AHIP Medicare Advantage (Part C) 1 — Questions and Answers
Question 1: Medicare Advantage (Part C) plans are required to cover at minimum:
- Part A benefits only
- Part B benefits only
- All benefits covered under Original Medicare (Parts A and B) (Correct answer)
- Part A, B, and D benefits combined
Correct answer: All benefits covered under Original Medicare (Parts A and B)
Medicare Advantage plans must cover all services covered under Original Medicare Parts A and B.
Question 2: Which type of Medicare Advantage plan typically requires members to use a specific network of providers and get referrals?
- PPO
- HMO (Correct answer)
- PFFS
- SNP
Correct answer: HMO
HMO (Health Maintenance Organization) plans generally require members to use network providers and obtain referrals for specialist care.
Question 3: What is the maximum out-of-pocket (MOOP) limit for Medicare Advantage plans?
- There is no federal limit
- CMS sets an annual limit that plans cannot exceed (Correct answer)
- Plans may set any limit approved by their state insurance commissioner
- The MOOP matches the Original Medicare deductible
Correct answer: CMS sets an annual limit that plans cannot exceed
CMS establishes an annual MOOP limit for Medicare Advantage plans; individual plans may set lower limits but cannot exceed the CMS cap.
Question 4: Medicare Advantage plans receive payment from CMS in the form of:
- Fee-for-service reimbursement per claim
- A fixed monthly capitation payment per enrolled member (Correct answer)
- Annual lump-sum grants
- State Medicaid matching funds
Correct answer: A fixed monthly capitation payment per enrolled member
CMS pays MA plans a risk-adjusted monthly capitation (per-member per-month) payment.
Question 5: Which Medicare Advantage plan type serves specific populations such as people with chronic conditions or dual-eligible individuals?
- PPO
- PFFS
- SNP (Special Needs Plan) (Correct answer)
- MSA
Correct answer: SNP (Special Needs Plan)
Special Needs Plans (SNPs) are tailored for specific populations including dual-eligible beneficiaries, institutionalized individuals, or those with certain chronic conditions.
Question 6: A Medicare Advantage PPO plan differs from an HMO primarily because:
- PPOs do not cover Part B services
- PPOs allow members to see out-of-network providers, usually at a higher cost (Correct answer)
- PPOs require referrals for all specialist visits
- PPOs only operate in rural areas
Correct answer: PPOs allow members to see out-of-network providers, usually at a higher cost
PPO plans offer more flexibility by allowing out-of-network care, typically with higher cost-sharing than in-network visits.
AHIP Medicare Advantage (Part C) 1
Medicare Advantage (Part C) plans are required to cover at minimum: