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AHIP Medicare practice questions

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Question 1Medicare Program Basics

Medicare Part A coverage is best described as which type of benefit?

  1. Prescription drug coverage
  2. Physician services coverage
  3. Hospital insurance Correct answer.
  4. Private supplemental coverage

Explanation

Part A is the hospital insurance component of Original Medicare and covers inpatient hospital stays, skilled nursing facility care after a qualifying stay, hospice, and some home health care. It is financed primarily through payroll taxes.

Question 2Medicare Program Basics

Which Medicare part generally covers outpatient physician visits and durable medical equipment?

  1. Part A
  2. Part D
  3. Part C
  4. Part B Correct answer.

Explanation

Part B is the medical insurance component and covers medically necessary outpatient services such as doctor visits, outpatient therapy, lab work, and durable medical equipment. It is funded through premiums and general revenues.

Question 3Medicare Program Basics

Medicare Advantage plans are offered under which part of Medicare?

  1. Part D
  2. Part B
  3. Part A
  4. Part C Correct answer.

Explanation

Part C is the Medicare Advantage program, under which beneficiaries may enroll in private plans that provide Part A and Part B benefits and often Part D drug coverage. Plans must follow Medicare rules but may use network and cost-sharing structures.

Question 4Medicare Program Basics

The Medicare Part D program provides coverage for which of the following?

  1. Outpatient prescription drugs Correct answer.
  2. Skilled nursing facility care
  3. Inpatient hospital stays
  4. Hospice care

Explanation

Part D is the voluntary outpatient prescription drug benefit delivered through private stand-alone prescription drug plans or through Medicare Advantage plans that include drug coverage. It does not cover inpatient hospital services.

Question 5Medicare Program Basics

Which agency administers the Medicare program at the federal level?

  1. The Social Security Administration
  2. The Department of Labor
  3. The Centers for Medicare & Medicaid Services Correct answer.
  4. The Department of Veterans Affairs

Explanation

The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services, administers Medicare. CMS sets coverage rules, contracts with plans, and oversees program integrity.

Question 6Medicare Program Basics

A beneficiary who wants Original Medicare plus separate drug coverage would typically enroll in which combination?

  1. Part A and Part B plus a stand-alone Part D plan Correct answer.
  2. Part B only
  3. Part C only
  4. Part A only

Explanation

Original Medicare consists of Part A and Part B, and beneficiaries who want drug coverage add a stand-alone Part D prescription drug plan. Medigap may also be purchased to help with cost sharing.

Question 7Medicare Program Basics

Medicare eligibility generally begins at which age for most people who are not otherwise eligible due to disability or disease?

  1. 65 Correct answer.
  2. 62
  3. 60
  4. 67

Explanation

Most people become eligible for Medicare at age 65 if they meet citizenship and work-history requirements. Younger eligibility can occur through disability or end-stage renal disease.

Question 8Medicare Program Basics

Which of the following is a hallmark feature of Original Medicare (Parts A and B) compared with Medicare Advantage?

  1. It uses closed provider networks
  2. It requires referrals for specialist care
  3. It generally allows care from any provider who accepts Medicare Correct answer.
  4. It includes routine dental and vision benefits

Explanation

Original Medicare is a fee-for-service program that generally permits beneficiaries to see any provider who accepts Medicare assignment. Medicare Advantage plans, by contrast, often use networks and may require referrals.

Question 9Medicare Program Basics

A Medicare beneficiary with limited income and resources may receive help paying Medicare premiums and cost sharing through which program?

  1. COBRA
  2. TRICARE
  3. Medigap
  4. Medicaid Correct answer.

Explanation

Medicaid is a joint federal-state program that can pay Medicare premiums and cost sharing for beneficiaries with limited income and resources. Such beneficiaries are sometimes described as dual eligibles.

Question 10Medicare Program Basics

A person who is entitled to Social Security retirement benefits and is turning 65 will generally be enrolled in which parts of Medicare automatically?

