Eligibility
At what age do most individuals become eligible for Medicare?
Age 65
What part of Medicare must you actively enroll in if not automatically enrolled at 65?
Medicare Part B
What does Medicare Part A generally cover?
Hospital stays, skilled nursing, hospice, some home health
What is a deductible?
The amount you pay before coverage begins
What is prior authorization?
Approval from the plan before receiving certain services
True or False: Individuals under 65 can qualify for Medicare due to disability.
True
What happens if someone misses their Initial Enrollment Period?
May face late enrollment penalties and coverage delays.
What does Medicare Part B generally cover?
Doctor visits, outpatient care, preventive services, durable medical equipment
What is coinsurance?
A percentage of costs you pay after reaching the annual deductible
True or False: All services require prior authorization under Medicare Advantage.
False – only specific services require it
What type of work history is typically required to qualify for premium-free Part A?
10 years (40 quarters) of work paying Medicare taxes
What is one way to enroll in an Aetna Medicare Advantage plan?
By visiting AetnaMedicare.com, calling Aetna directly, or working with a licensed agent.
What is the purpose of Medicare Advantage (Part C)?
Combines Parts A and B, often includes Part D and extra benefits
What is the difference between in-network and out-of-network cost sharing?
In-network usually costs less; out-of-network may have higher costs or no coverage
Who is responsible for obtaining prior authorization—member or provider?
The provider
Name one condition that qualifies someone for Medicare before age 65.
End-stage renal disease (ESRD).
What is the difference between Open Enrollment and Special Enrollment Periods?
Open Enrollment is annual; Special Enrollment is triggered by life events
Name one benefit that Medicare Advantage may offer that Original Medicare does not.
Dental, vision, hearing, fitness programs
True or False: Medicare Advantage plans have a maximum out-of-pocket limit.
True
What happens if a provider does not obtain required prior authorization?
Claim may be denied; member may be responsible for full cost
What government agency determines Medicare eligibility?
Social Security Administration
What is the difference between enrolling in Original Medicare and Medicare Advantage?
Original Medicare includes Parts A and B; Medicare Advantage (Part C) is offered by private insurers and may include additional benefits like Part D, dental, or vision
What is the difference between preventive and diagnostic services under Medicare?
Preventive services are routine screenings; diagnostic services investigate symptoms
What is the impact of using a non-participating provider?
Member may pay full cost; provider may bill member directly
What is the difference between a referral and prior authorization?
Referral is permission to see a specialist; PA is approval for a specific service