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2019AnnualCertification
MedicareBasicsandBeneficiaryRightsCourse
Updated
June29,2018
WelcometoSilverScriptUniversityȱ
MedicarePartDprescriptiondrugplans.
abouttheproductstheysell. certificationprogram. withquestionsonwhatyouhavelearned. tothenextcourse.
Onceyoupassallcourses:
midͲSeptember).
WelcometoSilverScriptUniversity
readytosupportyou. der Reference
Materialsforyourreference.
Inadditiontoth
agentorbrokerislicensed.
CourseObjective
OverviewofMedicare
OverviewofMedicareAdvantageHealthPlans
OverviewofOtherPlanTypes
OverviewofMedicaid
OverviewofMedigap
BeneficiaryRights
MedicarePartsandCoveredServices
kidneytransplant). There are4differenttypesofMedicare:
PartA,PartB,PartCandPartD
services. benefitsandservicesforanextracost.
MedicarePartD(Me
DescriptionsofMedicareOptions
feeͲforͲservicepaymentsystem
Runbythefederalgovernment
CoversPartAandBservicesandusuallypr
escription drugcoverage
Runbyprivateinsurancecompanies
MedicarePartD(MAͲPDsandPDPs)
MedicareBasics:
SomePeopleGetPartAandPartBAutomatically
monththeyturn65.
Ifthebirth
priormonth.
Under65andhaveadisability.
Securityorcer
tain disabilitybenefitsfromtheRRBfor24months.
PeopleautomaticallygetPartA.
IftheywantpartB,theyneedtosignupforit.
MedicareBasics:
SomePeopleNeedToSignUpForPartAandPartB
PeopleneedtosignupforPartAandPartBif:
MedicareBasics:
SomePeopleNeedToSignUpForPartAandPartB
WhentheyfirstgetMedicare
y havePartBandcouldhaveagapin theirhealthcoverage.
BetweenJanuary1ͲMarch31eachyear
ec ialEnrollmentPeriod(seebelow), year.
Specialcirc
umstances(SpecialEnrollmentPeriods)
Theyalsohavean8ͲmonthSEPtosignupfo
r PartAand/orPartBthatstartsthemonth penaltyiftheysignupduringanSEP.
MedicarePartAPremiums
amountfor2019.
Individualswhoareu
nder age65cangetPartAwithouthavingtopaypremiumsiftheperson: monthofdisabilitybenefits).
Isakidneydial
ysisorkidneytransplantpatient.
PeoplepayapremiumeachmonthforPartB.
payment.
Iftheirmodifiedadj
Amount
The standardPartBpremiumamountin2
018 is$134(orhigherdependingonincome).
Peoplewillpayadifferentamountif:
TheyenrollinPartBforthefirsttimein2018.
Theydon'tgetSocialSecuritybenefits.
TheyhaveMedicareandMe
dicaid, andMedicaidpaysthepremiums. above acertainamount. There isaPartBdeductibleandcoinsurance.
Peoplepay$183fortheirPartBdeductible.
Afterthedeductibleismet,peop
le typicallypay20%oftheMedicareͲapprovedamountfor
OverviewofMedicareAdvantagePlans
plan. servicesprovided.
AllMAplansmust:
CoverallPartAandPartBbenefits.
B, butmaybedifferentforspecificservices.
Includeanan
PartAandPartBservices.
MedicareAdvantagePlanTypes
There ude PartD) There areothertypesofMedicarehealthplans.
DemonstrationandPilotprograms
HealthMaintenanceOrganizations(HMOs)
Includesanetworkofproviders.
out
Membermustselectaprimarycarephysician.
PlancoversMed
icare
PartAandPartBservices.
Someplanscoverprescriptiondrugs.
out
ͲofͲareadialysis).
highercost.
Areprescriptiondrugscovered?
offersprescriptiondrugcoverage.
Domembersneedtochooseaprimarycaredoctor?
Checkwiththeplanformoreinformation.
mustchooseanotherdoctorintheplan. servicewhenneeded.
Checkwiththeplanformoreinformation.
Arepres
criptiondrugscovered? offersprescriptiondrugcoverage.
Domembersneedtochooseaprimarycaredoctor?
No.
