UHC CERTIFICATION ACTUAL EXAM 300 QUESTIONS AND
CORRECT ANSWERS 2023-2024 UPDATE ALREADY A GRADED
WITH EXPERT FEEDBACK
1. If you conduct an educational event and invite a provider or vendor to be a part of the event,
the provider/vendor must not do which of the following?
Answer: Provide free health screenings such as blood pressure checks or hearing tests as a
marketing activity
2. Agent John Rogers is planning a formal marketing/sales event and has decided to place an
advertisement in the local paper. What disclaimers must John include in the advertisement?
Answer: "For accommodation of persons with special needs at sales meetings, call 555-5551234, TTY 711."
3. Janine is conducting a marketing/sales event in a senior center cafeteria. The cafeteria
generally provides a dinner meal from 5pm to 6pm. Can Janine conduct her marketing/sales
meeting in the cafeteria between 5pm and 6pm?
Answer: No, she can conduct an event that ends no later than 5pm or wait until after 6pm.
4. Agent Rita Garcia must not do which of the following while conducting a marketing/sales
event?
Answer: State the plan she is presenting is the best plan on the market.
5. At a formal marketing/sales event, an agent presented information about prescription drug
coverage. Which statement is not accurate?
Answer: Members and providers are not able to ask the plan for exceptions to any utilization
management rules
6. At an informal marketing/sales event, which of the following activities is not permitted?
Answer: Approaching consumers as they pass by your booth/kiosk/table
7. Agent Santana has developed a relationship with Dr. Westberry, a Primary Care Provider
contracted with several Medicare Advantage Plans. Dr. Westberry is asked to attend a formal
marketing/sales event conducted by Agent Santana. Which of Dr. Westberry's actions is noncompliant?
Answer: Offers blood pressure screenings as consumers wait for the event to begin
8. Which of the following best describes the purpose of event observation?
Answer: An oversight activity where an individual evaluates an event as a means to ensure the
information provided by the agent was accurate and compliant.
9. Which of the following statements describes compliant activity during a formal
marketing/sales event?
Answer: Not one plan fits all
10. Which of the following statements is true about conducting a formal marketing/sales event in
a conference room inside a UnitedHealthcare Medicare Store?
Answer: All rules relating to formal marketing/sales events apply including event reporting and
providing a complete plan presentation.
11. When must an agent inform the consumer of the availability of no-cost interpreter services?
Answer: Whenever the agent is presenting a Medicare Advantage or Prescription Drug Plan.
12. Which of the following statements is true about eligibility requirements for Medicare
Prescription Drug Plans?
a. Consumers must live in the same zip code as the pharmacy they intend to use
b. A consumer must be entitled to Medicare Part A and/or enrolled in Medicare Part B
c. A consumer must receive a pension from a former employer
d. Consumers do not need to live in the plan's service area
Answer: A consumer must be entitled to Medicare Part A and/or enrolled in Medicare Part B
13. Aside from a stand-alone Medicare Prescription Drug Plan, how else could a Medicare
eligible consumer get Part D prescription drug coverage?
a. They could sign up for a pharmacy savings card through their local pharmacy.
b. There is no other way a Medicare consumer could get Part D prescription drug coverage.
c. They could enroll in a Medicare Supplement Insurance Plan.
d. They could enroll in a Medicare Advantage Plan or other Medicare health plan that includes
prescription drug coverage.
Answer: They could enroll in a Medicare Advantage Plan or other Medicare health plan that
includes prescription drug coverage.
14. Which of the following statements does not correctly define prescription drug stages?
a. The catastrophic coverage stage is when the member will only pay a small coinsurance or
copayment for covered drugs for the remainder of the plan year.
b. Initial coverage is the stage when the plan pays part and the member pays part, usually as
coinsurance or copayments.
c. A deductible is the amount the member must pay for every prescription medication, regardless
of what stage they are in.
d. The coverage gap ends when the member has spent $6,550 (in 2021) in out-of-pocket
expenses for the plan year.
Answer: A deductible is the amount the member must pay for every prescription medication,
regardless of what stage they are in.
15. Which of the following options are drug utilization management (UM) rules? (Select 3
Answer: Quantity Limit
Prior Authorization
Step Therapy
16. A consumer may have to pay a Late Enrollment Penalty (LEP) if they did not enroll in a
Medicare Advantage plan with Part D benefits or stand-alone prescription drug plan when they
were first eligible for Medicare Parts A and/or B or went without creditable prescription drug
coverage for
Answer: 63 continuous days or more
17. Through which means is financial assistance offered to a consumer who qualifies for Low
Income Subsidy for their part of Medicare Part D costs?
a. Through a combination of subsidies and annual refund checks
b. Through subsidies such as lower or no monthly plan premiums and lower or no copayments
c. Such financial assistance will no longer be available as of January 1, 2020
d. By receiving annual checks with a refund based on a predetermined percentage of Part D costs
Answer: Through subsidies such as lower or no monthly plan premiums and lower or no
copayments
18. Which of the following consumers would be eligible for Medicare?
Answer: Consumers age 65 or older, consumers under 65 years of age with certain disabilities
for more than 24 months and consumers of all ages with ESRD or ALS
19. Which of the following defines a Medicare Advantage (MA) Plan?
Answer: MA Plans are health plan options approved by Medicare and offered by private
insurance companies.
20. Janice wants to enroll in a 2021 Medicare Advantage plan. What eligibility requirements
must she meet? (Select the two answers that apply.)
Answer: Not have End Stage Renal Disease (permanent kidney failure) Reside in the plan's
service area
21. What must be explained to consumers enrolling in an HMO (Health Maintenance
Organization) MA Plan? (Select 3)
Answer: 1. The need for referrals for specialist care.
2. Network limitations.
3. Emergency and urgent care coverage.
22. Which of the following are MA Plans that focus on using network providers to maximize the
benefits and reduce out-of-network expenses?
Answer: HMO, POS, PPO
23. Which is true about Medicare Supplement Open Enrollment?
Answer: By federal law, Medicare Supplement Open Enrollment is the first 6 months a
consumer is 65 or older and enrolled in Medicare Part B.
24. How does the Medicare Advantage Out-of-Pocket (OOP) maximum work?
Answer: The OOP maximum is a feature that limits the amount of money a consumer will have
to spend on Medicare-covered health care services each year.
25. A consumer currently has Original Medicare and is enrolled in a stand-alone Prescription
Drug Plan (PDP). What will happen if the consumer enrolls in an MA Plan that has integrated
prescription drug coverage?
Answer: The consumer will be automatically disenrolled from their stand-alone PDP upon
enrollment in the MA Plan that has integrated prescription drug coverage
26. A government program, offered only through a private insurance company or other private
company approved by Medicare, that provides prescription drug coverage describes which of the
following:
Answer: Medicare Parts A and B
27. Which of the following statements is true about eligibility requirements for Medicare
Prescription Drug Plans?
