2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024, Exams of Nursing

Download 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 and more Exams Nursing in PDF only on Docsity! 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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 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 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 benefits will be paid for 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. 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. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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 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 obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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 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? - 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Correct Answer 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. 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 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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 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. Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan that includes drug 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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. 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 charge? - 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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 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 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. - Correct Answer I, II, and IV only 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? - Correct Answer 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. 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? - Correct Answer C-SNP 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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 by Part A. What should you tell him? - Correct Answer He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. 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? - Correct Answer Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. Mrs. Wang wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 you tell her? - Correct Answer Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part A and Part B services. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - Correct Answer Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Mr. Kelly wants to know whether he is eligible to sign up for a Private fee-for-service (PFFS) plan. What questions would you need to ask to determine his eligibility? - Correct Answer You would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area. Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 shingles. Mrs. Diaz hopes to avoid such an illness through vaccination. She asks you whether the cost of shingles vaccination will be covered under the plan you represent. What should you say? - Correct Answer Yes, there is no cost sharing for the shingles vaccine even in the deductible phase of her prescription drug plan because it is an adult vaccine recommended by the Advisory Committee on Immunization Practices (AICP). 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? - Correct Answer 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. Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service (PFFS) plan. All types of PFFS plans are available in her 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 area. Which options could Mrs. Roberts consider before selecting a PFFS plan? - Correct Answer A Medicare Advantage Prescription Drug (MA- PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone prescription drug plan. Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? a.Guy, who has illegally crossed the Canadian border. b. Jose, a grandfather who was granted asylum and has worked in the United States for many years. Correct: Jose, having been granted asylum, is legally present in the United States thus meeting one of the criteria for Part D eligibility. c.Betsy, a grandmother from overseas who has overstayed her visa. d.Helena, an overseas college student who has overstayed her visa. - Correct Answer Jose, a grandfather who was granted asylum and has worked in the United States for many years. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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? - Correct Answer 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. Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to? - Correct Answer Yes. Mrs. Walters must be entitled to Part A and/or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan? - Correct Answer She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution. 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? - Correct Answer If the Medicare Advantage plan is a Private Fee-for- Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. 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? - 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Correct Answer In general, he must select a single Part D premium payment mechanism that will be used throughout the year. 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? - Correct Answer 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. Mrs. Fields wants to know whether applying for the Part D low-income subsidy will be worth the time to fill out the paperwork. What could you tell her? - Correct Answer The Part D low-income subsidy could substantially lower her overall costs. She can apply by contacting her state Medicaid office or calling the Social Security Administration. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan. - Correct Answer I, II, and III only 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? - Correct Answer If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Correct Answer FeelBetter will pay Agent Chan initial year compensation for July through December. The renewal amounts will be paid starting in January if Ms. Park remains enrolled the following year. 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? - Correct Answer 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!" 