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UHC ETHICS AND COMPLIANCE EXAM 2025-2026|
ACTUAL QUESTIONS AND ANSWERS|GRADED A+
Joseph has Original Medicare and was a patient in the hospital last week. What part of Medicare helps cover the costs of his inpatient hospital stay? ANS:->>>Part A.The consumer must be in a valid MA election or disenrollment period. Which of the following consumers would be eligible for Medicare? ANS:->>> Consumers age 65 or older, consumers under 65 years of age with certain disabilities for more than 24 months and consumers of all ages with ESRD or ALS Which of the following defines a Medicare Advantage (MA) Plan? ANS:-
MA Plans are health plan options approved by Medicare and offered by private insurance companies. Janice wants to enroll in a 2021 Medicare Advantage plan. What eligibility requirements must she meet? (Select the two answers that
apply.) ANS:->>>Not have End Stage Renal Disease (permanent kidney failure)Reside in the plan's service area What must be explained to consumers enrolling in an HMO (Health Maintenance Organization) MA Plan? (Select 3) ANS:->>> Which of the following are MA Plans that focus on using network providers to maximize the benefits and reduce out-of-network expenses? ANS:->>>HMO, POS, PPO Which is true about Medicare Supplement Open Enrollment? ANS:-
By federal law, Medicare Supplement Open Enrollment is the first 6 months a consumer is 65 or older and enrolled in Medicare Part B. How does the Medicare Advantage Out-of-Pocket (OOP) maximum work? ANS:->>> The OOP maximum is a feature that limits the amount of money a consumer will have to spend on Medicare-covered health care services each year.
What are two options for Medicare consumers to get Part D prescription drug coverage (assuming they meet all eligibility requirements)? (Select 2) ANS:->>> Which of the following statements is not true about the Coverage Gap? ANS:->>>All members reach the Coverage Gap Which of the following options are drug utilization management (UM) rules? (Select 3) ANS:->>> Which of the following best describes the Late Enrollment Penalty (LEP)? ANS:->>> The amount added to the member's monthly plan premium if they did not enroll in a Medicare Advantage plan with Part D benefits or stand-alone prescription drug plan when they were first eligible for Medicare Parts A and/or B or went without creditable prescription drug coverage for 63 continuous days or more.
Through which means is financial assistance offered to a consumer who qualifies for Low Income Subsidy for their part of Medicare Part D costs? ANS:->>>Through subsidies such as lower or no monthly plan premiums and lower or no copayments Medications that are covered in a Plan's formulary have various levels of associated member cost-sharing (copayments or coinsurance). What are these drug levels called? ANS:->>>Drug tiers In states where Medicare Supplement Insurance underwriting criteria can apply, all of the following underwriting criteria apply EXCEPT: ANS:->>>Consumers may be underwritten to determine their acceptance and, if applicable, their rate. The new MACRA legislation, which went into effect January 1, 2020, applies to all carriers offering Medicare supplement plans. ANS:-
TRUE
The part of Medicare that offers combined medical and prescription drug coverage. The part of Medicare that helps with the cost of inpatient hospital stays. It also helps with hospice care and some skilled care for the homebound. The part of Medicare that helps with the cost of medically necessary doctor visits and other medical services, including outpatient care at hospitals and clinics, laboratory tests, some diagnostic screenings. ANS:->>>The part of Medicare that helps with the cost of inpatient hospital stays. It also helps with hospice care and some skilled care for the homebound. Which statement is true about a member of a Medicare Advantage (MA) Plan who wants to enroll in a Medicare Supplement Insurance Plan? When a consumer enrolls in a Medicare Supplement Insurance Plan,
he/she is automatically disenrolled from his/her MA Plan. A member does not need a valid election period to disenroll from an MA plan. When a consumer enrolls in a Medicare Supplement Insurance Plan, he/she is not automatically disenrolled from his/her MA Plan. A consumer can use a Medicare Supplement Insurance Plan and an MA Plan at the same time. ANS:->>>When a consumer enrolls in a Medicare Supplement Insurance Plan, he/she is automatically disenrolled from his/her MA Plan. Being 65 or older, being under 65 years of age with certain disabilities for more than 24 months, and being any age with ESRD or ALS are each eligibility requirements for which program? Medicaid Original Medicare Low Income Subsidy ANS:->>>Original Medicare To be eligible for this plan type, consumers must meet the