Answer: A consumer must be entitled to Medicare Part A and/or enrolled in Medicare Part B
28. Which of the following statements is not true about the Coverage Gap?
Answer: All members reach the Coverage Gap
29. Which of the following best describes the Late Enrollment Penalty (LEP)?
Answer: The amount added to the member's monthly plan premium if they did not enroll in a
Medicare Advantage plan with Part D benefits or stand-alone prescription drug plan when they
were first eligible for Medicare Parts A and/or B or went without creditable prescription drug
coverage for 63 continuous days or more.
30. Through which means is financial assistance offered to a consumer who qualifies for Low
Income Subsidy for their part of Medicare Part D costs?
Answer: Through subsidies such as lower or no monthly plan premiums and lower or no
copayments
31. Medications that are covered in a Plan's formulary have various levels of associated member
cost-sharing (copayments or coinsurance). What are these drug levels called?
Answer: Drug tiers
32. In states where Medicare Supplement Insurance underwriting criteria can apply, all of the
following underwriting criteria apply EXCEPT:
Answer: Consumers may be underwritten to determine their acceptance and, if applicable, their
rate.
33.The new MACRA legislation, which went into effect January 1, 2020, applies to all carriers
offering Medicare supplement plans.
Answer: TRUE
34. Which of the following is NOT true of Medicare Supplement Insurance Plans?
Answer: Plan benefit amounts automatically update when Medicare changes cost sharing
amounts, such as deductibles, coinsurance and copayments. NOT
35. Which definition best describes Medicare Part A?
a. The part of Medicare that is a voluntary program offered by private insurance companies that
provides prescription drug coverage for an additional monthly premium.
b. The part of Medicare that offers combined medical and prescription drug coverage.
c. The part of Medicare that helps with the cost of inpatient hospital stays. It also helps with
hospice care and some skilled care for the homebound.
d. The part of Medicare that helps with the cost of medically necessary doctor visits and other
medical services, including outpatient care at hospitals and clinics, laboratory tests, some
diagnostic screenings.
Answer: c. The part of Medicare that helps with the cost of inpatient hospital stays. It also helps
with hospice care and some skilled care for the homebound.
36. Which statement is true about a member of a Medicare Advantage (MA) Plan who wants to
enroll in a Medicare Supplement Insurance Plan?
a. When a consumer enrolls in a Medicare Supplement Insurance Plan, he/she is automatically
disenrolled from his/her MA Plan.
b. A member does not need a valid election period to disenroll from an MA plan.
c. When a consumer enrolls in a Medicare Supplement Insurance Plan, he/she is not
automatically disenrolled from his/her MA Plan.
d. A consumer can use a Medicare Supplement Insurance Plan and an MA Plan at the same time.
Answer: When a consumer enrolls in a Medicare Supplement Insurance Plan, he/she is
automatically disenrolled from his/her MA Plan.
37. Being 65 or older, being under 65 years of age with certain disabilities for more than 24
months, and being any age with ESRD or ALS are each eligibility requirements for which
program?
a. Medicaid
b. Original Medicare
c. Low Income Subsidy
Answer: Original Medicare
38. To be eligible for this plan type, consumers must meet the following requirements:- Entitled
to Medicare Part A and enrolled in Part B - Reside in the plan's service area Which plan is being
described?
a. Medicare Advantage
b. Prescription Drug
c. Medicaid
d. Original Medicare
Answer: Medicare Advantage
39. What must be explained to consumers enrolling in an HMO (Health Maintenance
Organization) MA Plan? (Select 3)
a. They must see contracted network providers in order to receive coverage under the plan.
b. In most cases, they will pay the entire cost of the service if they see an out-of-network
provider.
c. Most benefits are covered out-of-network but at a higher cost.
d. The exception to the provider network requirement is emergency visits, urgent care and renal
dialysis services, which can be obtained from out-of-network providers.
Answer: a. They must see contracted network providers in order to receive coverage under the
plan.
b. In most cases, they will pay the entire cost of the service if they see an out-of-network
provider.
d. The exception to the provider network requirement is emergency visits, urgent care and renal
dialysis services, which can be obtained from out-of-network providers.
40. What must be explained to consumers enrolling in an HMO (Health Maintenance
Organization) MA Plan? (Select 3)
a. They must see contracted network providers in order to receive coverage under the plan.
b. In most cases, they will pay the entire cost of the service if they see an out-of-network
provider.
c. Most benefits are covered out-of-network but at a higher cost.
d. The exception to the provider network requirement is emergency visits, urgent care and renal
dialysis services, which can be obtained from out-of-network providers.
Answer: a. In most cases, they will pay the entire cost of the service if they see an out ofnetwork provider.
c. Most benefits are covered out-of-network but at a higher cost.
d. The exception to the provider network requirement is emergency visits, urgent care and renal
dialysis services, which can be obtained from out-of-network providers.
41. When does Medicare Supplement Open Enrollment take place?
a. During the three months prior to the consumer's 65th birthday, the month of their birthday, and
the three months following the month of their 65th birthday and enrolled in Medicare Part B.
b. During the first six months a consumer is 65 or older and enrolled in Medicare Part B.
c. Annually from October 15 to December 7.
d. During the first three months a consumer is 65 or older and enrolled in Medicare Part B.
Answer: d. During the first six months a consumer is 65 or older and enrolled in Medicare Part
B.
42. How does the Medicare Advantage Out-of-Pocket (OOP) maximum work?
a. The OOP maximum is a feature that limits the amount of money a consumer will have to
spend on Medicare-covered health care services each year.
b. The OOP maximum is a feature that limits the amount of money a consumer will have to
spend on all health care services each year.
c. The OOP maximum is a feature that limits the amount of money a consumer will have to
spend on prescription drugs and plan premiums each year.
Answer: a. The OOP maximum is a feature that limits the amount of money a consumer will
have to spend on Medicare-covered health care services each year.
43. Which of the following statements is true about a Medicare Supplement Insurance Plan
member who wants to enroll in an MA Plan?
a. Medicare Supplement Insurance cannot be used in conjunction with an MA Plan; therefore,
after receiving confirmation of enrollment into the MA Plan, the member should submit to their
Medicare Supplement Insurance carrier a written request to cancel his/her policy.
b. When a member enrolls in the MA Plan their current Medicare Supplement Insurance Plan
will automatically cancel.
c. The member must submit a written request to cancel their Medicare Supplement Insurance
Plan the same day they submit their MA Plan enrollment application.
d. The member should not cancel their Medicare Supplement Insurance Plan because Medicare
Supplement Insurance can be used in conjunction with an MA Plan.
Answer: a. Medicare Supplement Insurance cannot be used in conjunction with an MA Plan;
therefore, after receiving confirmation of enrollment into the MA Plan, the member should
submit to their Medicare Supplement Insurance carrier a written request to cancel his/her policy.
44. Which of the following best defines Medicare Part D?
a. It is a government program, offered only through a private insurance company or other private
company approved by Medicare, which provides hospitalization coverage.
b. It is a government program, offered only through a private insurance company or other private
company approved by Medicare, which provides prescription drug coverage.
c. It is a government program, offered only through a private insurance company or other private
company approved by Medicare, which provides medical and hospitalization coverage.
d. It is a government program, offered only through a private insurance company or other private
company approved by Medicare, which provides medical coverage.
Answer: b. It is a government program, offered only through a private insurance company or
other private company approved by Medicare, which provides prescription drug coverage.
45. Medications that are covered in a Plan's formulary have various levels of associated member
cost-sharing (copayments or coinsurance). What are these drug levels called?
Answer: Drug tiers
46. Which of the following is true about Medicare Supplement Insurance underwriting criteria in
states where underwriting applies?
a. Underwriting is required if the consumer is not in his/her Medicare Supplement Open
b. Enrollment period or does not meet Guaranteed Issue criteria.
c. Consumers will never be underwritten to determine their rate.
d. If the consumer meets Guaranteed Issue criteria, he/she may be underwritten to determine
his/her rate.
e. During Medicare Supplement Open Enrollment, consumers will only be required to answer the
underwriting eligibility questions.
Answer: a. Underwriting is required if the consumer is not in his/her Medicare Supplement
Open Enrollment period or does not meet Guaranteed Issue criteria.
47. Which of the following is NOT true about the Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA) impact to Plans C and F?
a. Consumers eligible for Medicare Part A on or after January 1, 2020, will not be able to
purchase Medicare Supplement Insurance Plans C or F.
b. Consumers already enrolled in Plans C or F are required to change plans.
c. Consumers eligible for Medicare Part A before January 1, 2020, can enroll in Plan C or F even
after 2020 and can keep their plans as long as they choose.
Answer: b. Consumers already enrolled in Plans C or F are required to change plans.
48. Which of the following is true about Medicare Supplement Insurance Plans?
a. They are regulated by the Centers for Medicare & Medicaid Services (CMS).
b. Plan benefit amounts automatically update when Medicare changes cost sharing amounts, such
as deductibles, coinsurance and copayments.
c. To see a specialist, insured members must obtain referrals from a primary care physician.
d. They can only be purchased during the Annual Election Period (AEP).
Answer: b. Plan benefit amounts automatically update when Medicare changes cost sharing
amounts, such as deductibles, coinsurance and copayments.
49. Lisa turned 65 and is now eligible for Medicare. She already receives Social Security
benefits. How does she enroll in Original Medicare?
Answer: Her enrollment in Medicare Parts A and B is generally automatic if she meets all
eligibility requirements.
50. Which statement is true about a member of a Medicare Advantage (MA) Plan who wants to
enroll in a Medicare Supplement Insurance Plan?
Answer: When a consumer enrolls in a Medicare Supplement Insurance Plan, they are not
automatically disenrolled from their MA Plan.
51. Being 65 or older, being under 65 years of age with certain disabilities for more than 24
months, and being any age with ESRD or ALS are each eligibility requirements for which
program?
Answer: Original Medicare
52. Which of the following defines a Medicare Advantage (MA) Plan? (Select 2)
Answer: 1. MA Plans must provide benefits equivalent to Original Medicare, and most plans
also offer additional benefits.
2. MA Plans provide Medicare hospital and medical insurance and often include Medicare
prescription drug coverage.
53. Which of the following is NOT an eligibility requirement for enrollment in a Medicare
Advantage Plan?
Answer: Does not have any pre-existing conditions such as diabetes or End Stage Renal Disease
(ESRD)
54. Which of the following statements is correct about HMO MA Plans?
Answer: Members must receive covered services from contracted network providers with
limited exceptions.
55. Which of the following is NOT a correct statement about in-network provider services?
Answer: (INCORRECT) Network-based MA plans have a provider network the member can
use, and some plans also cover certain services outside the network.
56. What is true about Medicare supplement open enrollment?
Answer: A consumer who waits to enroll in Medicare Part B until age 66 or older cannot qualify
for Medicare Supplement Open Enrollment.
It is the only time a consumer is eligible to purchase a Medicare Supplement Insurance Plan.
57. Jennifer is enrolling into a Medicare Advantage (MA) plan and wants to know what counts
toward the Out-of-Pocket Maximum. Which of the following is accurate?
Answer: The Out-of-Pocket Maximum will include her costs toward any Medicare covered Part
A or B services.
58. Which of the following statements is true about a Medicare Supplement Insurance Plan
member who wants to enroll in an MA Plan?
Answer: Medicare Supplement Insurance cannot be used in conjunction with an MA Plan;
therefore, after receiving confirmation of enrollment into the MA Plan, the member must cancel
their Medicare Supplement Insurance policy according to their carrier's rules.
59. Which of the following best defines Medicare Part D?
Answer: It is a government program, offered only through a private insurance company or other
private company approved by Medicare, which provides prescription drug coverage.
60. Which of the following is a fact about Medicare Prescription Drug Plans?
Answer: To enroll, member must be in plans service area
61. What are two options for Medicare consumers to get Part D prescription drug coverage
(assuming they meet all eligibility requirements)? (Select 2)
Answer: Enroll in a stand-alone Medicare Prescription Drug Plan (PDP)
Enroll in a Medicare Advantage Plan or other Medicare health plan that includes prescription
drug coverage
62. Which of the following statements does NOT correctly define prescription drug stages?
Answer: A deductible is the amount the member must pay for every prescription medication,
regardless of what stage they are in.
63. Which of these statements is NOT true about the drug utilization management (UM) rules?
Answer: (INCORRECT) Prior authorization, quantity limit, and step therapy are some examples
of UM rules
64. What is the amount added to the member's monthly plan premium if they did NOT enroll in a
Medicare Advantage plan with Part D benefits or stand-alone prescription drug plan when they
were first eligible for Medicare Parts A and/or B or went without creditable prescription drug
coverage for 63 or more continuous days?
Answer: Late Enrollment Penalty (LEP)
65. Can a consumer who qualifies for Low Income Subsidy receive financial assistance for their
part of Medicare Part D costs?
Answer: Yes, through subsidies such as lower or no monthly plan premiums and lower or no
copayments
66. Formulary is defined as:
Answer: A list of medications covered within the benefit plan, based on CMS guidelines and
developed in collaboration with physicians and pharmacists.
67. Which of the following is true about Medicare Supplement Insurance underwriting criteria in
states where underwriting applies?
Answer: Underwriting is required if the consumer is not in their Medicare Supplement Open
Enrollment period or does not meet Guaranteed Issue criteria.
68. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which went into
effect January 1, 2020, applies to all carriers offering Medicare supplement plans.
Answer: True
69. Which of the following is NOT true of Medicare Supplement Insurance Plans?
Answer: (INCORRECT) Plan benefit amounts automatically update when Medicare changes
cost sharing amounts, such as deductibles, coinsurance and copayments.
70. Which of the following consumers are eligible for Medicare if other eligibility requirements
are met?
