Download Medicare Certification Questions and Answers: UHC 2025-2026 and more Exams Health sciences in PDF only on Docsity!
UHC Certification Latest 2025-2026.
Questions & Correct Answers. Graded A
____ does not allow for PDP enrollment changes? - ANS PDP A drug may require this type of approval by the plan prior to a member receiving it? - ANS prior authorization A list of drugs covered within the part D benefit plan - ANS formulary A medicare supplement insurance plan does NOT pay the cost-sharing of what type of plan? - ANS MA plan A medicare supplement insurance plan helps to cover some of the OOP costs associated with? - ANSoriginal medicare. AEP? - ANSannual enrollment period All medicare covered ( part A and part B) services count torward the? - ANSOOP maxium with MAP's An exception exisits for MA-only PFFS plans as a member can also be enrolled in a what? - ANSStand alone PDP
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? - ANSThe monthly premium applying for help for medicare prescription drug plan expenses does NOT automatically enroll him in a _______ plan - ANSprescription drug plan 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? - ANSthe 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) Before enrolling any customer into a PFFS plan, ask if they are enrolled in a state _____ program? - ANSmedicaid Can a customer call to terminate their Med Sup plan? - ANSno it must be done in writing Can a member with a POS plan see a specialist? - ANSYes, but they may have to pay a higher cost, and there coverage limits Can the pharmacy used impact OOP costs for covered drugs? - ANSyes. The customer should use a preferred or standard in network pharmacy
Do PPO's require a referal? - ANSNo Does a PCP need to be selected with a PFFS plan? - ANSNo does an employer senior supplement group retiree plan help pay for some or all the costs not covered by original medicare? - ANSyes. not only that but they have similar coverage as medicare supplement insurance plans and members can go to any provider that accepts medicare Does the OEP( Open enrollment period) allow for PDP changes? - ANSNo you cant make changes to PDP during the OEP Does UHC currently offer a MSA? - ANSno Extra help for customers with limited income and resources from Medicare to cover their part D premiums and Part D related OOP costs - ANSlow income subsidy For an HMO, they customer must us IN network providers, what are the exceptions to their rule? - ANSEmergencies, Urgent care, and renal dialysis services. for the coverage gap in a medicare drug coverage plan, who pays what? - ANSthe member pays most, and the plan pays a little
Generally, qualified individuals are passively enrolled into the state's coordinated care plan with the ability to opt-out and choose other medicare
- ANSoptions how does a customer qualify for extra help? - ANSthey receive both medicare and medicaid benefits, receive SSI and meet a certain income, and are a MSP participant( medicare savings program) How does MSA plans work? - ANSthe plan deposits money from emdicare in the account which can then be used to pay for medical expenses until their deductible is met How does the MTM program work? - ANSit helps physicians and members ensure their medications are working to help improve their health how many days does medicare allow before a customer accrues a penalty - ANS63 days How many tiers are there for medicare prescription drug coverage? - ANS How much is the yearly deductible for a medicare prescription drug coverage? - ANS$0-$ if a customer accrues a late penalty for not accepting medicare before the 63 day limit, the late enrollment penalty is added to what? - ANSthe monthly plan premium
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? - ANSyes. if the member is from a different carrier, the MOOP expense will NOT carry over to the new plans yearly deductible If a PCP is required and the customer does not indicate one on the enrollment application, a _____ will automatically assigned - ANSPCP In a HMO plan, does a member have to choose a PCP? and do they require referrals to see a specialist? - ANSYes in a MA-part D plan, A member will be disenrolled from their MA-PD upon enrollment in? - ANSa stand-alone PDP In a MA-Part D plan, A member will be disenrolled from their stand alone PDP upon enrollment in a? - ANSMA-PD In a Medicare prescription drug coverage plan, the member pays (all/some) of the yearly deductible? - ANSall- the plan pays nothing In a POS plan, does a member need a referral from their PCP to see a specialist? - ANSyes 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 _____? - ANSdoes not contribute
In catastrophic coverage, the member pays what? - ANSa small copay or coinsurance for drugs In catastrophic coverage, who pays what? - ANSThe member pays a little while the plan pays most in MA-only, a member will be disenrolled from their non-PFFS MA-only plan upon enrolling in a? - ANSStand alone PDP In order for a customer to obtain medicare part D, what must they have to do? - ANSthey 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? - ANSPart A and B in the coverage gap, member pays up to what percent of most brand named drugs - ANS25% In the coverage gap, the member pays what percent for generic drugs? - ANS37% 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? - ANS$3,
