Nurse Executive Certification Practice Exam

What is required for services under a Medicare Advantage Plan?

1. Preapproval for all treatments

2. No restrictions on provider choice

3. Immediate coverage without documentation

4. Unlimited specialist appointments

The correct answer is: Preapproval for all treatments

For services under a Medicare Advantage Plan, obtaining prior authorization or preapproval for certain treatments or services can be a requirement. This is a standard procedure in many managed care models, including Medicare Advantage, which helps ensure that the services being requested are necessary and meet the coverage criteria established by the plan. The preapproval process aids in managing costs and directing patients to appropriate care while ensuring adherence to the plan's network guidelines. In contrast, the other options reflect common misconceptions about Medicare Advantage Plans. For instance, while these plans often provide a network of providers, they typically do impose restrictions on provider choice, especially regarding out-of-network providers, which often require higher out-of-pocket costs or may not be covered at all. Immediate coverage without documentation generally does not apply as claims and treatment requests often need to be substantiated, especially for specific services. Furthermore, Medicare Advantage Plans usually have limitations on the number of specialist appointments, often necessitating a referral from a primary care provider. Understanding these aspects helps clarify the operational framework of Medicare Advantage Plans and the rationale for preapproval as a component of their service delivery model.