Answer: Consumers age 65 or older, consumers under 65 years of age with certain disabilities
for more than 24 months and consumers of all ages with ESRD or ALS
71. Which of the following defines a Medicare Advantage (MA) Plan? (Select 3)
Answer: An MA Plan is a health plan option approved by Medicare and offered by private
insurance companies.
An MA Plan provides Medicare hospital and medical insurance (Medicare Part A and Part B) and
often includes Medicare prescription drug coverage (Part D).
An MA Plan is part of Medicare and is also called Part C.
72. Janice wants to enroll in a Medicare Advantage plan. Which of the following is NOT an
eligibility requirement?
Answer: Does not have any pre-existing conditions, such as diabetes or End Stage Renal
Disease (ESRD)
73. Which of the following are MA Plans that focus on using network providers to maximize the
benefits and reduce out-of-network expenses?
Answer: HMO, POS, PPO
74. Margaret currently has an MAPD Plan. What would happen if you enrolled her into a standalone PDP?
Answer: She would be disenrolled automatically from her MAPD Plan.
75. What is Medicare Part D?
Answer: A voluntary program, offered by private insurance companies that are contracted with
the federal government, that provides prescription drug coverage for an additional monthly plan
premium
76. Which of the following statements is true about eligibility requirements for stand-alone
Medicare Prescription Drug Plans?
Answer: A consumer must be entitled to Medicare Part A and/or enrolled in Medicare Part B
77. Aside from a Medicare Advantage Plan or other health plan that includes prescription drug
coverage, how else could a Medicare-eligible consumer get Part D prescription drug coverage?
Answer: They could enroll in a stand-alone Medicare Prescription Drug Plan (PDP).
78.In what order do the four prescription drug coverage stages occur?
Answer: Deductible, Initial Coverage, Coverage Gap, Catastrophic Coverage
79. Step Therapy, Prior Authorization, Quantity Limit, 7-day limit, Dispensing Limit and Limited
Access are all examples of what?
Answer: Utilization Management Rules
80. A consumer may have to pay a Late Enrollment Penalty (LEP) if they did NOT enroll in a
Medicare Advantage plan with Part D benefits or stand-alone prescription drug plan when they
were first eligible for Medicare Parts A and/or B or went without creditable prescription drug
coverage for ______________.
Answer: 63 or more continuous days
81. Through which means is financial assistance offered to a consumer who qualifies for Low
Income Subsidy for their part of Medicare Part D costs?
Answer: Through subsidies such as lower or no monthly plan premiums and lower or no
copayments
82. Which of the following lists drug tiers from least expensive cost share to most expensive cost
share?
Answer: Preferred Generics, Generics, Preferred Brand (and some higher-cost generics), NonPreferred Drug (and some higher-cost generics), Specialty
83. Which of the following is NOT true about the Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA) impact to Plans C and F?
Answer: Consumers already enrolled in Plans C or F are required to change plans.
84. Which statement is true about medicare supplements?
Answer: Insured members have the freedom to choose any doctor who accepts Medicare
patients.
85. Cynthia is turning 65 on July 5. Her Medicare Part A and Part B will be effective on July 1.
Using her Initial Election Period (IEP), when can she submit an application for a Medicare
Advantage or Prescription Drug plan?
Answer: April 1 through October 31
86. Annual Election Period (AEP) is a time when . . .
Answer: Consumers can elect to switch to a different plan or join a Medicare Advantage plan or
Prescription Drug Plan.
87. Mrs. Violet asks agent Bob where she can find the Star Rating for the plan he has been
presenting. Which statement is correct?
Answer: Mrs. Violet can access the Star Rating for a plan on Medicare.gov or in the Enrollment
Guide.
88. In which of the following situations can telephonic contact be made with a Medicare eligible
consumer?
Answer: When the consumer consented to be contacted for sales activities and the permission
has not yet expired.
89. Which statement is true about discussing benefits with the consumer before an enrollment?
Answer: The agent must accurately and completely disclose any benefits discussed.
90. When completing an enrollment application in LEAN, why is an agent prohibited from
entering his or her own email address in a field available for the consumer's email address?
Answer: The consumer/member would not receive plan related correspondence intended for
him/her.
91. The __________ ensures that when consumers provide their verbal agreement during the
telephonic enrollment, they acknowledge and understand they are actually enrolling, in which
plan they are enrolling, as well as the standard disclosures.
Answer: Statement of Understanding
92. What is Scope of Appointment?
Answer: The agreement obtained from the consumer to that identifies the scope of products that
can be discussed at a personal/individual marketing appointment
93. Jane, an agent, is speaking to Albert about a Prescription Drug plan. Albert seems confused
and is struggling to understand the information Jane is explaining. Which option should Jane
consider?
Answer: Jane should ask Albert if someone, such as an Authorized Legal Representative, helps
him make health care or insurance-related decisions and should be present.
94. Melanie is currently enrolled in a Medicare Supplement Insurance Plan and a PDP. Assuming
she has a valid election period, what would happen if she enrolled in an HMO MAPD plan?
Answer: (INCORRECT) She would be automatically disenrolled from the Medicare Supplement
Insurance Plan and the PDP.
95. Medicare Advantage (MA) organization must disenroll a member from an MA plan in which
situation?
Answer: The member loses entitlement to either Medicare Part A or Part B.
96. Aries is currently a member of a stand-alone PDP. Aries would like to have additional
medical coverage. A thorough needs analysis indicates a Medicare Advantage Plan would be a
good fit, there are plans available in his area, and he is in a valid election period. Which option is
available to Aries?
Answer: Aries can enroll into a Medicare Advantage plan with prescription drug coverage,
which will disenroll him from his PDP.
97. In what product should agents enroll consumers?
Answer: A product that is suitable for the consumer's needs, goals and financial resources.
98. Dino, an agent, received a phone call on September 29 from a consumer interested in
Medicare Advantage plans for the new plan year. Dino proceeded to verify the consumer's
Medicare eligibility, describe the costs and benefit coverage of the plan, and explained that he
could not accept an enrollment application until October 15. What did Dino do that was NOT
compliant?
Answer: Presented a plan before October 1
99. Which of the following is NOT true about UnitedHealthcare Medicare plans carrying the
AARP name?
Answer: AARP endorses UnitedHealthcare MA, PDP and Medicare Supplement plans.
100. AARP expects agents offering AARP-branded products to demonstrate five key behaviors
when interacting with customers. AARP wants customers we work with to feel their relationship
with AARP is _____________.
Answer: Effortless and inspiring
101. Which of the following are part of being straightforward when servicing a customer? (Select
3)
Answer: Being upfront about what information means.
Communicating clearly to alleviate any confusion.
Providing the right information.
102. Do consumers have to be an AARP member to enroll in an AARP-branded plan with
UnitedHealthcare?
Answer: Yes, if the consumer is enrolling in a Medicare Supplement Plan.
103. How many status levels are in the Authorized to Offer Program?
Answer: 2
104. According to AARP, there are how many individual AARP members?
Answer: Nearly 37 million
105. Which of the following statements about AARP are TRUE? (Select 2)
Answer: The AARP motto is to serve, not be served.
