AHIP COMMUNITY NURSING QUESTIONS AND ANSWERS BEST COMPLETE SOLUTIONS WITH A+ GRADE, Exams of Nursing

Download AHIP COMMUNITY NURSING QUESTIONS AND ANSWERS BEST COMPLETE SOLUTIONS WITH A+ GRADE and more Exams Nursing in PDF only on Docsity! AHIP COMMUNITY NURSING QUESTIONS AND ANSWERS BEST COMPLETE SOLUTIONS WITH A+ GRADE 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? After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age Mr. Davis is 49 years old and has been receiving disability benefits from the Social Security Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescription Drug policy? No, he cannot purchase a Medicare Advantage or Part D policy because he has not received Social Security or Railroad Retirement disability benefits for 24 months. 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? In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes Mrs. Raskin is a widow who will attain aged 65 and enroll in Medicare in just a few weeks. She concerned about having prescription drug coverage. Which of the following statements provides the best advice? Prescription drug coverage can be obtained by enrolling in a Medicare Advantage plan that includes Part D coverage Mr. Hernandez is concerned that if he signs up for a Medicare Advantage plan, the health plan may, at some time in the future, reduce his benefits below what is available in Original Medicare. What should you tell him about his concern? Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs 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? Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end stage renal disease or Lou Gehrig’s disease, so she will be eligible for Medicare Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefit package of a Medicare Health Plan before she starts looking at specific plans. What could you tell her? Medicare Health Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services Mr. Meoni’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.Meoni? Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover 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? 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. 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? 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. 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 sub-populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP 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 like 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 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 Mrs. Lee is discussing with you the possibility of enrolling in a Private Fee-for- Service (PFFS) plan. As part of that discussion, what should you be sure to tell her? If she uses non-network providers, her doctors and hospital could decide whether to treat her on a visit-by-visit basis Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know what makes them different from an HMO or a PPO. What should you tell him? Enrollees in a PFFS plan can obtain care from any provider in the U.S. 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 If Dr. Elizabeth Brennan does not contract with the PFFS plan, but accepts the plan’s terms and conditions for payment, how will she be paid? Generally, the PFFS plan will pay Dr. Brennan directly the same amount Original Medicare would pay her. 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? 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 Mr. 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? 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 Which statement best describes PACE plans? It includes comprehensive medical and social service delivery systems using an interdisciplinary team approach in an adult day health center, supplemented by in- home and referral services 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? Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep Mrs. Walters 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 will coordinate benefits only with Medicaid participating providers. 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. Rivera has QMB-Plus eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later in the year, Mr. Rivera needs dentures, a service only covered under Medicaid. What action would you recommend he take in order to have this cost covered? He should go to a Medicaid provider or obtain the services through a Medicaid manage care plan if he is enrolled in one Module 2: Quick Review 6 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? He could enroll in one of the MA plans that include prescription drug coverage or a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan Mr. Katz reached the Part D coverage gap in August last year. His prescriptions have not changed, he is keeping the same Part D plan and the benefits, cost- sharing, and coverage of his drugs are all the same as last year. He asked what to expect for this year about his out-of- pocket costs. What could you tell him? Because he reached the coverage gap last year, he will probably reach it again this year close to the same time. Mrs. Grant uses several very expensive drugs and anticipates that she will enter catastrophic coverage at some point during the year. To help her determine when she is likely to qualify for catastrophic coverage, she asked which expenses count toward the out-of-pocket limit that qualifies her for catastrophic coverage. Which one of the following would count? Prescription drugs she purchases when in the Part D coverage gap Mr. Shapiro gets by on a very small fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him? The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. 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? 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. 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 medications to see if they offer an assistance program to help people with limited means 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. 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. 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, 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 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? In general, he must select a single Part D premium payment mechanism that will be used throughout the year Mrs. Fiore was in the Army for 35 years and is now retired. She has drug coverage through the VA. What issues might she consider with regard to whether to enroll in a Medicare prescription drug plan? She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the VA for the specific medications she needs and whether any additional benefits are worth the Part D premium costs. 