Medicare Advantage and Prescription Drug Plan Eligibility and Enrollment, Exams of Nursing

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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? a. 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. Correct: MA-PPO enrollees may seek care from any provider who accepts Medicare. However, enrollees are typically responsible for higher cost-sharing payments if their provider is out-of- network. b. In general, Mrs. Ramos can obtain care from any provider who participates in Original Medicare but will have to pay the difference between the plan’s allowed amount and the provider’s usual and customary charge. c. Mrs. Ramos should be aware that generally plan providers can decide, on a case-by-case basis, whether they will treat her. d. In general, Mrs. Ramos will need a referral to see specialists. Feedback Source: Module 2, Slide - MA Plan Types Coordinated Care Plans - PPOs. 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? a. Generally, employers prefer retirees to enroll in a stand-alone PDP, so he should consider that instead of the MA-PD. b. 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. Correct: The type of Medicare Advantage plans offered vary by employers. Therefore, beneficiaries should compare their employer’s retiree plan with other available plan options. c. When possible, it is always the best option to have both the employer’s plan and the MA-PD, so he would have no out-of-pocket expenses. d. Generally, employers prefer retirees to have both the retiree group plan and the MA-PD plan to fill in the gaps, but he would be better off with just the MA-PD plan. Feedback Source: Module 2, Slide - Employer/Union Plans. 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? a. 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. Correct: Mr. Gomez may receive health care services from any doctor allowed to bill Medicare, provided he shows the doctor the plan’s identification card, and the doctor accepts the PFFS’s payment terms and conditions. These terms may include balance billing up to 15% of the Medicare rate.

b. If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor accepts Original Medicare. c. He may receive services from any physician, regardless of whether or not that physician participates in the plan or Original Medicare. d. If he enrolls in the PFFS plan and shows his card to a doctor who participates in Original Medicare, then that doctor is required to accept the plan’s terms and conditions, which could include balance billing. Feedback Source: Module 2, Slide - MA Plan Types Private Fee-for-Service (PFFS) Plans, MA Plan Types Private Fee-for-Service Plans (2 of 3) and MA Plan Types Private Fee-for-Service Plans (3 of 3). Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? a. With any Medicare Advantage HMO, Mr. Kumar will be able to see any provider he likes, so long as that provider participates in Original Medicare. b. Mr. Kumar will be able to obtain routine care outside of the plan’s service area but will pay a higher co-payment (except in an emergency). c. In Medicare Advantage HMO plans, services provided by primary care physicians are covered at 100%, but those of specialists are covered at 80%. d. In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network). Correct: In most Medicare Advantage HMOs, as a general rule, an enrollee must obtain services only from providers within the plan's network, otherwise known as participating providers. An exception is made for emergency care. Feedback Source: Module 2, Slide - MA Plan Types Coordinated Care Plans - HMOs 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? a. He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. Correct: If a beneficiary enrolls in a MA PPO plan that does not include Part D coverage, the beneficiary cannot join a stand-alone Prescription Drug Plan (PDP). b. He could enroll in the MA-only PPO plan and a stand-alone Medicare prescription drug plan. c. He cannot enroll in a stand-alone prescription drug plan because you do not represent such a plan. d. He could enroll in the MA-only plan and purchase a Medigap plan with drug coverage. Feedback Source: Module 2, Slide - MA & Prescription Drugs. 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?