AARP advocates for the 50+ population in congress for legislation to lower medical costs.
106. Which of the following is TRUE about the production requirement for the Authorized to
Offer Elite status?
Answer: Each calendar year, agents need to have at least 30 commission-eligible, accepted, and
paid AARP Medicare Supplement Plan and/or Medicare Select Plan sales or retain a book of
business of 150 or more active members.
107. The value proposition for the AARP brand is seen in what kinds of benefits for the
members? (Select 3)
Answer: 1. Discounts on insurance products.
2. Access to financial tools and resources.
3. Exclusive member benefits and savings on travel, dining, and entertainment.
108. Which AARP-branded Medicare products does UnitedHealthcare offer? (Select 3)
Answer: MA, PDP, Supplements
109. Dual Special Needs Plans (D-SNP) are defined as which of the following:
Answer: Medicare Advantage Plans uniquely designed for consumers enrolled in both Medicare
and Medicaid.
110. When does the Special Election Period for Dual/LIS Change in Status begin for D-SNP
members that lose Medicaid eligibility?
Answer: Upon notification or effective date of the loss, whichever is earlier
111. Which consumer might benefit the most by enrolling in a D-SNP?
Answer: Joe, who receives Qualified Medicaid Beneficiary benefits (QMB+)
112. Which statement best describes a care management program that varies depending upon the
level of the member's health risk?
Answer: Support provided to C-SNP and D-SNP members that may have unique health care
needs
113. Select the statement that best describes a feature of D-SNPs.
Answer: D-SNPs are network-based
114. When selling D-SNPs, agents must:
Answer: Confirm the consumer's Medicaid level and that the consumer is entitled to Medicare
Part A and enrolled in Part B
115. Which consumer may be a good candidate for a D-SNP?
Answer: Anne, who does not pay a percentage of charges when she receives medical care
116. The following is a characteristic of consumers for whom a C-SNP may be most appropriate:
Answer: Consumers who have a qualifying chronic condition, are focused on their health issues
and may have concerns with having to manage their illness or dealing with multiple providers
117. On July 19, each of the following consumers met with an agent. Based on the information
provided, which consumer must wait until the Annual Election Period (AEP) or Open Enrollment
Period (OEP) to enroll?
Answer: Joy has a cardiovascular disorder, is enrolled in a C-SNP that covers the condition, and
wants to enroll in another CSNP offered by the plan that covers the same condition.
118. Which service will a C-SNP or D-SNP member in the high risk care management category
receive?
Answer: Case Management (telephonic, digital and/or face-to face) according to individual
needs
119. Which statement is true about provider information on the Chronic Condition Verification
Form?
Answer: The provider indicated on the form does not have to be contracted with the plan.
120. Which statement is true about the Medicaid program?
Answer: Benefits vary from state to state.
121. Which statement is true of D-SNP members?
Answer: Members who are QMB+ or are Full Dual-Eligible are not required to pay copayments
for Medicare-covered services obtained from a D-SNP in-network provider. Their provider
should bill the state Medicaid program, as appropriate, for these costs.
122. How long do plans using the C-SNP pre-enrollment verification process have to verify the
qualifying chronic condition until they must deny the enrollment request?
Answer: Within 21 days of the request for additional information or the end of the month in
which the enrollment request is made (whichever is longer).
123. Lucille is no longer eligible for her state Medicaid program and has lost her eligibility for
the D-SNP in which she is enrolled. What is her responsibility for cost sharing?
Answer: All, such as premiums, deductibles, copayments, and coinsurance
124. What type of event must an agent conduct when they want to be able to collect consumer
information, schedule future appointments, and accept enrollment applications?
Answer: Marketing/sales event
125. Which of the following does not describe a personal/individual marketing appointment?
Answer: It needs to be reported to UnitedHealthcare prior to advertising and not less than 7
calendar days prior to the date of the event
126. When conducting an event, agents should select a site that is compliant with the Americans
with Disabilities Act (ADA). Which of the following is not an ADA requirement?
Answer: Extra-wide sidewalks that accommodate wheelchairs
127. Which of the following elements does not need to be entered on the NEW Event Request
Form when reporting a new event?
Answer: The event venue manager/contact person
128. Jeff has an informal marketing/sales event scheduled this afternoon, but a consumer has
requested an in-home appointment during that time. He would like to cancel or reschedule the
event because he is certain to get an enrollment application at the appointment. Which of the
statements below is correct about Jeff's event?
Answer: Jeff is prohibited from canceling the event because it is within 1 business day and is not
due to inclement weather. Jeff must hold his event or he could work with his manager to get a
replacement to conduct the event.
129. On October 1, Sam reported the formal marketing/sales event he has scheduled for 9
a.m. on November 19. Luckily, before he had flyers printed, he remembered he has an 8 a.m.
dentist appointment November 19. Just to make sure he can get to his event on time, he
advertises the event to start at 9:30 a.m. What event reporting infraction(s) might Sam incur?
Answer: None, Sam reported the event prior to advertising and not less than 7 calendar days
prior to the date of the event
130. Marcus is planning an educational event and has decided to place an advertisement in the
local paper. What must the advertisement include?
Answer: A statement that makes it clear that the event is for educational purposes only.
131. Which of the following food and beverage options may be provided at an educational event
if the nominal retail value of the items when combined with other giveaways does not exceed
$15 per person? (Select 2)
Answer: Coffee, juice, fresh fruit, and pastries
132. Boxed lunch with assorted non-alcoholic beverages Medicare
Answer: Federal health insurance program
133. Medicare is administered by whom?
Answer: CMS (Centers for medicare and medicaid services)
134. Parts A & B of medicare are
Answer: federal health insurance program referred to as original medicare
135. Part A?
Answer: Hospital insurance
136. Part B?
Answer: Medical insurance
137. What doesn’t medicare cover?
Answer: routine dental, eye care hearing exam, deductibles, coinsurance and copayments
138. Part C?
Answer: Medicare Advantage Plans
139. MA covers?
Answer: Part A &B coverage, and some part D coverage
140. MA plans are not?
Answer: Medicare supplement insurance plans
141. What offers lower monthly premiums MADP or supplement?
Answer: MADP
142. Do MAP's have an annual maximum OOP maximum that limits the amount of money a
member must spend every year for covered services?
Answer: YES
143. MA plans integrate what type of additional coverage?
Answer: part D prescription drug coverage
144. If a customer wants to keep their standalone prescription drug plan, what may the customer
want to enroll in?
Answer: MA-only PFFS plan
145. What is a standalone drug plan called?
Answer: PDP
146. WHAT is PFFS?
Answer: Private Fee for Service (PFFS) - Plans that allow you to go to any doctor or hospital
that accepts their terms
147. If a customer lives in a rural area, what type of plan may they want because it gives them
freedom to access doctors that may not be in their network?