  1. Parts C and D
  2. Parts A and B Correct answer.
  3. Parts B and D
  4. Parts A and C

Explanation

Individuals already receiving Social Security or Railroad Retirement benefits are typically automatically enrolled in both Part A and Part B when they turn 65. They may decline Part B if they have qualifying employer coverage.

Question 11Medicare Program Basics

Which statement about the Part B premium is correct?

  1. It is waived for all Medicare Advantage enrollees
  2. It is generally deducted from Social Security benefits Correct answer.
  3. It is paid only by beneficiaries with high incomes
  4. It is funded entirely by payroll taxes

Explanation

Most beneficiaries pay a Part B premium that is commonly deducted from their monthly Social Security payment. Higher-income beneficiaries pay an income-related surcharge on top of the standard premium.

Question 12Medicare Program Basics

Medicare Advantage plans must provide at least the same benefits as which of the following?

  1. Medicaid state plan benefits
  2. Original Medicare Parts A and B Correct answer.
  3. Medigap Plans C and F
  4. The Federal Employees Health Benefits program

Explanation

By law, a Medicare Advantage plan must offer coverage for all services covered by Original Medicare Parts A and B, except hospice, which remains under Part A. Plans may add extra benefits beyond that minimum.

Question 13Medicare Program Basics

Which service is typically excluded from Original Medicare coverage?

  1. Outpatient chemotherapy
  2. Inpatient hospital care
  3. Routine hearing aids Correct answer.
  4. Skilled nursing facility care after a qualifying stay

Explanation

Original Medicare generally does not cover routine hearing aids, routine dental care, or routine vision care. Medically necessary hospital, chemotherapy, and post-hospital skilled care are covered.

Question 14Medicare Program Basics

A beneficiary enrolled in a Medicare Advantage HMO generally must do which of the following to see a specialist?

  1. Pay a Part D late enrollment penalty
  2. Disenroll from Part B
  3. Obtain a referral from the plan or primary care physician Correct answer.
  4. Enroll in Medigap first

Explanation

HMO-type Medicare Advantage plans typically require a referral or plan authorization before a member sees a specialist. This network and referral structure is a key difference from Original Medicare.

Question 15Medicare Program Basics

Which entity is responsible for setting Medicare payment rates for hospital services under Part A?

  1. The Centers for Medicare & Medicaid Services Correct answer.
  2. The Social Security Administration
  3. Each state insurance department
  4. Private Medicare Advantage plans

Explanation

CMS establishes payment methodologies and rates for Medicare-covered services, including hospital payments under Part A. Private plans and state agencies do not set Original Medicare rates.

Question 16Medicare Program Basics

A beneficiary who is still working and has employer group health coverage based on current employment may generally do which of the following when turning 65?

  1. Must disenroll from the employer plan
  2. May enroll in Medigap without Part B
  3. Must enroll in Part B immediately or lose all coverage
  4. May delay Part B without a late enrollment penalty while employer coverage continues Correct answer.

Explanation

Beneficiaries with group health coverage based on their own or a spouse's current employment may delay Part B without penalty. A special enrollment period is available when that coverage ends.

Question 17Medicare Program Basics

The Medicare Part D late enrollment penalty is generally based on which factor?

  1. The beneficiary's income level
  2. The number of months without creditable drug coverage Correct answer.
  3. The beneficiary's age at enrollment
  4. The number of prescriptions filled

Explanation

The Part D late enrollment penalty is calculated based on how long a beneficiary went without creditable prescription drug coverage after becoming eligible. The penalty is generally added to the monthly premium for as long as the beneficiary has Part D.

Question 18Medicare Program Basics

Which of the following best describes the role of a Medicare Advantage organization?

