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Medicare Stack #3
General Medicare Questions
| Question | Answer |
|---|---|
| Who Qualifies for Medicare A+B? | who qualifies? - us citizens or perm res (5yr) - must meet work history req (40 quarters or 10 years) - 65 or older - unless you have certain disabilities or collecting SSDI (24 months) - ALS or Lou Gehrig's Disease - End-Stage Renal Disease (ESRD) |
| What is Medicare Part C? | *medicare advantage plan* - offered by private insurance company - covers all PART A/PART B services - "can" include drug coverage (part D services |
| How much is the Part A Premium? | no monthly premium if: - you/spouse must have worked 40 quarters - due to disability, ESRD, ALS |
| How much is the Part A monthly premium if they have not worked enough quarters? | >30 qtrs $458 per month 30-39 qtrs $252 per month |
| How much is the Part A Deductible ? | Part A is hospital coverage, so it depends on how many days they have been in the hospital: - 1-60 days ($1408.00) - 61-90 ($352 co-pay (coinsurance) per day) - 91+? start deducting reserve days -- will be $704 co-pay (coinsurance) every single day! |
| How long is a Part A Benefit Period? | benefit period (60 days) |
| How much is the Part B Premium? | Premium ($144.60 monthly - changes every year slightly) - some people will pay more based on their income (see chart) and those with low income may be eligible for QMB |
| How much is the Part B Deductible and what happens after satisfied? | Deductible ($198 yearly) then 20% of the approved cost for Part B covered services |
| What happens after the Part B Deductible (yearly) is paid? | After deductible paid - 20% of the Medicare approved amount |
| For Part B, what if the caller is on social security? | If you are on SS, they take the monthly premium out of the dispersal If you are not, you pay it quarterly. |
| What are example of what Part A + B do not cover? (6) | - Long Term Care - Routine Dental Care and Dentures - Cosmetic Surgery - Acupuncture - Hearing Aids/Hearing Exams - Eyeglasses/Vision Exams |
| What is the main reason people delay part B? | They are working! |
| What is the timeframe (x-x-x) for IEP? | 3-1-3 |
| What is the timeframe (x-x-x) for ICEP? | 3-0-0 |
| What is the acronym for the time of year where ALL CURRENT AND NEW medicare advantage customers can make changes to their plan and what timeframe is it exactly? | AEP - annual enrollment period - (Oct 15-Dec7) |
| Who are the only callers who have an OEP election? | only for medicare adv members |
| What is the election called where they are making 1 change to a different Med Adv plan or PDP and happens between Jan 1 - March 31? | OEP Annual |
| What is the election where the caller can make a change after the first three months of Part A + B being effective and what is the timeframe (x-x-x)? | OEP New (0-1-2) |
| What are the 4 tiers of the election hierarchy for those with multiple elections, most important being first? | 1 - IEP (A+B) 2 - ICEP (delayed part B - 3 months before) 3 - OEP/OEP New (clarify for agent (SEP) 4 - AEP (Oct 15-Dec7) **busy time of year |
| How many times can a caller change their application during AEP and what is the effective date? | - election used from 10/15-12/07 every year - can enroll unlimited times until midnight 12/07 - last application sticks - effective date is 1/1 of following year |
| If the caller states they have ESRD - end stage renal (kidney) disease, can we help them? | Previously the answer would be no, BUT starting 2021 they will be eligible! * we will set up a callback Oct 15 |
| A private HMO, PPO or PFFS is an example of of which "part" or medicare? | Medicare Adv Plan (part C) |
| True or False? MA Part C plans have little to no monthly premium but DOES have set co-pays | True |
| True or False? MA Part C plans perform medical underwriting on all applications | False |
| True or False? MA Part C plans includes dental, vision, hearing coverage | True |
| What is another term for "Medicare Supplement" plans and are the monthly premiums generally high or low? | "Secondary" - High (but low out of pocket costs) |
| What are the two main scenarios for the LOC election? | 1st - receive a letter saying their PDC is no longer as good as medicare 2nd - involuntary loss of coverage (ex. Divorce) |
