2022 Ahip Review UNIT 1 Medicare Basics Question 1 Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell h... im? a. Medicare covers all screening tests that have been approved by the FDA on a frequency determined by the treating physician. b.Medicare covers treatments for existing disease, injury, and malformed limbs or body parts. As such, it does not cover any screening tests and these must be paid for by the beneficiary out-of-pocket. c.Medicare covers some screening tests that must be performed within the first year after enrollment. Beyond that point expenses for screening tests are the responsibility of the beneficiary. d.Medicare covers the periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered. Source: Module 1, Slide - Medicare Part B Benefits - Preventive Services and Screenings Question 2 Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-forService (FFS) Medicare? What could you tell him? a.Part C, which always covers dental and vision services, is covered under Original Medicare. b.Part A, which covers hospital, skilled nursing facility, hospice, and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare. c.Part A, which covers long-term custodial care services, is covered under Original Medicare. d.Part D, which covers prescription drug services, is covered under Original Medicare. Source: Module 1, Slide - Overview of Medicare Benefits and Coverage - Parts A, B, C, and Slide - Overview of Different Ways to Get Medicare Question 3 Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of 15 employees and offers employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employersponsored healthcare coverage. How would you respond? a.Juan is likely to be ineligible for Medicare since he was born outside the United States and has only contributed to the Medicare system for 20 years.b. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims but Smallcap must continue to offer him coverage under its employer-sponsored group health plan and would become a secondary payor. c.Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls his employer-sponsored coverage would continue to be the primary payor while Medicare would be considered a secondary payor of his healthcare claims. Incorrect: Medicare is the primary payor for individuals who have group health coverage due to their continued employment with a small employer. A small group health plan is one offered by a company with fewer than 20 employees. d. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan. Source: Module 1, Slide - Eligibility for Part A and Part B Benefits and Slide - Medicare for Individuals Who Are Still Working - Small GHPs and Slide - Medicare Coordination with Employer Group Health Plans Question 4 Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him? a.After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. b.Individuals who become eligible for such disability payments only have to wait 12 months before they can apply for coverage under Medicare. c.Individuals receiving such disability payments from the Social Security Administration continue to receive those payments but only become eligible for Medicare upon reaching age 65. d.He became eligible for Medicare when his disability eligibility determination was first made. Source: Module 1, Slide - Medicare Enrollment Part A & B Question 5 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? a.Medicare is a program for people who have incomes and assets below specific limits, so you will have to find out her exact financial situation before telling her whether she can obtain Medicare coverage. b.Eligibility for Medicare is based on whether or not a person has ever been employed by the federal government. If she or her husband were ever employed by the federal government, she can enroll in Medicare.c.Medicare is a program for people of all ages with specific mental health disabilities. Since she is in excellent health, she would not qualify, but should instead look into her state’s Medicaid program if she wants further coverage. d.Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, endstage renal disease, and Lou Gehrig’s disease so she will be eligible for Medicare. Source: Module 1, Slide - Eligibility for Part A and Part B Benefits Question 6 Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her? a. Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. b.Mrs. Duarte has no right to appeal this determination since her claim has been partially paid. c. Mrs. Duarte should file an appeal of this initial determination within 90 days of the date she received the MSN in the mail. If she still disagrees with Medicare Administrative Contractor's (MAC's) further decision she should request a reconsideration by a qualified independent party within 10 days. Incorrect: Beneficiaries must file an appeal related to Part A or B services within 120 days of the date they get the MSN in the mail. If a beneficiary disagrees with the Medicare Administrative Contractor’s decision, he/she has 180 days after getting the decision notice to request a reconsideration by a Qualified Independent Contractor. d.Mrs. Duarte should request a reconsideration of the decision by a qualified independent party within 60 days of the date she received the MSN in the mail. Source: Module 1, Slide - Appeals related to Part A and Part B Coverage and Payment Determinations. Question 7 Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife’s needs. What could you tell Mr. Moy? a.Medicare Supplemental Insurance would cover his dental, vision and hearing services only. b.Medicare Supplemental Insurance would help cover his Part A and Part B deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover. c.Medicare Supplemental Insurance would cover all of his IRS approved health care expenditures not covered under Original Fee-for-Service (FFS) Medicare. d.Medicare Supplemental Insurance would cover his long-term care services. Source: Module 1, Slide - Medigap (Medicare Supplement Insurance)Question 8 Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed? a.Tell prospect Jerry Smith that Medigap is simply a variation of a Medicare Advantage plan and the companies John represents offer more comprehensive coverage for a lower price. b.Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage. c.Tell prospect Jerry Smith that he should drop his Medigap coverage and put those premium dollars toward the purchase of a standalone Part D prescription drug plan because he can always reactivate his Medigap policy on a guaranteed issue basis. Furthermore, because he has had Medigap Jerry will not incur a Part D late enrollment penalty. d.Tell prospect Jerry Smith that he should keep his Medigap plan but he should supplement his healthcare coverage by purchasing a Medicare Advantage plan that offers prescription drug coverage (MA-PD). Source: Module 1, Slide - Medigap (Medicare Supplement Insurance) and Slide - Medigap is NOT Question 9 Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her? a. She must wait at least 30 days after her employment terminates before she may enroll in Medicare Part B. b.She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period after the last month on her employer plan that differs from the standard general enrollment period, during which she may enroll in Medicare Part B. c.She may not enroll in Part B while covered under an employer group health plan and must wait until the standard general enrollment period after she retires. d.She may only enroll in Part B during the general enrollment period whether she is retired or not. Source: Module 1, Slide - Enrollment in Parts A & B After the Initial Enrollment Period Question 10 Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her? a.Most individuals who are citizens and age 65 or over and are covered under Part A must pay a monthly premium for that coverage.b.Most individuals who are citizens and age 65 or over and wish to be covered under Part A must enroll in a Medicare Advantage Plan. c.Most individuals who are citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. d.All individuals who are citizens and age 65 or over will be covered under Part A. Source: Module 1, Slide - Eligibility for Part A & B Benefits and Slide - Medicare Premiums Part A Question 11 Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance? a.She can apply to the Medicare agency for lower premiums and cost-sharing. b.She should only seek help from private organizations to cover her Medicare costs. c.She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible. d.She should not sign up for a Medicare Advantage plan. Source: Module 1, Slide - Help for Individuals with Limited Income/Resources Question 12 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? a.He may sign-up for Medicare at any time and coverage usually begins immediately. Incorrect: Medicare coverage for individuals with ESRD typically begins on the fourth month after dialysis treatments start. b.He may not sign-up for Medicare until he reaches age 62, the date he first becomes eligible for Social Security benefits. c.He may sign-up for Medicare at any time however coverage usually begins on the sixth month after dialysis treatments start. d.He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Source: Module 1, Slide - Medicare Enrollment Part A & B Question 13 Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover?a.Medicare inpatient psychiatric coverage is limited to the same number of days covered for typical inpatient stays. b.Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime. c.Medicare will cover, at its allowable amount, as many stays as are needed throughout Mr. Rainey’s life, as long as no single stay exceeds 190 days. d.Inpatient psychiatric services are not covered under Original Medicare. Source: Module 1, Slide - Medicare Part A provides coverage for inpatient psychiatric care for up to 190 lifetime days. Question 14 Mr. Alonso receives some help paying for his two generic prescription drugs from his employer’s retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him? a. He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing. b.He generally would pay only a monthly premium and deductible. Medicare covers all other costs. c.He generally would pay only a per-prescription co-payment. Medicare covers all other costs. d. He generally would pay only a monthly premium. Medicare covers all other costs. Source: Module 1, Slide - Original Medicare and Part D Prescription Drug Coverage. Question 15 Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65, without paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her? a.Medicare beneficiaries only pay a Part B premium if they are enrolled in a Medicare Advantage plan. b.She is correct because she will be covered under Part A, without paying premiums and she has worked for 40 years so she will not have to pay Part B premiums. c.She is correct that she will not have to pay a premium because State programs cover the cost of Part B premiums for all Medicare beneficiaries. d.To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. Source: Module 1, Slide - Medicare Premiums for Part B Question 16 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 torequire 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? a.Under Original Medicare, if the inpatient hospital service is provided by a participating Medicare provider, the co-payment is waived. Co-payments are only charged when a beneficiary opts to receive care from a non-participating provider. b.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 coinsurance 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. c.Under Original Medicare, the inpatient hospital co-payment is a flat per-day amount that remains the same throughout the first 60 days of a beneficiary’s stay. After day 60 the amount gradually increases until day 90. After 90 days he would pay the full amount of all costs. d.Under Original Medicare, the inpatient hospital co-payment is a percentage of allowed charges. The percentage increases after 60 days and again after 90 days. Source: Module 1, Slide - Medicare Part A - Original Medicare Cost-Sharing for Inpatient Hospital Care Question 17 Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through massage therapy. She is concerned about whether or not Medicare will cover these items and services. What should you tell her? a.Medicare does not cover massage therapy, or, in general, glasses or dentures. b.Medicare covers 80% of the cost of these three services. c.Medicare covers 50% of the cost of these three services. d.Medicare covers glasses, but not dentures or massage therapy. Source: Module 1, Slide - Not Covered by Medicare Part A & b Question 18 Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to Medicare beneficiaries? a.Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots. b.Medicare Part A generally covers medically necessary physician and other health care professional services. c.Benefits covered by Medicare Parts A and B include routine dental care, hearing aids, and routine eye care.d.Medicare Part B generally provides prescription drug coverage. Source: Module 1, Slide - Medicare Part A & B Benefits, Slide - Medicare Part B Benefits: Preventive Services and Screening, and Slide - Not Covered by Medicare Part A & B Question 19 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? a. Medigap plans that cover costs not paid for by an MA plan are available only in Massachusetts, Minnesota, and Wisconsin. b. 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. c.Medigap plans are a form of Medicare Advantage, so purchasing both would be redundant coverage. d. Medigap policies designed to cover costs not paid for by an MA plan can be purchased, but only if the MA plan’s design is considered to be the “defined standard benefit.” Source: Module 1, Slide - Medigap is NOT Question 20 Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has but replace her existing Medigap plan with one that provides drug coverage. What should you tell her? a.Medigap is a replacement for Original Medicare and she has been paying for double coverage. She should simply drop her Medigap policy. b. Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan. c. Mrs. Gonzalez can purchase a Medigap plan that covers drugs, but it likely won’t offer coverage that is equivalent to that provided under Part D. d.Mrs. Gonzalez should purchase a K or L Medigap plan. Source: Module 1, Slide - Beneficiaries with Medigap Plans with Drug Coverage UNIT 2 Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr. Lombardi’s area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell him about this situation? a.He could enroll in the MA-only PPO plan and a stand-alone Medicare prescription drug plan.b.He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. c.He cannot enroll in a stand-alone prescription drug plan because you do not represent such a plan. d.He could enroll in the MA-only plan and purchase a Medigap plan with drug coverage. Source: Module 2, Slide - MA & Prescription Drugs. Question 2 Mr. Barker enjoys a comfortable retirement income. He recently had surgery 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 some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? a.You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. b.You could remind him that he cannot do anything until the next Annual Election Period when he will have an opportunity to change plans. c.You could suggest he call the doctor who performed the surgery to complain about the costs and ask for a discount on the charges. d.You could reassure him that such charges are typical, but if he needs assistance in paying, he should apply to the state for Medicaid assistance. Source: Module 2, Slide - Enrollee Protections, Slide - Enrollee Protections: Complaints, Coverage Decisions, Appeals Question 3 Mr. Lopez has heard that he can sign up for a product called “Medicare Advantage” but is not sure about what type of plan designs are available through this program. What should you tell him about the types of health plans that are available through the Medicare Advantage program? a.They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. b.They are custodial long-term care plans for people with Medicare. c.They are Medigap Supplemental plans that fill in the gaps not covered by Medicare. d.They are major medical policies but are only for low-income beneficiaries with Medicare. Source: Module 2, Slide - Medicare Advantage Plans (Overview). Question 4 Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?a.Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, before being accepted and enrolled. b.Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. c.Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States. d.Mrs. Radford must be enrolled in both Medigap and Part A to enroll in a Medicare Advantage plan. Source: Module 2, Slide - Medicare Advantage Eligibility Question 5 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? a.If he enrolls in the PFFS plan and shows his card to a doctor who participates in Original Medicare, then that doctor is required to accept the plan’s terms and conditions, which could include balance billing. b.If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor accepts Original Medicare. c.He may receive services from any physician, regardless of whether or not that physician participates in the plan or Original Medicare. d.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. Source: Module 2, Slide - MA Plan Types Private Fee-for-Service (PFFS) Plans, MA Plan Types Private Feefor-Service Plans (2 of 3) and MA Plan Types Private Fee-for-Service Plans (3 of 3). Question 6 Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him? a.SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. b.Since SNPs don’t cover prescription drugs Mr. Sinclair should consider a different option. c.SNPs offer care from any doctor or hospital Mr. Sinclair would like to use and his costs will always be lower than in Original Medicare. d.SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well. Source: Module 2, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description (2 of 2).Question 7 Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? a.Medicare Advantage is a new name for the Original Medicare program. b.Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. c.Medicare Advantage is a health insurance program operated jointly by the states with the Federal government. d.Medicare Advantage is designed to pick up where Original Medicare leaves off, covering those health care services that would not normally be covered by Original Medicare. Source: Module 2, Slide - Part C: Medicare Advantage Plans (Overview). Question 8 Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him? a.C-SNP b.I-SNP c.D-SNP d.FIDE-SNP Source: Module 2, Slide - Medicare Advantage Eligibility, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description (2 of 2). Question 9 Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the plan’s terms and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan charge? a.Dr. Brennan can charge Mary Rodgers more than the cost sharing specified in the PFFS plan’s terms and conditions as long as she treats all beneficiaries the same. Incorrect: Dr. Brennan cannot charge any PFFS plan enrollee more than the cost-sharing specified in that PFFS plan’s terms and conditions. b.Dr. Brennan can charge Mary Rogers no more than the cost sharing specified in the PFFS plan’s terms and condition of payment which may include balance billing up to 15% of the Medicare rate. c.Dr. Brennan can charge the beneficiary the same cost-sharing as Original Medicare as long as she sends the claim to Medicare and not the plan.d.Dr. Brennan can charge Mary Rodgers no more than the cost sharing specified in the PFFS plan’s terms and conditions of payment which may include balance billing up to 25% of the Medicare rate. Source: Module 2, Slide - MA Plan Types: Private Fee-for-Service Plans (3 of 3). Question 10 Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? a.Mrs. Chi is ineligible for a MA MSA plan because she is ineligible for Medicaid due to her income level. b.Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage it must be a MSAPD plan that includes drug coverage. Incorrect. MA MSA plans are prohibited from offering prescription drug coverage. If an MSA member wants prescription drug coverage, the member must enroll in a standalone PDP. c.Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. d.Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage she must also enroll in a Medicare Supplement Plan (Medigap) F that covers the Medicare Part B deductible and includes both drug coverage. Source: Module 2, Slide - MA & Prescription Drugs, Slide - Medicare Advantage Eligibility: MSAs Question 11 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? a.Generally, employers prefer retirees to have both the retiree group plan and the MA-PD plan to fill in the gaps, but he would be better off with just the MA-PD plan. b.He should compare the benefits in his employer-sponsored retiree group health plan with the benefits in his neighbor’s MA-PD plan to determine which one will provide sufficient coverage for his prescription needs. c.When possible, it is always the best option to have both the employer’s plan and the MA-PD, so he would have no out-of-pocket expenses. d.Generally, employers prefer retirees to enroll in a stand-alone PDP, so he should consider that instead of the MA-PD. Source: Module 2, Slide - Employer/Union Plans. Question 12Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? a.He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. b.He can enroll in a Medicare Advantage plan if he has dropped Part B less than 90 days ago. c.He is not eligible to enroll in a Medicare Advantage as a naturalized citizen. d.He can enroll in a Medicare Advantage plan but it will pay only the benefits associated with Medicare Part A. Source: Module 2, Slide - Medicare Advantage Eligibility. See also, Slide - Eligibility for Part A and Part B Question 13 Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her? a.Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. b.Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state’s Medicaid program. c.Medicaid will cover all of her PFFS out-of-pocket costs and Medicaid providers will accept amounts paid by the PFFS plan as payment in full. Incorrect: There are several types of Medicaid programs, called Medicare Savings Programs, that assist beneficiaries with premium and/or cost-sharing payments, but such programs do not guarantee Medicaid will cover all of a beneficiary’s out-of-pocket costs. d.If Mrs. Andrews joins a PFFS plan, the State will not cover any of her medical expenses because she will be using only Medicare providers. Source: Part 2, Slide -MA Plans and Dual Eligible Beneficiaries, continued and Slide - MA Plans and Dual Eligible Beneficiaries, continued Question 14 Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease (ESRD). What options will Mrs. Davenport have regarding her MA plan during the next open enrollment season? a.She may remain in her ABC MA plan, enroll in another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. b.She must remain enrolled in her ABC MA plan unless the plan terminates. c.She must immediately drop her ABC MA plan and enroll in Original Medicare.d.She must immediately drop her ABC MA plan and enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. Source: Module 2, Slide - Medicare Advantage Eligibility and Slide - Medicare Advantage Eligibility: SNPs Question 15 Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was disappointed with the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she would not have to put up with such poor access to care. What could you tell her? a.She should not expect to get in to see her doctor any more quickly since she is a Medicare patient. b.She must write to the plan and wait for a response and then, if she is still dissatisfied, she could file an appeal with her state Medicaid office requesting transfer to one of its managed care plans. c.She should call the doctor’s office to complain since the plan cannot do anything about the doctor’s schedule. d.She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Source: Module 2, Slide - Enrollee Protections, Slide - Enrollee Protections: Complaints, Coverage Decisions, Appeals and Slide - Enrollee Protections: Grievances. Question 16 Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? a.In Medicare Advantage HMO plans, services provided by primary care physicians are covered at 100%, but those of specialists are covered at 80%. b.In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network). c.With any Medicare Advantage HMO, Mr. Kumar will be able to see any provider he likes, so long as that provider participates in Original Medicare. d.Mr. Kumar will be able to obtain routine care outside of the plan’s service area but will pay a higher copayment (except in an emergency). Source: Module 2, Slide - MA Plan Types Coordinated Care Plans - HMOs Question 17 Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do?a.As long as his employer offers coverage that is equivalent to Medicare’s, he cannot enroll in Part B. b.He will not need to do anything. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan. c.He must wait until the next Annual Election Period, at which time he can enroll in a Medicare Advantage plan. d.He will have to enroll in Part B. Source: Module 2, Slide - Medicare Advantage Eligibility Question 18 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? a.SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. b.SNPs do not provide Part D prescription drug coverage, so if he does enroll, he should be aware that he will not have coverage for any medications he may need now or in the future. c.SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll. Incorrect: There are three types of SNPs, but only one of them involves assisting dual eligible individuals. Regardless, Mr.Greco’s circumstances would not meet the eligibility criteria to qualify him for any of the SNPs. d.SNPs only serve individuals in long-term care facilities, so he cannot enroll. Source: Module 2, Slide - Medicare Advantage Eligibility: SNPs, Medicare Advantage Eligibility: SNP Description (1 of 2) and Medicare Advantage Eligibility: SNP Description (2 of 2). Question 19 Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can go to for her health care. What should you tell her? a. In general, Mrs. Ramos will need a referral to see specialists. b. Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will have a higher cost-sharing amount if she sees a provider who/that is not a part of the PPO network. c.Mrs. Ramos should be aware that generally plan providers can decide, on a case-by-case basis, whether they will treat her.d.In general, Mrs. Ramos can obtain care from any provider who participates in Original Medicare but will have to pay the difference between the plan’s allowed amount and the provider’s usual and customary charge. Source: Module 2, Slide - MA Plan Types Coordinated Care Plans - PPOs. Question 20 Which of the following statement is/are correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. a.II and III only b.I and II only Incorrect: It is correct that MSAs may not have a network or may have a full or partial network of providers, and MSAs cover Part A and Part B benefits after the deductible. However, it is also correct that all non-network providers must accept the same amount that Original Medicare would pay them as payment in full. This is the amount the enrollee will pay the provider before the deductible is met. c. I, II, and III only d. I, II, and IV only Source: Module 2, Slide - MA Plan Types: Medical Savings Account (MSA) Plans. UNIT 3 MEDICARE PDP Question 1 Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? a.Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmetic purposes. b.Mr. Vaughn’s hair growth medication would only be covered under Part D if his balding resulted from an illness or was a side effect of a treatment such as chemotherapy. Incorrect: Even if Mr. Vaughn’s balding was the result of illness or a side effect of chemotherapy, by law Part D plans are not permitted to provide coverage for cosmetic purposes. c.The vitamins the Vaughns are taking will be covered under Part D because their physician suggested they should take vitamins, but the hair loss medication cannot be covered.d.Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn’s could look into that possibility. Source: Module 3, Slide - Drugs Excluded from Part D Coverage Question 2 Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him? a.Mr. Carlini can keep Original Medicare, but if he does not sign up for an MA plan that includes prescription drug coverage, he will only be able to obtain prescription drug coverage through a Medigap plan. b.To obtain prescription drug coverage, Mr. Carlini must enroll in an MA plan. The plan will cover his Part A and Part B services, as well as provide him with the desired prescription drug coverage. c.Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. d.Mr. Carlini can obtain drug coverage through the Federal government’s fallback plans, which are designed to provide an alternative to privately sponsored Medicare Advantage plans. Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basic and Slide - Medicare Prescription Drug Eligibility Question 3 Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? a.When medication costs exceed a certain threshold amount, which rises each year, a Medicare prescription drug plan is permitted to exclude coverage for all but the least expensive of the medications in a given category. Mrs. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives. b.Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs. c.Medicare prescription drug plans are required to include only a certain percentage of brand name drugs among those they cover. It may be possible that plans available in her area have opted not to include in their formularies the brand name drugs she needs. She may need to pay for this particular medication out of pocket.Incorrect: Medicare drug plans are not required to limit the percentage of brand name drugs they cover. Part D formularies must include at least two drugs in each therapeutic category whether generic versions are available or not. d.Medicare prescription drug plans are allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medications out of pocket. Source: Module 3, Slide - Covered Part D Drugs Question 4 Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums, and cost sharing. How can you explain this to him? a.The Part D standard model’s importance is that it is the only type of plan into which low-income beneficiaries can enroll and still receive any extra help for which they may qualify. b.The government bases its payments to Part D plans on the standard benefit model. For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries. c.The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval. d.Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. Source: Module 3, Slide - Part D Plan Benefits. Question 5 Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him? a.The only option available is to reduce his income so that he can qualify for the Part D extra help or wait until next year to see if the annual limits change. b.He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. c.He should contact his neighbors and family members and let them know that any contributions they make toward his drug expenses will be tax deductible. d.He should look into the possibility of purchasing his medications through the internet from off-shore pharmacies. Source: Module 3, Slide - Other Help for Low Income - Pharmaceutical Assistance Programs. Question 6Mrs. Mulcahy, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her? a.An individual who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. b.As long as Mrs. Mulcahy is 65, eligibility for a Medicare prescription drug plan is not dependent on entitlement to Part A or enrollment under Part B, so she should not be concerned. c.Like all Medicare beneficiaries, Mrs. Mulcahy will be automatically enrolled in a Medicare prescription drug plan when she turns 65. She will have a six-month window during which she can select a plan other than the one into which she has been automatically enrolled. d.To qualify for enrollment into a Medicare prescription drug plan, Mrs. Mulcahy must be entitled to Part A and enrolled under Part B. She should contact her local Social Security office and decide to enroll in Part B prior to selecting a prescription drug plan. Source: Module 3, Slide - Medicare Part D Eligibility Question 7 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? a.This is not a possibility. If Mrs. Berkowitz wants health coverage and drug coverage through a plan, she must purchase an MA-PD plan. b. Mrs. Berkowitz can enroll in any Medicare Advantage plan, regardless of whether it offers drug coverage, and enroll in any stand-alone Medicare prescription drug plan. c.If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. d.Mrs. Berkowitz can apply for any Medicare Advantage plan and, if it offers drug coverage, ask to have that element of the coverage eliminated, after which she can enroll in a stand-alone Medicare prescription drug plan in her service area. Source: Module 3, Slide - Medicare Part D Prescription Drug Eligibility. Question 8 Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband’s employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her? a.If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. b.If a Part D benefit is offered through her plan she must enroll in this plan.c.Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage. d.Mrs. Lopez must first seek COBRA benefits under her husband’s plan before she can apply for Part D coverage. Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics Question 9 All plans must cover at least the standard Part D coverage or its actuarial equivalent. Which of the following statements best describes some of the costs a beneficiary would incur for prescription drugs under the standard coverage? a.Standard Part D coverage would require payment of only fixed per-prescription co-payments. b.Standard Part D coverage would require payment of an annual deductible, fixed per-prescription copayments, and once catastrophic coverage begins, the plan covers 100% of all costs. c.Standard Part D coverage would require payment of an annual deductible, and once past the catastrophic coverage threshold, the beneficiary pays whichever is greater of either the co-pays for generic and brand name drugs or coinsurance of 5%. d.Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap. Source: Module 3, Slide - Part D Plan Benefits, Slide - Part D Benefits: The Standard Benefits for 2022 and Catastrophic Coverage. Question 10 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. What could you tell him to do? a.Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication. b.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. c.Mr. Zachow will have to wait until the Annual Election Period when he can switch Part D plans. In the meantime, he will have to pay for his drug out of pocket. d.Mr. Zachow could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him. Source: Module 3, Slide - Enrollee Rights: Requesting Exceptions for Drugs. Question 11Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her? a.She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan’s network. b.She may fill one prescription out-of-network per year and it will be fully covered. Her second prescription will require her to pay the full cost out-of-pocket. c.She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. Incorrect: In-network pricing depends on whether a pharmacy has contracted with a Part D plan to be considered within their network. The fact that Ms. Edwards is traveling does not alter the pharmacy’s network status. d.She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Source: Module 3, Slide - Part D Pharmacy Networks. Question 12 Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan’s formulary he takes several other medications. These include a prescription drug not on his plan’s formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say? a.The cost of the prescription drugs that are not on his plan’s formulary as well as the cost of the drug(s) to reduce joint swelling from the Canadian pharmacy will count toward TrOOP but the other medications in question will not count toward TrOOP. b.None of the costs of Mr. Wingate’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. c.The cost of the prescription drug that is not on his plan’s formulary will count toward TrOOP but the other medications in question will not count toward TrOOP. Incorrect: Some costs do not count toward TrOOP. These include costs for drugs not on a Part D plan’s formulary unless the beneficiary receives an exception under which the plan covers the drug. d.The cost of all medications bought within the United States not covered by his plan would count toward TrOOP. The cost of the Canadian bought medications would not count toward TrOOP. Source: Module 3, Slide - True Out-of-Pocket Costs? (TrOOP): What Counts and Slice - True Out-of-Pocket Costs (TrOOP): What is Excluded? Question 13Which 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. a.I, II, and III only B.I only c.I, II, III, and IV d.I and II only Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics, Slide - Medicare Part D Drug eligibility and Slide - Medicare Part D Pharmacy Network. Question 14 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? a.He should drop the employer coverage and enroll in a Medicare prescription drug plan. Employer plans are almost always more costly for beneficiaries and most do not cover the same range of drugs available from a Medicare prescription drug plan. b.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. c.If he has any sort of employer coverage, regardless of the level of coverage, he will incur no penalty if he does not enroll in a Part D plan when first eligible. Incorrect: A penalty will be incurred if the employer coverage is not “creditable.” Prescription drug coverage is “creditable” if on average it equals at least as much as Medicare’s standard Part D coverage expects to pay. d.He will need to enroll in a Medicare prescription drug plan upon becoming eligible for the program in order to avoid a premium penalty. To reduce his expenses, he should look for a plan with a zero premium. Source: Module 3, Slide - Employer/Union Coverage of Drugs and Slide - Part D Late Enrollment Penalty.Question 15 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 to her drug coverage? a.She can expect that all her prescriptions will be automatically delivered on a mail-order basis as a requirement of the Medicare Part D program. b.Medicaid will cover all drugs not covered under the Medicare Part D prescription drug plan into which Mrs. McIntire is enrolled. c.Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. d.She will continue to obtain her drug coverage through Medicaid. Source: Module 3, Slide - Medicaid Drug Coverage. Question 16 Mr. Schultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Schultz has lost his employer group coverage within the last two weeks. How would you advise him? a.Mr. Schultz should immediately enroll in a Part D plan but he can expect to pay a premium penalty because he failed to enroll when first eligible. b.Mr. Schultz can wait up to 180 days after the loss of his creditable employer group coverage before enrolling in a Part D plan without worrying payment a premium penalty. c.Mr. Schultz should seek to continue employer group coverage through COBRA because it is likely to have superior benefits at a more permanent solution. d.Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty. Source: Module 3, Slide - Employer Coverage of Drugs. Question 17 Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him? a.In general, to pay his Part D premium, he only can have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals. Incorrect: Part D beneficiaries have the option to pay their monthly premiums, not only through automatic payments from a checking account, but also from a savings account or automatic charges against their credit or debit card.b.In general, he must select a single Part D premium payment mechanism that will be used throughout the year. c.During 2017, many people experienced significant problems with deductions from their Social Security check for their Part D premium. As a result, this method of payment is no longer an option for Part D premium payments. d.As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding should begin, he can change his method of Part D premium payment and withholding will begin the month after his savings account is exhausted. Source: Module 3, Slide - Part D Premiums Question 18 Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. She currently does not have creditable coverage. What could you tell her about the implications of such a decision? a.If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will have to pay a one-time penalty equal to 10% of the annual premium amount. b.If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered. c.If she does not sign up for a Medicare prescription drug plan, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications. d.If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will be required to pay a higher premium during the first year that she is enrolled in the Medicare prescription drug program. After that point, her premium will return to the normal amount. Source: Module 3, Slide - Part D Late Enrollment Penalty. Question 19 What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? a.Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market. b.Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization.c.The Federal government establishes a set formulary, or list of covered drugs, each year that the Part D plans must use. Beneficiaries should consult the government’s list prior to deciding whether they wish to enroll in a Part D plan during that year. d.Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrict access through prior authorization. Source: Module 3, Slide - Part D Drug Management Tools. Question 20 Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? a.Betsy, a grandmother from overseas who has overstayed her visa. b.Guy, who has illegally crossed the Canadian border. c.Jose, a grandfather who was granted asylum and has worked in the United States for many years. d.Helena, an overseas college student who has overstayed her visa. Source: Module 3, Slide - Medicare Part D Eligibility. UNIT 4 MEDICARE ADVANTAGE AND PART D PLANS QUESTION 1 Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational? a.No. This action is permissible. Handing out enrollment forms, on the other hand, would not be permissible. Incorrect: Discussion of plan-specific information is prohibited at educational events. b.No. Attendees expect some “puffery” at any event on a product in which they may be potentially interested. c.yes. When an event has been advertised as “educational,” discussing plan-specific premiums is impermissible. d.Yes. Whether or not an event has been advertised as “educational” or a “sales presentation,” discussing plan-specific information is impermissible. Source: Module 4, Slide - Educational Events, Impermissible Activities. Question 2 Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request moreinformation about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong? a.Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located. b.Agent Armstrong needs to be licensed and appointed only in his state of residence. c.Agent Armstrong needs to be licensed and appointed only in the state where ABC Health Plan is headquartered. d.Agent Armstrong needs to be licensed and appointed only in the state where XYZ Agency is headquartered. Source: Module 4, Slide - Requirement to act as Plan Marketing Representative and Slide - Marketing Representatives - State Licensure Case Study Question 3 You will be holding a sales event soon, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation? a.Two or more gifts whose combined value does not exceed $15. Incorrect: This statement is incorrect because marketing representatives may offer more than one gift to sales event attendees provided the combined value of all items does not exceed $15. b.Gifts worth more than $15 but based on anticipated attendance will not exceed $15 per attendee. c.Gift cards or gift certificates of $15 or less that can be readily converted to cash. d.Gifts of nominal retail value ($15 or less) Source: Module 4, Slide - Gifts and Promotional Items. Question 4 Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual? a. Plans must immediately terminate their contracts with such individuals. b.Plans do not impose penalties. Instead, the Medicare agency has specific authority to fine such individuals for each violation. c. Her name will be reported to a publicly accessible database and could be advertised in local newspapers. d.The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. Source: Module 4, Slide - Plan Oversight and Enforcement. Question 5Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel? a.During the MA-OEP Miguel can purchase a list of individuals who have chosen MA plans during Annual Enrollment Period (AEP) and create a marketing plan aimed at targeting them to select a plan he sells. b.During the MA-OEP Miguel can send unsolicited print materials to seniors in his area advertising the opportunity to change from one MA plan to another. c.During the MA-OEP Miguel can make unsolicited calls to former enrollees who have selected a new plan during the Annual Enrollment Period (AEP). d.During the MA-OEP, Miguel can have one-on-one meetings with beneficiaries who have requested such meetings. Source: Module 4, Slide - Open Enrollment Period - Marketing Prohibitions and Slide - Promoting Health Plans During Open Enrollment Period. Question 6 You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation? a.Your name will be registered with the Medicare agency by the plans you are seeking to represent and you will be unable to contract with any Medicare Advantage or Part D plan. b.You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score. However, you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing. c.You will have to repeat the tests in three months, but may begin enrolling beneficiaries while you are waiting. d.You will have to attend one of several remedial training events sponsored by the Medicare agency before being allowed to retake the test. Source: Module 4, Slide - Requirements to act as Plan Marketing Representatives. Question 7 A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do? a.Before speaking with the individual, you must inquire as to her eligibility for MA and Part D plans and then complete a scope of appointment form for the plans for which she is eligible. b.You must set an appointment for another time, at least 48 hours from the point when she walked into your office.c.You do not have to do anything. You may proceed with the discussion and enroll the individual if she so desires. d.You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. Source: Module 4, Slide - Required Practices: Scope of Appointment. Question 8 You are working several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do? a.You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. b.You must state in the advertisement that it will be an educational event and that the education will consist of specific information about the participating plans. c.You must only ensure that the advertisement is factually accurate. d.Plans may not participate in advertising such an event. All advertising must be done by community organizations. Source: Module 4, Slide - Educational Events and Slide - Marketing and Educational Events. Question 9 Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members? a.Market non-health related items such as accident-only plans without the need for obtaining a HIPAA compliant authorization form from an enrollee. b.Market contact information lists of current members to third-party vendors of ancillary health products as permitted by Dodd-Frank legislation. Incorrect: Plan sponsors cannot market lists of current members without compliant permission. HIPAA Privacy Rules are applicable, not Dodd-Frank legislation. c.Market non-health related items or services such as life insurance or annuities policies to current members as permitted following HIPAA Privacy Rules. d.Market non-Medicare health-related products, such as financial planning, to current members as permitted by Dodd-Frank legislation. Source: Module 4, Slide - Required Practices: HIPAA and Confidentiality of Enrollee Information and Slide - Required Practices: Marketing & Non-Health Related Activities. Question 10Another 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 marketing requirements as the plans themselves. How should you respond to such a statement? a.