AHIP Final Exam- A comprehensive study guide-with 100% verified answers-2024-2025.docx, Exams of Nursing

Download AHIP Final Exam- A comprehensive study guide-with 100% verified answers-2024-2025.docx and more Exams Nursing in PDF only on Docsity! AHIP Final Exam- A comprehensive study guide-with 100% verified answers-2024-2025 Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through massage therapy. She is concerned about whether or not Medicare will cover these items and services. What should you tell her? a. Medicare covers glasses, but not dentures or massage therapy. b. Medicare does not cover massage therapy, or, in general, glasses or dentures. Correct: Neither Medicare Part A nor Part B covers massage therapy, dentures, or routine eye examinations to prescribe eyeglasses. c. Medicare covers 80% of the cost of these three services. d. Medicare covers 50% of the cost of these three services. Feedback Source: Module 1, Slide - Not Covered by Medicare Part A & B Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him? a. Medigap plans that cover costs not paid for by an MA plan are available only in Massachusetts, Minnesota, and Wisconsin. b. Medigap policies designed to cover costs not paid for by an MA plan can be purchased, but only if the MA plan’s design is considered to be the “defined standard benefit.” c. Medigap plans are a form of Medicare Advantage, so purchasing both would be redundant coverage. d. It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare. Correct: The purpose of Medigap plans is to supplement Original Medicare benefits. Medigap plans do not work with Medicare Advantage plans. It is illegal to sell a Medigap plan to someone already in a Medicare Advantage health plan. Feedback Source: Module 1, Slide - Medigap is NOT 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? a. He became eligible for Medicare when his disability eligibility determination was first made. b. After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. Correct: Individuals with disabilities who are under age 65 are automatically enrolled in Medicare Parts A and B the month after they have received Social Security or Railroad Retirement disability benefits for 24 months. c. Individuals receiving such disability payments from the Social Security Administration continue to receive those payments but only become eligible for Medicare upon reaching age 65. d. Individuals who become eligible for such disability payments only have to wait 12 months before they can apply for coverage under Medicare. Feedback Source: Module 1, Slide - Medicare Enrollment Part A & B 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? a. She must wait at least 30 days after her employment terminates before she may enroll in Medicare Part B. Correct: Costs for Part D beneficiaries typically include a monthly premium, annual deductible, and per-prescription cost-sharing. Feedback Source: Module 1, Slide - Original Medicare and Part D Prescription Drug Coverage. 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? a. Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs. Correct: Beneficiaries are responsible for a single deductible amount for each benefit period, followed by a per day coinsurance amount through day 90. For day 91 and beyond, there is a charge for each “lifetime reserve day” up to 60 days over a beneficiary’s lifetime. After this, he would be responsible for all costs. b. Under Original Medicare, the inpatient hospital co-payment is a percentage of allowed charges. The percentage increases after 60 days and again after 90 days. c. Under Original Medicare, if the inpatient hospital service is provided by a participating Medicare provider, the co-payment is waived. Co-payments are only charged when a beneficiary opts to receive care from a non-participating provider. d. Under Original Medicare, the inpatient hospital co-payment is a flat per-day amount that remains the same throughout the first 60 days of a beneficiary’s stay. After day 60 the amount gradually increases until day 90. After 90 days he would pay the full amount of all costs. Feedback Source: Module 1, Slide - Medicare Part A - Original Medicare Cost-Sharing for Inpatient Hospital Care Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her? a. All individuals who are citizens and age 65 or over will be covered under Part A. b. Most individuals who are citizens and age 65 or over and are covered under Part A must pay a monthly premium for that coverage. c. Most individuals who are citizens and age 65 or over and wish to be covered under Part A must enroll in a Medicare Advantage Plan. d. Most individuals who are citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. Correct: Most individuals who are citizens and age 65 or older may qualify for coverage either because they pay a monthly premium or because they paid Medicare taxes while working for a specific duration. Feedback Source: Module 1, Slide - Eligibility for Part A & B Benefits and Slide - Medicare Premiums Part A Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed? a. Tell prospect Jerry Smith that he should keep his Medigap plan but he should supplement his healthcare coverage by purchasing a Medicare Advantage plan that offers prescription drug coverage (MA-PD). b. Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage. Correct: Agent John Miller can help prospect Jerry select a standalone Part D prescription drug plan that complements his current Original Medicare and Medigap coverage. Alternatively, Agent Miller can suggest that Jerry drop his Medigap coverage and enroll in a MA-PD plan. c. Tell prospect Jerry Smith that he should drop his Medigap coverage and put those premium dollars toward the purchase of a standalone Part D prescription drug plan because he can always reactivate his Medigap policy on a guaranteed issue basis. Furthermore, because he has had Medigap Jerry will not incur a Part D late enrollment penalty. d. Tell prospect Jerry Smith that Medigap is simply a variation of a Medicare Advantage plan and the companies John represents offer more comprehensive coverage for a lower price. Feedback Source: Module 1, Slide - Medigap (Medicare Supplement Insurance) and Slide - Medigap is NOT Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him? a. Medicare covers all screening tests that have been approved by the FDA on a frequency determined by the treating physician. b. Medicare covers some screening tests that must be performed within the first year after enrollment. Beyond that point expenses for screening tests are the responsibility of the beneficiary. c. Medicare covers the periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered. Correct: Original Medicare and Medicare Advantage plans cover most preventive services, such as screening tests, but beneficiaries must confirm coverage of specific tests with their plans. d. Medicare covers treatments for existing disease, injury, and malformed limbs or body parts. As such, it does not cover any screening tests and these must be paid for by the beneficiary out-of- pocket. Feedback Source: Module 1, Slide - Medicare Part B Benefits - Preventive Services and Screenings b. Part A, which covers hospital, skilled nursing facility, hospice, and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare. Correct: Original Medicare consists of Part A and Part B. c. Part A, which covers long-term custodial care services, is covered under Original Medicare. d. Part D, which covers prescription drug services, is covered under Original Medicare. Feedback Source: Module 1, Slide - Overview of Medicare Benefits and Coverage - Parts A, B, C, and Slide - Overview of Different Ways to Get Medicare Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him? a. He may sign-up for Medicare at any time however coverage usually begins on the sixth month after dialysis treatments start. b. He may not sign-up for Medicare until he reaches age 62, the date he first becomes eligible for Social Security benefits. c. He may sign-up for Medicare at any time and coverage usually begins immediately. d. He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Correct: Individuals with ESRD may sign up for Medicare at any time. Coverage typically begins on the fourth month after dialysis treatments start, but it could be earlier if certain conditions are met. Feedback Source: Module 1, Slide - Medicare Enrollment Part A & B Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife’s needs. What could you tell Mr. Moy? a. Medicare Supplemental Insurance would cover his long-term care services. b. Medicare Supplemental Insurance would help cover his Part A and Part B deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover. Correct: Medicare Supplement Insurance (Medigap) fills "gaps" in Original Medicare coverages, such as all or part of the deductibles or coinsurance as well as possibly offering some services such as medical care when a beneficiary travels outside the United States. c. Medicare Supplemental Insurance would cover all of his IRS approved health care expenditures not covered under Original Fee-for-Service (FFS) Medicare. d. Medicare Supplemental Insurance would cover his dental, vision and hearing services only. Feedback Source: Module 1, Slide - Medigap (Medicare Supplement Insurance) 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? a. Medicare is a program for people of all ages with specific mental health disabilities. Since she is in excellent health, she would not qualify, but should instead look into her state’s Medicaid program if she wants further coverage. b. Eligibility for Medicare is based on whether or not a person has ever been employed by the federal government. If she or her husband were ever employed by the federal government, she can enroll in Medicare. c. Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig’s disease so she will be eligible for Medicare. Correct: Individuals that meet these criteria may be eligible to participate in Medicare. It is not based on income. d. Medicare is a program for people who have incomes and assets below specific limits, so you will have to find out her exact financial situation before telling her whether she can obtain Medicare coverage. Feedback Source: Module 1, Slide - Eligibility for Part A and Part B Benefits 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? a. Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime. Correct: Medicare Part A provides coverage for inpatient psychiatric care for up to 190 lifetime days. b. Medicare Advantage is designed to pick up where Original Medicare leaves off, covering those health care services that would not normally be covered by Original Medicare. c. Medicare Advantage is a health insurance program operated jointly by the states with the Federal government. d. Medicare Advantage is a new name for the Original Medicare program. Feedback Source: Module 2, Slide - Part C: Medicare Advantage Plans (Overview). Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was disappointed with the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she would not have to put up with such poor access to care. What could you tell her? a. She must write to the plan and wait for a response and then, if she is still dissatisfied, she could file an appeal with her state Medicaid office requesting transfer to one of its managed care plans. b. She should call the doctor’s office to complain since the plan cannot do anything about the doctor’s schedule. c. She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Correct: Enrollees or their representatives may file a grievance if they experience problems with their health care services, such as timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. d. She should not expect to get in to see her doctor any more quickly since she is a Medicare patient. Feedback Source: Module 2, Slide - Enrollee Protections, Slide - Enrollee Protections: Complaints, Coverage Decisions, Appeals and Slide - Enrollee Protections: Grievances. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid- February of 2021, her doctor confirms a diagnosis of end-stage renal disease (ESRD). What options will Mrs. Davenport have regarding her MA plan during the next open enrollment season? a. She must immediately drop her ABC MA plan and enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. b. She must remain enrolled in her ABC MA plan unless the plan terminates. c. She may remain in her ABC MA plan, enroll in another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. Correct: Mrs. Davenport has three clear choices: (1) remain in the ABC MA plan, (2) enroll in another MA plan in her service area, or (3) enroll in a Special Needs Plan (SPN) for persons suffering from ESRD if one is available in her area. d. She must immediately drop her ABC MA plan and enroll in Original Medicare. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility and Slide - Medicare Advantage Eligibility: SNPs 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. 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. 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 (3 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. 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. 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? 