2014 - Qm - Mapd/Pdp Benefits

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  • 1/15 Questions

    When there is additional coverage in the Coverage Gap, do those tiers need to be read?

    • Yes, they must always be read
    • No, as long as they are the same as the Initial Coverage tiers
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About This Quiz

This 2014 quiz titled 'QM - MAPD\/PDP Benefits' evaluates understanding of MAPD and PDP benefit structures in healthcare insurance. It assesses the accuracy of benefit communication, focusing on key aspects like Coverage Gap, Catastrophic Coverage, and more, ensuring adherence to quality management standards.

2014 - Qm - Mapd/Pdp Benefits - Quiz

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  • 2. 

    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?

    • N/A. If it is a non-required benefit it does not matter.

    • Yes, the ADP did more than they were supposed to.

    • Minor, If the ADP/BA reads a non-required benefit, it must be read accurately.

    Correct Answer
    A. Minor, If the ADP/BA reads a non-required benefit, it must be read accurately.
    Explanation
    The correct answer is "Minor, If the ADP/BA reads a non-required benefit, it must be read accurately." This is because even though Home Health Care is a non-required benefit, it still needs to be read accurately by the ADP. The fact that the ADP read it incorrectly and did not correct themselves indicates a minor issue in their performance.

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  • 3. 

    If the ADP read the entire portion from the HMO-POS section, would QM score them down?

    • No. The ADP went above and beyond what they had to read and should not be marked down.

    • Yes. The ADP only has to read four benefits as listed in the definitions

    • No. As long as long as they read them all accurately.

    Correct Answer
    A. No. As long as long as they read them all accurately.
    Explanation
    If the ADP reads the entire POS section and reads everything correctly, the QM should score 25 as a Yes. If the ADP reads the entire POS section and reads a benefit that is outside the specified four benefits incorrectly, QM will score 26 as a Minor

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  • 4. 

    If the drug deductible is $0, the BA/ADP does not have to read it to the customer during the benefits section. 

    • True

    • False

    Correct Answer
    A. False
    Explanation
    All deductibles must be read during the benefits section regardless of the dollar amount.

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  • 5. 

    The ADP must read additional benefits from the Full Summary of Benefits on a HMO-POS plan. What are those benefits?

    • Chiropractic Services

    • Inpatient Hospital Care/Hospital Stays

    • Primary Care Physician

    • Ambulatory Surgical Center

    • Physician Specialist Services

    • Physical Therapy

    • Diagnostic Radiological Services

    • Ambulance Services

    Correct Answer(s)
    A. Inpatient Hospital Care/Hospital Stays
    A. Primary Care Physician
    A. Physician Specialist Services
    A. Ambulance Services
  • 6. 

    If there is a "No" in a copay field, then that drug tier does not need to be read.

    • True

    • False

    Correct Answer
    A. True
    Explanation
    The statement is explaining that if there is a "No" in a copay field, then there is no need to read that drug tier. This implies that if the copay field is marked as "No," it indicates that there is no copay required for that particular drug tier. Therefore, it is true that if there is a "No" in a copay field, the drug tier does not need to be read.

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  • 7. 

    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.

    • Yes, because benefits are not required to be read verbatim

    • Minor, because the ADP did not read 'Worldwide Coverage'

    • Yes, the ADP read the correct copay amount

    • Minor, because the ADP did not say 'immediately'

    • Minor, because the ADP did not say 'In-Network'

    Correct Answer
    A. Minor, because the ADP did not say 'immediately'
    Explanation
    The correct answer is "Minor, because the ADP did not say 'immediately'." This is because the original statement mentioned that if the individual is immediately admitted to the hospital, they would pay $0 for the emergency room visit. However, the ADP did not include the word "immediately" in their statement, which is a minor deviation from the original statement.

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  • 8. 

    What additional benefits must be read if the customer resides in a nursing home?