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. b.Your coworker is correct. You are subject only to marketing requirements issued by your state department of insurance. c.Your coworker is correct because employed agents have to follow a stricter set of rules than do independent agents, such as yourself. d.Your coworker is correct. You may use any marketing techniques that do not involve providing misinformation to potential enrollees. Source: Module 4, Slide - Applicability of Medicare Marketing and Communication Rules to Marketing Representatives. Question 11 Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her? a.Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. b.While unsolicited contacts may be made through print media such as direct mail, marketing representatives may not initiate electronic contact. c.Marketing representatives may only use internet pop-up ads providing plan-specific information that have been approved by CMS when soliciting prospects through electronic means of communication. d.Marketing representatives may initiate electronic contact through e-mail and as long as an e-mail is opened marketing representatives may also follow-up with unsolicited telephone calls. Source: Module 4, Slide - Permitted Contracts and Slide - General Audience Marketing. Question 12 Melissa Meadows is a marketing representative for Best Care which has recently introduced a Medicare Advantage plan offering comprehensive dental benefits for $15 per month. Best Care has not submitted any potential posts to CMS for approval. Melissa would like to use the power of social media to reach potential prospects. What advice would you give her? a.Agent Meadows should post a tweet telling readers to contact her directly to learn more about Best Care’s comprehensive dental benefits at only $15 per month. b.As soon as CMS approves Best Care's social media posts, Agent Meadows could post a tweet stating that “Best Care offers an array of Medicare Advantage benefit packages. One might be right for you. Call me to find out more!”c.Due to cybersecurity dangers, social media cannot be used in the promotion of Medicare Advantage products. d.Despite the terms of her contract forbidding the use of social media, Agent Meadows could send out a tweet stating that “Best Care offers a Medicare Advantage benefit package offering the lowest cost comprehensive dental benefit package available. Call me direct to learn more.” because the content does not contain any plan-specific information about benefits, premiums, cost-sharing, or Star Ratings. Source: Module 4, Slide - Use of Social Media to Market and Slide - Social Media Example. Question 13 You have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respect to meals? a.There is no limitation on meals. You may continue to provide your Thanksgiving style meal, to any individual, in any manner you see fit. b.You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. c.As long as the meal is paid for by another person or entity, you are permitted to invite your clients and their friends to partake of the meal at your sales presentation. d.You may offer meals to existing enrollees of the plan(s) you represent, but potential enrollees may not have a meal. Source: Module 4, Slide - Medicare Communications and Marketing Rules: Sales Events and Slide - Sales Events, Prohibited Activity and Light Snacks versus Meals. Question 14 ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees’ information to market non-health related products such as life insurance and annuities. Which statement best describes ABC's obligation to its enrollees regarding marketing such products? a.It must obtain a HIPAA compliant authorization from an enrollee that indicates the plan or plan sponsor may use their information for marketing purposes. b.It is not necessary for ABC to obtain an authorization to simply explain pending state or federal legislation since there is no anticipation of selling a non-health related product in these circumstances. c.Once a plan sends out a written request for consent, a beneficiary can authorize consent by simply failing to reply within 21 days. d.The request for authorization may include a brief synopsis of non-health related content. Source: Module 4, Slide - Required Practices: Marketing & Non-Health Activities. Question 15You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns? a.Tell her that if a plan obtains permission from CMS for a marketing event in a provider facility, the event may go forward, regardless of where it occurs in the facility. b.Tell her that Medicare guidelines allow you to conduct marketing activities anywhere in the facility, so long as the affected providers agree to that event. c.Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider’s facility. d.Tell her that Medicare guidelines only allow you to conduct marketing activities in areas of the facility where individuals are waiting to receive health care services, but not in places where they would be receiving health care such as an examining room. Source: Module 4, Slide - Marketing Activities: Marketing in a Health Care Setting. Question 16 Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you on October 15. During the appointment, what are you permitted to do? a.You may leave an enrollment kit and discuss a new life insurance product she might like. b.You may provide her with the required enrollment materials and take her completed enrollment application. c.You may begin her enrollment application and require her to provide names of any of friends who may be interested in enrolling before completing her application. d.You may leave enrollment kits for several MA plans and offer to discuss a Medigap and Part D prescription drug plan she might like. Incorrect: Because Mrs. Lu only requested help regarding Medicare Advantage plan selection, that is her scope of appointment. Therefore, your offer to discuss Medigap and/or Part D would go beyond the scope of appointment. Source: Module 4, Slide - What are Individual Marketing Appointments?, Slide - Individual Marketing Appointments, Prohibited Activities and Slide - Required Practices: Scope of Appointment. Question 17 Your friend’s mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him? a.You appreciate the opportunity and would ask the facility to provide enrollment applications for the MA-PD plans you represent. b. You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request.c.You appreciate the opportunity and your friend would just need to complete scope of appointment forms on behalf of all the residents who would like to attend. Incorrect: Marketing representatives may schedule an appointment with a beneficiary in a long-term care facility only upon the request of the beneficiary (or authorized representative). While your friend may be an authorized representative for his mother, it is highly unlikely that he would be an authorized representative for others in the facility. d.You appreciate the opportunity and will ask the facility to provide a plan brochure and enrollment application in every resident’s room before the meeting to promote interest in the event. Source: Module 4, Slide - Marketing Activities: Marketing in a Long-term Care Facility and Slide - Marketing Activities in a Health Care Setting: Example. Question 18 During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her? a.Tell her that Medicare or CMS (the Medicare agency) has approved and endorsed the plan. b.Tell her that, because you represent a Medicare health plan, you therefore work for Medicare, and the information you offer her is a good basis of any decision she makes. c.Tell her that the Medicare agency does not endorse or recommend any plan. d.tell her that Medicare recommends that beneficiaries enroll in a Medicare Advantage plan because it will serve her better than Original Medicare. Source: Module 4, Slide - Prohibited Practices: Marketing and Communications Material and Activities and Prohibited Practices: Examples. Question 19 Next week you will be participating in your first “educational event” for prospective enrollees. To be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage? a.You should plan to answer questions and accept enrollment forms. b.You should plan to conduct sales presentations but must not accept enrollment forms. c.You should plan to conduct sales presentations and accept enrollment forms. d.You should plan to ensure that the educational event is an informative event and must not conduct a sales presentation or distribute or accept enrollment forms at the event. Source: Module 4, Slide - Marketing and Educational Events and Slide - Educational Events, Impermissible