Inmostcases,no.Che
ckwiththeplanformoreinformation. topa yextraforthesebenefits.
IfMedicarebeneficiariesjoinaPFFSpla
n thathasanetwork,themembercanalsoseeanyofthe network out
Arepres
criptiondrugscovered?
Domembersneedtochooseaprimarycaredoctor?
No. No. Wha ifthey'veneve r seenthememberbefore. evenifthey'veseenthememberbefore.
SpecialNeedsPlans(SNP)GeneralDetails
hospitals dialysis).
Areprescriptiondr
ugs covered?
Domembersneedtochooseaprimarycaredoctor?
Generally,yes.
Checkwithth
eplanformoreinformation. e eligibleforboth membership.
PlansbutarestillpartofMedicare.
PartDprescrip
Plans.
deductibles.
Memberscanleaveanytimeandre
turn toOriginalMedicare.
OtherTypesofMedicareHealthPlansͲPACE
PlansbutarestillpartofMedicare.
PartDprescrip
Plans.
ma inin thecommunity.
Be55orolder.
LiveintheserviceareaofaPACEorganization.
services homestayswhenevernecessary. care portionofthePACEbenefit.
OtherTypesofMedicareHealthPlansͲ
MedicareInnovationProjects
PlansbutarestillpartofMedicare.
PartDprescrip
Plans.
specificareas.
WhatareMedicareAdvantageplans?
companiesthatMedicareapproves. d icarebuttheygettheirPartAand providers. urgentcare. hospice membersenrolledinaMedi careAdvantageplan. andwellnessprograms. dicare
Advantageplan.
MedicareAdvantageplans.
ornonͲurgentcare).
Theserulescanchangeeachyear.
year.
DifferentTypesofMedicareAdvantagePlans
HealthMaintenanceOrganization(HMO)plans
doctorsorspecialists.
PreferredProviderOrganization(PPO)plans
belongtotheplan'snetwork.
PrivateFeeͲforͲService(PFFS)plans
andhowmuchmembersmustpaywhentheygetcare.
SpecialNeedsPlans(SNPs)
conditions.
DifferentTypesofMedicareAdvantagePlans
HMOPointͲofͲService(HMOPOS)plans
highercopaymentorcoinsurance.
MedicalSavingsAccount(MSA)plans
MSAplansdon'tofferMedicaredrugcoverage.
MedicareAdvantageConsiderations
thecostsmaybe.
Membersmustfollowplanrules.
responsibilities. d PPOs. services.
Oncemembersreachthislimit,the
y willpaynothingforcoveredservices.
JoiningandLeavingaMedicareAdvantagePlan
theirInitialEnrollmentPeriod.
MedicareAdva
requestbyDecember7. is period,they request. e ir
MedicareAdvantageplan.
g coverageandthe
MedicareAdvantagePlanCosts
u ctiblesforcertainservices.
ProviderOrga
membergoesoutͲofͲnetwork). (Medigap) care medicalcarewhenyoutraveloutsidetheU.S..
Medicare
Medigappoliciesarestandardized.
throughD,FthroughG,andKthroughN. theycankeepit.
Allpoliciesoff
e rthesamebasicbenefits,butsomeofferadditionalbenefitssopeoplecan choose whichonemeetstheirneeds. differentway. (Medigap)
ImportantFacts
(Part D).
MembersmusthavePartAandPartB.
Memberspaytheprivateins
e costscanvaryandmaygoupaspeopleget (Medigap)
WhentoBuy
Afterth
is enrollmentperiod,peoplemaynotbeabletobuyaMedigappolicy.
Ifpeopleareabletobuyone,itmaycostmore.
theysignupfo rPartB. under65.
OverviewofMedicaid
andresourcesandmeetotherrequirements. e irhealthcarecostscovered. (like anHMOorPPO). thatMedicaredoesn'tcover.
Theymaygetcoverag
e forservicesthatMedicaremaynotormaypartiallycover,likenursing
MedicaidQualifications
Medicaidprogramsvaryfromstatetostate.
caid inthepast,theymayqualifyunderthenew rules.
GeneralProvisionsofPrescriptionDrugPlans
th t itback. dependents.
JoiningandLeavingaMedicareDrugPlan
theirInitialEnrollmentPeriod. e General requestbyDecember7.
AtanytimeifpeoplequalifyforExtraHelp.
Inmostcases,membersmuststayenrolledfo
rthecalendaryearstartingthedatetheir onceduringthetimeframe.
MedicareDrugPlanCosts
Actualdrugplancostsvarydependingon:
Theplan.
out
ͲofͲnetwork,ormailorder).
Monthly
Premium
anamo unt forprescriptiondrugcoverage.
YearlyDeductible
CopaymentsorCoinsurance
amountsmayvary.
MedicareDrugPlanCostsͲCoverageGap
CoverageGap
amountforcovereddrugs. e red endofthecoveragegap.
Whatmemberspayinthecoveragegap.
gettingyououtofth e coveragegap. discounts 2020.
CoverageGapCostSharing
On thepathtoa25%costshare. • Generic cost share will drop to 37% in 2019 • Brand cost share will drop to 25% in 2019
Catastrophic
Coverage
drugsfortherestoftheyear.
Usually,th
e amountmemberspayforacoveredprescriptionisforamonth'ssupplyofadrug. refillsforalltheirmedications. get.
MedicarePartDServiceAreas
Itisimportanttonotethatanindividual:
Isrequiredtohavetheirper
theplan.
MedicarePartDStandardBenefitParameters
Source: Advance Notice of Methodological Changes for Calendar Year (CY) 2019 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2019 Call Letter andTotalDrugSpend
Applies
towardTrOOP
Deductibleifpaidbybeneficiaryor
qualifiedthirdparty(suchasSPAPs)
CoͲpaymentsorcoͲinsurancemadebythe
beneficiary
CoͲpaymentsorcoͲinsurancemadebya
qualifiedthirdparty(suchasSPAPs)on behalfofthebeneficiary
Lowincomesubsidyamounts
Moneyspentoutofpocketwhileinthe
CoverageGapifpaidbybeneficiaryor
qualifiedthirdparty(suchasSPAPs) Does notapplytowardTrOOP
Premiumpayments
Paymentsmadebygrouphealthplans,
insurers,governmentfundedhealth programs,orsimilarthirdparties(except forSPAPs)
Moneyspentondrugsnotcoveredby
MedicarePartD(excludeddrugs)
FormularyandFormularyRequirements
totreattheirconditions. g sbuttheydonotcoverOTCdrugsexceptas ug sforerectiledysfunction. excluded drugs.Forexample,aPartDdrugmustbeapr escribed drug,purchasedinUS,not coveredunderPartB. can drugsinsixclasses:antiͲps yc hotics,antiͲdepressants,antiͲconvulsants,immunosuppressants,cancer, andHIV/AIDSdrugs. (EOB) costs.
PartDExcludedDrugs
NonͲprescriptiondrugs.
BenzodiazepinesandBarbiturates.
SexualandErectileDysfunctiondr
ugs (exceptwhenusedforotherFDAapprovedusesuchas pulmonaryhypertension). drugsarecoveredaspartofanenhancedplan.
CostͲSharingTiers
Thecostsharingforeachtierisdifferent.
ug inahighertier. thatissafeandeffectivewillbeavailable.
ImportantDrugCoverageRules
Prior authorization prescriptions. it.
Quantitylimits
Steptherapy
prescribeddrug. The waived,memberscanaskforanexception.
TemporarySupplyandTransitionFillProcess
vs.PartDdrugsorPartBonlydrugs.
NewlyEnrolledin
PlanIncludes,notnecessarilylimitedto:
NewfollowingAEPorSEP
NewlyeligibleMedicare
beneficiaryfromother coverage
Switchingfromoneplanto
anotherafterstartofcontract year-evenundersame contract
ID Retail:30cumulativedayswithinfirst90
daysinnewpl an (ordefaultstoplansetup)
LTCand/orLICSIII:34daysperfill(lessas
written)cumulativetominimum91daysand maximum102days/first90days(ordefaults toplansetup)
LTC:14daysperfill(lessaswritten)oral
solidbrandscumulativetomaximum102days
RenewingMember
-acrossplan contractquotesdbs_dbs14.pdfusesText_20
[PDF] Insurance Handbook Chapter 12 Quizlet - 3CX