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UHC ETHICS AND COMPLIANCE EXAM|| 2025 -
2026||ACTUAL QUESTIONS WITH CORRECT
DETAILED AND VERIFIED ANSWERS. A+ GRADE
Joseph has Original Medicare and was a patient in the hospital last week. What part of Medicare helps cover the costs of his inpatient hospital stay? SOLUTION- Part A.The consumer must be in a valid MA election or disenrollment period. Which of the following consumers would be eligible for Medicare? SOLUTION- 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 Which of the following defines a Medicare Advantage (MA) Plan? SOLUTION-MA Plans are health plan options approved by Medicare and offered by private insurance companies. Janice wants to enroll in a 2021 Medicare Advantage plan. What eligibility requirements must she meet? (Select the two answers that apply.) SOLUTION- Not have End Stage Renal Disease (permanent kidney failure)Reside in the plan's service area
What must be explained to consumers enrolling in an HMO (Health Maintenance Organization) MA Plan? (Select 3) SOLUTION- Which of the following are MA Plans that focus on using network providers to maximize the benefits and reduce out-of-network expenses? SOLUTION-HMO, POS, PPO Which is true about Medicare Supplement Open Enrollment? SOLUTION-By federal law, Medicare Supplement Open Enrollment is the first 6 months a consumer is 65 or older and enrolled in Medicare Part B. How does the Medicare Advantage Out-of-Pocket (OOP) maximum work? SOLUTION- 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. 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? SOLUTION-The
SOLUTION-All members reach the Coverage Gap Which of the following options are drug utilization management (UM) rules? (Select 3) SOLUTION- Which of the following best describes the Late Enrollment Penalty (LEP)? SOLUTION- 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. Through which means is financial assistance offered to a consumer who qualifies for Low Income Subsidy for their part of Medicare Part D costs? SOLUTION- Through subsidies such as lower or no monthly plan premiums and lower or no copayments 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? SOLUTION-Drug tiers In states where Medicare Supplement Insurance underwriting criteria can apply, all of the following underwriting criteria apply EXCEPT: SOLUTION-Consumers may be underwritten to determine their acceptance and, if applicable, their rate. The new MACRA legislation, which went into effect January 1, 2020, applies to all carriers offering Medicare supplement plans. SOLUTION-TRUE Which of the following is NOT true of Medicare Supplement Insurance Plans? SOLUTION-Plan benefit amounts automatically update when Medicare changes cost sharing amounts, such as deductibles, coinsurance and copayments. NOT Which definition best describes Medicare Part 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.
he/she is not automatically disenrolled from his/her MA Plan. A consumer can use a Medicare Supplement Insurance Plan and an MA Plan at the same time. SOLUTION-When a consumer enrolls in a Medicare Supplement Insurance Plan, he/she is automatically disenrolled from his/her MA Plan. 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? Medicaid Original Medicare Low Income Subsidy SOLUTION-Original Medicare 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 areaWhich plan is being described? Medicare Advantage Prescription Drug Medicaid
Original Medicare SOLUTION-Medicare Advantage What must be explained to consumers enrolling in an HMO (Health Maintenance Organization) MA Plan? (Select 3) They must see contracted network providers in order to receive coverage under the plan. In most cases, they will pay the entire cost of the service if they see an out-of- network provider. Most benefits are covered out-of-network but at a higher cost. 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. SOLUTION- What must be explained to consumers enrolling in an HMO (Health Maintenance Organization) MA Plan? (Select 3)
During the first three months a consumer is 65 or older and enrolled in Medicare Part B. SOLUTION-During the first six months a consumer is 65 or older and enrolled in Medicare Part B. How does the Medicare Advantage Out-of-Pocket (OOP) maximum work? 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. 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. 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. SOLUTION- Which of the following statements is true about a Medicare Supplement Insurance Plan member who wants to enroll in an MA Plan? 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. When a member enrolls in the MA Plan their current Medicare Supplement
Insurance Plan will automatically cancel. The member must submit a written request to cancel their Medicare Supplement Insurance Plan the same day they submit their MA Plan enrollment application. The member should not cancel their Medicare Supplement Insurance Plan because Medicare Supplement Insurance can be used in conjunction with an MA Plan. SOLUTION-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. Which of the following best defines Medicare Part D? It is a government program, offered only through a private insurance company or other private company approved by Medicare, which provides hospitalization
B
Aside from a stand-alone Medicare Prescription Drug Plan, how else could a Medicare- eligible consumer get Part D prescription drug coverage? They could sign up for a pharmacy savings card through their local pharmacy. There is no other way a Medicare consumer could get Part D prescription drug coverage. They could enroll in a Medicare Supplement Insurance Plan. They could enroll in a Medicare Advantage Plan or other Medicare health plan that includes prescription drug coverage. SOLUTION-They could enroll in a Medicare Advantage Plan or other Medicare health plan that includes prescription drug coverage. Which of the following statements does not correctly define prescription drug stages? 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. Initial coverage is the stage when the plan pays part and the member pays part, usually as coinsurance or copayments. A deductible is the amount the member must pay for every prescription medication, regardless of what stage they are in.
The coverage gap ends when the member has spent $6,550 (in 2021) in out-of- pocket expenses for the plan year. SOLUTION-A deductible is the amount the member must pay for every prescription medication, regardless of what stage they are in. Which of the following options are drug utilization management (UM) rules? (Select 3 SOLUTION-Quantity Limit Prior Authorization Step Therapy 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 SOLUTION- 63 continuous days or more
If the consumer meets Guaranteed Issue criteria, he/she may be underwritten to determine his/her rate. During Medicare Supplement Open Enrollment, consumers will only be required to answer the underwriting eligibility questions. SOLUTION-Underwriting is required if the consumer is not in his/her Medicare Supplement Open Enrollment period or does not meet Guaranteed Issue criteria. Which of the following is NOT true about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) impact to Plans C and F? 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. Consumers already enrolled in Plans C or F are required to change plans. 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. SOLUTION- Consumers already enrolled in Plans C or F are required to change plans.
Which of the following is true about Medicare Supplement Insurance Plans? They are regulated by the Centers for Medicare & Medicaid Services (CMS). Plan benefit amounts automatically update when Medicare changes cost sharing amounts, such as deductibles, coinsurance and copayments. To see a specialist, insured members must obtain referrals from a primary care physician. They can only be purchased during the Annual Election Period (AEP). SOLUTION-