| If the caller has an SPAP, and wants to enroll in a MA plan, is that possible? | Yes, they can make one change per year |
| "Non-renewing", "Loss of Pace", "5 Star", "Other Creditable Coverage", "Retroactive" are all examples of? | Additional (not as common) Elections |
| Why is it important to continue an AEP call even if the caller states they signed up for a plan already? | The person who assisted them may have missed/misunderstood something, and if you find something, the last application sticks! |
| What is the effective date of all AEP applications? | Always 1/1 of the following year |
| What does the SUP - Plan F cover? | pays 100% of what Medicare leaves behind + $0 cost at DR/HOSP |
| What does the SUP - Plan C/G cover? | pays 100% of what Medicare leaves behind, after the client pays their part B deductible + $198 deductable, and then $0 cost rest of year |
| How much does Med Adv PCP copay, Specialist, and ER visit? | PCP: $0-20 - Spec: $20-60 - ER: $90-120 |
| What does/can a MA plan cover? | all services covered by Medicare Parts A and B. + They usually also offer additional benefits, like dental, vision, and hearing (DVH), over-the-counter drug allowances, fitness memberships, and health management programs |
| What factors (4) can effect the total cost of an MA plan? | monthly premiums yearly deductible copayments coinsurances. |
| What is considered a "MA-Only Plan"? | MA plan (A,B,C) without a part D / PDP |
| How are $0-Premium Plans (part C) possible? | Private insurers can save costs by establishing networks for their MA plans, and then put those savings into making those plans have a low or $0 premium. A low- or $0-premium plan will have a higher maximum out-of-pocket limit |
| What is a Medicare Medical Savings Account (MSA) Plan? | lump sum deposited annually into savings account by plan via Medicare. - unused balance of the annual deposit will roll over year after year. - must spend their balance on qualified health expenses or save it for future costs. |
| What are examples of qualified expenses for an MSA plan? Does it include a Part D? | e.g., hospital, medical, dental, vision, and long-term care costs members would need to buy a stand-alone Part D plan, unless they have another form of creditable coverage to avoid late enrollment penalties |
| Hospital, skilled nursing, rehabs and hospices are examples of covered areas in which Part? | Part A (4 examples) |
| Best way to explain Part B to someone and 4 examples | supplementary to Part A, allows access to a broad range of outpatient services (ex. physician care,labs, medical equipment, preventative services) |
| Medicare Part E (lesser known) includes these two programs | Medicare cost plans (limited number of states) Medicare supplemental insurance (Medigap) |
| What are the four different ways that beneficiaries can choose to receive their Medicare coverage? | 1) Original Medicare (A+B) - can be combined with a sup or pdp) 2) MA (with/without D coverage) 3) PDP 4) Medicare Cost Plan |
| In what three cases are people automatically enrolled in Original Medicare? | 1) people receiving SS after 65 (can refuse B) 2) people w/ disabilities under 65 + receiving SS (can refuse B) 3) people with ALS + receiving SS * ESRD is not included here, if they get SS they can sign up and coverage begins 4th month after dialysis |
| Who typically enrolls during OEP and when is it? | people who did not enroll in Part B (or part A if they have to buy it) + can enroll during OEP (Jan1-March31) |
| When does coverage begin if enrolling during OEP? | July 1st of the year they enroll |
| To be eligible for Part C , the person must (2): | be entitled to Part A and be enrolled in Part B and reside in the plan service area |
| To be eligible for Part D, the person must (2): | be entitled to Part A and/or enrolled in Part B and reside in plan service area |
| To be eligible for Cost Plans, the person must (2): | be entitled to Part A and/or enrolled in Part B (if not entitled to Part A this plan does not provide it) and reside in (Part D) plan service area |
| What does a QMB program pay for and who does it generally go to? | People with low incomes + pays for Part A and B premiums and other medicare costs |