What must be explained to consumers enrolling in an HMO (Health Maintenance Organization) MA Plan? (Select 3) They must see contracted network providers in order to receive coverage under the plan. In most cases, they will pay the entire cost of the service if they see an out-of-network provider. Most benefits are covered out-of-network but at a higher cost. The exception to the provider network requirement is emergency visits, urgent care and renal dialysis services, which can be obtained from out-of-network providers. ANS:->>>In most cases, they will pay the entire cost of the service if they see an out- of-network provider. Most benefits are covered out-of-network but at a higher cost. The exception to the provider network requirement is emergency visits, urgent care and renal dialysis services, which can be obtained from out-
of-network providers. When does Medicare Supplement Open Enrollment take place? During the three months prior to the consumer's 65th birthday, the month of their birthday, and the three months following the month of their 65th birthday and enrolled in Medicare Part B. During the first six months a consumer is 65 or older and enrolled in Medicare Part B. Annually from October 15 to December 7. During the first three months a consumer is 65 or older and enrolled in Medicare Part B. ANS:->>>During the first six months a consumer is 65 or older and enrolled in Medicare Part B. How does the Medicare Advantage Out-of-Pocket (OOP) maximum work? The OOP maximum is a feature that limits the amount of money a consumer will have to spend on Medicare-covered health care services each year. The OOP maximum is a feature that limits the amount of money a
Medicare Supplement Insurance can be used in conjunction with an MA Plan. ANS:->>>Medicare Supplement Insurance cannot be used in conjunction with an MA Plan; therefore, after receiving confirmation of enrollment into the MA Plan, the member should submit to their Medicare Supplement Insurance carrier a written request to cancel his/her policy. Which of the following best defines Medicare Part D? It is a government program, offered only through a private insurance company or other private company approved by Medicare, which provides hospitalization coverage. It is a government program, offered only through a private insurance company or other private company approved by Medicare, which provides prescription drug coverage. It is a government program, offered only through a private insurance company or other private company approved by Medicare, which
provides medical and hospitalization coverage. It is a government program, offered only through a private insurance company or other private company approved by Medicare, which provides medical coverage. ANS:->>> It is a government program, offered only through a private insurance company or other private company approved by Medicare, which provides prescription drug coverage. Which of the following statements is true about eligibility requirements for Medicare Prescription Drug Plans? Consumers must live in the same zip code as the pharmacy they intend to use A consumer must be entitled to Medicare Part A and/or enrolled in Medicare Part B A consumer must receive a pension from a former employer Consumers do not need to live in the plan's service area ANS:->>>A consumer must be entitled to Medicare Part A and/or enrolled in Medicare Part B
medication, regardless of what stage they are in. The coverage gap ends when the member has spent $6,550 (in 2021) in out-of-pocket expenses for the plan year. ANS:->>>A deductible is the amount the member must pay for every prescription medication, regardless of what stage they are in. Which of the following options are drug utilization management (UM) rules? (Select 3 ANS:->>>Quantity Limit Prior Authorization Step Therapy A consumer may have to pay a Late Enrollment Penalty (LEP) if they did not enroll in a Medicare Advantage plan with Part D benefits or stand-alone prescription drug plan when they were first eligible for Medicare Parts A and/or B or went without creditable prescription drug coverage for ANS:->>>63 continuous days or more
Through which means is financial assistance offered to a consumer who qualifies for Low Income Subsidy for their part of Medicare Part D costs? Through a combination of subsidies and annual refund checks Through subsidies such as lower or no monthly plan premiums and lower or no copayments Such financial assistance will no longer be available as of January 1, 2020 By receiving annual checks with a refund based on a predetermined percentage of Part D costs ANS:->>>Through subsidies such as lower or no monthly plan premiums and lower or no copayments Medications that are covered in a Plan's formulary have various levels of associated member cost-sharing (copayments or coinsurance). What are these drug levels called? ANS:->>>Drug tiers Which of the following is true about Medicare Supplement Insurance
Consumers eligible for Medicare Part A before January 1, 2020, can enroll in Plan C or F even after 2020 and can keep their plans as long as they choose. ANS:->>> Consumers already enrolled in Plans C or F are required to change plans. Which of the following is true about Medicare Supplement Insurance Plans? They are regulated by the Centers for Medicare & Medicaid Services (CMS). Plan benefit amounts automatically update when Medicare changes cost sharing amounts, such as deductibles, coinsurance and copayments. To see a specialist, insured members must obtain referrals from a primary care physician. They can only be purchased during the Annual Election Period (AEP). ANS:->>>