  1. It sets national Medicare coverage policy
  2. It contracts with CMS to deliver Medicare benefits through a private plan Correct answer.
  3. It processes Social Security retirement claims
  4. It administers state Medicaid eligibility

Explanation

A Medicare Advantage organization contracts with CMS to provide Part A and Part B benefits, and often Part D, through a private plan. CMS retains oversight and sets coverage policy.

Question 19Medicare Program Basics

Which statement accurately describes the relationship between Medigap and Medicare Advantage?

  1. Medigap is sold only by CMS
  2. Medigap replaces Part A for Medicare Advantage enrollees
  3. Medigap can be used to pay Medicare Advantage cost sharing
  4. Medigap policies generally cannot be used with Medicare Advantage plans Correct answer.

Explanation

Medigap policies are designed to supplement Original Medicare and generally cannot be used to pay cost sharing under a Medicare Advantage plan. Beneficiaries typically choose either Medigap with Original Medicare or a Medicare Advantage plan.

Question 20Medicare Program Basics

A beneficiary who moves out of a Medicare Advantage plan's service area will generally have which option?

  1. Remain enrolled with the same network
  2. Automatically be enrolled in Medigap
  3. Lose Medicare eligibility entirely
  4. Use a special enrollment period to choose another plan or return to Original Medicare Correct answer.

Explanation

Moving outside a plan's service area triggers a special enrollment period allowing the beneficiary to select another Medicare Advantage plan or return to Original Medicare, often with Part D. Medicare eligibility itself is unaffected.

Question 21Medicare Program Basics

Which of the following correctly explains why Medicare Part A is described as payroll-tax financed?

  1. Part A is funded by state income taxes
  2. Part A is funded by general revenues only
  3. Part A is funded largely through payroll taxes paid by workers and employers Correct answer.
  4. Part A is funded by premiums paid only by enrollees

Explanation

Part A is financed primarily through payroll taxes contributed by workers and employers, which is why most beneficiaries pay no Part A premium if they have sufficient work history. Part B and Part D rely more heavily on premiums and general revenues.

Question 22Medicare Program Basics

A beneficiary with End-Stage Renal Disease may become eligible for Medicare under which circumstance?

  1. After meeting specific dialysis or transplant requirements Correct answer.
  2. Only after a 24-month disability waiting period
  3. Only after reaching age 65
  4. Only if enrolled in Medicaid

Explanation

Individuals with End-Stage Renal Disease may qualify for Medicare based on requirements involving regular dialysis or a kidney transplant, without waiting for age 65. The 24-month waiting period applies to most disability-based eligibility, not to ESRD.

Question 23Medicare Program Basics

Which statement best explains the difference between Medicare and Medicaid?

  1. Medicare is a federal health program for eligible individuals; Medicaid is a joint federal-state program for low-income individuals Correct answer.
  2. Medicare is income-based; Medicaid is age-based
  3. Both are administered solely by the states
  4. Medicaid covers only hospital services

Explanation

Medicare is a federal program with uniform national eligibility rules, while Medicaid is jointly funded and administered by federal and state governments and is based on income and resources. Many low-income beneficiaries qualify for both.

Question 24Medicare Program Basics

A Medicare Advantage plan advertises extra benefits beyond Original Medicare. Which statement is accurate?

  1. Extra benefits may be offered but the plan must still cover all Medicare-covered services Correct answer.
  2. Extra benefits are prohibited by CMS
  3. Extra benefits replace the need to cover Medicare-covered services
  4. Extra benefits are available only to dual eligibles

Explanation

Medicare Advantage plans may offer supplemental benefits such as fitness or dental coverage, but they must still provide coverage for all services covered by Original Medicare. Extra benefits cannot substitute for required benefits.

Question 25Medicare Program Basics

Which of the following best describes how a beneficiary's choice between Original Medicare and Medicare Advantage affects provider access?