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? 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 Mr. Jenkins has coverage for medical services and medications through his employer’s retiree plan. He is considering switching to a Medicare prescription drug plan because his retiree plan does not cover two important medications. What should he consider before making a change? If Mr. Jenkins drops his drug coverage through the retiree plan, he may not be able to get it back and he also may lose his medical health coverage Mr. Shultz 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. Shultz has lost his employer group coverage. 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 to avoid a premium penalty. 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 with respect to her drug coverage? Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Module 4 Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services’ Marketing Guidelines to ensure he is compliant for which type of products? Medicare Advantage (MA) and Prescription Drug (PDP) plans Another 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 requirements as the plans themselves. How should you respond to such a statement? 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 You work for a company that has marketed Medigap products for many years. The company has added Medicare Advantage and Part D plans and you will begin marketing those plans this fall. You are planning what materials to use to easily show the differences in benefits, You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To be in compliance with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plans? You will have to avoid calling any potential client, unless he or she initiates contact with you and specifically asks that you give him or her a call Module 4: Quick Review 5 You have received an advertisement from a vendor who says they can provide you with an extensive list of publicly available e-mail addresses for individuals who are Medicare beneficiaries. In addition, one of your Medicare Advantage clients offered to share her e-mail address book with you so you could contact her Medicare- eligible friends. In considering these sources of leads, what rules must you be sure to abide by? You may send an e-mail to a beneficiary about Medicare Advantage plan information if the beneficiary provides his/her email address to the plan and agrees to receive e-mails from the plan Agent Mark Andrews would like to employ technology to facilitate the growth of his Medicare Advantage (MA) practice. What step(s) would you recommend that Mark take? Purchase Internet pop-up ads providing plan-specific information that have been reviewed and approved by CMS Module 4: Quick Review 6 ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees' protected health information to market non-health related products such as life insurance and annuities. To do so it must obtain authorization from the enrollees. Which statement best describes the authorization process? Authorization may be obtained by directing a beneficiary to a website to provide consent During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5-star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the correct statement to say to her? The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4- stars Mr. Valesquez asked if the Private Fee-for-Service plan you have discussed is like Original Medicare or a Medigap supplement plan. What should you say about a Private Fee-for-Service (PFFS) plan to explain it to Mr. Valesquez? It is not Original Medicare and it works differently than a Medicare supplement plan. Ajax Agency is targeting potential enrollees for MSA plans. Which of the following statements best describes the rules that apply to the MSA materials it distributes? The materials must make clear that Medicare MSA plans do not cover prescription drugs and that beneficiaries can join a separate Part D prescription drug plan Module 4: Quick Review 7 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? Tell her that the Medicare agency does not endorse or recommend any plan. By contacting plans available in your area, you have learned that the plan you represent has a significantly lower monthly premium than the others. Furthermore, you see that the plan you represent has a unique benefit package. What should you do to make sure your clients know about these pieces of information? You may present comparative information that has been created and approved by the Medicare agency (CMS), such as a print-out from the Medicare plan comparison website. 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? You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. Ordinarily, you provide clients who purchase various types of insurance products from you with a gift when they enroll and you let them know that they will receive it after their enrollment is complete. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan? You may not provide any gift or prize as an inducement to enroll. One of your colleagues argues that face-to-face meetings with potential enrollees should be required because they cannot make an appropriate decision with the minimal information that can be provided over the phone or in small brochures. How should you respond to this argument? This is incorrect. Brokers and agents cannot require face to face meetings in order to answer questions or enroll a Medicare beneficiary Agent Harriet Walker has recently begun marketing Medicare Advantage and related products aimed at meeting the needs of senior citizens. Client Mildred Jones has expressed interest in a Medicare Advantage plan. It is now the beginning of September. If you were in Agent Walker's position, what would you do? Inquire whether the client qualifies for a special enrollment period, and if not, solicit an enrollment application once the annual open enrollment election period begins on October 15th. Mr. Murphy is an agent. A neighbor invited him to discuss the Medicare Advantage (MA) and Part D plans he sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Mr. Murphy tell his neighbor about the kinds of food that can be provided to potential enrollees who attend the sales presentation? The neighbors may not provide a meal, but light snacks would be permitted. If you are to be in compliance with Medicare’s guidance regarding educational events, which of the following would be acceptable activities? You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent You are working with a number of plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do? You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. You plan to participate in an educational event sponsored by a large regional health care system. One of your colleagues suggests that you do a presentation on one of the Medicare Health plans you market, and modify it to include information about preventive screening tests showcased at the event. How should you respond to your colleague’s suggestion? You should tell your colleague no because participation in an educational event may not include a sales presentation. Agent Mary Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational in nature. 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? Yes. When an event has been advertised as “educational,” discussing plan-specific premiums is impermissible. Module 4: Quick Review 12 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? The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. BestCare Health Plan has received a request from a state insurance department in connection with the investigation of several marketing representatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response? Cooperate with the state and supply requested information. ABC Health Plan has just learned that several individuals marketing their Medicare Advantage plans in a state are unlicensed. What actions must ABC take in response? Among other steps, ABC must terminate these individuals and report to both the state and CMS incidences of submission of applications by unlicensed agents and or brokers Roberta is a retiree who has just learned that she has purchased a Medicare Advantage (MA) plan from an unlicensed individual representing BestCare Health Plan. What are Roberta's options, if any? Roberta may request to change plans upon receiving notification of the agent’s unlicensed status. Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted with regard to the marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise him concerning the type of scrutiny he will be under? 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? Mr. Tully’s daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions 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? You may correct this information as long as you add your initials and date next to the correction Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare's efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment site, which of the following must Phiona consider? I. If a legal representative is completing an electronic enrollment request, he or she must first upload proof of his or her authority. II. All data elements required to complete an enrollment request must be captured. III. The process must include a clear and distinct step that requires the applicant to activate an "Enroll Now" or "I Agree" type of button or tool. IV. The mechanism must capture an accurate time and date stamp at the time the applicant enters the online site. II and III only Module 5: Quick Review 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? If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan You are doing a sales presentation for Mrs. Pearson. You know that the Medicare marketing guidelines prohibit certain types of statements. Apply those guidelines to the following statements and identify which would be prohibited. “If you’re not in very good health, you will probably do better with a different product.” 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 record 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? You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has end stage renal disease or one of the conditions that would qualify her for a special needs plan. Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard? Implying that only seniors can enroll in a Medicare Advantage plan when meeting with Mr. Hernandez, who is 58 but qualifies for Medicare because she is disabled MA and Part D Enrollment Periods Brief Summary Module 5: Quick Review 4 Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? He will have one opportunity to enroll in a Medicare Advantage plan Mrs. Kendrick is six months away from turning 65. She wants to know what she will have to do to enroll in a Medicare Advantage (MA) plan as soon as possible. What could you tell her? She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B 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? 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. 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 prior the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams? This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form prior to the start of the AEP Module 5: Quick Review 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? It is a time 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 Mr. Garcia was told he qualifies for a Special Election Period (SEP), but he lost the paper that explains what he could do during the SEP. What can you tell him? If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage. Mrs. Gunner thought she was enrolling in a stand-alone PDP, but when she received her plan materials, she found out she was enrolled in a Private Fee-for- Service (PFFS) plan with drug coverage. She called her marketing representative for help. What should the marketing representative tell her? If she believes she received misleading information, she must contact Medicare and, if she qualifies for a Special Enrollment Period, she can select a new option, which could include a different MA plan, a PDP, or Original Medicare. Module 5: Quick Review 7 Which of the following individuals are likely to qualify for a special enrollment period (SEP) for both MA and Part D due to a change of residence? I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan's service area. II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's service area. III. Gilbert moves into a plan service area where there is no Part D plan available. IV. Henry makes a permanent move providing him with new MA and Part D options. II and IV only 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 that his employer is cutting back on prescription drug benefits, and as of June his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special enrollment periods (SEPs)? Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends two months later. Ms. Lee is enrolled in an MA-PD plan, but will be moving out of the plan’s service area next month. She is worried that she will not be able to enroll in another plan available in her new residence until the Annual Election Period. What should you tell her? She is eligible for a Special Election Period that begins either the month before her permanent move, if the plan is notified in advance, or the month she provides notice of the move, and this period typically lasts an additional two months 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? It means that he qualifies for a one-time opportunity to enroll into an MA- PD or Part D prescription drug plan. Mrs. Schneider has Original Medicare Parts A and B and has just qualified for her state’s Medicaid program, so the state is now paying her Part B premium. Will gaining eligibility for this program affect her ability to enroll in a Medicare Advantage or Medicare Prescription Drug plan? Yes. Qualifying for this state program gives Mrs. Schneider access to a Special Election Period that allows her to make changes to her MA and/or Part D enrollment at any time. If Mr. Johannsen gains the Part D low-income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan? He can enroll in or disenroll from a Part D plan at any time and the subsidy will apply to the plan he chooses. Mr. Carter, who is enrolled in a stand-alone Part D plan, receives the Part D low- income subsidy and just received a letter from the Social Security Administration informing him that he will no longer qualify for the subsidy? He is wondering if he can switch to a lower cost Part D plan. What should you tell him? He qualifies for a Special Election Period which begins the month he was notified of his loss and continues for two more months. This SEP allows him one opportunity to enroll into another PDP or an MA-PD 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? Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment, but he should revaluate if he really wants to drop his employer coverage. Module 5: Quick Review 8 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? Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan 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? His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility Mrs. Lenard is enrolled in a Medicare Cost plan. Recently the cost plan has transitioned to a Medicare Advantage (MA) contract, and Mrs. Lenard has been told that she has been subject to "deemed enrollment." What does this mean? Mrs. Leonard will be automatically enrolled in an MA plan offered by the same organization as the cost plan, notified by CMS, and given the opportunity to choose another option Module 5: Quick Review 9 You are completing a PFFS plan sale to Mr. West who is new to Medicare, and as you are finishing up, what should you tell him about next steps in the enrollment process? You need to get Mr. West’s phone number and include it on the enrollment form because the plan must call him after you leave to ensure that he understood the nature of the PFFS plan he selected and to verify his intent to enroll. Mrs. Johnson calls to tell you she has not received her new plan ID card yet, but she needs to see a doctor. What can she expect to receive from the plan after the plan has received her enrollment form? Evidence of plan membership, information on how to obtain services, and the effective date of coverage Mrs. Reynolds just signed up for a Medicare Advantage plan on the second of the month. She is leaving for vacation in two weeks and wants to know if her new coverage will start before she leaves. What should you tell her? Typically her coverage would begin on the first day of the next month, so she should not expect her coverage to begin before she leaves You meet with Mrs. Wilson to complete her enrollment in a Medicare Advantage plan. You tell her that there will be an enrollment verification process to confirm that she is enrolled in the plan coverage. The prescription drug coverage has not been comparable to that offered by Medicare Part D for several years and despite notification, Mr. Kelly took no action. Which of the following statements best describes what will occur if Mr. Kelly now decides to enroll in Medicare Part D? He will avoid any financial penalty or late enrollment fee under the grandfathering provisions of Medicare Part D. Ms. Lopez is an independent agent under contract with MarketCo, a third-party marketing organization. MarketCo has a contract with BestCare health plan, a Medicare Advantage (MA) organization, to offer marketing services through its contracted agents and agencies. Ms. Lopez returns calls to individuals who contact MarketCo in response to its mailers promoting BestCare health plan. Which of the following best describes the responsibilities of Ms. Lopez? Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. Agent Hilary Baxter has recently become licensed and appointed to sell Medicare Advantage (MA) plans. She intends to reach out to members of her community who might be interested in such products. How would you advise Agent Baxter as to what steps would be permissible for her to undertake? Agent Baxter should consider a direct mail campaign targeted throughout her community using CMS approved materials Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to you for advice as to what options, if any, she has. What should you say regarding special enrollment periods (SEPs)? You have until November 30, one time Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her? Part D covers prescription drugs and she should look at her premiums, formulary, and cost sharing among other factors to see if they have changed. Part D covers prescription drugs and she should look at her premiums, form have changed Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation rules apply to this situation? This situation is considered a “dual enrollment,” and CMS compensation rules are applied to the two plans at once and independently of each other. You have had a good meeting with Mr. Claggett and he has selected a Medicare Advantage plan. He would like you to help him complete the enrollment application because he wants to make sure he gets into the right plan. You offer to help, but you tell him that you cannot do which of the following? Help him fill out any portion of the enrollment form. 