2024 AHIP TRAINING MODULE 2
EXAM WITH CORRECT ANSWERS
LOPEZ has heard that he can sign up for a product called MA, but is not sure
about what type of plan designs are available through this program
(MA plan, types) - CORRECT-ANSWERSThey are Medicare health plans such
as HMO, PPO, PFFS, SNP AND MSA
MA PFFS Options available - CORRECT-ANSWERS-Enrolling in PFFS plan
offering only Medicare A/B benefits and NOT obtaining Part D coverage
-Enrolling in PFFS that combines A/B and Part D Rx benefits MA-PD plan
-Enrolling in a stand-alone Part D plan
-Generally pay non-network providers the same amt. Original Medicare
would pay them.
-Providers are NOT permitted to charge the enrollee more than the cost
sharing specified in PFFS terms and conditions of payment
-PFFS MUST have max limit on member out of pocket costs for network and
NON-network providers of NOT greater than $6,700 per year.
MA MSA Coordinate Care Plans - CORRECT-ANSWERS-IS a higher deductible
health plan combined with a savings acct of health care expenses. Medicare
makes a contribution to the savings acct.
-Enrollees pay for health care expenses from the savings acct and then out
of pocket until annual deductible has been met, then plan pays 100%
covered services.
-Cover Part A/B benefits, but NOT Part D (may enroll in stand-alone)
-Enrollees pay the Part B premium and any premium for supplement benefits
-May receive covered services from any Medicare approved provider in US
-May NOT have a network or MSA's may have a network of providers who will
provide services at lower costs
-ALL providers must accept the same amt. that the Original Medicare would
pay them as payment in full
-Plans MUST offer coverage of preventive services before the enrollee has
net the deductible. +
MA EMPLOYER/UNION PLANS - CORRECT-ANSWERS-May contact directly with
CMS or offer an M plan to its retirees.
-Usually cover Medicare eligible spouses
-Plan options vary depending on the employer or union.
-Beneficiaries SHOULD check with their employer/union group benefits
admin. before changing plans to avoid losing coverage they want to keep.
, -SOME beneficiaries may be able to use their employer/union coverage along
with a Medicare plan.
MA PACE Coordinate Care Plans
Programs of All Inclusive Care for the Elderly - CORRECT-ANSWERS-Medicare
plan for frail, elderly beneficiaries
-Available in limited areas of the country
-Include comprehensive medical and social service delivery systems using an
interdisciplinary team approach in an Adult Day health center, supplemented
by in-home and referral services.
MA AND DUAL ELIGIBLE beneficiaries - CORRECT-ANSWERS-Who qualify for
both Medicare-Medicaid
-For services covered under M&M, most dual eligible will NOT have to pay
costs sharing more than the Medicaid cost sharing amts. for the services.
-Whether network providers accept both M&M patients
-Whether single M&M plan that combines M&M benefits is available to the
beneficiary
Dual eligible beneficiaries Categories - CORRECT-ANSWERSQMB only-Part
A/B premiums; cost sharing for A/B benefits
QMB Plus-Part A/B premiums; cost sharing A/B benefits; full Medicaid
benefits.
SLMB ONLY-Part B premiums
SLMB PLUS-Part B premium; full Medicaid benefits
QI-Part B premium
Other FBDE-Part B premium; full Medicaid benefits
QDWI (qualified disabled and working individual)-Part A premium
-May enroll in any type of MA plan EXCEPT an MA MSA
MA AND RX - CORRECT-ANSWERS-An organization offering coordinated care
MA plans MUST offer at least one MA plan with Rx coverage (MA-PD) in every
service area
-Outpatient Rx benefits offered by MA plans MUST meet Part D program
requirements
-CMS requires MA and Part D to maintain a medical lost ratio of at least 85%
-If administrative costs NOT related to patient care and profits exceed 15%,
MA and Part D plans will be obligated to return the excess to CMS with
further penalties in the future if this problem continues
-If beneficiaries enrolls in an MA plan that includes Part D Rx coverage,
beneficiary can ONLY receive Part D Rx coverage through that plan
-If beneficiary enrolls in MA plan that is an HMO or PPO
that DOESN'T include Part D coverage, the beneficiary CAN'T joint a stand-
alone Rx plan.
(Enrollees in certain Employer/Union retiree group plans may have different
options.
