Understanding Medicare Coverage and Medicare Advantage Plans, Exams of Nursing

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verified solutions latest update a+ graded Edward IP suffered from serious kidney disease. As a result. Edward became eligible for Medicare coverage due to end-stage renal disease (ESRD). A close relative donated their kidney and Edward successfully underwent transplant surgery 12 months ago. Edward is now age 50 and asks you if his Medicare coverage will continue, what should you say? - Correct Answer Individuals eligible for Medicare based on ESRD generally lose eligibility 36 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward may, however, remain enrolled in Part B but solely for coverage of

verified solutions latest update a+ graded immunosuppressive drugs if he has no other health care coverage that would cover the drugs. Mildred Savage enrolled in Allcare Medicare Advantage plan several years ago. Mildred recently learned that she is suffering from inoperable cancer and has just a few months to live. She would like to spend these final months in hospice care. Mildred's family asks you whether hospice benefits will be paid for under the Allcare Medicare Advantage plan. What should you say? - Correct Answer Mildred may remain enrolled in Allcare and make a hospice election. Hospice benefits will be paid for

verified solutions latest update a+ graded by Original Medicare under Part A and Allcare will continue to pay for any non-hospice services. Mr. Diaz continued working with his company and was insured under his employer's group plan until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know how much he will have to pay. What should you tell him?

• Correct Answer Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan.

verified solutions latest update a+ graded 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? - Correct Answer 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. 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

verified solutions latest update a+ graded because she was not born in the United States. What should you tell her? - Correct Answer 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. 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? - Correct Answer After receiving such disability

verified solutions latest update a+ graded payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. 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? - Correct Answer Beneficiaries under Original Medicare have no cost- sharing for most preventive services which include immunizations such as annual flu shots. Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard

verified solutions latest update a+ graded she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her? - Correct Answer 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. 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

verified solutions latest update a+ graded tell him? - Correct Answer He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline, who has only worked part-time for the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her? - Correct Answer

verified solutions latest update a+ graded You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband's long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at more than the standard lowest rate but less than the highest rate due her substantial income. 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? - Correct Answer To

verified solutions latest update a+ graded obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. - Correct Answer 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. 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

verified solutions latest update a+ graded 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? - Correct Answer Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage. 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? - Correct Answer

verified solutions latest update a+ graded Medicare is a program for people age 65 or 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. 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? - Correct Answer It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare.

verified solutions latest update a+ graded Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance? - Correct Answer 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. Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee- for-Service (FFS) Medicare. What could you tell him? - Correct Answer Part A, which covers hospital, skilled nursing facility, hospice, and home health services and Part B, which covers

verified solutions latest update a+ graded professional services such as those provided by a doctor are covered under Original Medicare. Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-income subsidy. Where might he turn for help with his prescription drug costs? - Correct Answer Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program. Shirly Thomas was enrolled in Medicaid during the Public Health Emergency (PHE). This coverage has recently been terminated due to the end of the

verified solutions latest update a+ graded PHE. While Shirley was enrolled in Medicaid, she missed an opportunity to enroll in Medicare and now wants Part B. Which of the following statements best describes Shirley's ability to now enroll in Medicare Part B? - Correct Answer Shirley is eligible for a Special Enrollment Period (SEP) for up to six months after the termination of her Medicaid coverage. Under this SEP, Shirley can choose retroactive coverage back to the date of termination from Medicaid or coverage beginning the month after the month of enrollment. Anthony Boniface turned 65 in 2023. He was not receiving Social Security or Railroad Retirement

verified solutions latest update a+ graded Benefits on his 65th birthday. He was interested in obtaining Medicare coverage and is eligible for premium-free Part A. Before he could enroll in Medicare, his entire area was impacted by a hurricane causing massive flooding and severe wind damage. The Federal government declared this to be a natural disaster which has recently ended. During this period Anthony's initial enrollment period expired. Anthony asks you how he can now obtain Medicare coverage. What should you say? - Correct Answer Anthony is eligible for a special enrollment period (SEP) because he missed an enrollment period due to the impact of the Federally declared disaster. This SEP will allow Anthony to enroll in Part B up to six months after

verified solutions latest update a+ graded the end of the emergency declaration. Anthony may enroll in premium-free Part A at any time and his Part A coverage will be retroactive for up to 6 months. Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan? - Correct Answer All MSAs cover Part A and Part B

verified solutions latest update a+ graded benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling in a separate prescription drug plan. 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? - Correct Answer 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.

verified solutions latest update a+ graded 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? - Correct Answer 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.

verified solutions latest update a+ graded 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? - Correct Answer 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. 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

verified solutions latest update a+ graded charge? - Correct Answer 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. 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? - 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

verified solutions latest update a+ graded doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing. Juan Hernandez is turning 65 next month, Juan legally entered the United States over twenty years ago but is not a citizen. Since his entry into the country, Juan has worked at Smallcap Incorporated and contributed to the Medicare system. Juan suffers from diabetes. He will soon retire and asks you if he can enroll in a Medicare Advantage plan that you represent. How would you respond? - Correct Answer Juan is eligible to enroll in a Medicare Advantage as long as he is entitled to Part

verified solutions latest update a+ graded A and enrolled in Part B. Juan should go to the Social Security website to enroll in Medicare Part A and B if he has not done so already. Once he is enrolled, he can choose a Medicare Advantage plan. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? - Correct Answer Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by

verified solutions latest update a+ graded 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? - Correct Answer You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. 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

verified solutions latest update a+ graded 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? - Correct Answer She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Which of the following statement(s) 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.