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. Agent Chan is conducting a sales presentation on senior issues where he hopes to enroll some attendees in the Medicare Advantage (MA) plans he represents. What action(s) may Agent Chan take during the event? Distribute just a portion of enrollment materials to encourage follow- up individual meetings. Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him? He will have to enroll in Part B before he can enroll in a Part D prescription drug plan. Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage (MA) health plans. This year she has decided to focus on non-MA products. What advice would you give Melanie if she wishes to continue to receive renewal fees? Melanie must remain trained, tested, licensed, and appointed, regardless of whether she is actively selling MA products 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? Mr. Diaz will not pay any penalty because he had continuous coverage under his employer’s 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? 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. Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is interested in that product. She wants to be sure she also has coverage for prescription drugs. Would she be able to obtain drug coverage if she enrolled in the SNP? Yes. All SNPs are required to provide Part D coverage for prescription drugs 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? She may enroll at any time while she is covered under her employer plan enrollment period that differs from the standard general enrollment period, d Part B He might qualify for help with Part D prescription drug costs and help paying Part A an cost sharing Mr. Yu has limited income and resources so you have encouraged him to see if he qualifies for some type of financial assistance. Mr. Yu is not sure it is worth the trouble to apply and wants to know what the assistance could do for him if he qualifies. What could you tell him? 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 to require 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? Under Original Medicare, there is a single deductible amount due for the fi stay, after which it converts into a per-day amount through day 90. After day 60 days over his lifetime, after which he would be responsible for all costs Mrs. Kanof is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled nursing facility? Medicare will cover Mrs. Kanof‘s skilled nursing services provided durin which she would have a copay until she has been in the facility for 100 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? Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern? Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. required to take corrective action and sometimes pay damages, and it may be sued by individuals. Which area of potential discrimination is not generally covered by ACA Section 1557? Employment (with the exception of the provision of health insurance). Medicare Fraud, Waste and Abuse FWA Quick Review 1 Which of the following requires intent to obtain payment and the knowledge that the actions are wrong? Fraud Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting Fraud, Waste, and Abuse (FWA)? Deportation FWA Quick Review 2 A person comes to your pharmacy to drop 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? Call the prescriber to verify the quantity 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 job you verify, through a certain process, that the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust/add risk diagnosis codes for certain individuals. What should you do? Report the incident to the compliance department (via compliance hotline or other mechanism) You are in charge of payment of claims submitted by providers. You notice a certain diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize that Doe Diagnostics' claims far exceed any other provider that you reviewed. What should you do? Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit (SIU), or other mechanism) You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do? Follow your pharmacy’s procedures Once a corrective action plan is started, the corrective actions must be monitored annually to ensure they are effective. These are examples of issues that should be reported to a Compliance Department: suspected Fraud, Waste, and Abuse (FWA); potential health privacy violation, and unethical behavior/employee misconduct. What are some of the penalties for violating Fraud, Waste, and Abuse (FWA) laws? Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Any person who knowingly submits false claims to the Government is liable for five times the Government's damages caused by the violator plus a penalty. You can help prevent Fraud, Waste, and Abuse (FWA) by doing all of the following: Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which includes Medicare) constitute fraud by the person making as well as the person receiving them. Some of the laws governing Medicare Parts C and D Fraud, Waste, and Abuse (FWA) include the Health Insurance Portability and Accountability Act (HIPAA); the False Claims Act; the Anti- Kickback Statute; the List of Excluded Individuals and Entities (LEIE); and the Health Care Fraud Statute. Ways to report potential Fraud, Waste, and Abuse (FWA) include 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. Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only. False Ways to report a compliance issue include: All of the above What is the policy of non-retaliation? Protects employees who, in good faith, report suspected non-compliance These are examples of issues that can be reported to a Compliance Department: suspected Fraud, Waste, and Abuse (FWA); potential health privacy violation, and unethical behavior/employee misconduct. True Once a corrective action plan begins addressing non-compliance or Fraud, Waste, and Abuse (FWA) committed by a Sponsor's employee or First-Tier, Downstream, or Related Entity's (FDR's) employee, ongoing monitoring of the corrective actions is not necessary. False Medicare Parts C and D plan Sponsors are not required to have a compliance program False At a minimum, an effective compliance program includes four core requirements. False Standards of Conduct are the same for every Medicare Parts C and D Sponsor. False Correcting non-compliance Protects enrollees, avoids recurrence of the same non-compliance, and promotes efficiency What are some of the consequences for non-compliance, fraudulent, or unethical behavior? All of the above