Core Concepts
What is Medicare Part C and what does it cover?
Medicare Part C (Medicare Advantage) is offered by private companies and covers all Part A and Part B benefits; many plans also include Part D drug coverage and supplemental benefits.
How do HMO plans handle provider networks and referrals?
They generally require members to use in-network providers, select a primary care physician, and get referrals for specialists
What is an SNP?
A Medicare Advantage plan designed for specific populations with special healthcare needs.
Basic MA eligibility requirements?
Must have Part A and B, live in the service area, and be a U.S. citizen or lawfully present.
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bat
What are the main types of Medicare Advantage (MA) plans?
HMO, PPO, PFFS, and MSA plans
When can HMO enrollees receive out-of-network care?
For emergencies, urgent care, dialysis when traveling, or when services aren’t available in-network.
What is a D-SNP?
A plan for individuals eligible for both Medicare and Medicaid
List three types of cost sharing
Deductibles, copayments, and coinsurance.
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MAINE
What is a maximum out-of-pocket (MOOP) limit?
It is the maximum amount a member pays for Part A and B services before the plan covers 100% of
Key difference between HMO and PPO plans?
PPOs allow more flexibility to see out-of-network providers without referrals, while HMOs are more
Who qualifies for a C-SNP?
Individuals with specific chronic conditions like diabetes, cancer, or heart disease.
2025 MOOP limits?
2025 MOOP limits?
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Dunning-Kruger effect
What are supplemental benefits?
Extra benefits not covered by Original Medicare, such as vision, dental, and hearing services.
Explain Cost-sharing in PPO plans?
Members pay higher cost-sharing for out-of-network services compared to in-network care
Eligibility for an I-SNP?
Individuals needing or expected to need institutional-level care for 90+ days
Who is NOT eligible for an MSA plan?
Includes dual eligibles, those with other coverage paying deductibles, hospice patients, and certain
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Canada
How do MA plans differ from Original Medicare?
MA plans are provided by private insurers, often include networks, may offer extra benefits, and include a MOOP limit, unlike Original Medicare
Features of a PFFS plan?
Members can see any provider who accepts plan terms; no required network, but providers must
Three main types of SNPs?
C-SNP, I-SNP, and D-SNP.
Why can’t an HMO enrollee without drug coverage enroll in a PDP?
Because HMO/PPO MA enrollees must get drug coverage through their MA plan, not a standalone
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Mali Empire