  1. Both options use identical networks
  2. Original Medicare generally offers broader provider access; Medicare Advantage plans may use networks Correct answer.
  3. Original Medicare requires referrals for all specialists
  4. Medicare Advantage always offers broader access

Explanation

Original Medicare generally allows care from any provider who accepts Medicare, while Medicare Advantage plans often use defined networks and may require referrals. This difference is central to plan selection.

Question 26Medicare Program Basics

Which part of Medicare primarily covers inpatient hospital stays, skilled nursing facility care after a qualifying hospital stay, and hospice care?

  1. Part C
  2. Part A Correct answer.
  3. Part D
  4. Part B

Explanation

Part A is the hospital insurance component of Medicare and covers inpatient hospital care, skilled nursing facility care following a qualifying stay, hospice, and some home health care. Part B covers outpatient and physician services, Part C refers to Medicare Advantage, and Part D covers prescription drugs.

Question 27Medicare Program Basics

A beneficiary wants to know how Medicare Part B is financed. Which statement is accurate?

  1. It is funded solely by payroll taxes on current workers.
  2. It is funded solely by state Medicaid matching funds.
  3. It is funded solely by premiums paid to private insurers.
  4. It is funded by beneficiary premiums and general federal revenues. Correct answer.

Explanation

Part B is financed through monthly premiums paid by enrollees plus transfers from the federal government's general revenues. Payroll taxes fund Part A, not Part B. Medicaid is a separate program with different financing.

Question 28Medicare Program Basics

Which of the following services is covered under Medicare Part B?

  1. Medically necessary physician office visits Correct answer.
  2. Routine dental cleanings
  3. Hearing aids for general age-related hearing loss
  4. Long-term custodial nursing home care

Explanation

Part B covers medically necessary outpatient services, including physician office visits, outpatient therapy, and preventive services. Custodial long-term care, routine dental care, and most hearing aids are generally excluded from Medicare coverage.

Question 29Medicare Program Basics

How does the Medicare Advantage program deliver benefits to enrollees?

  1. Through private plans under contract with CMS that provide Part A and Part B benefits Correct answer.
  2. Through the federal government directly paying all claims on a fee-for-service basis
  3. Through state governments administering benefits under Medicaid waivers
  4. Through employers who self-fund retiree health benefits

Explanation

In Medicare Advantage, CMS contracts with private organizations that deliver Medicare benefits, and enrollees generally receive Part A and Part B services through the plan. Original Medicare, by contrast, pays claims on a fee-for-service basis directly.

Question 30Medicare Program Basics

A beneficiary is enrolled in Original Medicare and wants to add prescription drug coverage. Which approach is consistent with program rules?

  1. Enroll in a standalone Medicare Part D prescription drug plan Correct answer.
  2. Obtain drug coverage only through a state Medicaid program
  3. Add drug coverage through the Part B premium
  4. Enroll in a Medigap plan that includes drug coverage

Explanation

Standalone Part D plans are available to beneficiaries in Original Medicare to provide outpatient prescription drug coverage. Medigap policies sold today cannot include drug coverage, and Part B premiums do not purchase drugs.

Question 31Medicare Program Basics

Which statement about the Medicare Part D late enrollment penalty is accurate?

  1. It applies only to beneficiaries enrolled in Medicare Advantage.
  2. It is a one-time flat fee charged at the first drug purchase.
  3. It is waived automatically for anyone who enrolls during the annual enrollment period.
  4. It is calculated based on how long the beneficiary went without creditable drug coverage. Correct answer.

Explanation

The Part D late enrollment penalty is a permanent premium increase calculated using the number of months a beneficiary went without creditable prescription drug coverage after becoming eligible. It is not a one-time fee and is not waived simply by using an enrollment period.

Question 32Medicare Program Basics

A beneficiary wants supplemental insurance to help pay Original Medicare cost-sharing, such as coinsurance. Which product is designed for that purpose?