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? - Correct Answer You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Your client, Alexis Jones, calls you on December 4th about changing her Medicare Advantage plan during the annual election period which ends December 7th. What should you do? - Correct Answer Complete a scope of appointment (SOA) during the call and indicate that they will meet to discuss Medicare Advantage plans during an appointment the following day. Linda Sanchez is conducting a previously agreed upon appointment with client, Maria Gomez about a MA-Part D plan she represents. Before an enrollment form is completed, Linda needs to provide Maria with information about ____ I. whether or not Maria's primary care provider is in the plan's network.II. whether Maria's current prescriptions are covered by the plan.III. the monthly premium cost(s).IV. the life insurance products that Linda also sells - Correct Answer I, II, and III only You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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? - Correct Answer 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. 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? - Correct Answer The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. 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? - Correct Answer It must obtain a HIPAA compliant authorization from an 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 plans that are available in his area. Which of the following statements best describes any steps Hector is required to take? - Correct Answer During the first minute of a sales call, Hector must use a disclaimer that says "I do not represent every plan available in your area. I represent 3 organizations that offer 10 plans in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all your options." 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? - Correct Answer Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. Sal D'Angelo is new to the Medicare marketplace having previously been focused on life insurance and disability income protection products. He intends to conduct an educational seminar during the AEP at a local hotel and then invite those who attend to a subsequent marketing meeting to discuss the benefits of next year's plans. How 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 would you advise Sal? - Correct Answer Sal should conduct the education seminar as an early morning meeting and the marketing meeting on the following day in the late afternoon so that there are at least 12 hours between the two meetings. 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? - Correct Answer She can enroll in a Medigap plan to supplement the benefits of the MA plan that she's also enrolling in. You are visiting with Mr. Tully and his daughter at her request. He has advanced Alzheimer's and is incapable of understanding the implications of choosing a Medicare Advantage or prescription drug plan. Can his daughter fill out the enrollment form and sign it for him? - Correct Answer Mr. Tully's daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has a durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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? - Correct Answer Her daughter should come in November. 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? - Correct Answer 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. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Period (OEP) that takes place between January 1 and March 31, but Ms. Gonzales cannot use it because eligibility to use the OEP is available only to MA enrollees. 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? - Correct Answer His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility. Torie Jones is a new marketing representative. Torie asks you for advice as to what topics must be discussed with a Medicare beneficiary prior to enrollment in a Medicare Advantage (MA-PD) plan. What should you say? - Correct Answer Torie, there are many required questions and topics regarding beneficiary needs to be discussed prior to enrollment in an MA plan. These include information regarding primary care providers and specialists whether they are in the plan network, whether 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 or not a beneficiary's current prescriptions are covered as well as premiums, benefits, and costs of health care services. 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? - Correct Answer He qualifies for a special election period and can enroll in or disenroll from a Part D plan once during that period. 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? - Correct Answer 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. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 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)? - Correct Answer 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. 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? - Correct Answer 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. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Apply those guidelines to the following statements and identify which would be prohibited. - Correct Answer "If you're not in very good health, you will probably do better with a different product." Mrs. Goodman enrolled in an MA-PD plan during the Annual Election Period. In mid-January of the following year, she wants to switch back to Original Medicare and enroll in a stand-alone prescription drug plan. What should you tell her? - Correct Answer During the MA Open Enrollment Period, from January 1 - March 31, she may disenroll from the MA-PD plan into Original Medicare and also may add a stand-alone prescription drug plan. 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? - 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. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Mr. Polanski likes the cost of an HMO plan available in his area but would like to be able to visit one or two doctors who aren't participating providers. He wants to know if the Point of Service (POS) option available with some HMOs will be of any help in this situation. What should you tell him? - Correct Answer The POS option might be a good solution for him as it will allow him to visit out-of-network providers, generally without prior approval. However, he should be aware that it is likely he will have to pay higher cost-sharing for services from out-of- network providers. Able, Baker, and Charles are engaged in the marketing to and enrollment of beneficiaries into Medicare health plans. Mr. Able is an independent agent paid directly by a health plan. Ms. Baker is an independent agent paid through a field marketing organization (FMO). Mr. Charles is an independent agent paid for his work by a third-party marketing organization (TMO). How do the CMS compensation rules apply to these three agents? - Correct Answer Baker and Charles are subject to CMS compensation rules because they are paid by third parties. Able is not because he is paid directly by a health plan. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Mr. Landry is approaching his 65th birthday. He has signed up for Medicare Part A, but he did not enroll in Part B because he has employer-sponsored coverage and intends to keep working for several more years. But he is considering enrolling in Part D prescription drug coverage because he believes it is superior to his employer plan. How would you advise him? - Correct Answer Mr. Landry is eligible for Part D since he has Part A, and his initial enrollment period (IEP) for Part D will continue for three months after his 65th birthday. Who is most likely to be eligible to enroll in a Part D prescription drug plan? - Correct Answer Ms. Davis who is entitled to Part A and has just enrolled in Part B. Ms. Bushman has two homes in different states and is concerned about restrictions on where she can get her medications. What should you tell her? - Correct Answer Part D prescription drug plans use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 ACA, such as disability income insurance, do not fall under the scope of 1557. Which entity enforces Section 1557 for programs that receive funding from on are administered by HHS? - Correct Answer The Office of Civil Rights (OCR) of HHS. Section 1557 of the Affordable Care Act applies to - Correct Answer all health programs and activities administered by or receiving federal financial assistance from HHS. Auxiliary aids and services must be provided to individuals with disabilities, such as those suffering from vision or hearing impairments, free of charge, and in a timely manner. Auxiliary aids and services include which of the following: I. large print materials II. qualified sign language interpreters III. braille materials and displays 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 IV. screen reader software - Correct Answer I, II, III, and IV For a health plan, what are the possible consequences of violations of ACA Section 1557? - Correct Answer Loss of federal business and compensatory damages. Loss of federal business and compensatory damages. - Correct Answer cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge. cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge. - Correct Answer Broker Mary Jones has recruited a diverse workforce. She encourages her agents to prospect through community-based marketing and within their community of influence. Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 job, you use a process to verify the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain individuals. What should you do? - Correct Answer Report the incident to the compliance department (via compliance hotline or other mechanism) A person drops off a prescription for a beneficiary who is a "regular" customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step? - Correct Answer Call the prescriber to verify the quantity Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud, waste, and abuse (FWA)? - Correct Answer Deportation Which of the following requires intent to obtain payment and the knowledge the actions are wrong? - Correct Answer Fraud 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Conduct yourself in an ethical manner Ensure accurate and timely data and billing Ensure you coordinate with other payers Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance Verify all information provided to you - Correct Answer True These are examples of issues that should be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA); potential health privacy violation, unethical behavior, and employee misconduct. - Correct Answer True Once a corrective action plan is started, the corrective action plan must be monitored annually to ensure they are effective. - Correct Answer False 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Waste includes any misuse of resources, such as the overuse of services or other practices that directly or indirectly result in unnecessary costs to the Medicare Program. - Correct Answer True What are some of the penalties for violating fraud, waste, and abuse (FWA) laws? a.Civil Monetary Penalties b.Imprisonment c.Exclusion from participation in all Federal health care programs d.All of the above - Correct Answer All of the above Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA) include the Health Insurance Portability and Accountability Act (HIPAA), the Civil False Claims Act, the Anti-Kickback Statute, and the Criminal Health Care Fraud Statute. - Correct Answer True You work for a Sponsor. Last month, while reviewing a Centers for Medicare & Medicaid Services (CMS) monthly report, you identified 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 multiple individuals not enrolled in the plan but for whom the Sponsor is paid. You spoke to your supervisor who said don't worry about it. This month, you identify the same enrollees on the report again. What should you do? - Correct Answer Although you know about the Sponsor's non-retaliation policy, you are still nervous about reporting— to be safe, you submit a report through your compliance department's anonymous tip line to avoid identification A sales agent, employed by the Sponsor's first-tier, downstream, or related entity (FDR), submitted an application for processing and requested two things: 1) to back-date the enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary. What should you do? - Correct Answer Process the application properly (without the requested revisions)—inform your supervisor and the compliance officer about the sales agent's request You discover an unattended email address or fax machine in your office receiving beneficiary appeals requests. You suspect no one is processing 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 b.Termination of employment c.Exclusion from participating kin all Federal health care programs d.All of the above - Correct Answer All of the above Ways to report a compliance issue include: a.Telephone hotlines b.Report on the Sponsor's website c.In-person reporting to the compliance department/supervisor d.All of the above - Correct Answer All of the above Mary Samuels recently suffered a stroke while visiting her daughter and grandchildren. As a result, Mary has been admitted to a rehabilitation hospital where she is expected to reside for several months. The rehabilitation hospital is located outside the geographic area served by her current Medicare Advantage (MA) plan. What options are available to Mary regarding her health plan coverage? - Correct Answer Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Richard is a licensed agent who represents Spartan Health Plan and its Medicare Advantage (MA) plans. Richard has several clients who have recently come to him for help who are in their initial coverage election period (ICEP) and are interested in enrolling in one of Spartan Health Plan's MA plans. Alice will soon turn 65 and retire. Alice has coverage through Spartan Health Plan offered by her employer. Bob had health coverage through Spartan but dropped the coverage when he retired early to travel overseas. Bob, who has just turned age 65, is now back in the United States. Charlotte, who will turn 65 next month, has coverage through Athena Health plan - a company Richard also represents. Who qualifies for the opt-in simplified enrollment mechanism? - Correct Answer Alice because she will not have a break between her non- Medicare and Medicare coverage through Spartan Health Plan. Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable income only sporadically. Her husband worked full- time throughout his long career and paid Medicare taxes. She has heard that to qualify for Medicare Part A she has to have worked and paid Medicare taxes for a sufficient time. What should you tell her? - Correct 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Answer Since her husband paid Medicare taxes during the entire time he was working, she will automatically qualify for Medicare Part A without having to pay any premiums. Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him? - Correct Answer Formularies must be developed with input from pharmacists, doctors, and other experts. If a beneficiary is enrolled in a stand-alone prescription drug plan and wants to keep that plan, what type of Medicare health plan could the individual also enroll in, without being automatically disenrolled from the stand-alone prescription drug plan? - Correct Answer The beneficiary could enroll in a private fee-for-service (PFFS) plan that does not include prescription drug coverage; a Cost plan; or a Medicare Medical Savings Account (MSA) plan. 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 Part B. She wants to know if she is eligible to enroll in a Medicare Advantage plan that includes prescription drug coverage. What do you tell her? - Correct Answer Ms. Morris can enroll in an MA-PD plan now since her initial election period (IEP) for Part D prescription drug coverage and initial coverage period are occurring together beginning March 1st and ending September 30th. You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA) plans you represent. Before you conduct such sales presentations, what must you do? - Correct Answer You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in- home presentation. Ms. Hernandez has marketed several different types of insurance products in her home state and has typically sought approval of her materials from her State Department of Insurance. What would you advise her regarding seeking such approval for materials she uses to 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 market Medicare Advantage plans? - Correct Answer Materials need only be reviewed and approved by the company(s) she represents. Ms. Gates has recently become dually eligible for Medicare and Medicaid. She is very concerned about how this will affect her prescription drug coverage. What should you tell her? - Correct Answer As a dual eligible beneficiary, her Part D drugs will be covered by Medicare once she is enrolled in a Part D plan. If she doesn't select a plan, Medicare will select a plan for her. Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her? - Correct Answer The letter is to inform her that the drug coverage offered through her Medigap plan does not offer drug coverage that is at least comparable to that provided under the Medicare Part D prescription drug program. If she does not have such creditable coverage during 2024 AHIP well Reviewed with Certified Solutions Latest Update 2023\2024 periods when she is first eligible for the Part D program, she will face a premium penalty if she enrolls in a Part D plan at a later date. During an appointment scheduled to discuss a Medicare Advantage Prescription Drug plan (MA-PD), Mr. Peters asked his agent to describe a stand-alone prescription drug plan (Part D plan) that his neighbor told him about. What should his agent do? - Correct Answer Since Mr. Peters requested a description of the Part D plan, his agent must have Mr. Peters sign a new scope of appointment form that includes Part D, and then the agent may discuss the Part D plan so Mr. Peters can compare plans and make an informed enrollment choice during the appointment. You would like to offer gifts of nominal value to potential enrollees who call for more information about a plan you represent. You would then like to offer additional gifts if they come to a marketing event. Each of the gifts meets the CMS definition of nominal value, but together, the gifts are more than the nominal value. Is this permissible? - Correct