| In what case will a 10% late penalty be charged for Part A unless they do what? | people who are not eligible for premium-free Part A and those who don't buy Part A when they are first eligible unless they enroll during a special election period |
| What are the three ways Part B premiums can be deducted? | SS checks, Railroad Retirement checks, Office of Personnel Management (civil service annuity) checks |
| True or False? Employers can choose to pay part B monthly premiums for their retirees | True |
| Explain the Part B late enrollment penalty and what is the exception? | people who do not enroll when first eligible, the part B premium is increased 10% for each full 12 month period except when the caller or caller spouse is on group plan |
| What is included in "inpatient hospital care" (part A)? | acute care hospitals, critical access hospitals, rehab, and long term care hospitals |
| How many days in the hospital is the standard requirement for approved skilled nursing/rehab for Part A and what can waive that? | 3 - MA plans can include the right to waive this req |
| How many days of inpatient psychiatric care does part A cover? | up to 190 lifetime days |
| True or False: Part A covers custodial or long term care | False, it does not |
| What are the three cost tiers (by days) for benes using Part A skilled nursing and rehab care? | 1-20 ($0 per benefit period) 21-100 ($176 coinsurance per day per bp) 101+ (all costs) |
| What are some other Part B items and services? Limits will apply to some? (8) | Ambulance Chiropractic Diabetic Supplies Eyeglasses post cataract surgery Kidney Dialysis Mental Health Occ/Pys Therapy Telehealth |
| What preventive services/screenings does Part B cover? (4) | - (1 time) welcome to medicare physical - annual wellness visit after 12 months - immunizations (not shingles thats part D) - bone mass measurement (per 24 months) |
| When the caller has original medicare and employer group coverage, which pays first? | employer has 20 or more employees, then generally the plan pays first and Medicare pays second. fewer than 20 employees, Medicare generally pays first. |
| What are the three types of MA plans? | Coordinated Care Plans (HMO, PPO) PFFS MSA |
| What are two examples of mechanisms MA plans use to manage utilization of covered services? | Referrals + Prior Auth |
| What is step therapy in terms of utilization of MA plans? | bene req to try less expensive options before stepping up to drugs that cost more |
| Persons with ESRD trying to get coverage before 01/01/21, they must meet one of these criteria | -bene enrolled in plan by same org same state before becoming eligible for medicare - MA plan is a special needs plan - MA plan is an employer group waiver plan - bene got ESRD after being enrolled - bene was enrolled and that plan terminated |
| What is a SNP? 3 types? | limits enrollment to benes who meet specified criteria + always include PDC 1-Chronic (C-SNPs) 2- Dual Eligible (D-SNPs) 3- Institutional (I-SNPs) |
| What is a C- SNP? | restrict enrollment to special needs with specific sever or disabling conditions |
| What is a D-SNP? | benes entitled to both medicare and medicaid |
| What is a I-SNP? | bene eligible for an MA who (for 90+ days) will require LTC |
| What is a EGWP? | enrollment based on employment based health coverage |
| Who is not eligible for an MSA? | benes who get their deductible covered, bene who is enrolled in a Federal Employee Health Benefits plan or eligible for benefits through VA, dual-eligible benes, not going to be in US for at least 183 days, bene elected hospice |
| What are the max out-of-pocket costs for HMOs in 2020 and 2021? | 2020 - $6700 per year 2021 - $7550 per year |
| What should benes know about an HMO-POS? | plan may limit services available out of network or may put dollar cap on amount of out-of-pocket coverage |
| What are the max out-of-pocket costs for HMOs in 2020 and 2021? What is the aggregate limit for the same years? | 2020 - $6700 per year 2021 - $7550 per year aggregate 2020 - $10000 2021 - $11300 |
| True or False: except for emergencies, PFFS plan members must inform providers before they receive services | True |
| PFFS is NOT? (2) | NOT - original medicare NOT - a med supp, medgap, or medselect |
| PFFS cost sharing can include balance billing up to what %? | depending on the plans terms, up to 15% |