  1. Medigap policy Correct answer.
  2. Medicare Savings Program
  3. Medicare Advantage plan
  4. Standalone Part D plan

Explanation

Medigap policies are private supplemental insurance sold to beneficiaries in Original Medicare to help cover cost-sharing such as coinsurance and deductibles. Medicare Advantage plans replace Original Medicare delivery, Part D covers drugs, and the Medicare Savings Program is a low-income assistance program.

Question 33Medicare Program Basics

A beneficiary is considering a Medicare Advantage plan instead of Original Medicare. Which statement accurately describes a key structural difference?

  1. The plan pays secondary to Original Medicare for the same services.
  2. The plan eliminates all cost-sharing for covered services.
  3. The plan must allow the beneficiary to see any provider in the country who accepts Medicare.
  4. The plan may use provider networks and prior authorization requirements that Original Medicare does not. Correct answer.

Explanation

Medicare Advantage plans may use provider networks and utilization management tools such as prior authorization, which are features Original Medicare generally does not impose. Plans must still cover Medicare benefits but may structure access and cost-sharing differently.

Question 34Medicare Program Basics

Which of the following best describes the Medicare Advantage open enrollment period that occurs early in the year?

  1. A period when a beneficiary may change Medigap policies without medical underwriting
  2. A period when a beneficiary may enroll in a standalone Part D plan for the first time
  3. A period when a beneficiary in Original Medicare may first enroll in Part B
  4. A period when a beneficiary in a Medicare Advantage plan may switch to another Medicare Advantage plan or to Original Medicare Correct answer.

Explanation

The Medicare Advantage open enrollment period allows individuals already enrolled in a Medicare Advantage plan to make a one-time change, such as switching to another Medicare Advantage plan or returning to Original Medicare, with the option to add drug coverage. Initial Part B enrollment and Medigap underwriting rules are governed by different provisions.

Question 35Medicare Program Basics

Which of the following is a characteristic of Medicare Part A eligibility for most people who have worked and paid Medicare taxes for the required number of quarters?

  1. They must first enroll in Part B to receive Part A.
  2. They are entitled to premium-free Part A. Correct answer.
  3. They must pay a monthly premium for Part A.
  4. They must be enrolled in Medicaid to receive Part A.

Explanation

Individuals, or their spouses, who have paid Medicare taxes for a sufficient number of quarters are generally entitled to premium-free Part A. Those without sufficient work history may be able to buy Part A by paying a premium.

Question 36Medicare Program Basics

A beneficiary with both Medicare and full Medicaid coverage may have most Medicare cost-sharing paid by which source?

  1. Medicaid Correct answer.
  2. A Medigap policy
  3. The Social Security Administration
  4. The Part D plan sponsor

Explanation

For beneficiaries dually eligible for Medicare and Medicaid, Medicaid may pay Medicare premiums and cost-sharing such as deductibles and coinsurance. Medigap is a separate private product, and neither Part D sponsors nor the Social Security Administration pay Medicare cost-sharing.

Question 37Medicare Program Basics

Which statement accurately describes the relationship between Original Medicare and Medicare Advantage regarding guaranteed issue of Medigap policies?

  1. Trying Medicare Advantage during a trial period may create a limited guaranteed issue right to buy certain Medigap policies. Correct answer.
  2. Medigap guaranteed issue rights are identical in all states at all times.
  3. Medigap policies are sold only to beneficiaries enrolled in Medicare Advantage.
  4. Enrolling in Medicare Advantage permanently eliminates any right to buy a Medigap policy.

Explanation

Federal rules provide limited guaranteed issue rights in certain situations, including a trial right for people who try a Medicare Advantage plan and then return to Original Medicare within a specified period. Medigap is marketed primarily to people with Original Medicare, and state rules can vary.

Question 38Medicare Program Basics

Which of the following best describes the role of the Centers for Medicare & Medicaid Services (CMS) in the Medicare program?