Activities. Question 20 One of your colleagues argues that it is better to focus your time and energy exclusively in neighborhoods with single-family homes. He further argues that their older owners are more likely tohave higher incomes and purchase the Medicare Advantage products you represent compared to those living in apartment complexes. How should you respond? a.This is not a discriminatory activity since this is merely a widely recommended sales practice. b.This could be considered discriminatory activity, but it is not a prohibited practice. c.This is not a discriminatory activity since it is based on the incomes of likely prospects and not based on race or gender. d.This could be considered discriminatory activity and a prohibited practice. Source: Module 4, Slide - Prohibited Practices: Marketing and Communications Materials and Activities. UNIT 5 ENROLLMENT GUIDANCE MA AND PART D QUESTION 1 Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application before the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams? a.This is a bad idea. Mrs. Young should complete an online application now so that Agent Adams will be given immediate credit for his work once the AEP begins. B.This is a good idea. This locks Mrs. Young into a plan and protects Agent Adams’ commission. c.This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form before the start of the AEP. d.This is a good idea. The plan will retain Mrs. Young’s application and process it when the AEP begins. Source: Part 5, Slide – Enrollment Periods - Annual Election Period and Slide – Enrollment Periods Annual Election Period, Timeframe for Submitting Enrollment Forms Question 2 Mrs. Reeves is newly eligible to enroll in a Medicare Advantage plan and her MA Initial Coverage Election Period (ICEP) has just begun. Which of the following can she not do during the ICEP? a.During her ICEP, she can make an enrollment choice and change that choice during her MA Open Enrollment Period (MA OEP) that follows her election. b.She can compare various MA plan options and select one to enroll in. c.She can enroll in a Medigap plan to supplement the benefits of the MA plan that she’s also enrolling in. d.She can choose to enroll in a MA-PD plan, provided that her Part D initial election period and MA ICEP occur at the same time.Source: Part 5, Enrollment Periods MA ICEP, continued. Question 3 Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He found a stand-alone Medicare prescription drug plan in his area that offers better coverage than that available through his MA-PD plan and in addition, has a low premium. It won’t cost him much more and, because he has the means to do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan. What should you tell him? a.If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. b. If Mr. Block wants to enroll in both a MA-PD and a stand-alone PDP, he may buy the extra coverage without any adverse effect. c. Mr. Block will have to wait until the annual election period, beginning October 15, and then he can add the stand-alone coverage to the MA-PD. d.If Mr. Block enrolls in a stand-alone Medicare prescription drug plan, he can request that his Medicare Advantage plan remove the drug benefit from the package they offer and reduce his premium accordingly. Source: Part 5, Slide – Beneficiary Acknowledgements when Enrolling. Question 4 Mr. Yoo’s employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a Special election period. Mr. Yoo contacted you to find out more about what this means. What can you tell him? a.It means that he qualifies for a one-time opportunity to enroll in an MA-PD or Part D prescription drug plan. b.It means that he will be able to purchase continued drug coverage from the insurer that had provided it to the company retirees, but that he will not have to pay the entire premium himself. Incorrect. The special election period (SEP) he would qualify for is because of an involuntary loss of creditable drug coverage. The SEP begins the month he was advised of the loss of coverage, and it ends 2 months after the loss of creditable coverage. The SEP does not mean that he’ll be able to purchase continued drug coverage from the insurer that the company had provided to its retirees. c.It means that he will have a one time opportunity to enroll in a Medigap policy with drug coverage. d.It means that he will be able to enroll in a state-funded pharmacy assistance program for retirees that will cover 80 percent of his drug costs. Source: Part 5, Slide – Typical SEPs – Involuntary Loss of Creditable Drug Coverage and Slide – Enrollment Periods – SEPs, LimitationsQuestion 5 Mr. Rockwell, age 67, is enrolled in Medicare Part A, but because he continues to work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special election periods (SEPs)? a.Mr. Rockwell is eligible for a SEP that begins in June and ends three months later, during which he may enroll, disenroll, and reenroll in Part D plans, with his last selection considered binding. b.Mr. Rockwell must wait until the next annual election period (AEP) to sign up for Part D prescription drug coverage. c.Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends on September 1- two months after the loss of creditable coverage. d.Mr. Rockwell is eligible for a SEP that begins three months before the month in which he receives notice of loss of creditable coverage and ends three months after that month. Source: Part 5, Slide – Typical SEPs – Involuntary Loss of Creditable Drug Coverage. Question 6 Mrs. Schmidt is moving and a friend told her she might qualify for a “Special election period” to enroll in a new Medicare Advantage plan. She contacted you to ask what a special election period is. What could you tell her? a.It is a single period from January 1 – March 31, created by statute, when any Medicare beneficiary who has moved out of the area of their Medicare Advantage or Part D plan can add, drop or change their Medicare prescription drug coverage. b.It is a period when only Medicare beneficiaries who have moved out of the area and are dually eligible for Medicaid may add, drop, or change their prescription drug coverage. c.It is a period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically the Special election period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area. d.It is a period when beneficiaries who are newly eligible for Medicare may make their first choice of a Medicare prescription drug plan. Source: Part 5, Slide - Enrollment Periods - SEPs and Slide - Enrollment Periods - SEPs, continued. Question 7 When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice would you give her?a.She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA plan. b.She could enroll in an MA plan during the period including the three months before, the month of, and up to three months after turning 68. c.She should wait until the new year to disenroll from Original Medicare and select an MA plan between January 1 and March 31. d.She could immediately enroll in MA plan based on the one-time special election period available to those 70 and younger. Source: Part 5, Slide – Enrollment Periods - MA Initial Coverage Election Period (ICEP) and Slide Enrollment Periods- Annual Election Period. Question 8 Mr. and Mrs. Nunez attended one of your sales presentations. They’ve asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do? a.You should sign the form for Mrs. Nunez yourself, since she informed you, as the plan’s representative, that she wanted to enroll. b.As long as she can do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time. c.You can countersign Mrs. Nunez’ application, along with her husband, indicating that she approved this choice verbally. This witness signature is sufficient to make the enrollment valid. d.Legal spouses can sign enrollment forms for one another under federal law. You may enroll both Mr. and Mrs. Nunez, as long as her husband signs on her behalf. Source: Part 5, Slide – Who May Complete the Enrollment Form? Question 9 Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard certain MA plans might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him? a.If there is a special needs plan (SNP) in Mr. Wendt’s area that specializes in caring for individuals with diabetes, he may enroll in the SNP during the MA Open Enrollment Period which takes place between January 1 and March 31. b.Mr. Wendt must wait until the next annual open enrollment period (AEP) before he can enroll in a special needs plan (SNP).c.If there is a special needs plan (SNP) in Mr. Wendt’s area that specializes in caring for individuals with diabetes, he may enroll in the SNP at any time under a special election period (SEP) d.Because of the severity of his condition, Mr. Wendt must remain enrolled in Original Medicare and also enroll in a Medigap plan to supplement his additional medical needs. Source: Part 5, Slide – Typical SEPs -Severe or Disabling Chronic Conditions Question 10 A client wants to give you an enrollment application on October 1 before the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him? a.You must tell him you are not permitted to take the form. If he sends the form directly to the plan, the plan will process the enrollment on the day the Annual Election Period begins. b.You must tell him you are not permitted to take the form and if he sends it to the plan, the application will be rejected and he will need to fill out another form and submit it after the Annual Election Period begins. c.You must send it to the plan for immediate processing, although the enrollment will not become effective until January 1. d.You must accept the application, but hold it