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AHIP TRAINING MODULE #2 Q & A ALL CORRECT

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AHIP TRAINING MODULE #2 Q & A ALL CORRECT LOPEZ has heard that he can sign up for a product called MA, but is not sure about what type of plan designs are available through this program (MA plan... , types) Correct Answer: They are Medicare health plans such as HMO, PPO, PFFS, SNP AND MSA WHALEN is trying to understand the difference between Original Medicare and MA. (MA vs Original Medicare) Correct Answer: MA is a way of covering ALL of the Original Medicare benefits through private health insurance companies. During a sales presentation in Ms. Sully's home, she tells you that she has hearing about a type of Medicare plan known as PFFS. She wants to know if this would be available to her. (MA-PFFS) Correct Answer: A PFFS plan is one of various types of MA plans offered by private entities and she may enroll in one if it is available in her area. RADFORD asks whether there are any special eligibility requirement s for MA (MA requirements/eligibility) Correct Answer: Mrs. Radford MUST be entitled to Part A and enrolled in Part B to enroll in MA. BASS lives on a limited fixed income and is concerned about the cost of healthcare. What should you tell her about the sort of help available to low income individuals under the Medicare program? (Help for individuals with limited income/resources) Correct Answer: As a Medicare beneficiary with limited income/resources she may contact her State Medicaid agency to apply for assistance paying for the Part B premium and cost sharing and Part D Rx coverage. KUMAR is considering MA HMO and has questions about his ability to access providers. (MA HMO providers) Correct Answer: In MOST MA HMO's, Mr. Kumar MUST obtain his services only from providers who have a contractual relationship with the plan (Except in an Emergency) RAMOS is considering a MA PPO and has questions about which providers she can go to for her health care. (MA PPO providers) Correct Answer: Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will be charged a lower co-payment if she goes to one of the plan's PREFERRED providers. 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 MA SNP. (MA SNP eligibility) Correct Answer: SNP's have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide Rx coverage that could be very helpful as well. 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 MA SNP. His friend has mentioned that the SNP charges very low cost sharing amts. and Mr. Greco would like to join the plan. (MA SNP eligibility) Correct Answer: SNP LIMIT enrollment to certain sub-populations of beneficiaries. Given his current situation, he is unlikely to qualify and would NOT be able to enroll in the SNP GOMEZ notes that a PFFS plan available in his area has an attractive premium. He wants to know if he must use doctors in a network like his current HMO plan requires him to do. (MA PFFS providers) Correct Answer: He may receive health care services from ANY doctor allowed to bill Medicare, as long as he shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing. LEE is discussing with you the possibility of enrolling in a PFFS plan. As part of the discussion, what should you be sure to tell her? (MA PFFS) Correct Answer: If she uses NON-NETWORK providers, he doctors and hospital could decide whether to treat her on a VISIT BY VISIT basis. McTAGGERT notes that a PFFS plan available in his area has an attractive premium. He wants to know what makes them different from an HMO or a PPO. (MA PFFS vs. HMO or PPO) Correct Answer: Enrollees in a PFFS plan can obtain care from ANY provider in the US, who accepts Original Medicare, as long as the provider has a reasonable opportunity to access the plan's terms and conditions and agrees to accept them. Dr. Elizabeth Brennan does not contract with the PFFS plan, but accepts the plan's terms and conditions for payment, how will she get paid? (MA PFFS provider payment) Correct Answer: Generally, the PFFS plan will pay Dr. Brennan directly the same amt. Original Medicare would pay her. LYONS is in good health, uses a single Rx, and lives independently in her own home. She is attracted by the idea of maintaining control over a MSA, but is not sure if the plan associated with the acct. will fit her needs. (MA MSA) Correct Answer: ALL MSA's cover Part A and Part B benefits, but NOT Part D Rx benefits, which could be obtained by also enrolling in a separate Rx plan. DAVIES is turning 65 next month. he would like to enroll in a Medicare health plan, but does not want to be limited in terms of where he obtains his care. What should you tell him about how a Medicare cost plan might fit his needs. (MA costs) Correct Answer: Cost plan enrollees can choose to receive Medicare covered services under the plan's benefits by going to plan network providers and paying plan cost sharing, or may receive services from Non-network providers and pay cost-sharing due under Original Medicare. ROMERO is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan that includes Rx coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and because he takes numerous Rx's, he is considering signing up for it. (MA-PD_ Correct Answer: It is ALWAYS the best option to talk with his benefits administrator to see whether he needs both an employer sponsored plan and a private MA-PD and what might happen if he were to sign up for both. WALTER'S is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Health plan? (Medicaid) Correct Answer: Medicaid will coordinate benefits ONLY with Medicaid participating providers. ANDREWS asked how a 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? (PFFS and Medicaid) Correct Answer: Medicaid may provide additional benefits, but Medicaid will coordinate benefits ONLY with Medicaid participating providers. LOMBARDI is interested in a MA PPO plan that you represent. It is one of three plan 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 Rx plan. (MA PPO) Correct Answer: He could enroll in one of the MA plans that include Rx coverage or a Medigap plan and a stand-alone Rx plan, but he CAN'T enroll in the MA-only PPO plan and a stand-alone Rx plan. CHOU likes a PFFS plan available in her area that does not offer drug coverage. She wants to enroll in the plan and enroll in a stand-alone Rx plan. What should you tell her? (MA-PFFS) Correct Answer: She COULD enroll in a PFFS plan and a stand-alone Medicare Rx plan. Medicare Advantage plans Correct Answer: **Private companies offer health plan that cover all Medicare Part A and B benefits. --Many also cover Part D Rx benefits MA-PD plans --ALL MA plans offer a max out of pocket limit. --Many MA plans offer extra benefits that Medicare DOESN'T cover --Certain plans can restrict enrollment eligibility to: ****SNP; employees and/or retirees waiver plans*** Other types of Medicare plans such as: MEDICARE COST PLANS; PACE PLANS; MEDICARE-MEDICAID; DEMONSTRATION PLAN; AND PILOT PROGRAMS Types of MA plans are: Correct Answer: --HMOs; some have a POS benefit --PPO, local and regional --PFFS --MSA MA Eligibility Correct Answer: --Must be entitled to Part A AND enrolled in Part B --Must live in MA plan's service area --Must continue to pay Part B premium --May need to pay a MA plan premium MA limited income help from state or CMS to pay: Correct Answer: --Part A and B premiums, deductibles and cost sharing --Some Part D Rx costs and/or some benefits NOT covered by Medicare (personal care or rides to doctor appts. MA HMO Coordinate Care Plans Correct Answer: -enrollees MUST use doctors and hospitals within plan networks to receive most covered services -ER and urgently needed services outside plan network are covered -temporarily absent from plan's service area, dialysis are covered -OTHER CASES if care is out of network w/o prior authorization from the plan, they have to pay it themselves. -MUST have a max limit on member out of pocket costs not greater than [Show More]

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