a. If Mrs. Andrews joins a PFFS plan, the State will not cover any of her medical expenses because she will be using only Medicare providers. b. Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. Correct: Dual eligible beneficiaries may enroll in any type of MA plan (except an MA MSA). However, Medicaid will only pay for items and services if they are furnished by Medicaid participating providers. Therefore, Mrs. Andrews should consider these factors when enrolling in a MA plan. c. Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state’s Medicaid program. d. Medicaid will cover all of her PFFS out-of-pocket costs and Medicaid providers will accept amounts paid by the PFFS plan as payment in full. Feedback Source: Part 2, Slide -MA Plans and Dual Eligible Beneficiaries, continued and Slide - MA Plans and Dual Eligible Beneficiaries, continued Which of the following statement is/are correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. a. I, II, and III only b. II and III only c. I, II, and IV only Correct: MSAs may not have a network or may have a full or partial network of providers. MSAs cover Part A and Part B benefits after the deductible. All non- network providers must accept the same amount that Original Medicare would pay them as payment in full. This is the amount the enrollee will pay the provider before the deductible is met. d. I and II only Feedback Source: Module 2, Slide - MA Plan Types: Medical Savings Account (MSA) Plans. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? a. Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States. b. Mrs. Radford must be enrolled in both Medigap and Part A to enroll in a Medicare Advantage plan. c. Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, before being accepted and enrolled. d. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Correct: To be eligible to enroll in Medicare Advantage, an individual must be entitled (not enrolled) to Part A and enrolled in Part B. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility 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? a. SNPs only serve individuals in long-term care facilities, so he cannot enroll. b. SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll. c. SNPs do not provide Part D prescription drug coverage, so if he does enroll, he should be aware that he will not have coverage for any medications he may need now or in the future. d. 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. Correct: Mr.Greco’s circumstances would not meet the eligibility criteria to qualify him for any of the SNPs.

Feedback Source: Module 2, Slide - Medicare Advantage Eligibility: SNPs, Medicare Advantage Eligibility: SNP Description (1 of 2) and Medicare Advantage Eligibility: SNP Description (2 of 2). 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? a. Since SNPs don’t cover prescription drugs Mr. Sinclair should consider a different option. b. SNPs offer care from any doctor or hospital Mr. Sinclair would like to use and his costs will always be lower than in Original Medicare. c. SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. d. 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. Correct: Chronic condition SNPs (C-SNPs) restrict enrollment and tailor services to individuals with chronic conditions, such as Mr. Sinclair. All SNPs include prescription drug coverage. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description ( of 2). 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? a. Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage it must be a MSA-PD plan that includes drug coverage. b. Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage she must also enroll in a Medicare Supplement Plan (Medigap) F that covers the Medicare Part B deductible and includes both drug coverage. c. Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. Correct. MA MSA plans are prohibited from offering prescription drug coverage. If an MSA member wants prescription drug coverage, the member must enroll in a standalone PDP. d. Mrs. Chi is ineligible for a MA MSA plan because she is ineligible for Medicaid due to her income level. Feedback Source: Module 2, Slide - MA & Prescription Drugs, Slide - Medicare Advantage Eligibility: MSAs Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do? a. He will not need to do anything. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan. b. He must wait until the next Annual Election Period, at which time he can enroll in a Medicare Advantage plan. c. He will have to enroll in Part B.

Correct. To be eligible to enroll in a Medicare Advantage plan, a beneficiary must be entitled to Part A and enrolled in Part B.

d.As long as his employer offers coverage that is equivalent to Medicare’s, he cannot enroll in Part B. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility 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? a. Dr. Brennan can charge the beneficiary the same cost-sharing as Original Medicare as long as she sends the claim to Medicare and not the plan. b. Dr. Brennan can charge Mary Rodgers more than the cost sharing specified in the PFFS plan’s terms and conditions as long as she treats all beneficiaries the same. c. Dr. Brennan can charge Mary Rodgers no more than the cost sharing specified in the PFFS plan’s terms and conditions of payment which may include balance billing up to 25% of the Medicare rate. d. 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. Correct: Because Dr. Brennan accepts the plan’s terms and conditions for payment, she is permitted to charge this amount. Feedback Source: Module 2, Slide - MA Plan Types: Private Fee-for-Service Plans ( of 3). Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? a. You could suggest he call the doctor who performed the surgery to complain about the costs and ask for a discount on the charges. b. You could remind him that he cannot do anything until the next Annual Election Period when he will have an opportunity to change plans. c. You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Correct: Medicare Advantage (MA) plan enrollees have a right to obtain a review (appeal) to certain decisions about health care payment, coverage of services, or prescription drug coverage. Medicare health plans must provide enrollees with a written description of the appeals process. d. You could reassure him that such charges are typical, but if he needs assistance in paying, he should apply to the state for Medicaid assistance. Feedback Source: Module 2, Slide - Enrollee Protections, Slide - Enrollee Protections: Complaints, Coverage Decisions, Appeals Mr. Lopez has heard that he can sign up for a product called “Medicare Advantage” but is not sure about what type of plan designs are available through this program. What should you tell him about the types of health plans that are available through the Medicare Advantage program? a. They are major medical policies but are only for low-income beneficiaries with Medicare.

b. They are Medigap Supplemental plans that fill in the gaps not covered by Medicare. c. They are custodial long-term care plans for people with Medicare.

d. They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Correct: There are coordinated care Medicare Advantage plans that include HMOs and PPOs. There are also Private-Fee-for-Service (PFFS), Medicare Savings Account (MSA), and Special Needs Plans (SNPs). Feedback Source: Module 2, Slide - Medicare Advantage Plans (Overview). 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? a. C-SNP Correct: Because Daniel’s bronchitis is a chronic condition, a Chronic condition SNP would be most appropriate for him to enroll in. b. I-SNP c. D-SNP d. FIDE-SNP Feedback Source: Module 2, Slide - Medicare Advantage Eligibility, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description (2 of 2). What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? a. Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrict access through prior authorization. b. Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market. c. The Federal government establishes a set formulary, or list of covered drugs, each year that the Part D plans must use. Beneficiaries should consult the government’s list prior to deciding whether they wish to enroll in a Part D plan during that year. d. Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization. Correct: Part D plans are not required to cover all prescriptions on the market. But they have various methods to manage costs including formularies, cost-sharing tiers, step therapy, prior authorization and substitution. Feedback Source: Module 3, Slide - Part D Drug Management Tools. 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? a. Mrs. Berkowitz can apply for any Medicare Advantage plan and, if it offers drug coverage, ask to have that element of the coverage eliminated, after which she can enroll in a stand- alone Medicare prescription drug plan in her service area. b. Mrs. Berkowitz can enroll in any Medicare Advantage plan, regardless of whether it offers drug coverage, and enroll in any stand-alone Medicare prescription drug plan. c. This is not a possibility. If Mrs. Berkowitz wants health coverage and drug coverage through a plan, she must purchase an MA-PD plan. d. 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.

Correct: An individual may enroll in a stand-alone Medicare Part D prescription drug plan (PDP) if they are enrolled in a PFFS plan that does not include Part D drug coverage or a MSA plan. Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Eligibility. Question 4 Correct Question text Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan’s formulary. What could you tell him to do? a. Mr. Zachow will have to wait until the Annual Election Period when he can switch Part D plans. In the meantime, he will have to pay for his drug out of pocket. b. Mr. Zachow could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him. c. Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication. d. Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan’s website, fill it out, and submit it to his plan. Correct: Formulary exception requests can be used to request coverage of a drug not on a Part D plan’s formulary or to cover a formulary drug at a lower cost formulary tier. Feedback Source: Module 3, Slide - Enrollee Rights: Requesting Exceptions for Drugs. 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? a. He will need to enroll in a Medicare prescription drug plan upon becoming eligible for the program in order to avoid a premium penalty. To reduce his expenses, he should look for a plan with a zero premium. b. If he has any sort of employer coverage, regardless of the level of coverage, he will incur no penalty if he does not enroll in a Part D plan when first eligible. c. 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. Correct: To avoid a late enrollment penalty, Mr. Hutchinson must have “creditable” coverage. If he does not, he must enroll in Medicare Part D during his initial eligibility period to avoid a late enrollment penalty. d. He should drop the employer coverage and enroll in a Medicare prescription drug plan. Employer plans are almost always more costly for beneficiaries and most do not cover the same range of drugs available from a Medicare prescription drug plan. Feedback Source: Module 3, Slide - Employer/Union Coverage of Drugs and Slide - Part D Late Enrollment Penalty.