| In an MSA, what is the max deductible for 2020 and 2021? | 2020 - $13,400 2021 - $14,150 |
| Employers and unions may offer retires and benes these two plan options: | 1) MA ind or group provided by plan sponsor 2) MA through direct contact with CMS |
| True or False: employers with less than 20 employees can offer MA plans to active employees and their dependents | TRUE |
| Who is eligible for a Medicare Cost Plan? (2) | 1) those with original medicare 2) those with just part B |
| 4 categories of Medicare Savings Programs | 1) QMB 2)SLMB 3)QI 4)QDWI |
| QMB beneficiaries fall into two categories: | 1)QMB Only - only getting help paying for medicare premiums and cost-sharing 2)QMB plus - also eligible for full Medicaid |
| Two special rules for QMBs | 1) when enrolling, bene does not have to pay more cost sharing than any minimal copayment that would apply under medicaid 2) all providers are prohibited from billing QMBs for any Medicare cost-sharing amounts |
| Issues important to duel eligible benes on medicaid enrolment are | 1) is the bene eligible for medicaid 2) will the bene need help finding providers who accept both medicare and medicaid |
| True or False? bene enrolls in HMO/PPO that does not include part D coverage cannot join a PDP | True |
| What are the two medicare processes where a bene can address concerns/grievances? | 1) grievance process 2) appeals process |
| What are examples of when a bene would need a coverage decision? | get prior auth, obtain payment, continue a service, rx exceptions etc |
| An appeal can be filed if? (3) | 1) enrollee believes plan did not pay/authorize a service that should be covered 2) enrollee believes an authorized service is ending too soon 3) enrollee believes plan did not auth an Rx that should have been covered |
| Name the three main types of Part D plans and where else can it be included? (2) | 1) stand alone pdp 2) medicare advantage w/ prescription drug cov 3) cost-pd plans - medicare cost plan that cover part D as optional sup benefit also PACE plans + medicare-medicaid plans |
| True or False: generally, only benes enrolled in Original Medicare, an MA MSA, PFFS or Cost plan may enroll in a standalone PDP for Part D? | True - depending on what they have currently, there are other variables at play |
| True or False: benes enrolled in a MA HMO or PPO may only obtain Part D benefits through their HMO/PPO? | True - and employer group plan enrollees may have additional choices |
| True or False: benes enrolled in an MA MSA can get their Part D any way they like | False - they can only obtain through a standalone PDP |
| What options does a bene enrolled in a MA MSA or a Cost plan have for getting Part D coverage? | Both persons may only obtain Part D benefits through a standalone PDP |
| If a bene has medicare and medicaid, or if a bene is in a PACE plan where do they get their part D coverage? | for both, from that plan, not elsewhere |
| Who is eligible for standard Part D and what must be true about the bene? | 1) benes entitles to Part A and/or enrolled in Part B 2) bene must live in the plans service area |
| True or False: PDPs must enroll any eligible beneficiary who applies regardless of health status? | True |
| Who is eligible for a MA-PD plan? | 1) certain benes with ESRD (only for plans with effective date before 01/01/21 2) bene not entitled to Part A but has Part B 3) bene who does not meet eligibility criteria of C-SNP |
| Generally, what are the 4 areas where Part D will usually cover? | 1) Rx 2) biologics (allergy shots/gene therapy) 3) insulin 4) medical supplies for injecting insulin 3) certain vaccines |
| Why does Part D not cover ALL Rx? And what two criteria must Part D Rx meet? | only formulary Rx because in some cases several similar drugs are available to treat the same medical condition and the criteria are: 1) at least 2 drugs in each therapeutic category 2) generic and brand name drugs |
| Part D does not cover all drugs, name the most common 7 examples: | 1) weight loss/gain, fertility, cosmetic, symptomatic relief of cough or cold 2) vitamins 3) medical foods 4) erectile dysfunction (check plan) 5) non-prescription 6) some off-label use drugs 7) rx covered under A+ B (even if bene doesn't have) |
| True or False: all Part D plans must cover at least the Part D standard benefit or its actuarial equivalent? | True - if not standard they are considered "alternative" coverage |
| What are the 4 phases of the Part D "standard benefit structure"? | 1) a deductible 2) time between deductible and initial coverage limit 3)"coverage" gap between initial coverage limit + out-of-pocket threshold (donut hole) 4) after out-of-pocket its catastrophic |
| What is considered Part D "alternative coverage"? | rx coverage at least actuarially equivalent to standard drug coverage and - annual deductible does not exceed annual deductible under standard benefit -imposes cost-sharing <std benefit after OOP met |
| What would be considered Part D "enhanced alternative benefits"? | (+) monthly premium, MAY include: - reduction of deductible - coverage of excluded Rx - increase in the initial coverage limit |
| For 2021 what is the standard benefit cost for Part D? | $445 deductible - 25% of Rx costs during initial phase post deductible up to $4130 (initial coverage limit) 25% of the cost of generic Rx and 25% of undiscounted costs of brand name drugs during "coverage gap" phase |
| Explain what the "Manufacturers Discount" is and what % is it? | 70% (cost of drug) during the "coverage gap" phase - which is attributed to bene out-of-pocket costs and counts towards the spending necessary to reach the catastrophic phase (even tho bene doesn't pay for it) |
| What if a bene using Part D has reached the "catastrophic" phase? How does that impact the out-of-pocket costs for the bene? | Bene exceeds $6550 in out-of-pocket costs (aka "true out-of-pocket") costs aka "TrOOp" |
| For Part D, on what basis is TrOOp calculated and which payments count towards it? | Annual Basis - bene payments on Rx, manufacturers discount, AIDS program, IHS, SPAPs, most charities, HSA/FSA/MSA accounts |
| For Part D, what are some examples of costs that do not count towards TrOOp? | -Rx not on formulary (unless bene gets exception) -OTC and other non-Part D Rx - part D Rx obtained out-of-network - costs paid for/reimbursed to an enrollee from 3rd party (see list) - costs for Rx purchased outside USA |
| True or False: Part D coverage is generally provided through local hospitals and urgent cares | False - generally provided through contracted pharmacies (network pharmacies) in the part D plan service area (PFFS plans not required to) |
| What are two reasons for someone (Part D) filling prescriptions at out-of-network pharmacies? | 1) illness or loses a drug while traveling outside service area 2) limited drug access from in-network pharmacies |
| True or False: for Part D, a higher premium means higher out-of-pocket costs for the plan? | Fasle - a higher premium means lower out-of-pocket costs for the plan |
| What are the three options for Part D enrollees paying their premium? What is the default if a selection is not made? | 1) electronic (checking/savings or debit/credit) 2) direct monthly billing (default) 3) deduction from monthly SSA check |
| For Part D coverage, how long does it typically take to start and stop SSA withholding for the premium? | 2-3 months to begin or end which means the first pull will be for 2-3 months of premiums then it goes back to 1 month |
| What are the two scenarios where the Part D premium penalty comes into play? | 1) caller does not have creditable coverage and does not enroll when first eligible 2) there has been a period of at least 63 continuous days following bene IEP (Part D) where the bene did not have Part D or creditable drug coverage |
| What is the Part D premium penalty? How long is it in effect? | 1% of the national average bene premium for each month the bene did not have Part D or creditable coverage and it is in effect for as long as the bene has Medicare PDC* * benes who qualify for LIS/EH do not get this charge |
| If the caller did not sign up for Part D when he was eligible because he had creditable coverage through his employer, its AEP and he/she wants to apply, would the caller be charged the premium penalty? | If the caller is not eligible for LIS/EH then yes, the caller would need to pay a 1% penalty on each month they did not have creditable coverage - if the caller does qualify for LIS, no penalty |
| For Part D Rx, many plans group drugs into 3 or 4 tiers with lower tiers costing higher than higher tiers. What are the four tiers, lowest (1) to highest (4)? | Tier 1 - generic Tier 2 - preferred brand name Tier 3 - non-preferred brand name Tier 4 - high-cost or "specialty" |
| For Part D Rx, what is step therapy? (not what it sounds like) | one or more similar lower-cost Rx must be tried before the more expensive ones are tried |
| For Part D, how does the CARA program come into play? | plans may impose certain limitations on prescribers/pharmacies a bene can us to manage utilization fro benes who are at risk of misusing or abusing drugs |
| New enrollees in Part D, enrollees switching Part D plans, and current enrollees affected by formulary changes who need their non-formulary Rx are entitled to what? | Must receive 1 month fill of their non-formulary Rx during the first 90 days after their enrollment, the plans switch, or the formulary change |
| What if a current enrollee in a part D plan is in a long-term care setting and outside their 90 day transition period? | The sponsor must still provide the 1 month Rx fill, while an exception or prior auth request is being processed |
| True or False: For Part D, enrollees can request exception for a non-formulary Rx? also, where do they go to start that process? | True, a standard form is available on the Part D plan website to request the exception |
| For Part D, some individuals automatically qualify and are signed up for LIS/EH if they meet any one of these 4 criteria: | 1) they have full medicaid coverage 2) medicaid helps pay their part B premiums 3) they receive SSI benefits medicare mails them a purple letter to let them know they auto-qualify and are in the program - they save that card for their records |
| True or False: individuals who qualify for LIS or partial-LIS have higher cost sharing | False, those who qualify for LIS enjoy lower cost sharing |
| For 2021, if you qualify for full-LIS and ARE a FBDE with income AT OR BELOW 100% of the FPL will have a cost-sharing in their Part D plan of what? | $1.30 for generic drugs and $4.00 for other drugs is the maximum and no cost-sharing after out-of-pocket threshold is reached (no deductible) |
| For 2021, if you qualify for full-LIS and ARE a FBDE with income ABOVE 100% of the FPL will have a cost-sharing in their Part D plan of what? | $3.70 for generic and $9.20 for other drugs and no cost-sharing after out-of-pocket threshold is reached (no deductible) |
| For 2021, if you qualify for full-LIS and ARE NOT a FBDE with income UP TO 135% of the FPL will have a cost-sharing in their Part D plan of what? | $3.70 for generic and $9.20 for other drugs and no cost-sharing after out-of-pocket threshold is reached (no deductible) |
| For 2021, if you qualify for PARTIAL-LIS (INCOME LESS THAN 150% OF FPL) will have a deductible and cost-sharing in their Part D plan of what? | Deductible of $92 and maximum cost-sharing of: 1) 15% up to the max out-of-pocket threshold 2) $3.70 for generic and $9.20 for other drugs |
| What is important to know about Employer/Union coverage in a part D plan? (also applies to creditable TriCare, VA, or FEHBP plans) | The alternative coverage must be creditable and that is fine there will not be a penalty If the alternative coverage is not creditable, they will need to switch to Medicare Part D during his/her IEP to avoid late enrollment penalty |
| What if a bene in a Part D plan has creditable coverage elsewhere, loses it and needs to get coverage through Part D? | as long as the bene obtains new creditable drug coverage elsewhere, they would join a Medicare Part D plan and it would have to happen within 63 days to avoid any penalties |
| True or False? When a medicaid bene becomes eligible for medicare, the medicare will be covering the Part D drugs once the bene is enrolled in a Part D plan. | True - if medicaid benes don't pick a medicare plan, medicare will select one for them |
| How often can Medicaid benes change their part D plans and what can cause additional limitations to making changes? | can change throughout the year, once per quarter, limitations can apply to benes designated at risk or potentially at risk for opioid abuse |
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cmazzariti
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