UHC certification

 UHC certification


Federal health insurance program

Medicare is administered by whom?

CMS ( Centers for medicare and medicaid services)

Parts A & B 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?


do MAP's have a annual maximum OOP maximum that limits the amount of money a member must spend every year for covered services?


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?


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?


Do PPO's require a referal?


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?


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?


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?


In a POS plan, does a member need a referral from their PCP to see a specialist?


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?


Does a PCP need to be selected with a PFFS plan?


What is the only plan to offer non-network PFFS plans?


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


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?


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 ?


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


To avoid member complaints, encourage customers to select a ____and make sure the _____ is accepting new patients


In which plan ( HMO/POS) are out of network benefits available at a higher cost?


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?


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?


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?


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.

If a customer on medicaid applies for a PFFS plan, the customer may be responsible for?

cost sharing

Only enroll a dual eligible customer into a PFFS plan if the customer insists on enrolling and disclose the potential impacts of


What type of plan can be network based or non-network based?


UHC does not offer network-based ___ plans?


what is deeming?

a key feature of a PFFS plan is that the member can choose their health care provider both at home and when they travel in the US

What us a deemed provider?

one that is

A) aware in advance of furnishing health care services that the individual receiving the services is enrolled in a PFFS plan

B) Has reasonable access to the plans terms and conditions of payment in advance of furnishing services

C) furnishes services that are covered by the plan

What is a deemed provider

must participate in medicare and agree to the plans terms and conditions of payment

PFFS member responsibilities?

the member must choose to use medicare-eligible provides who agree to the plan's terms and conditions of payment in order to receive coverage under the plan

present the member ID and inform provider of the PFFS membership prior to each visit and before receiving covered services

CMS allows the PFFS plan to decide if balance ____ is permitted


Plans must ___ what is permitted in the terms and conditions of payment


MA plan should not be referred to as a

supplement replacement, supplement, replacement no cost, free plan or zero cost plan

Medicare part D is a state program or a federal program

federal program

In order for a customer to obtain medicare part D, what must they have to do?

they must enroll individually in a plan offered by a private insurance company approved by medicare

In order to be eligible for part D, what must a client also have?

Part A and B

When a client enrolls in part D prescription drug coverage when they first become eligible, what is that time period often called?

Initial enrollment period

consumers can also enroll, disenroll or change coverage each year between when?

october 15- dec 15th during the annual election period( AEP)


annual enrollment period


Open enrollment period

MA plan members whop use the OEP to disenroll from their MA plan and obtain coverage from original medicare, may enroll in a stand alone what plan?

part D plan

____ does not allow for PDP enrollment changes?


What is a PDP?

a stand alone medicare prescription drug plan

What do PDP's do?

add prescription drug coverage to original medicare, MSA's, some medicare cost plans, and some medicare private fee for service PFFS plans

WHat type of stand alone variations to medicare can give extra benefits?



When a consumer has original medicare and a prescription drug plan, they can also have a medicare________ insurance plan

medicare supplement insurance plan

There are 4 stages to medicare part standard prescription drug coverage; what are they?

1) yearly deductible

2) initial coverage

3) Coverage gap

4) Catastrophic coverage

To determine when a member moves from one stage to the next in medicare prescription drug coverage, the plan keeps track of the members TrOOP costs. What does Troop stand for?

True out of pocket

Any money spent during the deductible, initial coverage, and coverage gap stages counts towards the TrOOP costs. What doesn't count toward the TrOOP costs?

The monthly premium

How much is the yearly deductible for a medicare prescription drug coverage?


In a Medicare prescription drug coverage plan, the member pays (all/some) of the yearly deductible?

all- the plan pays nothing

is the initial coverage for the medicare prescription drug coverage plan covered entirely by the customer or plan?

member pays part, the plan pays part

in the initial coverage, drug costs are shared by the member and plan until total drug costs paid by both, including the deductible reaches what amount?


for the coverage gap in a medicare drug coverage plan, who pays what?

the member pays most, and the plan pays a little

in the coverage gap, member pays up to what percent of most brand named drugs


In the coverage gap, the member pays what percent for generic drugs?


When OOP costs for the coverage gap reaches what amount, they will move onto the catastrophic coverage?


Catastrophic coverage is what in the order of medicare prescription drug plan


In catastrophic coverage, who pays what?

The member pays a little while the plan pays most

In catastrophic coverage, the member pays what?

a small copay or coinsurance for drugs

PDP break down for 2019

Annual deductible= $415

Initial coverage- $3820

Coverage gap- $5,100

What is the coverage gap for medicare prescription drug coverage?

Its a temporary limit on what the medicare prescription drug plan will cover

When a customer reaches the ____ They will pay 25% for most brand named drugs and 37% for generic drugs

coverage gap

consumers with limited _____ may qualify for extra help from medicare to cover their part D premiums and Part D related OOP costs

income and resources

TO qualify for low income subsidy on part D, the consumers income must be at or below

150% of the FPL ( federal poverty level)

when does approved extra help begin?

the first day of the month the customer becomes eligible

how does a customer qualify for extra help?

they receive both medicare and medicaid benefits, receive SSI and meet a certain income, and are a MSP participant( medicare savings program)

if a customer who automatically qualifies for extra help doesnt enroll in a prescription drug plan, medicare may automatically enroll them in one so they will be able to use the_____?

extra help

What is creditable coverage?

its a prescription drug coverage that is expected to pay on average at least as much as medicare's standard prescription drug coverage

What are some examples of creditable coverage?

drug plan from an employer, union, TRICARE, indian health service, or department of veterans affairs

consumers with creditable coverage when they become eligible for medicare can generally keep that coverage without paying a ____ if they decide to enroll in medicare prescription drug coverage later?


The organization providing the prescription drug coverage MUST inform the consumer annually if the prescription drug coverage is ________

creditable coverage

how many days does medicare allow before a customer accrues a penalty

63 days

if a customer accrues a late penalty for not accepting medicare before the 63 day limit, the late enrollment penalty is added to what?

the monthly plan premium

What is the late enrollment penalty?

1% x 35.02(2018 NBBP or national base beneficiary premium) x # of months= penalty

Can the pharmacy used impact OOP costs for covered drugs?

yes. The customer should use a preferred or standard in network pharmacy

Under the part D benefit, drugs filled at an OON pharmacy are covered only when the member is not able to use an in-network pharmacies for covered medications, generally at a higher ________

OOP cost

What is a preferred pharmacy?

A contracted network pharmacy that offers medicare part D members covered Part D drugs at negotiated prices. The prices are lower levels of cost-sharing than apply at a non-preferred (standard) pharmacy

What is a formulary drug list?

A list of covered drugs selected by the plan with the help of a team of doctors and pharmacists

The drug list often represents the level of cost-sharing associated with various groupings of medications(preferred generics, generics, preferred brands, non preferred drugs)

The list must meet requirements set by medicare ( CMS)

Medicare approved the plan's drug list

How many tiers are there for medicare prescription drug coverage?


What are the 5 tiers for medicare prescription drug coverage?

Tier 1, 2,3,4,5

Tier 1?

Member pays lowest copayment and lower cost commonly used generic drugs are covered

Tier 2?

Member pays a low copayment, many generic drugs are covered

Teir 3?

Member pays a medium copayment and many common brand name drugs and some higher cost generic drugs are covered

Tier 4

Member pays copayment ( MA-PD) coinsurance (PDP) and non-preferred generic and non-preferred grand name drugs are covered

Tier 5

Member pays coinsurance, and unique and or very high cost drugs are covered

What is strep up therapy?

its an effective, clinically proven, lower-cost alternative to some drugs that treat the same health condition. A plan may require that a member try an alternate drug before covering the requested drug. if a member has already tried other drugs or a provider thinks other drugs are not right for the situation, a member or their doctor can ask the plan to cover these drugs

To ensure safe and efficient use of a drug, the plan and/or medicare sets a quantity limit that defines how much of a medication a member can receive at a time. some drugs require approval from the plan prior to the member filling their prescription.

if a member is prescribed or requires more of a medication than allows, the member or their doctor can contact the plan and ask for an exception.

Some drugs require pre-approval by the plan. A member of their provider can ask a plan to cover the drug.

the plan may ask the member or provider for additional information to help ensure the drug is appropriate for medicare-eligible health conditions. A member might be asked to try another drug on the formulary before the plan will cover the drug they are requesting.