Answer: PFFS plan
148. Do HMO's require referals?
Answer: Yes
149. Do PPO's require a referal?
Answer: No
150. When a member enrolls in a MA plan, they receive their coverage from medicare or the MA
plan?
Answer: MA plan
151. When a customer is enrolled in a MA plan, they must continue paying their premiums for
what other plan?
Answer: Part B
152. MA plans have a maximum annual limit on OOP costs called a?
Answer: MOOP amount (Maximum out of pocket)
153. 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 _____?
Answer: effective date
154. An exception exists for MA-only PFFS plans as a member can also be enrolled in a what?
Answer: Standalone PDP
155. If a member enrolls in a MA plan, what must the member do?
Answer: Cancel in writing their medicare supplement insurance policy with the carrier after
their request to enroll in MA plan has been approved.
156. Medicare supplement insurance policies cannot be used in conjunction with what type of
plan?
Answer: MA plan
157. A medicare supplement insurance plan helps to cover some of the OOP costs associated
with?
Answer: original medicare.
158. A medicare supplement insurance plan does NOT pay the cost-sharing of what type of plan?
Answer: MA plan
159. When a client enrolls in a MA plan, will it automatically terminate their MA plan?
Answer: NO
160. Can a customer call to terminate their Med Sup plan?
Answer: no it must be done in writing
161. What are the different types of MA plans?
Answer: HMO, POS, PPO, RPPO, PFFS, SNP, and MSA
162. For an HMO, they customer must us IN network providers, what are the exceptions to their
rule?
Answer: Emergencies, Urgent care, and renal dialysis services.
163. In a HMO plan, does a member have to choose a PCP? and do they require referrals to see a
specialist?
Answer: Yes
164. In a POS plan, does a member need a referral from their PCP to see a specialist?
Answer: yes
165. Can a member with a POS plan see a specialist?
Answer: Yes, but they may have to pay a higher cost, and there coverage limits
166. With a PFFS plan, can a member seek treatment from any medicare eligible provider who
agrees to accept the plans conditions and payment rates?
Answer: Yes
167. Does a PCP need to be selected with a PFFS plan?
Answer: No
168. What is the only plan to offer non-network PFFS plans?
Answer: UHC
169. What are SNP's for? (Dual SNP)
Answer: People who have both medicare and Medicaid
170. Institutional SNP?
Answer: Nursing homes
171. Chronic condition SNP?
Answer: people who have certain chronic medical conditions
172. MSA?
Answer: Medical savings account
173. What does a MSA do?
Answer: Combines a high deductible medicare advantage plan and a bank account
174. How does MSA plans work?
Answer: the plan deposits money from emdicare in the account which can then be used to pay
for medical expenses until their deductible is met
175. Does UHC currently offer a MSA?
Answer: no
176. MA plans include some key features such as?
Answer: Prescription drug coverage, PCPs and a OOP maximum
177. In a MA-Part D plan, A member will be disenrolled from their standalone PDP upon
enrollment in a ?
Answer: MA-PD
178. In a MA-part D plan, A member will be disenrolled from their MA-PD upon enrollment in?
Answer: a stand-alone PDP
179. With MA only, a member will be disenrolled from their standalone PDP upon enrolling in a?
Answer: Non-PFFS MA-only plan
180. In MA-only, a member will be disenrolled from their non-PFFS MA-only plan upon
enrolling in a?
Answer: Standalone PDP
181. Most MA plans require a what? although not all plans require that the chosen ____
coordinate the members care
Answer: PCP selection
182. If a PCP is required and the customer does not indicate one on the enrollment application, a
_____ will automatically assigned
Answer: PCP
183. To avoid member complaints, encourage customers to select a ____ and make sure the
_____ is accepting new patients
Answer: PCP
184. In which plan (HMO/POS) are out of network benefits available at a higher cost?
Answer: POS
185. With a PFFS plan, does a PCP need to be selected? and are prior authorizations or referrals
from a PCP required?
Answer: No, NO
186. Once a member with a MAP reaches the maximum OOP expenses, is there cost sharing for
any additional services?
Answer: no
187. MA plans with an OON component may or may not have an?
Answer: OOP maximum for OON services depending on the plan
188. All medicare covered (part A and part B) services count toward the?
Answer: OOP maximum with MAP's
189. Services and deatures that do not count toward the maximum OOP in a MAP include?
Answer: plan premium, part D prescription drugs and any non-medicare covered services such
as eyewear and hearing aids
190. Is the OOP maximum amount different between MA plans?
Answer: Yes
191. UHC strongly discourages Dual-eligible customers, from enrolling into a PFFS plan due to?
Answer: having potential negative impacts to the customer
192. What does dual eligible customers mean?
Answer: having both medicare and medicaid
193. Before enrolling any customer into a PFFS plan, ask if they are enrolled in a state _____
program?
Answer: medicaid
194. If a customer is enrolled in a state medicaid program, explain to them that a PFFS plan may
Answer: Impact their ability to continue seeing their current providers, and may create OOP
expenses they may not be able to afford.
195. If a customer on medicaid applies for a PFFS plan, the customer may be responsible for?
Answer: cost sharing
196. Only enroll a dual eligible customer into a PFFS plan if the customer insists on enrolling
and disclose the potential impacts of
Answer: enrolling
197. What type of plan can be network based or non-network based?
Answer: PFFS
198. UHC does not offer network-based ___ plans?
Answer: PFFS
199. What is deeming?
Answer: a 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
200. What us a deemed provider?
Answer: one 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
201. What is a deemed provider
Answer: must participate in medicare and agree to the plans terms and conditions of payment
202. PFFS member responsibilities?
Answer: the 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 present the member
ID and inform provider of the PFFS membership prior to each visit and before receiving covered
services
203. CMS allows the PFFS plan to decide if balance ____ is permitted
Answer: balance
204. Plans must ___ what is permitted in the terms and conditions of payment
Answer: decide
205. MA plan should not be referred to as a
Answer: supplement replacement, supplement, replacement no cost, free plan or zero cost plan
206. Medicare part D is a state program or a federal program
Answer: federal program
207. In order for a customer to obtain medicare part D, what must they have to do?
Answer: they must enroll individually in a plan offered by a private insurance company
approved by medicare
208. In order to be eligible for part D, what must a client also have?
Answer: Part A and B
209. When a client enrolls in part D prescription drug coverage when they first become eligible,
what is that time period often called?
Answer: Initial enrollment period
210. Consumers can also enroll, disenroll or change coverage each year between when?
Answer: October 15 - dec 15th during the annual election period(AEP)
211. AEP?
Answer: annual enrollment period
212. OEP?
Answer: Open enrollment period
213. MA plan members who use the OEP to disenroll from their MA plan and obtain coverage
from original medicare, may enroll in a standalone what plan?
Answer: part D plan
214. ____ does not allow for PDP enrollment changes?