MA plans include some key features such as? - ANSPrescription drug coverage, PCPs and a OOP maxium MA plans integrate what type of additonal coverage? - ANSpart D prescription drug coverage MA plans with an OON component may or may not have an? - ANSOOP maximum for OON services depending on the plan Medicare - ANSFederal health insurance program Medicare is administered by whom? - ANSCMS ( Centers for medicare and medicaid services) Medicare part D is a state program or a federal program - ANSfederal program Medicare supplement insurance policies cannot be used in conjunction with what type of plan? - ANSMA 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 - ANSTrOOP most MA plans require a what? although not all plans require that the chosen____ cordinate the members care - ANSPCP selection
MSA? - ANSMedical savings account OEP? - ANSOpen enrollment period once a member with a MAP reaches the maximum OOP expenses, is there cost sharing for any additional services? - ANSno Only enroll a dual eligible customer into a PFFS plan if the customer insists on enrolling and disclose the potential impacts of - ANSenrolling Part A? - ANSHospital insurance Part B? - ANSMedical insurance Part C? - ANSMedicare Advantage Plans Parts A & B of medicare are - ANSfederal health insurance program referred to as original medicare PDP break down for 2019 - ANSAnnual deductible= $ Initial coverage- $ Coverage gap- $5, PFFS member responsibilities? - ANSthe 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
There are 4 stages to medicare part standard prescription drug coverage; what are they? - ANS1) yearly deductible
- initial coverage
- Coverage gap
- Catastrophic coverage Tier 1? - ANSMember pays lowest copayment and lower cost commonly used generic drugs are covered Tier 2? - ANSMember pays a low copayment, many generic drugs are covered Tier 4 - ANSMember pays copayment ( MA-PD) coinsurance (PDP) and non-preferred generic and non-preferred grand name drugs are covered Tier 5 - ANSMember pays coinsurance, and unique and or very high cost drugs are covered To avoid member complaints, encourage customers to select a ____and make sure the _____ is accepting new patients - ANSPCP To be enrolled in a MTM, a customer MUST - ANS1) have a chronic health condition
- member takes several different medications
- 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 - ANS1) member has more than one chronic health condition
- Member takes several different medications
- 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. 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? - ANSTrue out of pocket 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. - ANSif 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. TO qualify for low income subsidy on part D, the consumers income must be at or below - ANS150% of the FPL ( federal poverty level) UHC does not offer network-based ___ plans? - ANSPFFS
What does dual eligible customers mean? - ANShaving both medicare and medicaid What does MMP do? - ANSindividuals can receive both medicare parts A &B and full medicaid benefits through one health plan what does MMP stand for? - ANSMedicare-medicaid plan What doesnt medicare cover? - ANSroutine dental, eye care hearing exam,deductibles, coinsurance and copayments what happens when a customer is enrolled in a employee or union sponsored health plan and decides to enroll in a PDP? - ANSthe 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 What is a deemed provider - ANSmust participate in medicare and agree to the plans terms and conditions of payment What is a formulary drug list? - ANSA 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 What is a PDP? - ANSa stand alone medicare prescription drug plan What is a preferred pharmacy? - ANSA 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 stand alone drug plan called? - ANSPDP What is creditable coverage? - ANSits a prescription drug coverage that is expected to pay on average at least as much as medicare's standard prescription drug coverage what is deeming? - ANSa 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 is PFFS? - ANSPrivate Fee for Service (PFFS) - Plans that allow you to go to any doctor or hospital that accepts their terms What is strep up therapy? - ANSits 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
WHat type of stand alone variations to medicare can give extra benefits? - ANSA+B+D C+D What us a deemed provider? - ANSone 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 when a client enrolls in a MA plan, will it automatically terminate their MA plan? - ANSNO When a client enrolls in part D prescription drug coverage when they first become eligible, what is that time period often called? - ANSInitial enrollment period When a consumer has original medicare and a prescription drug plan, they can also have a medicare________ insurance plan - ANSmedicare supplement insurance plan When a customer is enrolled in a MA plan, they must continue paying their premiums for what other plan? - ANSPart B When a customer reaches the ____ They will pay 25% for most brand named drugs and 37% for generic drugs - ANScoverage gap
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? - ANSis counted towards his/her MOOP in the new MA plan IF:
- 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
- the new plan is a different type than the previous plan ( eg HMO to PPO) and both plans have the SAME legal entity When a member enrolls in a MA plan, they receive their coverage from medicare or the MA plan? - ANSMA plan 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_____? - ANSeffective date when does approved extra help begin? - ANSthe first day of the month the customer becomes eligible When OOP costs for the coverage gap reaches what amount, they will move onto the catastrophic coverage? - ANS$5, Who allows the PFFS plan to decide if balance billing is permitted? - ANSCMS. Plans must disclose what is permitted in the terms and conditions