Who qualifies for a medication therapy management program?

members enrolled in a medicare prescription drug plan who take medications for multiple medical conditions may qualify at no additional cost, for a medication therapy management program( MTM)

How does the MTM program work?

it helps physicians and members ensure their medications are working to help improve their health

To be enrolled in a MTM, a customer MUST

1) have a chronic health condition

2) member takes several different medications

3) Member's medications have a combined cost of more than $3,919 per year

to be enrolled in the MTM program ( medication therapy program) the enrolled member must meet all of the following

1) member has more than one chronic health condition

2) Member takes several different medications

3) Member's medications have a combined cost of more than $3,919 per year

( the dollar amount can change per year) is estimated based on OOP costs and the costs the plan pays for the medications each calendar year. the plan can help members determine if they may reach this dollar limit.

A list of drugs covered within the part D benefit plan


Money spent ( excluding premiums) during the Deductible, initial coverage and coverage gap stages count toward ____, which determines when a member moves from the drug coverage stage to the next


The stage in Medicare part D prescription drug coverage in which there is a temporary limit on what the plan will cover for drugs

coverage gap

A drug may require this type of approval by the plan prior to a member receiving it?

prior authorization

Extra help for customers with limited income and resources from Medicare to cover their part D premiums and Part D related OOP costs

low income subsidy

applying for help for medicare prescription drug plan expenses does NOT automatically enroll him in a _______ plan

prescription drug plan

what does MMP stand for?

Medicare-medicaid plan

What does MMP do?

individuals can receive both medicare parts A &B and full medicaid benefits through one health plan

Generally, qualified individuals are passively enrolled into the state's coordinated care plan with the ability to opt-out and choose other medicare


Why would someone want to enroll in a MA-only PFFS plan?

they want to keep their stand alone prescription drug plan (PDP)

when a member enrolls in a different MA plan offered by the same MA organization, his/her year to date contribution toward the annual OOP maximum plan is what?

is counted towards his/her MOOP in the new MA plan IF:

1) the new plan is the same type as the previous plan ( eg HMO to HMO) and both plans are on the contract and/or have the same legal entity

2) the new plan is a different type than the previous plan ( eg HMO to PPO) and both plans have the SAME legal entity

If a member is switching from one MA plan to another, does the member have to be apart of the same carrier to retain his/her MOOP expenses?

yes. if the member is from a different carrier, the MOOP expense will NOT carry over to the new plans yearly deductible

What type of plans are network based plans?

HMO's, POS's, and PPO's

What type of plan can either be network based or non- network based?


Before enrolling a customer in a MA plan, you must verify the network status of each provider the customer currently uses or intends to use by checking what?

the plans provider directory or by contacting the plan. If possible, use an online directory over a printed directory as they are more current. Remind the customer to check their providers status before receiving care to ensure that their network status has not changed. ( see provider search job aid on jarvis, UHC's agent portal)

Is emergency care covered in a PFFO plan regardless of whether the provider agrees to accept the plans payment?

yes it is`

Who allows the PFFS plan to decide if balance billing is permitted?

CMS. Plans must disclose what is permitted in the terms and conditions

Does the OEP( Open enrollment period) allow for PDP changes?

No you cant make changes to PDP during the OEP

If a customer enrolled in a MAP( with or without prescription drug coverage), will be automatically ________from that plan and returned to original medicare upon enrolling in a PDP ( except MA-only PFFS plans)


what happens when a customer is enrolled in a employee or union sponsored health plan and decides to enroll in a PDP?

the customer MAY lose coverage for themselves and their dependents upon enrollment in a PDP, and may not be able to re-enroll in the employer or union plan at a later date

in an employer/union-sponsored group retiree plan, or more specifically a subsidized plan, the employer contributes to the premium, but with an endorsed plan, the employer _____?

does not contribute

WHat kind of medicare plan is only available through employer groups?

employer senior supplement group retiree plans

does an employer senior supplement group retiree plan help pay for some or all the costs not covered by original medicare?

yes. not only that but they have similar coverage as medicare supplement insurance plans and members can go to any provider that accepts medicare

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