EXAM WITH CORRECT ANSWERS
LOPEZ has heard that he can sign up for a product called MA, but is not sure
about what type of plan designs are available through this program
(MA plan, types) - CORRECT-ANSWERSThey are Medicare health plans such
as HMO, PPO, PFFS, SNP AND MSA
MA PFFS Options available - CORRECT-ANSWERS-Enrolling in PFFS plan
offering only Medicare A/B benefits and NOT obtaining Part D coverage
-Enrolling in PFFS that combines A/B and Part D Rx benefits MA-PD plan
-Enrolling in a stand-alone Part D plan
-Generally pay non-network providers the same amt. Original Medicare
would pay them.
-Providers are NOT permitted to charge the enrollee more than the cost
sharing specified in PFFS terms and conditions of payment
-PFFS MUST have max limit on member out of pocket costs for network and
NON-network providers of NOT greater than $6,700 per year.
MA MSA Coordinate Care Plans - CORRECT-ANSWERS-IS a higher deductible
health plan combined with a savings acct of health care expenses. Medicare
makes a contribution to the savings acct.
-Enrollees pay for health care expenses from the savings acct and then out
of pocket until annual deductible has been met, then plan pays 100%
covered services.
-Cover Part A/B benefits, but NOT Part D (may enroll in stand-alone)
-Enrollees pay the Part B premium and any premium for supplement benefits
-May receive covered services from any Medicare approved provider in US
-May NOT have a network or MSA's may have a network of providers who will
provide services at lower costs
-ALL providers must accept the same amt. that the Original Medicare would
pay them as payment in full
-Plans MUST offer coverage of preventive services before the enrollee has
net the deductible. +
MA EMPLOYER/UNION PLANS - CORRECT-ANSWERS-May contact directly with
CMS or offer an M plan to its retirees.
-Usually cover Medicare eligible spouses
-Plan options vary depending on the employer or union.
-Beneficiaries SHOULD check with their employer/union group benefits
admin. before changing plans to avoid losing coverage they want to keep.
, -SOME beneficiaries may be able to use their employer/union coverage along
with a Medicare plan.
MA PACE Coordinate Care Plans
Programs of All Inclusive Care for the Elderly - CORRECT-ANSWERS-Medicare
plan for frail, elderly beneficiaries
-Available in limited areas of the country
-Include comprehensive medical and social service delivery systems using an
interdisciplinary team approach in an Adult Day health center, supplemented
by in-home and referral services.
MA AND DUAL ELIGIBLE beneficiaries - CORRECT-ANSWERS-Who qualify for
both Medicare-Medicaid
-For services covered under M&M, most dual eligible will NOT have to pay
costs sharing more than the Medicaid cost sharing amts. for the services.
-Whether network providers accept both M&M patients
-Whether single M&M plan that combines M&M benefits is available to the
beneficiary
Dual eligible beneficiaries Categories - CORRECT-ANSWERSQMB only-Part
A/B premiums; cost sharing for A/B benefits
QMB Plus-Part A/B premiums; cost sharing A/B benefits; full Medicaid
benefits.
SLMB ONLY-Part B premiums
SLMB PLUS-Part B premium; full Medicaid benefits
QI-Part B premium
Other FBDE-Part B premium; full Medicaid benefits
QDWI (qualified disabled and working individual)-Part A premium
-May enroll in any type of MA plan EXCEPT an MA MSA
MA AND RX - CORRECT-ANSWERS-An organization offering coordinated care
MA plans MUST offer at least one MA plan with Rx coverage (MA-PD) in every
service area
-Outpatient Rx benefits offered by MA plans MUST meet Part D program
requirements
-CMS requires MA and Part D to maintain a medical lost ratio of at least 85%
-If administrative costs NOT related to patient care and profits exceed 15%,
MA and Part D plans will be obligated to return the excess to CMS with
further penalties in the future if this problem continues
-If beneficiaries enrolls in an MA plan that includes Part D Rx coverage,
beneficiary can ONLY receive Part D Rx coverage through that plan
-If beneficiary enrolls in MA plan that is an HMO or PPO
that DOESN'T include Part D coverage, the beneficiary CAN'T joint a stand-
alone Rx plan.
(Enrollees in certain Employer/Union retiree group plans may have different
options.