    • Home Health Care

    • Skilled Nursing Facility (SNF)

    • Long Term Care Pharmacy Drug Tiers

    • Outpatient rehabilitation services

    Correct Answer
    A. Long Term Care Pharmacy Drug Tiers
    Explanation
    If the customer resides in a nursing home, they must consider the additional benefits of Long Term Care Pharmacy Drug Tiers. This is because nursing home residents often require specialized medications and pharmacy services that are tailored to their long-term care needs. Long Term Care Pharmacy Drug Tiers provide coverage for medications specifically designed for long-term care patients, ensuring that the customer receives the necessary pharmaceutical support while residing in the nursing home.

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  • 9. 

    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?

    • Minor, because the ADP did not read 'Medicare-covered ambulance benefits'

    • Yes, because benefits do not need to be read verbatim

    • Minor, because the ADP was required to read both lines

    • C. Yes, because when there are two different copays or coinsurance listed, the ADP is only expected to read the first benefit

    Correct Answer
    A. Minor, because the ADP was required to read both lines
    Explanation
    The ADP would be marked Minor because the copay amounts are for air and ground.

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  • 10. 

    The headers for each benefit must be read prior to reading the benefit.

    • True

    • False

    Correct Answer
    A. False
    Explanation
    As long as there is a clear indication as to what the benefit pertains to, the headers do not need to be read. The only exception is Coverage Gap and Catastrophic Coverage. If those headers are not read, QM will coach the BA/ADP.

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  • 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?

    • Yes

    • Minor

    • N/A

    Correct Answer
    A. Yes
    Explanation
    The information in parenthesis is not required to be read.

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  • 12. 

    Out of the 16 line items in the Benefits section, how many can be scored as a Major?

    • None

    • One

    • Three

    • Sixteen

    Correct Answer
    A. One
    Explanation
    Only number 11 could be Majored. The remaining line items would only be scored as a Minor if marking down.

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  • 13. 

    The ADP did not read the headers for Coverage Gap and Catastrophic Coverage. How does QM score number 24?

    • Yes because headers do not need to be read

    • Minor because the ADP did not read the benefits verbatim

    • Yes and the ADP should be coached

    • N/A

    Correct Answer
    A. Yes and the ADP should be coached
    Explanation
    Check 2nd bullet under number 24: When reading the Coverage Gap and the Catastrophic Coverage benefits the verbiage must be read verbatim. If the ADP/BA does not read the headers for Coverage Gap and Catastrophic Coverage, this should be coached

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  • 14. 

    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:

    • Yes, benefits are not required to be read verbatim

    • Minor, because the ADP left out 'For Medicare-covered hospital stays:'

    • Minor, because the ADP said 'Days 11 - and beyond there is no copay' instead of '- Days 11 - 90: $0 copay per day'

    • Minor because the ADP said 'Days 1 - 10: $150 copay per stay' instead of '- Days 1 - 10: $150 copay per day'

    Correct Answer
    A. Minor because the ADP said 'Days 1 - 10: $150 copay per stay' instead of '- Days 1 - 10: $150 copay per day'
    Explanation
    Minor, because the ADP incorrectly stated 'Days 1 - 10: $150 copay per stay' instead of the correct statement '- Days 1 - 10: $150 copay per day'. The ADP omitted the word 'day' in the statement, which could potentially cause confusion for the reader. However, this error does not significantly impact the overall understanding of the information provided.

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  • 15. 

    The ADP did not read the Part B Premium statement in the PDP Summary of Benefits. How would number 13 be scored?

    • Yes

    • Minor

    • N/A

    Correct Answer
    A. N/A
    Explanation
    Since the ADP did not read the Part B Premium statement in the PDP Summary of Benefits, it means that the ADP did not have any information or response to provide for number 13. Therefore, the answer for number 13 would be marked as N/A, indicating that it is not applicable in this case.

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  • Current Version
  • Mar 19, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Jul 16, 2014
    Quiz Created by
    Bthorup
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