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?

a. If a Part D benefit is offered through her plan she must enroll in this plan. b. Mrs. Lopez must first seek COBRA benefits under her husband’s plan before she can apply for Part D coverage. c. Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage. d. If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. Correct: Mrs. Lopez is enrolled in a Cost plan. This provides her with options as to how she secures Part D benefits. Beneficiaries enrolled in a Cost plan may obtain Part D benefits through their plan (if offered) or through a stand-alone Prescription Drug Plan (PDP). Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? a. Medicare prescription drug plans are required to include only a certain percentage of brand name drugs among those they cover. It may be possible that plans available in her area have opted not to include in their formularies the brand name drugs she needs. She may need to pay for this particular medication out of pocket. b. Medicare prescription drug plans are allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medications out of pocket. c. When medication costs exceed a certain threshold amount, which rises each year, a Medicare prescription drug plan is permitted to exclude coverage for all but the least expensive of the medications in a given category. Mrs. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives. d. Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs. Correct: Part D formularies must include at least two drugs in each therapeutic category whether or not generic versions are available. Mrs. Allen should be able to find a plan that covers the medications she needs. Feedback Source: Module 3, Slide - Covered Part D Drugs Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? a. Betsy, a grandmother from overseas who has overstayed her visa. 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. Helena, an overseas college student who has overstayed her visa. d. Guy, who has illegally crossed the Canadian border. Feedback Source: Module 3, Slide - Medicare Part D Eligibility. Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription

drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her? a. She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan’s network.

b. She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. c. She may fill one prescription out-of-network per year and it will be fully covered. Her second prescription will require her to pay the full cost out-of-pocket. d. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Correct: There are some circumstances that allow for enrollees to utilize a non- network pharmacy. However, these prescriptions are typically filled at a higher cost to these enrollees. Feedback Source: Module 3, Slide - Part D Pharmacy Networks. 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 to her drug coverage? a. Medicaid will cover all drugs not covered under the Medicare Part D prescription drug plan into which Mrs. McIntire is enrolled. b. She will continue to obtain her drug coverage through Medicaid. c. She can expect that all her prescriptions will be automatically delivered on a mail-order basis as a requirement of the Medicare Part D program. d. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Correct: If a Medicaid beneficiary does not choose a Part D plan once they become eligible for Medicare, then Medicare will select one for them. Feedback Source: Module 3, Slide - Medicaid Drug Coverage. Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan’s formulary he takes several other medications. These include a prescription drug not on his plan’s formulary, over- the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say? a. None of the costs of Mr. Wingate’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. Correct: None of the costs of Mr. Wingate’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. If he receives an exception under which the plan covers the drug, it could count toward TrOOP. b. The cost of the prescription drugs that are not on his plan’s formulary as well as the cost of the drug(s) to reduce joint swelling from the Canadian pharmacy will count toward TrOOP but the other medications in question will not count toward TrOOP. c. The cost of the prescription drug that is not on his plan’s formulary will count toward TrOOP but the other medications in question will not count toward TrOOP. d. The cost of all medications bought within the United States not covered by his plan would count toward TrOOP. The cost of the Canadian bought medications would not count toward TrOOP. Feedback Source: Module 3, Slide - True Out-of-Pocket Costs? (TrOOP): What Counts and Slice - True Out-of-Pocket Costs (TrOOP): What is Excluded?

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. a. I and II only b. I only c. I, II, and III only Correct: Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. Also, private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. Additionally, beneficiaries enrolled in an MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. d. I, II, III, and IV Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics, Slide

• Medicare Part D Drug eligibility and Slide - Medicare Part D Pharmacy Network. 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? a. He should contact his neighbors and family members and let them know that any contributions they make toward his drug expenses will be tax deductible. b. He should look into the possibility of purchasing his medications through the internet from off-shore pharmacies. c. The only option available is to reduce his income so that he can qualify for the Part D extra help or wait until next year to see if the annual limits change. d. 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. Correct: Some pharmaceutical manufacturers operate programs that assist low- income individuals. In addition, some states have assistance programs specifically for their residents. Some of the state programs are “qualified” and count toward TrOOP and some do not. Feedback Source: Module 3, Slide - Other Help for Low Income - Pharmaceutical Assistance Programs. Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums, and cost sharing. How can you explain this to him? a. The Part D standard model’s importance is that it is the only type of plan into which low- income beneficiaries can enroll and still receive any extra help

for which they may qualify. b. The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval.

c. Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. Correct: Part D plans must cover at least the Part D standard benefits or its actuarial equivalent. Part D plans are permitted to offer supplemental benefits that cover certain drugs not covered under Part D. Some Part D plans may offer these supplemental benefits for an additional monthly premium. d. The government bases its payments to Part D plans on the standard benefit model. For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries. Feedback Source: Module 3, Slide - Part D Plan Benefits. 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? a. Mr. Carlini can keep Original Medicare, but if he does not sign up for an MA plan that includes prescription drug coverage, he will only be able to obtain prescription drug coverage through a Medigap plan. b. Mr. Carlini can obtain drug coverage through the Federal government’s fallback plans, which are designed to provide an alternative to privately sponsored Medicare Advantage plans. c. 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. Correct: Mr. Carlini can stay in Original Medicare and obtain prescription drug benefits through a stand-alone Part D plan. He does not have to enroll in a MA plan. d. To obtain prescription drug coverage, Mr. Carlini must enroll in an MA plan. The plan will cover his Part A and Part B services, as well as provide him with the desired prescription drug coverage. Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basic and Slide - Medicare Prescription Drug Eligibility 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? a. As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding should begin, he can change his method of Part D premium payment and withholding will begin the month after his savings account is exhausted. b. In general, to pay his Part D premium, he only can have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals. c. During 2017, many people experienced significant problems with deductions from their Social Security check for their Part D premium. As a result, this method of payment is no longer an option for Part D premium payments.

d. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Correct: Generally, a Part D beneficiary must stay with a premium payment option for the entire plan year. Feedback Source: Module 3, Slide - Part D Premiums

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 within the last two weeks. How would you advise him? a. Mr. Schultz should immediately enroll in a Part D plan but he can expect to pay a premium penalty because he failed to enroll when first eligible. b. Mr. Schultz should seek to continue employer group coverage through COBRA because it is likely to have superior benefits at a more permanent solution. c. 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. Correct: Mr. Schultz should enroll in a Part D plan, or otherwise obtain creditable drug coverage, before he has a 63-day break in order to avoid a premium penalty. d. Mr. Schultz can wait up to 180 days after the loss of his creditable employer group coverage before enrolling in a Part D plan without worrying payment a premium penalty. Feedback Source: Module 3, Slide - Employer Coverage of Drugs. Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. She currently does not have creditable coverage. What could you tell her about the implications of such a decision? a. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will be required to pay a higher premium during the first year that she is enrolled in the Medicare prescription drug program. After that point, her premium will return to the normal amount. b. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will have to pay a one-time penalty equal to 10% of the annual premium amount. c. If she does not sign up for a Medicare prescription drug plan, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications. d. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered. Correct: Most Individuals should sign up for Part D as soon as they are eligible to do so. Otherwise, they face a permanent premium penalty of 1% of the national average premium for each month the individual does not have Part D coverage. Beneficiaries who qualify for the low-income subsidy, however, are not subject to the late enrollment penalty. Feedback Source: Module 3, Slide - Part D Late Enrollment Penalty. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? a. The vitamins the Vaughns are taking will be covered under Part D because

their physician suggested they should take vitamins, but the hair loss medication cannot be covered. b. Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmetic purposes. c. Mr. Vaughn’s hair growth medication would only be covered under Part D if his balding resulted from an illness or was a side effect of a treatment such as chemotherapy.

d. Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn’s could look into that possibility. Correct. The drugs the Vaughns are interested in may be covered as supplemental benefits. Feedback Source: Module 3, Slide - Drugs Excluded from Part D Coverage Mrs. Mulcahy, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her? a. Like all Medicare beneficiaries, Mrs. Mulcahy will be automatically enrolled in a Medicare prescription drug plan when she turns 65. She will have a six-month window during which she can select a plan other than the one into which she has been automatically enrolled. b.As long as Mrs. Mulcahy is 65, eligibility for a Medicare prescription drug plan is not dependent on entitlement to Part A or enrollment under Part B, so she should not be concerned. c. An individual who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. Correct: Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. d. To qualify for enrollment into a Medicare prescription drug plan, Mrs. Mulcahy must be entitled to Part A and enrolled under Part B. She should contact her local Social Security office and decide to enroll in Part B prior to selecting a prescription drug plan. Feedback Source: Module 3, Slide - Medicare Part D Eligibility All plans must cover at least the standard Part D coverage or its actuarial equivalent. Which of the following statements best describes some of the costs a beneficiary would incur for prescription drugs under the standard coverage? a. Standard Part D coverage would require payment of an annual deductible, fixed per- prescription co-payments, and once catastrophic coverage begins, the plan covers 100% of all costs. b. Standard Part D coverage would require payment of only fixed per- prescription co- payments. c. Standard Part D coverage would require payment of an annual deductible, and once past the catastrophic coverage threshold, the beneficiary pays whichever is greater of either the co- pays for generic and brand name drugs or coinsurance of 5%. Correct: Standard Part D coverage would require payment of an annual deductible, and once through the catastrophic coverage threshold, the beneficiary pays either co-pays for generic and brand name drugs or co-insurance of 5%, whichever is greater. d. Standard Part D coverage would require payment of fixed per-prescription co- payments and 75% of the costs in the coverage gap. Feedback Source: Module 3, Slide - Part D Plan Benefits, Slide - Part D Benefits: The Standard Benefits for 2022 and Catastrophic Coverage. You will be holding a sales event soon, at which you would like to offer door prizes

to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation? a. Gifts of nominal retail value ($15 or less)

Incorrect: This statement is incorrect because marketing representatives may offer gifts to sales event attendees provided they are of nominal value and are worth $15 or less. b. Gifts worth more than $15 but based on anticipated attendance will not exceed $15 per attendee. c. Two or more gifts whose combined value does not exceed $15. d. Gift cards or gift certificates of $15 or less that can be readily converted to cash. Feedback Source: Module 4, Slide - Gifts and Promotional Items. Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational. 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? a. Yes. Whether or not an event has been advertised as “educational” or a “sales presentation,” discussing plan-specific information is impermissible. b. Yes. When an event has been advertised as “educational,” discussing plan-specific premiums is impermissible. Correct: Discussion or distribution of plan-specific information is prohibited at any educational event. c. No. This action is permissible. Handing out enrollment forms, on the other hand, would not be permissible. d. No. Attendees expect some “puffery” at any event on a product in which they may be potentially interested. Feedback Source: Module 4, Slide - Educational Events, Impermissible Activities. 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? a. Tell her that Medicare or CMS (the Medicare agency) has approved and endorsed the plan. b. Tell her that the Medicare agency does not endorse or recommend any plan. Correct: Centers for Medicare and Medicaid Services (CMS), the government agency responsible for Medicare, does not endorse or recommend any of the Medicare Advantage (MA) plans it approves. Medicare beneficiaries should choose either Original Medicare or a MA plan based on their particular needs and circumstances. c. Tell her that Medicare recommends that beneficiaries enroll in a Medicare Advantage plan because it will serve her better than Original Medicare. d. Tell her that, because you represent a Medicare health plan, you therefore work for Medicare, and the information you offer her is a good basis of any decision she makes. Feedback Source: Module 4, Slide - Prohibited Practices: Marketing and Communications Material and Activities and Prohibited Practices: Examples. A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do? a. You must set an appointment for another time, at least 48 hours from the point when she walked into your office.

b. You do not have to do anything. You may proceed with the discussion and enroll the individual if she so desires. c. Before speaking with the individual, you must inquire as to her eligibility for MA and Part D plans and then complete a scope of appointment form for the plans for which she is eligible.