until the annual election period begins, after which you must send it to the plan for processing. Source: Part 5, Slide -Enrollment Periods: Annual Election Period, Timeframe for Submitting Enrollment Forms Question 11 Mr. White has Medicare Parts A and B with a Part D plan. Last year, he received a notice that his plan sponsor identified him as a “potential at-risk” beneficiary. This month, he started receiving assistance from Medicaid. He wants to find a different Part D plan that’s more suitable to his current prescription drug needs. He believes he’s entitled to a SEP since he is now a dual eligible. Is he able to change to a different Part D plan during a SEP for dual eligible individuals? a.No. Individuals identified by the plan sponsor as “potential at-risk” must wait 2 years to switch plans, after which time the designation is lifted. b.Yes. “Potential at-risk” designations are just a warning. Only “at-risk” beneficiaries are prohibited from using this SEP while the designation is in place. c.Yes. The “potential at-risk” designation only impacts the services he may receive from the Part D plan he enrolls, but it doesn’t affect his ability to change plans during this SEP. Incorrect.: Once an individual is identified by the plan sponsor as a “potential at-risk” or “at-risk” beneficiary and the plan sponsor has sent written notice to the individual, he or she cannot use this SEP to change plans while this designation is in place.d.No. Once he is identified by the plan sponsor as a “potential at-risk” beneficiary, he cannot use the dual eligible SEP to change plans while this designation is in place. Source: Part 5, Slide – Typical SEPs – Beneficiaries who are dual eligible or who have LIS eligibility; and Slide – Typical SEPs – Beneficiaries who are dual eligible or who have LIS eligibility, limitations for at-risk and potential at-risk beneficiaries Question 12 You are meeting with Ms. Berlin and she has completed an enrollment form for a MA-PD plan you represent. You notice that her handwriting is illegible and as a result, the spelling of her street looks incorrect. She asks you to fill in the corrected street name. What should you do? a.You may correct this information as long as you add your initials and date next to the correction. b.You may correct the information since it was a simple mistake. You do not need to do anything further to the application form. c.Under no circumstances may you make corrections to information a beneficiary has provided. Review of enrollment forms is the sole responsibility of the plan sponsor. d.You may correct the information, but she will need to write a brief statement indicating she authorized you to make the change. Source: Part 5, Slide – Who May Complete the Enrollment Form? Marketing Representative Participation. Mr. Chen is enrolled in his employer’s group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him? a.Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan, but he must wait until the next Annual Election Period. b.Mr. Chen must convert his current coverage to employer-sponsored retiree coverage and wait one year before enrolling in a MA or Part D plan. c.Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. d.Mr. Chen can disenroll from the employer-sponsored plan and his only option is to choose a Medigap plan. Source: Part 5, Slide Other Common SEPs. Question 14 Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? a.He will have one opportunity to enroll in a Medicare Advantage plan.b.He will have a nine month period during which he may enroll in as many Medicare Advantage plans as he chooses, with the last enrollment being the effective one. c.If he has a disability, he must enroll in Original Fee-for-Service Medicare during the MA Initial Coverage Election Period. d.He may change or drop MA plans, but may not drop drug coverage. Source: Module 5, Slide - Enrollment Periods: MA Initial Coverage Election Period (ICEP) and Slide – Enrollment Periods MAICEP, continued Question 15 Mr. Roberts is enrolled in an MA plan. He recently suffered complications following hip replacement surgery. As a result, he has spent the last three months in Resthaven, a skilled nursing facility. Mr. Roberts is about to be discharged. What advice would you give him regarding his health coverage options? a.Mr. Roberts must return to Original Medicare within two months of discharge, but he may continue to enroll and disenroll in Part D for 12 months following discharge. Incorrect. An institutionalized individual, such as Mr. Roberts, does not have to return to Original Medicare within two months of discharge. He may make a Medicare Advantage enrollment request or at his option return to Original Medicare and enroll in Part D. b.His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility. c.His open enrollment period as an institutionalized individual will continue for 12 months following his date of discharge. d.Mr. Roberts has two months following his discharge to continue under his current MA plan before he must return to Original Medicare for the remainder to the calendar year. Source: Part 5, MA Open Enrollment Period for Institutionalized (OEPI) Individuals Part D SEP for Institutionalized Individuals. Question 16 Mr. Johannsen is entitled to Medicare Part A and Part B. He gains the Part D low-income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan? a.He can enroll in a different plan or disenroll from his current plan during the next Annual Election Period. b.He qualifies for a special election period and can enroll in or disenroll from a Part D plan once during that period. c.He can apply the subsidy amount to his existing plan immediately, but he cannot enroll in a different plan. d.He can only enroll in or disenroll from an MA-PD plan.Incorrect. He is not restricted only to enrolling in or disenrolling from a MA-PD plan. He is also eligible to enroll in or disenroll from a Part D plan. Source: Part 5, Slide -Typical SEPs – Beneficiaries who are dual eligible or who have LIS eligibility, and Slide - Typical SEPs - Change in Medicaid or LIS Status. Question 17 Mrs. Kumar would like her daughter, who lives in another state, to meet with you during the Annual Election Period to help her complete her enrollment in a Part D plan. She asked you when she should have her daughter plan to visit. What could you tell her? a.She should wait for at least six months into the plan year to be sure that she really wants to make the change. If she still wants to do so, she can make any sort of change she likes at that point. b.Her daughter should come in November. c.Her daughter should come during the three month period that begins on the first day of her birthday month and runs for three full months. d.Her daughter should come sometime between January 1 and March 31. Source: Part 5, Slide -Enrollment Periods: Annual Election Period. Question 18 You have come to Mrs. Midler’s home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical records available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan. What should you do? a.If she brings up the topic of her health, you can ask Mrs. Midler as many questions as she is willing to answer, so you can determine which plan is most suitable for her health needs. b.You can initiate a detailed discussion of all of Mrs. Midler’s health conditions only to better understand her situation and to advise her to choose a different plan if she is experiencing significant health problems. c. You cannot, under any circumstances, ask Mrs. Midler any health-related questions. Incorrect. Marketing representatives may ask health screening questions during the completion of an enrollment request if they are necessary to determine eligibility to enroll in a SNP. d.You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has one of the conditions that would qualify her for a special needs plan. Source: Part 5, Slide - Enrollment Discrimination Prohibitions. Question 19 Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D. What could you tell him?a.He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may only enroll in an MA-PD plan. b.He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may make one Part D enrollment choice, including enrollment in a stand-alone Part D plan or an MA-PD plan. c.He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may only add standalone Medicare prescription drug coverage. d.He must first enroll in a Medicare Part D plan, before enrolling in a Medicare Advantage plan. Source: Part 5,Slide - Enrollment Periods: Part D Initial Enrollment Period (IEP). Question 20 Mrs. Margolis contacts you in August because she will become eligible for Medicare for the first time in November. She would like to meet and discuss plan choices with you. What advice should you give her? a.Tell her to wait until October to discuss plan choices with you so that you can share plan benefits for the current year as well as any changes for the following year that may impact her choice b.Tell her you can meet with her immediately to discuss plan options for the following plan year only. c.Tell her that you should meet to discuss her plan choices as soon as possible so she has more time to weigh her options for the current and following plan years before her enrollment would become effective in November. d.Tell her you are not permitted to meet with her until after she becomes eligible for Medicare in November. Source: Module 5, Slide – Enrollment Periods – Annual Election Period, Timeframes for Submitting Enrollment Forms, continued and Slide – Timeframes for Submitting Enrollment Forms, continued. [Show More]
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