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) d. You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. Correct: A signed scope of appointment form describing the types of products she wishes to discuss must be completed before you begin your discussion. Feedback Source: Module 4, Slide - Required Practices: Scope of Appointment. 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? a. As long as the meal is paid for by another person or entity, you are permitted to invite your clients and their friends to partake of the meal at your sales presentation. b. There is no limitation on meals. You may continue to provide your Thanksgiving style meal, to any individual, in any manner you see fit. c. You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. Correct: Presentations may include light snacks, but marketing representatives cannot bundle multiple snacks to constitute a full meal regardless of the total value. d. You may offer meals to existing enrollees of the plan(s) you represent, but potential enrollees may not have a meal. Feedback Source: Module 4, Slide - Medicare Communications and Marketing Rules: Sales Events and Slide - Sales Events, Prohibited Activity and Light Snacks versus Meals. One of your colleagues argues that it is better to focus your time and energy exclusively in neighborhoods with single-family homes. He further argues that their older owners are more likely to have higher incomes and purchase the Medicare Advantage products you represent compared to those living in apartment complexes. How should you respond? a. This is not a discriminatory activity since this is merely a widely recommended sales practice. b. This could be considered discriminatory activity, but it is not a prohibited practice. c. This is not a discriminatory activity since it is based on the incomes of likely prospects and not based on race or gender. Incorrect: This action could be considered discriminatory. CMS communications and marketing rules prohibit marketing representatives from engaging in a discriminatory activity such as attempting to recruit Medicare beneficiaries from higher-income areas without making comparable efforts to recruit Medicare beneficiaries from lower-income areas. d. This could be considered discriminatory activity and a prohibited practice. Feedback Source: Module 4, Slide - Prohibited Practices: Marketing and Communications Materials and Activities. 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? a. The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. Correct: Plans must take corrective action in the event of verified misconduct by a marketing representative. Such disciplinary action might include withholding or withdrawing commissions, retraining, termination, and reporting agent termination to a state department of insurance. b. Plans do not impose penalties. Instead, the Medicare agency has specific authority to fine such individuals for each violation. c. Plans must immediately terminate their contracts with such individuals. d. Her name will be reported to a publicly accessible database and could be advertised in local newspapers. Feedback Source: Module 4, Slide - Plan Oversight and Enforcement. You are working several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do? a. You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. Correct. Educational events must be explicitly advertised as educational b. You must only ensure that the advertisement is factually accurate. c. Plans may not participate in advertising such an event. All advertising must be done by community organizations. d. You must state in the advertisement that it will be an educational event and that the education will consist of specific information about the participating plans. Feedback Source: Module 4, Slide - Educational Events and Slide - Marketing and Educational Events. You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns? a. Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider’s facility. Correct: Marketing representatives may engage in marketing activities in common areas of health care settings. This includes a cafeteria, community or recreational room as well as a conference room. b. Tell her that Medicare guidelines allow you to conduct marketing activities anywhere in the facility, so long as the affected providers agree to that event. c. Tell her that Medicare guidelines only allow you to conduct marketing activities in areas of the facility where individuals are waiting to receive health care services, but not in places where they would be receiving health care such as an examining room. d. Tell her that if a plan obtains permission from CMS for a marketing event in a provider facility, the event may go forward, regardless of where it occurs in the facility. Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you on October 15. During the appointment, what are you permitted to do? a. You may leave enrollment kits for several MA plans and offer to discuss a Medigap and Part D prescription drug plan she might like. b. You may begin her enrollment application and require her to provide names of any of friends who may be interested in enrolling before completing her application. c. You may leave an enrollment kit and discuss a new life insurance product she might like. d. You may provide her with the required enrollment materials and take her completed enrollment application. Correct: Because you are meeting for an individual marketing appointment, you are permitted to distribute plan materials and accept enrollment forms. Feedback Source: Module 4, Slide - What are Individual Marketing Appointments?, Slide - Individual Marketing Appointments, Prohibited Activities and Slide - Required Practices: Scope of Appointment. Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel? a. During the MA-OEP, Miguel can have one-on-one meetings with beneficiaries who have requested such meetings. Correct: During the MA-OEP, those enrolled in a Medicare Advantage plan have the opportunity to change plans or enroll in Original Medicare. Marketing representatives may respond to beneficiary requests for one-on-one meetings. b. During the MA-OEP Miguel can purchase a list of individuals who have chosen MA plans during Annual Enrollment Period (AEP) and create a marketing plan aimed at targeting them to select a plan he sells. c. During the MA-OEP Miguel can make unsolicited calls to former enrollees who have selected a new plan during the Annual Enrollment Period (AEP). d. During the MA-OEP Miguel can send unsolicited print materials to seniors in his area advertising the opportunity to change from one MA plan to another. Feedback Source: Module 4, Slide - Open Enrollment Period - Marketing Prohibitions and Slide - Promoting Health Plans During Open Enrollment Period. Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members? a. Market non-health related items such as accident-only plans without the need for obtaining a HIPAA compliant authorization form from an enrollee. b. Market contact information lists of current members to third-party vendors of ancillary health products as permitted by Dodd-Frank legislation. c. Market non-health related items or services such as life insurance or annuities policies to current members as permitted following HIPAA Privacy Rules. Correct: Plan sponsors must obtain HIPAA compliant authorization forms from enrollees before the Plan sponsor may use (or may request a marketing representative to use on their behalf) information about the enrollee to market non- health related items or services such as life insurance or annuity policies. d. Market non-Medicare health-related products, such as financial planning, to current members as permitted by Dodd-Frank legislation. Feedback Source: Module 4, Slide - Required Practices: HIPAA and Confidentiality of Enrollee Information and Slide - Required Practices: Marketing & Non-Health Related Activities. Your friend’s mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him? a. You appreciate the opportunity and your friend would just need to complete scope of appointment forms on behalf of all the residents who would like to attend. b. You appreciate the opportunity and will ask the facility to provide a plan brochure and enrollment application in every resident’s room before the meeting to promote interest in the event. c. You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request. Correct: Marketing representatives may schedule an appointment with a beneficiary in a long- term care facility only upon their request. d. You appreciate the opportunity and would ask the facility to provide enrollment applications for the MA-PD plans you represent. Correct: A marketing representative may initiate electronic contact through e-mail since that is now considered general audience marketing similar to print media. Rules regarding unsolicited contact do not apply to marketing through these materials. However, use of electronic media must provide an opt-out process. c. Marketing representatives may only use internet pop-up ads providing plan-specific information that have been approved by CMS when soliciting prospects through electronic means of communication. d. Marketing representatives may initiate electronic contact through e-mail and as long as an e-mail is opened marketing representatives may also follow-up with unsolicited telephone calls. Feedback Source: Module 4, Slide - Permitted Contracts and Slide - General Audience Marketing. ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees’ information to market non-health related products such as life insurance and annuities. Which statement best describes ABC's obligation to its enrollees regarding marketing such products? a. The request for authorization may include a brief synopsis of non-health related content. b. Once a plan sends out a written request for consent, a beneficiary can authorize consent by simply failing to reply within 21 days. c. It is not necessary for ABC to obtain an authorization to simply explain pending state or federal legislation since there is no anticipation of selling a non-health related product in these circumstances. d. It must obtain a HIPAA compliant authorization from an enrollee that indicates the plan or plan sponsor may use their information for marketing purposes. Correct: A plan sponsor must obtain HIPAA authorization from an enrollee before using or disclosing the enrollee’s information to market non-health related items such as life insurance. Therefore, this answer is the best description of ABC's obligation to its enrollees in these circumstances. Feedback Source: Module 4, Slide - Required Practices: Marketing & Non-Health Activities. 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? a. Mr. Block will have to wait until the annual election period, beginning October 15, and then he can add the stand-alone coverage to the MA-PD. b. If Mr. Block wants to enroll in both a MA-PD and a stand-alone PDP, he may buy the extra coverage without any adverse effect. c. If Mr. Block enrolls in a stand-alone Medicare prescription drug plan, he can request that his Medicare Advantage plan remove the drug benefit from the package they offer and reduce his premium accordingly. d. If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. Correct. When an applicant enrolls in an MA plan, they acknowledge that they understand enrollment in another MA plan, PDP, or MA-PD automatically disenrolls them from their current plan. If Mr. Block enrolls in a standalone PDP, he will be disenrolled from his current MA plan. Feedback Source: Part 5, Slide – Beneficiary Acknowledgements when Enrolling. A client wants to give you an enrollment application on October 1 before the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him? a. You must send it to the plan for immediate processing, although the enrollment will not become effective until January 1. b. You must accept the application, but hold it until the annual election period begins, after which you must send it to the plan for processing. c. You must tell him you are not permitted to take the form. If he sends the form directly to the plan, the plan will process the enrollment on the day the Annual Election Period begins. Correct. If a beneficiary sends an unsolicited AEP paper enrollment request to the plan on or after October 1 but before the Annual Election Period begins, the plan will process the application beginning on the first day of the election period (October 15) d. You must tell him you are not permitted to take the form and if he sends it to the plan, the application will be rejected and he will need to fill out another form and submit it after the Annual Election Period begins. Feedback Source: Part 5, Slide -Enrollment Periods: Annual Election Period, Timeframe for Submitting Enrollment Forms Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard certain MA plans might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him? a. If there is a special needs plan (SNP) in Mr. Wendt’s area that specializes in caring for individuals with diabetes, he may enroll in the SNP during the MA Open Enrollment Period which takes place between January 1 and March 31. b. Because of the severity of his condition, Mr. Wendt must remain enrolled in Original Medicare and also enroll in a Medigap plan to supplement his additional medical needs. c. If there is a special needs plan (SNP) in Mr. Wendt’s area that specializes in caring for individuals with diabetes, he may enroll in the SNP at any time under a special election period (SEP) Correct. Beneficiaries who have severe or disabling chronic conditions and wish to enroll in a SNP designed to serve individuals with their specific condition have a SEP during which they can enroll in a SNP designed to serve individuals with their b. He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may only add stand-alone Medicare prescription drug coverage. c. He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may only enroll in an MA-PD plan. d. He must first enroll in a Medicare Part D plan, before enrolling in a Medicare Advantage plan. Feedback Source: Part 5,Slide - Enrollment Periods: Part D Initial Enrollment Period (IEP). 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? a. It is a period when only Medicare beneficiaries who have moved out of the area and are dually eligible for Medicaid may add, drop, or change their prescription drug coverage. b. It is a period when beneficiaries who are newly eligible for Medicare may make their first choice of a Medicare prescription drug plan. c. It is a 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. Correct. MA eligible and Part D eligible beneficiaries who experience certain qualifying events, such as a change in residence, are provided a special period to change their election, known as a special election period or “SEP.” d. It is a single period from January 1 – March 31, created by statute, when any Medicare beneficiary who has moved out of the area of their Medicare Advantage or Part D plan can add, drop or change their Medicare prescription drug coverage. Feedback Source: Part 5, Slide - Enrollment Periods - SEPs and Slide - Enrollment Periods - SEPs, continued. 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? a. Mr. Roberts must return to Original Medicare within two months of discharge, but he may continue to enroll and disenroll in Part D for 12 months following discharge. b. Mr. Roberts has two months following his discharge to continue under his current MA plan before he must return to Original Medicare for the remainder to the calendar year. c. His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility. Correct. The open enrollment period (OEPI) for institutionalized individuals is a continuous open enrollment period as long as an individual is in an institution. The OEPI ends two months after the month the individual moves out of the institution. d. His open enrollment period as an institutionalized individual will continue for 12 months following his date of discharge. Feedback Source: Part 5, MA Open Enrollment Period for Institutionalized (OEPI) Individuals Part D SEP for Institutionalized Individuals. Mr. White has Medicare Parts A and B with a Part D plan. Last year, he received a notice that his plan sponsor identified him as a “potential at-risk” beneficiary. This month, he started receiving assistance from Medicaid. He wants to find a different Part D plan that’s more suitable to his current prescription drug needs. He believes he’s entitled to a SEP since he is now a dual eligible. Is he able to change to a different Part D plan during a SEP for dual eligible individuals? a. No. Once he is identified by the plan sponsor as a “potential at-risk” beneficiary, he cannot use the dual eligible SEP to change plans while this designation is in place. Correct: Typically, an individual with Medicare Parts A and B that receives Medicaid assistance receives a SEP during the first 9 months of each calendar year. However, once an individual is identified by the plan sponsor as a “potential at-risk” or “at-risk” beneficiary and the plan sponsor has sent written notice to the individual, he or she cannot use this SEP to change plans while this designation is in place. b. No. Individuals identified by the plan sponsor as “potential at-risk” must wait 2 years to switch plans, after which time the designation is lifted. c. Yes. “Potential at-risk” designations are just a warning. Only “at-risk” beneficiaries are prohibited from using this SEP while the designation is in place. Mrs. Margolis contacts you in August because she will become eligible for Medicare for the first time in November. She would like to meet and discuss plan choices with you. What advice should you give her? a. Tell her you are not permitted to meet with her until after she becomes eligible for Medicare in November. b. Tell her that you should meet to discuss her plan choices as soon as possible so she has more time to weigh her options for the current and following plan years before her enrollment would become effective in November. Incorrect: You are not permitted to discuss the following year’s plan options in August. Marketing representatives are permitted to simultaneously market plans for the current and prospective years starting on October 1, provided marketing materials indicate what plan year is being discussed. c. Tell her to wait until October to discuss plan choices with you so that you can share plan benefits for the current year as well as any changes for the following year that may impact her choice. d. Tell her you can meet with her immediately to discuss plan options for the following plan year only. Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid- September, 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 before the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams? a. This is a good idea. This locks Mrs. Young into a plan and protects Agent Adams’ commission. b. This is a bad idea. Mrs. Young should complete an online application now so that Agent Adams will be given immediate credit for his work once the AEP begins. c. This is a good idea. The plan will retain Mrs. Young’s application and process it when the AEP begins. d. This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form before the start of the AEP. Correct. Marketing representatives may not accept enrollment forms before October 15 for enrollments under the Annual Election Period. Feedback Source: Part 5, Slide – Enrollment Periods - Annual Election Period and Slide – Enrollment Periods Annual Election Period, Timeframe for Submitting Enrollment Forms Mrs. Kumar would like her daughter, who lives in another state, to meet with you during the Annual Election Period to help her complete her enrollment in a Part D plan. She asked you when she should have her daughter plan to visit. What could you tell her? a. Her daughter should come during the three-month period that begins on the first day of her birthday month and runs for three full months. b. Her daughter should come sometime between January 1 and March 31. c. Her daughter should come in November. Correct. She can enroll in a Part D plan during the Annual Election Period (AEP), which takes place from October 15 to December 7. d. She should wait for at least six months into the plan year to be sure that she really wants to make the change. If she still wants to do so, she can make any sort of change she likes at that point. Feedback Source: Part 5, Slide -Enrollment Periods: Annual Election Period. 