  1. It licenses insurance agents who sell Medigap policies.
  2. It sets the annual Part B premium without any statutory framework.
  3. It administers the Medicare program and oversees Medicare Advantage and Part D plans. Correct answer.
  4. It adjudicates individual Medicare claims for all providers.

Explanation

CMS is the federal agency that administers Medicare, including oversight of Medicare Advantage and Part D plan participation. Premiums are set under statutory formulas, agents are licensed by states, and claims are processed by contractors or plans rather than CMS directly.

Question 39Medicare Program Basics

A beneficiary who is entitled to Medicare due to disability generally becomes eligible after receiving Social Security disability benefits for how long?

  1. 6 months
  2. 12 months
  3. 24 months Correct answer.
  4. 60 months

Explanation

Most individuals under age 65 who qualify for Social Security Disability Insurance become eligible for Medicare after receiving disability benefits for 24 months. Certain conditions, such as ALS, have different rules.

Question 40Medicare Program Basics

A beneficiary asks whether a Medicare Advantage plan may offer benefits beyond what Original Medicare covers. Which statement is accurate?

  1. Extra benefits must be identical in every Medicare Advantage plan nationwide.
  2. Plans are prohibited from offering any benefits beyond Medicare-covered services.
  3. Plans may offer extra benefits such as dental, vision, or fitness programs as part of their plan offerings. Correct answer.
  4. Extra benefits are permitted only if the beneficiary also buys a Medigap policy.

Explanation

Medicare Advantage plans are permitted to offer supplemental benefits beyond Medicare-covered services, such as dental, vision, hearing, or fitness benefits, and these vary by plan. They are not prohibited, are not tied to Medigap purchase, and are not uniform across plans.

Question 41Medicare Advantage and Other Medicare Health Plans

A Medicare Advantage (MA) plan's annual maximum out-of-pocket limit applies to which type of cost sharing?

  1. Only prescription drug cost sharing
  2. Both Part A and Part B covered services under the plan Correct answer.
  3. Only services received from out-of-network providers
  4. Only hospital inpatient cost sharing

Explanation

MA plans must establish a mandatory annual maximum out-of-pocket limit that caps enrollee cost sharing for both Part A and Part B covered services, which is a key protection distinguishing MA from Original Medicare. Drug cost sharing is handled separately under the Part D benefit within the plan.

Question 42Medicare Advantage and Other Medicare Health Plans

Which type of Medicare Advantage plan typically requires enrollees to use network providers and obtain referrals from a primary care physician for specialist care?

  1. Preferred Provider Organization (PPO) plan
  2. Private Fee-for-Service (PFFS) plan
  3. Health Maintenance Organization (HMO) plan Correct answer.
  4. Medical Savings Account (MSA) plan

Explanation

HMO plans generally restrict care to a defined network and often require PCP referrals for specialists, in exchange for typically lower cost sharing. PPOs, PFFS plans, and MSAs operate with fewer or no referral and network restrictions.

Question 43Medicare Advantage and Other Medicare Health Plans

In a Medicare Advantage Preferred Provider Organization (PPO) plan, what happens when an enrollee receives covered care from an out-of-network provider?

  1. Coverage is allowed but generally at higher cost sharing Correct answer.
  2. The service is never covered under any circumstances
  3. The enrollee must switch to an HMO to receive reimbursement
  4. The plan pays the same as in-network with no difference

Explanation

PPO plans permit enrollees to use out-of-network providers, but typically with higher cost sharing than in-network care. This flexibility is a defining feature that distinguishes PPOs from HMOs.

Question 44Medicare Advantage and Other Medicare Health Plans

Which statement accurately describes a Medicare Medical Savings Account (MSA) plan?

  1. It is a supplemental policy that pays Original Medicare cost sharing
  2. It requires enrollees to assign a primary care physician for referrals
  3. It combines a high-deductible MA plan with a tax-advantaged savings account Correct answer.
  4. It is a stand-alone prescription drug plan with no medical coverage

Explanation

An MSA plan pairs a high-deductible Medicare Advantage plan with a medical savings account into which the plan deposits funds for the enrollee to use toward health care costs. It is a distinct MA plan type, not a supplement or a stand-alone drug plan.