Answer: PDP
215. What is a PDP?
Answer: a standalone medicare prescription drug plan
216. What do PDP's do?
Answer: add prescription drug coverage to original medicare, MSA's, some medicare cost plans,
and some medicare private fee for service PFFS plans
217. WHAT type of standalone variations to medicare can give extra benefits?
Answer: A + B + D
C+D
218. When a consumer has original medicare and a prescription drug plan, they can also have a
medicare ________ insurance plan
Answer: medicare supplement insurance plan
219. There are 4 stages to medicare part standard prescription drug coverage; what are they?
Answer: 1) yearly deductible
2) initial coverage
3) Coverage gap
4) Catastrophic coverage
220. 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?
Answer: True out of pocket
221. 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?
Answer: The monthly premium
222. How much is the yearly deductible for a medicare prescription drug coverage?
Answer: $0-$415
223. In a Medicare prescription drug coverage plan, the member pays (all/some) of the yearly
deductible?
Answer: all - the plan pays nothing
224. is the initial coverage for the medicare prescription drug coverage plan covered entirely by
the customer or plan?
Answer: member pays part, the plan pays part
225. 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?
Answer: $3,820
226. For the coverage gap in a medicare drug coverage plan, who pays what?
Answer: the member pays most, and the plan pays a little
227. In the coverage gap, member pays up to what percent of most brand named drugs
Answer: 25%
228. In the coverage gap, the member pays what percent for generic drugs?
Answer: 37%
229. When OOP costs for the coverage gap reaches what amount, they will move onto the
catastrophic coverage?
Answer: $5,100
230. Catastrophic coverage is what in the order of medicare prescription drug plan
Answer: last
231. In catastrophic coverage, who pays what?
Answer: The member pays a little while the plan pays most
232. In catastrophic coverage, the member pays what?
Answer: a small copay or coinsurance for drugs
233. PDP break down for 2019
Answer: Annual deductible = $415
Initial coverage = $3820
Coverage gap = $5,100
234. What is the coverage gap for medicare prescription drug coverage?
Answer: It’s a temporary limit on what the medicare prescription drug plan will cover
235. When a customer reaches the ____ They will pay 25% for most brand named drugs and
37% for generic drugs
Answer: coverage gap
236. Consumers with limited _____ may qualify for extra help from medicare to cover their part
D premiums and Part D related OOP costs
Answer: income and resources
237. TO qualify for low income subsidy on part D, the consumers income must be at or below
Answer: 150% of the FPL (federal poverty level)
238. When does approved extra help begin?
Answer: the first day of the month the customer becomes eligible
239. How does a customer qualify for extra help?
Answer: they receive both medicare and medicaid benefits, receive SSI and meet a certain
income, and are a MSP participant(medicare savings program)
240. If a customer who automatically qualifies for extra help doesn’t enroll in a prescription drug
plan, medicare may automatically enroll them in one so they will be able to use the _____?
Answer: extra help
241. What is creditable coverage?
Answer: it’s a prescription drug coverage that is expected to pay on average at least as much as
Medicare’s standard prescription drug coverage
242. What are some examples of creditable coverage?
Answer: drug plan from an employer, union, TRICARE, Indian health service, or department of
veterans affairs
243. Consumers with creditable coverage when they become eligible for medicare can generally
keep that coverage without paying an ____ if they decide to enroll in medicare prescription drug
coverage later?
Answer: penalty
244. The organization providing the prescription drug coverage MUST inform the consumer
annually if the prescription drug coverage is ________
Answer: creditable coverage
245. How many days does medicare allow before a customer accrues a penalty
Answer: 63 days
246. If a customer accrues a late penalty for not accepting medicare before the 63 day limit, the
late enrollment penalty is added to what?
Answer: the monthly plan premium
247. What is the late enrollment penalty?
Answer: 1% x 35.02(2018 NBBP or national base beneficiary premium) x # of months = penalty
248. Can the pharmacy used impact OOP costs for covered drugs?
Answer: yes. The customer should use a preferred or standard in network pharmacy
249. Under the part D benefit, drugs filled at an OON pharmacy are covered only when the
member is not able to use an in-network pharmacies for covered medications, generally at a
higher ________
Answer: OOP cost
250. What is a preferred pharmacy?
Answer: A 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 nonpreferred (standard) pharmacy
251. What is a formulary drug list?
Answer: A 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
252. How many tiers are there for medicare prescription drug coverage?
Answer: 5
253. What are the 5 tiers for medicare prescription drug coverage?
Answer: Tier 1, 2,3,4,5
254. Tier 1?
Answer: Member pays lowest copayment and lower cost commonly used generic drugs are
covered
255. Tier 2?
Answer: Member pays a low copayment, many generic drugs are covered
256. Teir 3?
Answer: Member pays a medium copayment and many common brand name drugs and some
higher cost generic drugs are covered
257. Tier 4
Answer: Member pays copayment (MA-PD) coinsurance (PDP) and nonpreferred generic and
non-preferred grand name drugs are covered
258. Tier 5
Answer: Member pays coinsurance, and unique and or very high cost drugs are covered
259. What is strep up therapy?
Answer: it’s 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 requested drug. if a member has already tried other drugs or a provider thinks other drugs are
not right for the situation, a member or their doctor can ask the plan to cover these drugs
260. 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.
Answer: if 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.
261. Some drugs require pre-approval by the plan. A member of their provider can ask a plan to
cover the drug.
Answer: the plan may ask the member or provider for additional information to help ensure the
drug is appropriate for medicare-eligible health conditions. A member might be asked to try
another drug on the formulary before the plan will cover the drug they are requesting.
262. Who qualifies for a medication therapy management program?
Answer: members enrolled in a medicare prescription drug plan who take medications for
multiple medical conditions may qualify at no additional cost, for a medication therapy
management program (MTM)
263. How does the MTM program work?
Answer: it helps physicians and members ensure their medications are working to help improve
their health
264. To be enrolled in a MTM, a customer MUST
Answer: 1) have a chronic health condition
2) member takes several different medications
3) Member's medications have a combined cost of more than $3,919 per year
265. to be enrolled in the MTM program (medication therapy program) the enrolled member
must meet all of the following
Answer: 1) member has more than one chronic health condition
2) Member takes several different medications
3) 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.
266. A list of drugs covered within the part D benefit plan
Answer: formulary
267. 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
Answer: TrOOP
268. The stage in Medicare part D prescription drug coverage in which there is a temporary limit
on what the plan will cover for drugs
Answer: coverage gap
269. A drug may require this type of approval by the plan prior to a member receiving it?
Answer: prior authorization
270. Extra help for customers with limited income and resources from Medicare to cover their
part D premiums and Part D related OOP costs
Answer: low income subsidy
271. applying for help for medicare prescription drug plan expenses does NOT automatically
enroll him in a _______ plan
Answer: prescription drug plan
272. What does MMP stand for?
Answer: Medicare-medicaid plan
273. What does MMP do?
Answer: individuals can receive both medicare parts A &B and full medicaid benefits through
one health plan
274. Generally, qualified individuals are passively enrolled into the state's coordinated care plan
with the ability to opt-out and choose other medicare
Answer: options
275. Why would someone want to enroll in a MA-only PFFS plan?
Answer: they want to keep their standalone prescription drug plan (PDP)
276. 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?
