment periods apply. Can get Part D Rx coverage if available, or apply for a separate PDP. Medicare Entitlement/Enrollment - Part A & Part B Individuals with ESRD may sign up at anytime. Date on which coverage begins is the fourth month after dialysis begins. Medicare Enrollment Period Individuals who do not enroll in Part B when first eligible can enroll during a General Enrollment Period, Jan 1st to Mar 31st each year. Coverage begins July 1st of that year. Medicare Enrollment Period - Group Health Coverage Individuals who have group health coveage through employer may enroll in Part A and/or Part B anytime while on group coverage during a Special Enrollment Period. Occurs during the 8 month period following last month of group coverage. Medicare Part A Premium Free if worked 40 quarters of your life and paid Medicare taxes. Premium is $240.00 for individuals or spouses who paid Medicare taxes for 30 - 39 quarters. Premium is $437.00 for less than 30 quarters. Medicare Part A Penalty Don't enroll in Part A when fist eligible, will pay a late penalty of up to 10% unless enroll during a Special Enrollment Period. Medicare Part B Premium In 2019, the standard monthly premium is $135.50 or higher depending on income. Deducted from S.S. check or Railroad Retirement check. Do not enroll when first eligible, premium is increased 10% for each 12 month period not enrolled. Deductible for 2019 is $185.00 Part C Medicare Advantage plans Entiled to benefits under Part A AND enrolled in Part B. Part D Prescription Drug benefits Entitled to benefits under Part A but not enrolled in Part B. Must be entitled to Part A AND/OR enrolled in Part B. Part D Low Income Subsidy Do not qualify for Part D Low Income Subsidy, but are of limited means, may qualify for help in Part D costs through State Pharmaceutical Assistance Program. Part A Benefits $1364.00 deductible for each benefit period. Days 1 - 60: $0 coinsurance. Days 61 - 90: $341.00 coinsurance per day. days 91 and beyond: $682.00 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over a beneficiarys lifetime. Beyond lifetime reserve days, all costs. Part A Benefits Blood, hospice, home health care, skilled nursing and rehabilitative care only after a 3 day hospital stay up to 100 days in a benefit period. In 2019, will pay $170.50 coinsurance for days 21 - 100 each benefit period. In patient psychiatric care is 190 lifetime days. Does not cover custodial or long term care. Part D Prescription Drug Coverage Late enrollment penalty of 1% of national standard premium for every month that beneficiary could have had Part D but didn't enroll. No penalty for beneficiaries with low income assistance or who join a Part D within 63 days of losing creditable coverage. Medigap Prescription Drug Coverage If coverage is not creditable, individual dropping coverage and enrolling in Part D coverage will pay a late enrollment penalty, unless they qualify for "ExtraHelp" or enroll in Part D during Special Enrollment Period for loss of creditable coverage. If informed non Medicare is no longer creditable, will have an SEP to enroll without penalty. Medicare Advantage Eligibility Not eligible if have ESRD unless: MA Plan is a SNP plan for people with ESRD, OR person developed ESRD after enrolling in MA plan. Medicare Advantage Special Needs Plans Three types. Chronic Condition (CSNP) for specific severe or disabling conditions. Dual Eligible (DSNP) for entitlement to both Medicare and Medicaid. Institutionalized (ISNP) for individuals who need services in skilled nursing facility for 90 days or longer. All SNP plans include prescription drug coverage. MA Plan Types - Coordinated Care Plans - HMO's Some HMO's offer Point Of Service option. Allows enrollees to go to no plan doctors/hospitals without prior approval for sertain services. HMO-POS may limit services out of network or put cap on out of network coverage. Cost sharing is generally higher than from network providers MA Plan Types - Coordinated Care Plans - PPO's Do not need referral for out of network providers. May pay higher cost sharing amount. MA Plan Types - Private Fee For Service plans - PFFS Individuals in PFFS plan may receive covered services from any provider who is eligible to provide Medicare services, and agrees to the plans terms and conditions of payment. Enrollees must inform provider they are a PFFS member, so the provider can decide whether to accept terms and conditions. Not permitted to charge more than cost sharing specified in plan. Cost sharing may include balance billing up to 15%. MA Plan Types - Medical Savings Account - MSA plan High deductible plan. Medicare makes contribution to beneficiaries savings account. Max deductible in 2019 is $12,650.00. In 2020, $13,400.00. Do not cover Part D prescription drug benefits. Must enroll in stand alone Part D PDP. MA Plan Types - Medical Savings Account - MSA plan May not have network. May have partial or full network. No network providers must accept amount Medicare pays them as payment in full. Medicare Cost Plans May offer Part D drug coverage, but not required to do so. Must have Part A & B. If only Part B, will not have Part A unless they buy it. Medicare Cost Plans May enroll in a Cost Plan AND a PDP. May have longer enrollment periods. Most Cost Plans are open for enrollment all year long. MA Plan Types - Private Fee For Service plans - PFFS Have option of providing prescription drug coverage, but not required to do so. Medicare Advantage & Prescription Drugs If a beneficiary enrolls in an HMO or PPO plan that does not include prescription drug coverage, CAN NOT join a stand alone PDP. Medicare Advantage & Prescription Drugs Individual enrolled in an MA PFFS plan that does not include a Part D benefit, may enroll in a stand alone PDP. An individual enrolled in an MA MSA plan must join a stand alone PDP plan if they want drug benefits. If enrolled in a Cost Plan, can join a stand alone PDP if the Cost Plan does not offer prescription drug benefits.