Question 45Medicare Advantage and Other Medicare Health Plans

Which entity must approve a Medicare Advantage organization's plan benefit package and marketing materials before they are used?

  1. The Social Security Administration
  2. The Centers for Medicare & Medicaid Services (CMS) Correct answer.
  3. The state department of insurance only
  4. The plan's contracted provider network

Explanation

CMS regulates Medicare Advantage organizations and reviews and approves plan benefit packages and marketing materials before use. State regulators may have a role, but CMS is the federal authority for MA plan approval.

Question 46Medicare Advantage and Other Medicare Health Plans

Under the Medicare Advantage program, an enrollee who wants to disenroll from a plan and return to Original Medicare may generally do so during which period?

  1. Only if the plan is terminated by CMS
  2. Only during the Annual Enrollment Period
  3. Only during the first 30 days of enrollment
  4. During a valid enrollment period, such as the Medicare Advantage Open Enrollment Period Correct answer.

Explanation

Enrollees can disenroll during valid election periods, including the Medicare Advantage Open Enrollment Period (January 1 through March 31), during which an MA enrollee may switch to Original Medicare or another MA plan. Disenrollment is not limited to the first month or to plan termination.

Question 47Medicare Advantage and Other Medicare Health Plans

A Special Needs Plan (SNP) is a type of Medicare Advantage plan that is designed to serve which population?

  1. Beneficiaries with specific chronic conditions, institutional status, or dual eligibility Correct answer.
  2. Any Medicare beneficiary regardless of health status
  3. Only beneficiaries who are veterans
  4. Only beneficiaries under age 65

Explanation

SNPs are MA plans that restrict enrollment to special needs individuals, which include those with certain severe or disabling chronic conditions, those who are institutionalized, and those dually eligible for Medicare and Medicaid. SNPs cannot enroll the general Medicare population.

Question 48Medicare Advantage and Other Medicare Health Plans

Which of the following is a required element of a Medicare Advantage plan's provider network adequacy demonstration to CMS?

  1. A commitment to cover services worldwide
  2. A showing that the network includes enough providers to serve enrollees Correct answer.
  3. A requirement that every enrollee has a private duty nurse
  4. A guarantee that all providers accept Original Medicare assignment

Explanation

MA organizations must demonstrate to CMS that their networks contain a sufficient number and range of providers to deliver covered services to enrollees. This network adequacy requirement protects access to care.

Question 49Medicare Advantage and Other Medicare Health Plans

A beneficiary enrolled in a Private Fee-for-Service (PFFS) plan goes to a provider who has not agreed to the plan's terms and conditions. How is coverage typically affected?

  1. The service is automatically covered as in-network care
  2. The service is covered only if the provider agrees to the plan's terms and conditions Correct answer.
  3. The enrollee is disenrolled from the plan
  4. The provider must treat the enrollee anyway at plan rates

Explanation

In a PFFS plan, the plan sets payment terms and the provider must agree to accept those terms and conditions before furnishing covered services. If a provider does not agree, the enrollee may be responsible for payment or must find a participating provider.

Question 50Medicare Advantage and Other Medicare Health Plans

A dual-eligible beneficiary qualifies for both Medicare and full Medicaid benefits. Which type of Medicare Advantage plan is specifically designed to coordinate these benefits?

  1. A PACE organization
  2. A Dual Eligible Special Needs Plan (D-SNP) Correct answer.
  3. A Cost plan
  4. A Medicare MSA plan

Explanation

A D-SNP is a type of Special Needs Plan that limits enrollment to individuals dually eligible for Medicare and Medicaid and coordinates their benefits. PACE is a separate program model, and MSA and Cost plans are not SNP types.