AHIP Medicare Advantage (Part C) 2 — Questions and Answers
Question 1: To enroll in a Medicare Advantage plan, a beneficiary must:
- Have only Part A
- Have both Part A and Part B and live in the plan's service area (Correct answer)
- Have Part B only
- Be enrolled in a Medigap plan
Correct answer: Have both Part A and Part B and live in the plan's service area
Beneficiaries must be enrolled in both Medicare Part A and Part B and reside in the plan's service area to join a Medicare Advantage plan.
Question 2: What is the Medicare Advantage Open Enrollment Period (MA OEP)?
- October 15 – December 7
- January 1 – March 31 (Correct answer)
- April 1 – June 30
- July 1 – September 30
Correct answer: January 1 – March 31
The MA OEP runs January 1–March 31, allowing current MA enrollees to switch plans or return to Original Medicare once.
Question 3: Risk adjustment in Medicare Advantage is used to:
- Penalize plans with unhealthy members
- Adjust payments based on enrollees' health status and diagnoses (Correct answer)
- Set uniform premiums across all plans
- Limit enrollment to healthy beneficiaries
Correct answer: Adjust payments based on enrollees' health status and diagnoses
Risk adjustment ensures MA plans receive higher payments for sicker enrollees, compensating for higher expected costs.
Question 4: Which star rating system does CMS use to evaluate Medicare Advantage plan quality?
- 1–5 star scale (Correct answer)
- A–F letter grades
- Bronze/Silver/Gold tiers
- Tier 1–4 ranking
Correct answer: 1–5 star scale
CMS rates MA plans on a 1 to 5 star scale, where 5 stars represents the highest quality.
Question 5: What happens to a beneficiary's Original Medicare coverage when they enroll in a Medicare Advantage plan?
- It is permanently terminated
- It is suspended but retained; the MA plan provides benefits instead (Correct answer)
- It remains fully active alongside the MA plan
- It converts to Medicaid automatically
Correct answer: It is suspended but retained; the MA plan provides benefits instead
Enrollees keep their Medicare Parts A and B entitlement, but the MA plan provides and administers their benefits instead of Original Medicare.
Question 6: A Medicare Advantage PFFS (Private Fee-for-Service) plan is characterized by:
- Strict network requirements and mandatory referrals
- Setting its own payment rates; any provider who accepts the terms can treat the member (Correct answer)
- Coverage only for preventive services
- Requiring enrollment in a Part D drug plan
Correct answer: Setting its own payment rates; any provider who accepts the terms can treat the member
PFFS plans set their own reimbursement rates and terms; any Medicare-participating provider who accepts those terms may provide care.
AHIP Medicare Advantage (Part C) 2
To enroll in a Medicare Advantage plan, a beneficiary must: