Medicare
Federal health insurance program
Medicare is administered by whom?
CMS ( Centers for medicare and medicaid services)
Parts A & B
... [Show More] of medicare are
federal health insurance program referred to as original medicare
Part A?
Hospital insurance
Part B?
Medical insurance
What doesnt medicare cover?
routine dental, eye care hearing exam,deductibles, coinsurance and copayments
Part C?
Medicare Advantage Plans
MA covers?
Part A &B coverage, and some part D coverage
MA plans are not?
Medicare supplement insurance plans
What offers lower monthly premiums MADP or supplement?
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?
YES
MA plans integrate what type of additonal coverage?
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?
MA-only PFFS plan
What is a stand alone drug plan called?
PDP
WHat is PFFS?
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?
PFFS plan
Do HMO's require referals?
Yes
Do PPO's require a referal?
No
When a member enrolls in a MA plan, they receive their coverage from medicare or the MA plan?
MA plan
When a customer is enrolled in a MA plan, they must continue paying their premiums for what other plan?
Part B
MA plans have a maxium annual limit on OOP costs called a?
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_____?
effective date
An exception exisits for MA-only PFFS plans as a member can also be enrolled in a what?
Stand alone PDP
If a member enrolls in a MA plan, what must the member do?
Cancel in writing their medicare supplement insurance policy with the carrier after their request to enroll in MA plan has been approved.
Medicare supplement insurance policies cannot be used in conjunction with what type of plan?
MA plan
A medicare supplement insurance plan helps to cover some of the OOP costs associated with?
original medicare.
A medicare supplement insurance plan does NOT pay the cost-sharing of what type of plan?
MA plan
when a client enrolls in a MA plan, will it automatically terminate their MA plan?
NO
Can a customer call to terminate their Med Sup plan?
no it must be done in writing
What are the different types of MA plans?
HMO, POS, PPO, RPPO, PFFS, SNP, and MSA
For an HMO, they customer must us IN network providers, what are the exceptions to their rule?
Emergencies, Urgent care, and renal dialysis services.
In a HMO plan, does a member have to choose a PCP? and do they require referrals to see a specialist?
Yes
In a POS plan, does a member need a referral from their PCP to see a specialist?
yes
Can a member with a POS plan see a specialist?
Yes, but they may have to pay a higher cost, and there coverage limits
With a PFFS plan, can a member seek treatment from any medicare eligible provider who agrees to accept the plans conditions and payment rates?
Yes
Does a PCP need to be selected with a PFFS plan?
No
What is the only plan to offer non-network PFFS plans?
UHC
What are SNP's for? ( Dual SNP)
People who have both medicare and Medicaid
Institutional SNP?
Nursing homes
Chronic condition SNP?
people who have certain chronic medical conditions
MSA?
Medical savings account
What does a MSA do?
Combines a high deductible medicare advantage plan and a bank account
How does MSA plans work?
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?
no
MA plans include some key features such as?
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 ?
MA-PD
in a MA-part D plan, A member will be disenrolled from their MA-PD upon enrollment in?
a stand-alone PDP
With MA only, a member will be disenrolled from their stand alone PDP upon enrolling in a?
Non-PFFS MA-only plan
in MA-only, a member will be disenrolled from their non-PFFS MA-only plan upon enrolling in a?
Stand alone PDP
most MA plans require a what? although not all plans require that the chosen____ cordinate the members care
PCP selection
If a PCP is required and the customer does not indicate one on the enrollment application, a _____ will automatically assigned
PCP
To avoid member complaints, encourage customers to select a ____and make sure the _____ is accepting new patients
PCP
In which plan ( HMO/POS) are out of network benefits available at a higher cost?
POS
With a PFFS plan, does a PCP need to be selected? and are prior authorizations or referrals from a PCP required?
No, NO
once a member with a MAP reaches the maximum OOP expenses, is there cost sharing for any additional services?
no
MA plans with an OON component may or may not have an?
OOP maximum for OON services depending on the plan
All medicare covered ( part A and part B) services count torward the?
OOP maxium with MAP's
Services and deatures that do not count toward the maxium OOP in a MAP include?
plan premium, part D prescription drugs and any non-medicare covered services such as eyewear and hearing aids
Is the OOP maximum amount different between MA plans?
Yes
UHC strongly discourages Dual-eligible customers, from enrolling into a PFFS plan due to?
having potential negative impacts to the customer
What does dual eligible customers mean?
having both medicare and medicaid
Before enrolling any customer into a PFFS plan, ask if they are enrolled in a state _____ program?
medicaid
If a customer is enrolled in a state medicaid program, explain to them that a PFFS plan may
Impact their ability to continue seeing their current providers, and may create OOP expenses they may not be able to afford. [Show Less]