Answer: is counted towards his/her MOOP in the new MA plan IF:
1) 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
2) the new plan is a different type than the previous plan (eg HMO to PPO) and both plans have
the SAME legal entity
277. If a member is switching from one MA plan to another, does the member have to be a part
of the same carrier to retain his/her MOOP expenses?
Answer: yes. if the member is from a different carrier, the MOOP expense will NOT carry over
to the new plans yearly deductible
278. What type of plans are network based plans?
Answer: HMO's, POS's, and PPO's
279. What type of plan can either be network based or non - network based?
Answer: PFFO
280. 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?
Answer: the 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)
281. Is emergency care covered in a PFFO plan regardless of whether the provider agrees to
accept the plans payment?
Answer: yes it is`
282. Who allows the PFFS plan to decide if balance billing is permitted?
Answer: CMS. Plans must disclose what is permitted in the terms and conditions
283. Does the OEP (Open enrollment period) allow for PDP changes?
Answer: No you can’t make changes to PDP during the OEP
284. If a customer enrolled in a MAP (with or without prescription drug coverage), will be
automatically ________ from that plan and returned to original medicare upon enrolling in a
PDP (except MA-only PFFS plans)
Answer: disenrolled
285. What happens when a customer is enrolled in a employee or union sponsored health plan
and decides to enroll in a PDP?
Answer: the customer MAY lose coverage for themselves and their dependents upon enrollment
in a PDP, and may not be able to reenroll in the employer or union plan at a later date
286. 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 _____?
Answer: does not contribute
287. WHAT kind of medicare plan is only available through employer groups?
Answer: employer senior supplement group retiree plans
288. Does an employer senior supplement group retiree plan help pay for some or all the costs
not covered by original medicare?
Answer: yes. not only that but they have similar coverage as medicare supplement insurance
plans and members can go to any provider that accepts medicare
289. Which statement is true about the Medicare Advantage (MA) Out - of pocket Maximum?
Answer: All MA plans have an Out - of Pocket maximum to help limit the member's out of
pocket cost for Medicare-covered services.
290. A consumer currently has Original Medicare and is enrolled in a standalone PDP. What will
happens if the consumer enrolls in a n MA Plan that has integrated PDP coverage?
Answer: The consumer will be automatically disenrolled from their stand-alone PDP upon
enrollment in the MA Plan has integrated prescription drug coverage.
291. What is Medicare Part D?
Answer: A voluntary program, offered by private insurance companies that are contracted with
the federal government, that provide prescription drug coverage for an additional monthly plan
premium.
292. Which of the following statement is true about eligibility requirement for stand alone
Medicare prescription drug plans?
Answer: A consumer must be entitled to Medicare Part A/ or enrolled in Medicare Part B
293. Aside from a Medicare Advantage Plan or other health plan that includes prescription drug
coverage, how else could a Medicare-eligible consumer get Part D PDP ?
Answer: They could enroll in a stand-alone Medicare Prescription Drug Plan (PDP)
294. In what order do they four prescription drug coverage stages occur?
Answer: Deductible, Initial coverage, coverage gap, catastrophic coverage
295. Step Therapy, prior authorization, quantity limit 7-day limit, dispensing limit and limited
access are all examples of what?
Answer: These are all examples of utilization management techniques used by health plans or
insurance companies to control the use of medications and healthcare services.
296. Which of the following best describes the Late Enrollment Penalty (LEP)?
Answer: The amount added to the member's monthly plan premium if they did not enroll in a
Medicare advantage plan with part d benefits or standalone PDP when they are first eligible
Medicare Part and B or went without creditable coverage for 63 days or more days
297. Through which means if financial assistance offered to a consumer who qualifies for a LIS
for their parts of Medicare part D costs?
Answer: Through subsidies such as lower or no monthly plan premiums and lower or no
copayments
298. Which of the following list drug tiers from least expensive cost share to most expensive cost
shares
Answer: 1. Tier 1 – Generic drugs (least expensive)
2. Tier 2 – Preferred brand-name drugs
3. Tier 3 – Non-preferred brand-name drugs
4. Tier 4 – Specialty drugs (most expensive)
299. In states where Medicare Supplements Insurance underwriting criteria can apply, all of the
following underwriting criteria apply EXCEPT:
Answer: Denial Based on Pre-existing Conditions (in certain states)
1. Health status
2. Age
3. Gender
4. Tobacco use
5. Medicare enrolment date
6. Pre-existing condition waiting period
300. Lisa turned 65 and is now eligible for Medicare. She already received Social Security
benefits. How does she enroll in original Medicare?
Answer: Hern enrollment in Medicare Part A is generally automatic if she meets all eligibility
requirements.
301. Which statement is true about a member of a Medicare Advantage (MA) who wants to
enroll in a Medicare Supplements Insurance Plan?
Answer: A member does not need valid election period to disenroll from an Ma plan
302. Provided other eligibility requirements are met, who is eligible for Medicare?
Answer: Consumer age 65 or older, consumers under 65 years of age with certain disabilities for
more than 24 months and consumers of all ages with ESRD or ALS
303. Which of the following is NOT an eligibility requirement for enrollment in a Medicare
Advantage Plan?
Answer: Does not have any pre-existing condition such as diabetes or ESRD
304. Which of the following is not a correct statement about in-network providers services?
Answer: HMO - POS plans only cover in - network services
305. When does Medicare Supplements Open Enrollment take place?
Answer: During the first 6 months a consumer is 65 or older ad enrolled in Medicare Part B
306. Roger wants to know what counts towards the out - of- pocket maximum on the
Medicare Advantage Plan he is considering. Which statement is accurate?
Answer: The out – of - pocket maximum includes cost the member pays for any Medicare covered Part A or B services
307. A government program, offered only through a private insurance company or other private
company approved by Medicare, that provides prescription drug coverage describes which of the
following:
Answer: Medicare Part D
308. Which consumer is eligible for a standalone Medicare prescription drug plans?
Answer: Joseph, who is enrolled in Medicare Part A and Medicare Part B and resides in the
plan's service area
309. Asides from a Medicare Advantage Plan or other health plan that includes prescription drug
coverage how else could a Medicare - eligible consumer get Part D prescription drug coverage?
Answer: They could enroll in a standalone Medicare prescription drug plan (PDP)
310. In what order do the four prescription drug coverage stages occur?
Answer: Deductible, Initial coverage, coverage gap, catastrophic coverage
311. Which of these statement is true about the drug utilization management (UM) rules?
Answer: Prior authorization, quantity limit, and step therapy are some examples of the UM rules
312. In states where Medicare Supplements Insurance underwriting criteria can apply all of the
following underwriting criteria apply EXCEPT:
Answer: Most consumer who are switching from another Medicare supplement plan are entitled
to guaranteed issue and therefore are not subject to underwriting
