AHIP - Final examination Questions and Answers

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Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. W... hat could you tell him to do? - ANSWER Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan. Mr. Polanski likes the cost of an HMO plan available in his area, but would like to be able to visit one or two doctors who aren't participating providers. He wants to know if the Point of Service (POS) option available with some HMOs will be of any help in this situation. What should you tell him? - ANSWER The POS option might be a good solution for him as it will allow him to visit out-of-network providers, generally without prior approval. However, he should be aware that it is likely he will have to pay higher cost-sharing for services from out-of-network providers. Mr. Barker had surgery recently and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included a number of services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? - ANSWER You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is interested in that product. She wants to be sure she also has coverage for prescription drugs. Would she be able to obtain drug coverage if she enrolled in the SNP? - ANSWER a. Yes. All SNPs are required to provide Part D coverage for prescription drugs. b. Yes, but only if she qualifies for Part D prescription drug coverage under her state Medicaid program. c. No. Medicare beneficiaries who enroll in an SNP must always obtain their drug coverage through a stand-alone Part D Medicare prescription drug plan that they sign up for independent of their enrollment in the SNP. d. Maybe. Some SNPs offer Part D coverage for prescription drugs and some do not. = ????? Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare's efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment site, which of the following must Phiona consider? - ANSWER II. All data elements required to complete an enrollment request must be captured. III. The process must include a clear and distinct step that requires the applicant to activate an "Enroll Now" or "I Agree" type of button or tool. Ms. Lewis understands that Medicare prescription drug plans may use various methods to control the use of specific drugs. She has heard about a technique called "step therapy" and is wondering if you can explain what that is. What should you tell her? - ANSWER Step therapy involves using one or more lower priced drugs before trying a more expensive drug when all are used to treat the same condition. Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him? - ANSWER He may receive health care services from ANY doctor allowed to bill Medicare, as long as he shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing. Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-income subsidy. Where might he turn for help with his prescription drug costs? - ANSWER Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program. You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA) plans you represent. Before you conduct such sales presentations, what must you do? - ANSWER Mr. Wong is a single individual. He has had a successful business career and is now able to retire with a comfortable income. Mr. Wong's taxable income is in excess of $100,000. Mr. Wong has health coverage through his employer but will sign-up Medicare Part A, Part B and Part D when he leaves the workforce. How would you advise him as he budgets for Medicare premiums? - ANSWER a. Due to the provisions of MACRA, his Part B and D coverage will be combined and covered through a low-cost Medigap policy to supplement his Part A coverage. b. Due to his participation in the workforce he will not have to pay premiums for Part A and he will pay the lowest monthly premium rates for Part B and Part D. c. Due to his participation in the workforce he will not have to pay premiums for Part A but he will pay higher premiums for Part B and Part D due to the amount of his income. d. Due to his participation in the workforce he will not have to pay premiums for Part A and will pay reduced premiums for Part B and Part D. ????? Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services' communication and Marketing Guidelines to ensure he is compliant for which type of products? - ANSWER Medicare Advantage (MA) and Prescription Drug (PDP) plans Correct Ms. Hernandez has marketed several different types of insurance products in her home state and has typically sought approval of her materials from her State Department of Insurance. What would you advise her regarding seeking such approval for materials she uses to market Medicare Advantage plans? - ANSWER a. States often volunteer to review marketing materials on behalf of the Medicare agency. She should check with her Department of Insurance to see if such a review is available and would satisfy CMS requirements. b. Materials for marketing Medicare health plans to individuals are subject to Medicare's uniform national requirements. They do not need to be reviewed by the state, but the company she represents must obtain approval from the Medicare agency (CMS) for any materials she uses. c. Obtaining approval of her materials from the State Department of Insurance is a good practice and she should continue it with materials for the Medicare health plans she represents. d. Materials need only be reviewed and approved by the company(s) she represents. Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen with respect to her drug coverage? - ANSWER Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him? - ANSWER It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare. Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him? - ANSWER Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug coverage. What should you tell her about obtaining drug coverage? - ANSWER Medicare Advantage HMO or PPO may only obtain Part D benefits through their plan. They may not enroll in a standalone PDP. (Employer group plan enrollees may have additional choices.) Able, Baker, and Charles are engaged in the marketing to and enrollment of beneficiaries into Medicare health plans. Mr. Able is an independent agent paid directly by a health plan. Ms. Baker is an independent agent paid through a field marketing organization (FMO). Mr. Charles is an independent agent paid for his work by a third-party marketing organization (TMO). How do the CMS compensation rules apply to these three agents? - ANSWER Baker and Charles are subject to CMS compensation rules because they are paid by third parties. Able is not because she is paid directly by a health plan. Agent Willis had several clients who disenrolled from the plans he represents during the AEP to try new Medicare Advantage plans. Agent Willis believes that the choices they made are not ideal for them and would like to get their business back during the Medicare Advantage Open Enrollment Period (MA-OEP). What can agent Willis do? - ANSWER He can wait until October and send them information about the plans he represents. Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that plan. What should you tell him? - ANSWER SNPs limit enrollment to certain sub populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. Mrs. Patterson is a new enrollee in the HealthBest Medicare Advantage (MA-PD) plan. She is new to this type of coverage and asks you what materials, if any, she should expect to receive. How would you reply? - ANSWER 1. Plan ratings information, summary of benefits, and pre-enrollment checklist Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern? - ANSWER Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end stage renal disease or Lou Gehrig's disease, so she will be eligible for Medicare. Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same requirements as the plans themselves. How should you respond to such a statement? - ANSWER Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules. This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do? - ANSWER You may go ahead and call them. Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? - ANSWER Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan. - ANSWER I, II AND III ONLY Mr. Albert has heard about something called the Star Rating system for Medicare Advantage plans. He asks you to explain it to him since he is interested in enrolling in a plan that is newly available in his area. After you explain that it is the way for consumers to judge plan performance, what else would you say? - ANSWER ?????? Beneficiaries who live in the service area of a 5-star plan and are enrolled in an MA or PDP plan, or beginning in 2013, a Cost plan Beneficiaries who live in the service area of a 5-star plan, are enrolled in Original Medicare, and meet the eligibility requirements for Medicare Advantage or Part D plans The SEP is available each year beginning on December 8 and may be used once through November 30 of the following year. For example, the SEP for calendar year 2018 can be used from December 8, 2017 through November 30, 2018. Disenroll from an MA plan, PDP or Cost plan or leave Original Medicare Enroll in a 5-star MA plan, PDP or Cost plan Eligible individuals may enroll in a 5-star plan through 1-800-MEDICARE, Medicare.gov, or directly through the 5-star plan. Mr. Davies is turning 65 next month. He would like to enroll in a Medicare health plan, but does not want to be limited in terms of where he obtains his care. What should you tell him about how a Medicare Cost Plan might fit his needs? - ANSWER Cost plan enrollees can choose to receive Medicare covered services under the plan's benefits by going to plan network providers and paying plan cost sharing, or may receive services from non-network providers and pay cost sharing due under Original Medicare. Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage (MA) health plans. This year she has decided to focus on non-MA products. What advice would you give Melanie if she wishes to continue to receive renewal fees? - ANSWER Alice is enrolled in a MA-PD plan. She makes a permanent move across the country and wonders what her options are for continuing MA-PD coverage. What would you say to her in regard to a special enrollment period (SEP)? - ANSWER Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for Medicare as well. He is concerned about changes in his cost-sharing. What should you tell him? - ANSWER He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers. Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him? - ANSWER Formularies must be developed with input from pharmacists,doctors, and other experts. Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales presentation? - ANSWER A meal cannot be provided, but light snacks would be permitted. Mr. Jackson just turned 65. He has been seeing the same general practitioner for annual check-ups for the past 15 years, likes these yearly visits, and would like to continue obtaining these services as a Medicare beneficiary. What should you tell him about annual check-ups? - ANSWER Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her area. Ms. Levi often travels to visit relatives and is concerned that she may need emergency care outside of her plan's service area. What should you tell her about coverage of emergency care? - ANSWER Plans are required to cover out-of network emergency care. Which of the following individuals are likely to qualify for a special enrollment period (SEP) for both MA and Part D due to a change of residence? I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan's service area. II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's service area. III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area where no Part D plan was available. IV. Henry makes a permanent move providing him with new MA and Part D options. - ANSWER II, III, and IV only Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted with regard to the marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise him concerning the type of scrutiny he will be under? - ANSWER Organizations sponsoring Medicare health plans are responsible for the behavior of their contracted representatives and will be conducting monitoring activities to ensure compliance with all applicable Federal law and guidance and plan policies. Furthermore, state agent licensure laws are not preempted and he must abide by their requirements. Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to you for advice as to what options, if any, she has. What should you say regarding special enrollment periods (SEPs)? - ANSWER Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the fivestar plan. Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this? - ANSWER If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account, Mrs. Berkowitz can do this. Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a meeting so that she can learn about Medicare and the products you represent. How should you respond? - ANSWER Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan that includes drug coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him? - ANSWER Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep. Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of misusing or abusing frequently abused drugs? I. Identifying at risk individuals by using criteria that includes the number of opioid prescriptions the beneficiary has and the number of prescribers who have written those prescriptions. II. Locking an at-risk beneficiary into one pharmacy. III. Locking an at-risk beneficiary into one prescriber. IV. Increasing deductibles and copays for at-risk beneficiaries. - ANSWER I, II and III only. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - ANSWER Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation rules apply to this situation? - ANSWER This situation is considered a "dual enrollment" and CMS compensation rules are applied to the two plans at once and independently of each other. Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirements several years ago. Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the first time. Unfortunately, Mrs. Ridgeway has found that many of her providers are not in the MA plan's network. She has come to you for advice? What should you tell her? - ANSWER She qualifies for a special enrollment period (SEP) that will allow her to make a one-time election to return to Original Medicare and she also has a guaranteed eligibility period to rejoin her Medigap plan. This year you decide to focus your efforts on marketing to employer and union groups. Which of the following statements best describes what you can and cannot do in order to stay in compliance? - ANSWER You are not required to submit copies of disseminated materials to CMS at the time of use, but CMS may request and review copies if employee complains occur. Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her? - ANSWER Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him? - ANSWER He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him? - ANSWER If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Next week you will be participating in your first "educational event" for prospective enrollees. In order to be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage? Choose one answer. - ANSWER You should plan to ensure that the educational event is a social event, and must not conduct a sales presentation or distribute or accept enrollment forms at the event. Eleanor takes several high-cost prescription drugs. She would like to enroll in a standalone Part D prescription drug plan that is available in her area. In what type of Medicare Health Plan can she enroll if she also wishes to enroll in the standalone Part D plan? - ANSWER [Show More]

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