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? a. Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan, but he must wait until the next Annual Election Period. b. Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. Correct. Individuals disenrolling from employer-sponsored coverage to elect an MA plan have a SEP that ends 2 months after the month the employer-sponsored coverage ends. c. Mr. Chen can disenroll from the employer-sponsored plan and his only option is to choose a Medigap plan. d. Mr. Chen must convert his current coverage to employer-sponsored retiree coverage and wait one year before enrolling in a MA or Part D plan. Feedback Source: Part 5, Slide Other Common SEPs. Mr. Johannsen is entitled to Medicare Part A and Part B. He gains the Part D low- income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan? a. He qualifies for a special election period and can enroll in or disenroll from a Part D plan once during that period. Correct. Because he is entitled to Medicare Part A and Part B and has a change in his low income subsidy status, he is eligible for a special election period. During the SEP, he can enroll in or disenroll from a Part D plan once. b. He can only enroll in or disenroll from an MA-PD plan. c. He can apply the subsidy amount to his existing plan immediately, but he cannot enroll in a different plan. d. He can enroll in a different plan or disenroll from his current plan during the next Annual Election Period. Feedback Source: Part 5, Slide -Typical SEPs – Beneficiaries who are dual eligible or who have LIS eligibility, and Slide - Typical SEPs - Change in Medicaid or LIS Status. a. She should wait until the new year to disenroll from Original Medicare and select an MA plan between January 1 and March 31. b. She could immediately enroll in MA plan based on the one-time special election period available to those 70 and younger. c. She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA plan. Correct. The Annual Election Period (AEP) takes place from October 15 to December 7 each year and is available to all MA and Part D eligible beneficiaries. d. She could enroll in an MA plan during the period including the three months before, the month of, and up to three months after turning 68. Feedback Source: Part 5, Slide – Enrollment Periods - MA Initial Coverage Election Period (ICEP) and Slide Enrollment Periods- Annual Election Period. Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? a. He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Correct: In order to enroll in a Medicare Advantage (MA) plan, an individual must be entitled to Part A and enrolled in Part B. Mr. Castillo is covered by Plan A but no longer enrolled in Medicare Part B so he cannot enroll in MA plan until he re- enrolls in Part B. b. He can enroll in a Medicare Advantage plan but it will pay only the benefits associated with Medicare Part A. c. He is not eligible to enroll in a Medicare Advantage as a naturalized citizen. d. He can enroll in a Medicare Advantage plan if he has dropped Part B less than 90 days ago. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility. See also, Slide - Eligibility for Part A and Part B You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation? a. Your name will be registered with the Medicare agency by the plans you are seeking to represent and you will be unable to contract with any Medicare Advantage or Part D plan. b. You will have to attend one of several remedial training events sponsored by the Medicare agency before being allowed to retake the test. c. You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score. However, you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing. Correct: You are required to pass the test in order to represent any Medicare Advantage or Part D plans. There is no testing requirement for agents/brokers that only market employer/union group plans. d. You will have to repeat the tests in three months, but may begin enrolling beneficiaries while you are waiting. Feedback - Source: Module 4, Slide - Requirements to act as Plan Marketing Representatives. 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 marketing requirements as the plans themselves. How should you respond to such a statement? a. Your coworker is correct. You are subject only to marketing requirements issued by your state department of insurance. b. Your coworker is correct because employed agents have to follow a stricter set of rules than do independent agents, such as yourself. c. Your coworker is correct. You may use any marketing techniques that do not involve providing misinformation to potential enrollees. d. 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. Correct: Plan marketing representatives are subject to the same requirements related to marketing and communications as the plans. Feedback Source: Module 4, Slide - Applicability of Medicare Marketing and Communication Rules to Marketing Representatives. Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you on October 15. During the appointment, what are you permitted to do? a. You may leave an enrollment kit and discuss a new life insurance product she might like. b. You may leave enrollment kits for several MA plans and offer to discuss a Medigap and Part D prescription drug plan she might like. c. You may begin her enrollment application and require her to provide names of any of friends who may be interested in enrolling before completing her application. d. You may provide her with the required enrollment materials and take her completed enrollment application. Correct: Because you are meeting for an individual marketing appointment, you are permitted to distribute plan materials and accept enrollment forms. Feedback Source: Module 4, Slide - What are Individual Marketing Appointments?, Slide - Individual Marketing Appointments, Prohibited Activities and Slide - Required Practices: Scope of Appointment. Next week you will be participating in your first “educational event” for prospective enrollees. To be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage? a. You should plan to conduct sales presentations and accept enrollment forms. b. You should plan to conduct sales presentations but must not accept enrollment forms. c. You should plan to ensure that the educational event is an informative event and must not conduct a sales presentation or distribute or accept enrollment forms at the event. Correct: Sales presentations and distribution or acceptance of enrollment forms are prohibited when an event is advertised as educational. d. You should plan to answer questions and accept enrollment forms. Feedback Source: Module 4, Slide - Marketing and Educational Events and 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, 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. 