Medicare Specialist Coverage Planning Options Flashcards

A client wants to enroll in a Medicare Supplement plan but was diagnosed with diabetes 2 years ago. During what period can they enroll without being subject to medical underwriting?

Answer: During their Medigap Open Enrollment Period (6 months after Part B effective date)

The Medigap Open Enrollment Period is a 6-month window starting when the beneficiary is both 65+ and enrolled in Part B, during which insurers cannot use medical underwriting.

Under Medicare Part A, what is the benefit period and how does it affect cost-sharing?

Answer: A benefit period begins with hospitalization and ends after 60 consecutive days without inpatient care; the deductible applies once per period

A Part A benefit period begins on the day of hospital admission and ends when the beneficiary has been out of inpatient care for 60 consecutive days, with a new deductible required for each new period.

Which of the following best describes the Extra Help (Low Income Subsidy) program for Medicare Part D?

Answer: A federal program that helps eligible low-income beneficiaries pay Part D premiums, deductibles, and copays

Extra Help is a federal Social Security Administration program that reduces Part D costs including premiums, deductibles, and copays for Medicare beneficiaries with limited income and resources.

A Medicare beneficiary is considering a Medicare Advantage plan with a $0 premium. What costs should a specialist remind them to evaluate beyond the premium?

Answer: Copays, coinsurance, deductibles, network restrictions, and the plan's maximum out-of-pocket limit

A $0 premium does not mean $0 cost; beneficiaries must evaluate all cost-sharing elements including copays, coinsurance, out-of-pocket maximums, and whether their providers are in-network.

How does Medicare coordinate benefits when a beneficiary is covered by both Medicare and an employer group health plan from a small employer (fewer than 20 employees)?

Answer: Medicare is primary and the employer group health plan is secondary for small employers

For employers with fewer than 20 employees, Medicare is the primary payer and the employer group health plan pays secondary, unlike large employers where the group plan pays first.

What is the purpose of the Medicare Annual Notice of Change (ANOC) that Medicare Advantage and Part D plans must send?

Answer: To inform enrollees of changes to plan costs, benefits, or formulary for the upcoming year

Plans must mail the ANOC by September 30 each year to allow enrollees time to review upcoming plan changes and decide whether to make changes during the AEP.

A client's physician does not accept Medicare assignment. Under Original Medicare, what is the maximum amount above the Medicare-approved amount the physician can legally charge?

Answer: 10% above the Medicare-approved amount (limiting charge)

Non-participating providers who have not opted out of Medicare are subject to the Medicare limiting charge, which caps their fee at 115% of the non-participating fee schedule (approximately 109.25% of the Medicare-approved amount), never exceeding 15% above the approved amount.