2014 - Qm - Mapd/Pdp Benefits

15 Questions | By Bthorup | Updated: Mar 19, 2022 | Attempts: 228

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Summary of Benefits for MAPD/PDPs

Questions and Answers

1.

The ADP did not read the headers for Coverage Gap and Catastrophic Coverage. How does QM score number 24?
- A.
  
  Yes because headers do not need to be read
- B.
  
  Minor because the ADP did not read the benefits verbatim
- C.
  
  Yes and the ADP should be coached
- D.
  
  N/A
2.

The ADP must read additional benefits from the Full Summary of Benefits on a HMO-POS plan. What are those benefits?
- A.
  
  Chiropractic Services
- B.
  
  Inpatient Hospital Care/Hospital Stays
- C.
  
  Primary Care Physician
- D.
  
  Ambulatory Surgical Center
- E.
  
  Physician Specialist Services
- F.
  
  Physical Therapy
- G.
  
  Diagnostic Radiological Services
- H.
  
  Ambulance Services
3.

The ADP read the information for Home Health Care in the Brief Summary of benefits and read it incorrectly. The ADP did not correct himself. How would QM score number 26?
- A.
  
  N/A. If it is a non-required benefit it does not matter.
- B.
  
  Yes, the ADP did more than they were supposed to.
- C.
  
  Minor, If the ADP/BA reads a non-required benefit, it must be read accurately.
4.

If the ADP read the entire portion from the HMO-POS section, would QM score them down?
- A.
  
  No. The ADP went above and beyond what they had to read and should not be marked down.
- B.
  
  Yes. The ADP only has to read four benefits as listed in the definitions
- C.
  
  No. As long as long as they read them all accurately.
5.

The ADP did not read the Part B Premium statement in the PDP Summary of Benefits. How would number 13 be scored?
- A.
  
  Yes
- B.
  
  Minor
- C.
  
  N/A
6.

Out of the 16 line items in the Benefits section, how many can be scored as a Major?
- A.
  
  None
- B.
  
  One
- C.
  
  Three
- D.
  
  Sixteen
7.

What additional benefits must be read if the customer resides in a nursing home?
- A.
  
  Home Health Care
- B.
  
  Skilled Nursing Facility (SNF)
- C.
  
  Long Term Care Pharmacy Drug Tiers
- D.
  
  Outpatient rehabilitation services
8.

If the drug deductible is $0, the BA/ADP does not have to read it to the customer during the benefits section.
- A.
  
  True
- B.
  
  False
9.

If there is a "No" in a copay field, then that drug tier does not need to be read.
- A.
  
  True
- B.
  
  False
10.

When there is additional coverage in the Coverage Gap, do those tiers need to be read?
- A.
  
  Yes, they must always be read
- B.
  
  No, as long as they are the same as the Initial Coverage tiers
11.

Here is the verbiage for Catastrophic Coverage:Catastrophic CoverageAfter your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:-5% coinsurance, or- $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.The BA/ADP did not read (including brand drugs treated as generic). How should QM score number 24?
- A.
  
  Yes
- B.
  
  Minor
- C.
  
  N/A
12.

Ambulance benefits are shown in the SSC as:In-Network40% of the cost for Medicare-covered ambulance benefits$125 copay for Medicare-covered ambulance benefitsThe ADP only read "40% of the cost for ambulance benefits". How should QM score number 19?
- A.
  
  Minor, because the ADP did not read 'Medicare-covered ambulance benefits'
- B.
  
  Yes, because benefits do not need to be read verbatim
- C.
  
  Minor, because the ADP was required to read both lines
- D.
  
  C. Yes, because when there are two different copays or coinsurance listed, the ADP is only expected to read the first benefit
13.

Number 17, Inpatient Hospital CareIn-NetworkNo limit to the number of days covered by the plan each hospital stay.For Medicare-covered hospital stays:- Days 1 - 10: $150 copay per day- Days 11 - 90: $0 copay per day$0 copay for each additional non-Medicare-covered hospital day.Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.ADP read:In-NetworkNo limit to the number of days covered by the plan each hospital stay.- Days 1 - 10: $150 copay per stay- Days 11 - and beyond there is no copay$0 copay for each additional non-Medicare-covered hospital day.Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.Select the correct answer on how this should be scored:
- A.
  
  Yes, benefits are not required to be read verbatim
- B.
  
  Minor, because the ADP left out 'For Medicare-covered hospital stays:'
- C.
  
  Minor, because the ADP said 'Days 11 - and beyond there is no copay' instead of '- Days 11 - 90: $0 copay per day'
- D.
  
  Minor because the ADP said 'Days 1 - 10: $150 copay per stay' instead of '- Days 1 - 10: $150 copay per day'
14.

The headers for each benefit must be read prior to reading the benefit.
- A.
  
  True
- B.
  
  False
15.

Number 20, Emergency Care:In-Network$50 copay for Medicare-covered emergency room visitsWorldwide coverage.If you are immediately admitted to the hospital, you pay $0 for the emergency room visit.How should number 20 be scored if the ADP read: $50 copay for Medicare-covered emergency room visitsIf you are admitted to the hospital, you pay $0 for the emergency room visit.
- A.
  
  Yes, because benefits are not required to be read verbatim
- B.
  
  Minor, because the ADP did not read 'Worldwide Coverage'
- C.
  
  Yes, the ADP read the correct copay amount
- D.
  
  Minor, because the ADP did not say 'immediately'
- E.
  
  Minor, because the ADP did not say 'In-Network'