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 or CMS (the Medicare agency) has approved and endorsed the plan. d. Tell her that Medicare recommends that beneficiaries enroll in a Medicare Advantage plan because it will serve her better than Original Medicare. Feedback Source: Module 4, Slide - Prohibited Practices: Marketing and Communications Material and Activities and Prohibited Practices: Examples. 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. No. Attendees expect some “puffery” at any event on a product in which they may be potentially interested. b. No. This action is permissible. Handing out enrollment forms, on the other hand, would not be permissible. c. 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. d. Yes. Whether or not an event has been advertised as “educational” or a “sales presentation,” discussing plan-specific information is impermissible. Feedback Source: Module 4, Slide - Educational Events, Impermissible Activities. 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 do not have to do anything. You may proceed with the discussion and enroll the individual if she so desires. b. 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. c. You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. Correct: A signed scope of appointment form describing the types of products she wishes to discuss must be completed before you begin your discussion. d. You must set an appointment for another time, at least 48 hours from the point when she walked into your office. Feedback Source: Module 4, Slide - Required Practices: Scope of Appointment. 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? a. Plans must immediately terminate their contracts with such individuals. b. The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. Correct: Plans must take corrective action in the event of verified misconduct by a marketing representative. Such disciplinary action might include withholding or d. Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located. Correct: State licensure and plan appointment applies to the states where the beneficiaries are being marketed to are located. Feedback Source: Module 4, Slide - Requirement to act as Plan Marketing Representative and Slide - Marketing Representatives - State Licensure Case Study 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? a. There is no limitation on meals. You may continue to provide your Thanksgiving style meal, to any individual, in any manner you see fit. b. You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. Correct: Presentations may include light snacks, but marketing representatives cannot bundle multiple snacks to constitute a full meal regardless of the total value. c. You may offer meals to existing enrollees of the plan(s) you represent, but potential enrollees may not have a meal. d. As long as the meal is paid for by another person or entity, you are permitted to invite your clients and their friends to partake of the meal at your sales presentation. Feedback Source: Module 4, Slide - Medicare Communications and Marketing Rules: Sales Events and Slide - Sales Events, Prohibited Activity and Light Snacks versus Meals. Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel? a. During the MA-OEP, Miguel can have one-on-one meetings with beneficiaries who have requested such meetings. Correct: During the MA-OEP, those enrolled in a Medicare Advantage plan have the opportunity to change plans or enroll in Original Medicare. Marketing representatives may respond to beneficiary requests for one-on-one meetings. b. During the MA-OEP Miguel can make unsolicited calls to former enrollees who have selected a new plan during the Annual Enrollment Period (AEP). c. During the MA-OEP Miguel can purchase a list of individuals who have chosen MA plans during Annual Enrollment Period (AEP) and create a marketing plan aimed at targeting them to select a plan he sells. d. During the MA-OEP Miguel can send unsolicited print materials to seniors in his area advertising the opportunity to change from one MA plan to another. Feedback Source: Module 4, Slide - Open Enrollment Period - Marketing Prohibitions and Slide - Promoting Health Plans During Open Enrollment Period. Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid- September, 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 before the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams? a. This is a bad idea. Mrs. Young should complete an online application now so that Agent Adams will be given immediate credit for his work once the AEP begins. b. This is a good idea. The plan will retain Mrs. Young’s application and process it when the AEP begins. c. This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form before the start of the AEP. It is a 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. Correct. MA eligible and Part D eligible beneficiaries who experience certain qualifying events, such as a change in residence, are provided a special period to change their election, known as a special election period or “SEP.” b. It is a period when only Medicare beneficiaries who have moved out of the area and are dually eligible for Medicaid may add, drop, or change their prescription drug coverage. c. It is a period when beneficiaries who are newly eligible for Medicare may make their first choice of a Medicare prescription drug plan. d. It is a single period from January 1 – March 31, created by statute, when any Medicare beneficiary who has moved out of the area of their Medicare Advantage or Part D plan can add, drop or change their Medicare prescription drug coverage. Feedback Source: Part 5, Slide - Enrollment Periods - SEPs and Slide - Enrollment Periods - SEPs, continued. Question 4 Correct Question text 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? a. Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. Correct. Individuals disenrolling from employer-sponsored coverage to elect an MA plan have a SEP that ends 2 months after the month the employer-sponsored coverage ends. b. Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan, but he must wait until the next Annual Election Period. c. Mr. Chen must convert his current coverage to employer-sponsored retiree coverage and wait one year before enrolling in a MA or Part D plan. d. Mr. Chen can disenroll from the employer-sponsored plan and his only option is to choose a Medigap plan. Feedback Source: Part 5, Slide Other Common SEPs. Question 5 Correct Question text 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? a. 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. Correct: He is currently within his Part D IEP, which begins 3 months before the month he meets the eligibility requirements for Part B and ends 3 months after the month of eligibility. During the Part D IEP, beneficiaries may make one Part D enrollment choice, including enrollment in a stand-alone Part D plan or an MA-PD plan if they are eligible for MA. b. He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may only add stand-alone Medicare prescription drug coverage. c. diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him? a. If there is a special needs plan (SNP) in Mr. Wendt’s area that specializes in caring for individuals with diabetes, he may enroll in the SNP during the MA Open Enrollment Period which takes place between January 1 and March 31. b. Because of the severity of his condition, Mr. Wendt must remain enrolled in Original Medicare and also enroll in a Medigap plan to supplement his additional medical needs. c. If there is a special needs plan (SNP) in Mr. Wendt’s area that specializes in caring for individuals with diabetes, he may enroll in the SNP at any time under a special election period (SEP) Correct. Beneficiaries who have severe or disabling chronic conditions and wish to enroll in a SNP designed to serve individuals with their specific condition have a SEP during which they can enroll in a SNP designed to serve individuals with their condition. The SEP lasts as long as the individual has the qualifying condition and ends once the individual enrolls in a MA SNP. d. Mr. Wendt must wait until the next annual open enrollment period (AEP) before he can enroll in a special needs plan (SNP). Feedback Source: Part 5, Slide – Typical SEPs -Severe or Disabling Chronic Conditions Question 8 Correct Question text Mr. and Mrs. Nunez attended one of your sales presentations. They’ve asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do? a. You can countersign Mrs. Nunez’ application, along with her husband, indicating that she approved this choice verbally. This witness signature is sufficient to make the enrollment valid. b. Legal spouses can sign enrollment forms for one another under federal law. You may enroll both Mr. and Mrs. Nunez, as long as her husband signs on her behalf. c. You should sign the form for Mrs. Nunez yourself, since she informed you, as the plan’s representative, that she wanted to enroll. d. As long as she can do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time. Correct. A Medicare beneficiary is generally the only individual who may execute a valid request for enrollment in an MA plan. CMS will allow a legal representative or another individual to execute an enrollment request on behalf of the beneficiary if authorized under state law. Depending on state law, this may include court appointed legal guardians, individuals with a durable power of attorney for health care decisions. A spouse does not automatically fall into these sanctioned categories. Feedback Source: Part 5, Slide – Who May Complete the Enrollment Form? Question 9 Correct Correct. She can enroll in a Part D plan during the Annual Election Period (AEP), which takes place from October 15 to December 7. d. She should wait for at least six months into the plan year to be sure that she really wants to make the change. If she still wants to do so, she can make any sort of change she likes at that point. Feedback Source: Part 5, Slide -Enrollment Periods: Annual Election Period. Question 11 Correct Question text Mr. White has Medicare Parts A and B with a Part D plan. Last year, he received a notice that his plan sponsor identified him as a “potential at-risk” beneficiary. This month, he started receiving assistance from Medicaid. He wants to find a different Part D plan that’s more suitable to his current prescription drug needs. He believes he’s entitled to a SEP since he is now a dual eligible. Is he able to change to a different Part D plan during a SEP for dual eligible individuals? a. Yes. The “potential at-risk” designation only impacts the services he may receive from the Part D plan he enrolls, but it doesn’t affect his ability to change plans during this SEP. b. No. Once he is identified by the plan sponsor as a “potential at-risk” beneficiary, he cannot use the dual eligible SEP to change plans while this designation is in place. Correct: Typically, an individual with Medicare Parts A and B that receives Medicaid assistance receives a SEP during the first 9 months of each calendar year. However, once an individual is identified by the plan sponsor as a “potential at-risk” or “at-risk” beneficiary and the plan sponsor has sent written notice to the individual, he or she cannot use this SEP to change plans while this designation is in place. c. No. Individuals identified by the plan sponsor as “potential at-risk” must wait 2 years to switch plans, after which time the designation is lifted. d. Yes. “Potential at-risk” designations are just a warning. Only “at-risk” beneficiaries are prohibited from using this SEP while the designation is in place. Feedback Source: Part 5, Slide – Typical SEPs – Beneficiaries who are dual eligible or who have LIS eligibility; and Slide – Typical SEPs – Beneficiaries who are dual eligible or who have LIS eligibility, limitations for at-risk and potential at-risk beneficiaries Question 12 Correct Question text When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice would you give her? a. She should wait until the new year to disenroll from Original Medicare and select an MA plan between January 1 and March 31. b. She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA plan. Correct. The Annual Election Period (AEP) takes place from October 15 to December 7 each year and is available to all MA and Part D eligible beneficiaries. c. She could enroll in an MA plan during the period including the three months before, the month of, and up to three months after turning 68. d. She could immediately enroll in MA plan based on the one-time special election period available to those 70 and younger. Feedback