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A series of questions and answers related to medicare, covering various aspects of the program, including eligibility, enrollment, coverage, and costs. It is designed to help students understand the complexities of medicare and prepare for exams or quizzes.
Typology: Exams
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Mrs. Pena 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 ensureno gap in coverage. What can you tell her? ✓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. Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employedfull 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? ✓Most individuals who are citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes whileworking, though some may be covered as a result of paying monthly premiums. 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 butreplace her existing Medigap plan
with one that provides drug coverage. What should you tell her? ✓✓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. Mrs. West wears glasses and dentures and has enjoyed considerable pain relieffrom arthritis through massage therapy. She is concerned about whether or notMedicare will cover these items and services. What should you tell her? ✓✓Medicare does not cover massage therapy, or, in general, glasses or dentures. 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 mightbe exposed to under Medicare if he were to require hospitalization as a result of anillness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? ✓✓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 wouldbe responsible for all costs. 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 yearsand paying Medicare taxes. What should you tell her? ✓✓To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. 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? ✓He may sign-up for Medicare at any time however coverage usually begins on the fourth month afterdialysis treatments start. Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of15 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 willbe entitled to Medicare and if he enrolls how that will impact his employer- sponsored healthcare coverage. How would you respond? ✓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. 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? ✓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 someservices that Medicare does not cover. Mr. Alonso receives some help paying for his two generic prescription drugs fromhis employer's retiree coverage, but he wants to compare it to a Part D prescriptiondrug plan. He asks you what costs he would generally expect to encounter when enrolling
into a standard MedicarePart D prescription drug plan. What should you tell him? ✓✓He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing.
Ms. Moore plans to retire when she turns 65 in a few months. She is in excellenthealth and will have considerable income when she retires. She is concerned thather income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern? ✓✓Medicare is a program for people age 65or older and those under age 65 with certain disabilities, end-stage renal disease,and Lou Gehrig's disease so she will be eligible for Medicare. 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? ✓✓Dr. Brennan can charge MaryRogers 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. 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? ✓✓He may receive
health care services from any doctor allowed to bill Medicare, as longas he shows the doctor the plan's identification card and the doctor agrees to acceptthe PFFS plan's payment terms and conditions, which could include balance billing. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? ✓✓Medicare Advantage is a way of covering all the Original Medicare benefits through privatehealth insurance companies.
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? ✓✓Mrs.Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, puttinghim at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him? ✓✓.C-SNP Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD planand 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?
✓✓She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. 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? ✓✓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 theSNP. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? ✓✓Mrs. Radford must be entitledto Part A and enrolled in Part B to enroll in Medicare Advantage. 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? Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers.
Mr. 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 byPart A. What should you tell him? ✓✓He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several yearsago. 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? ✓✓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. Mr. Kumar is considering a Medicare Advantage HMO and has questions about hisability to access providers. What should you tell him? 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).ur clients, Lauren Nichols, has heard about a Medica
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 excessof 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? ✓✓You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the carehe has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him? ✓✓SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful aswell. 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? ✓✓They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.
Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in PartB because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do? ✓✓He will have to enroll in Part B. 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 noton his Part D plan's formulary. What could you tell him to do? ✓✓Mr. Zachow hasa right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan. Mr. 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? ✓✓He could check with the manufacturers of his medicationsto 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.
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 tohave their Medicare prescription drug plan cover these drug needs. What should you tell them? ✓✓Medicare prescription drug plans are not permitted to cover theprescription 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. 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 asksyou if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say? ✓✓None of the costs of Mr. Wingate's other medications would currently count toward TrOOP but he maywish to ask his plan for
an exception to cover the prescription not on its formulary.
Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescriptiondrug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her? ✓✓She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a highercost than paid at an in-network pharmacy. 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. Sheis interested in enrolling in a Medicare Part D prescription drug plan (PDP). Whatshould you tell her? ✓✓If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. 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 shouldyou tell her? ✓✓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. 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? ✓✓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 forevery month that she was not covered. Mr. Shultz was still working when he first qualified for Medicare. At that time, hehad 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. Shultz has lost his employer group coverage within the last two weeks. How would you advise him? ✓✓Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order toavoid a premium penalty.
Mrs. 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 isnot enrolled under Medicare Part B.
What should you tell her? ✓✓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 notneed to enroll under Part B before enrolling in a prescription drug plan. What types of tools can Medicare Part D prescription drug plans use that affect theway their enrollees can access medications? ✓✓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. 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 abeneficiary would incur for prescription drugs under the standard coverage? ✓✓Standard Part D coverage would require payment of an annual deductible, andonce 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%. 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, hesees a wide range in what they charge for deductibles, premiums, and cost sharing.How can you explain this to him? ✓✓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. 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 youtell him? ✓✓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. Which of the following individuals is most likely to be eligible to enroll in a Part DPlan? ✓✓Jose, a grandfather who was granted asylum and has worked in the United States for many years. Mr. Hutchinson has drug coverage through his former employer's
retiree plan. Heis 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? 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 topay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligiblefor Medicare as well. What can she expect will happen to her drug coverage? ✓✓Unless she chooses a Medicare Part D prescription drug plan on her own, shewill be automatically enrolled in one available in her area. 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? ✓✓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.
Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any eligible beneficiary who applies regardless of healthstatus except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy networkbut may choose to have one. III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan mayonly obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through astandalone PDP or through their plan. I, II, and III only Mr. Torres has a small savings account. He would like to pay for his monthly PartD premiums with an automatic monthly withdrawal from his savings account untilit is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him? In general, he must select a single Part D premium payment mechanism that will be used throughout the year. You will be holding a sales event soon, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare