2015 Health Alliance - Il Private Exchange Exam - Medicare

Health Alliance Medicare received a CMS Star Rating of 4.5 stars on their HMO plan. This indicates that their plan has a high level of quality and performance, as CMS Star Ratings are used to assess the overall performance and quality of Medicare Advantage and Part D plans. A rating of 4.5 stars suggests that Health Alliance Medicare's HMO plan has excelled in various areas, such as member satisfaction, preventive services, managing chronic conditions, and customer service. This high rating demonstrates their commitment to providing excellent healthcare services to their members.

The correct answer is "All the above" because the Choice90Rx program allows members to receive a 90-day supply of certain drugs at two copayments for a 90-day supply at Walmart and Sam's (preferred pharmacy), as well as three copayments for a 90-day supply at any other contracted pharmacies. This means that members have the option to choose between Walmart and Sam's or any other contracted pharmacy to receive their 90-day supply, with different copayment options available.

Medicare Advantage members have the right to file an appeal or grievance if they are dissatisfied with their plan. This means that if they have any concerns or issues with the coverage or services provided by their plan, they can formally request a review or resolution. Filing an appeal or grievance allows members to seek a fair and unbiased assessment of their concerns and potentially receive a resolution or change in their plan's coverage. Therefore, the statement that Medicare Advantage members have rights to file an appeal or grievance for any level of dissatisfaction with a plan is true.

The correct answer accurately reflects the pharmacy copayments for the HMO 20 plan in 2015. It states that there is a brand deductible of $220, and then provides the specific copayments for each tier. Tier 1 has a $0 copayment at Walmart and a $10 copayment at other pharmacies. Tier 2 has a $33 copayment, Tier 3 has a $45 copayment, Tier 4 has a $95 copayment, and Tier 5 has a 27% copayment.

Health Alliance Medicare does not have a yearly medical deductible on both the HMO and PPO plans. This means that members of Health Alliance Medicare do not have to pay a certain amount of money out of pocket for medical expenses before their insurance coverage begins. Therefore, the statement "True" is correct.

The correct answer is $100. This means that for both in-network and out-of-network ambulance services, there is a copayment of $100. This copayment is a fixed amount that the insured person is responsible for paying out of pocket for each ambulance service they receive, regardless of the total cost of the service.

Health Alliance Medicare has a closed formulary for all Part D individual plans. This means that they have a specific list of covered medications for their Part D individual plans, and any medications not on this list may not be covered. This closed formulary helps to control costs and ensure that members have access to necessary and effective medications.

An individual beneficiary cannot enroll in both a Medicare Advantage HMO plan and a different plan's PDP (Prescription Drug Plan) at the same time. Medicare Advantage plans, including HMOs, typically include prescription drug coverage, so enrolling in a separate PDP would not be necessary. Therefore, the statement is false.

The correct answer is $75.90. This is the monthly premium for the Basic PDP plan.

The correct answer is $5,050 because the out-of-pocket maximum is the maximum amount that an individual will have to pay for covered healthcare services in a given year. Once this amount is reached, the insurance plan will cover 100% of the remaining costs for covered services. Therefore, on the HMO Basic plan option, the out-of-pocket maximum is $5,050.

The statement is false because the HMO 20 plan does not have a deductible. This means that the plan does not require the insured individual to pay a certain amount of money out of pocket before their insurance coverage kicks in.

The Specialty Office Visit copayment on PPO10 in-network is $30. This means that individuals with PPO10 insurance will have to pay $30 out of pocket for each specialty office visit that they have within their network. This copayment amount is higher compared to the other options given, indicating that individuals will have to pay a higher fee for specialty office visits on this insurance plan.

The correct answer is $175 a day for days 1-7. This means that for the first seven days of hospitalization, the copayment amount is $175 per day. This copayment is applicable for each day of the hospital stay within the first week.

Beneficiaries who want both Medicare Advantage HMO or PPO and Medicare Part D must enroll in both with the same company. This means that if a beneficiary chooses a specific company for their Medicare Advantage plan, they must also select the same company for their Medicare Part D prescription drug coverage. This requirement ensures that the beneficiary receives coordinated and integrated healthcare services from a single provider. Choosing different companies for these two plans may result in fragmented and less efficient healthcare coverage.

The explanation for the given correct answer is that according to Medicare rules, a beneficiary is only allowed to be enrolled in one Medicare Advantage/Part D plan at a time. If they successfully enroll in a new plan, their previous enrollment in another Medicare health plan or prescription drug plan will automatically be terminated. This ensures that beneficiaries do not have overlapping coverage or receive duplicate benefits from multiple plans. Therefore, the statement is true.