AHIP FINAL EXAM TEST QUESTIONS WITH COMPLETE VERIFIED SOLUTIONS 2024/2025, Exams of Nursing

Download AHIP FINAL EXAM TEST QUESTIONS WITH COMPLETE VERIFIED SOLUTIONS 2024/2025 and more Exams Nursing in PDF only on Docsity! AHIP Final Exam TEST 2024/2025 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? ✓He may sign-up for Medicareatanytimehowevercoverageusuallybeginsonthefourthmonthafter dialysis treatments start. Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of15 employees and offers employer-sponsored healthcare coverage. Juan is a naturalized citizen and hascontributedtotheMedicaresystemforover20years.Juanasksyouifhewill be entitled to Medicare and if he enrolls how that will impact his employer- sponsored healthcare coverage. How would you respond? ✓Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would becometheprimarypayorofhishealthcareclaimsandSmallcapdoesnothaveto continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan. Mr.Moy'swifehasaMedicareAdvantageplan,buthewantstounderstandwhat coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy? ✓Medicare Supplemental Insurance would help cover his Part A and Part B deductibles or coinsuranceinOriginalFee-for-Service(FFS)Medicareaswellaspossiblysome services that Medicare does not cover. Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire nextyear.SheheardshemustenrollinPartBatthebeginningoftheyeartoensure no gap in coverage. What can you tell her? ✓She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period after the last month on her employer plan that differs from the standard general enrollment period, during which she may enroll in Medicare Part B. Mrs.Chenwillbe65soon,hasbeenacitizenfortwelveyears,hasbeenemployed 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? ✓Most individuals who are citizens and age 65 oroverare covered underPart Abyvirtueofhaving paid Medicare taxes while working,thoughsomemaybecoveredasaresultofpayingmonthlypremiums. Mrs.GonzalezisenrolledinOriginalMedicareandhasaMedigappolicyaswell, but it provides nodrug coverage.Shewould liketo keepthecoverageshehasbut replace her existing Medigap plan with one that provides drug coverage. What should you tell her? ✓✓Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan. Mrs.Westwearsglassesanddenturesandhasenjoyedconsiderablepainrelief fromarthritisthroughmassagetherapy.Sheisconcernedaboutwhetherornot Medicare will cover these items and services. What should you tell her? ✓✓Medicaredoesnotcovermassagetherapy,or,ingeneral,glassesordentures. Mr. Patel is in good health and is preparing a budget in anticipation of his retirementwhenheturns66.Hewantstounderstandthehealthcarecostshemight beexposedtounderMedicareifhewereto requirehospitalization as aresult ofan illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? ✓✓Under Original Medicare, there is a single deductibleamountdueforthefirst60daysofanyinpatienthospitalstay,after whichitconvertsintoaper-daycoinsuranceamountthroughday90.Afterday90, hewouldpayadailyamountupto60days overhislifetime,afterwhichhewould be responsible for all costs. Ms. Henderson believes that she will qualify for Medicare Coverage when she turns65,withoutpayinganypremiums,becauseshehasbeenworkingfor40years and paying Medicare taxes. What should you tell her? ✓✓To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. Mr.Alonsoreceivessomehelppayingforhistwogenericprescriptiondrugsfrom hisemployer'sretireecoverage,buthewantstocompareittoaPartDprescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into astandard MedicarePart D prescriptiondrugplan.What should you tell him? ✓✓He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing. prescriptiondrugplan.What should you tellhimaboutthissituation? ✓✓Hecould enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. Mrs.RamosisconsideringaMedicareAdvantagePPOandhasquestionsabout which providers she can go to for her health care.What should you tell her? ✓✓Mrs.Ramos canobtaincarefromany provider who participatesin Original Medicare, but generally will have a higher cost-sharing amount if she sees a provider who/that is not a part of the PPO network. Mr. Romero is 64, retiring soon, and considering enrollment in his employer- sponsored retiree group health plan that includes drug 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? ✓✓He should compare the benefits in his employer- sponsoredretireegrouphealthplanwiththebenefitsinhisneighbor'sMA-PDplan todetermine whichone will providesufficient coverage for hisprescription needs. 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.HowmuchmayDr.Brennancharge?✓✓Dr.BrennancanchargeMary Rogers no more than the cost sharing specified in the PFFS plan's terms and condition of payment which may include balance billing up to 15% of the Medicare rate. Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him? ✓✓He mayreceivehealth care services fromanydoctor allowedtobillMedicare, as long asheshowsthedoctortheplan'sidentificationcardandthedoctoragreestoaccept the PFFS plan's payment terms and conditions, which could include balance billing. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? ✓✓Medicare AdvantageisawayofcoveringalltheOriginalMedicarebenefitsthroughprivate health insurance companies. Mrs.Chiisage75andenjoysacomfortablebutnotextremelyhigh-incomelevel. She wishes to enroll in a MAMSAplan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicareandastandalone PartDplan.Howwould you adviseMrs.Chi? ✓✓Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. Danielisamiddle-incomeMedicarebeneficiary.Hehaschronicbronchitis,putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which typeofSNPislikelytobemost appropriateforhim? ✓✓. C- SNP Mrs.Burtonisaretireewithsubstantialincome.SheisenrolledinanMA-PDplan 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? ✓✓She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Mr. Greco is in excellenthealth, lives in his own home, and has asizeableincome from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost- sharing amounts and Mr. Greco would like to join that plan. What should you tell him? ✓✓SNPs limit enrollment to certain subpopulations of beneficiaries. Given hiscurrentsituation,heisunlikelytoqualifyandwouldnotbeabletoenrollinthe SNP. Mrs. Radford asks whether there are any special eligibility requirements for MedicareAdvantage.Whatshouldyoutellher? ✓✓Mrs.Radfordmustbeentitled to PartAand enrolled in Part B to enroll in MedicareAdvantage. Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access toservices since she receives some assistance forherhealth care costs from theState.Whatshouldyoutellher?Medicaidmayprovideadditionalbenefits,but Medicaid will coordinate benefits only with Medicaid participating providers. Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recentlystoppedpayinghisPartBpremium.Mr.CastilloisstillcoveredbyPartA. HewouldliketoenrollinaMedicareAdvantage(MA)planandisstillcoveredby Part A. What should you tell him? ✓✓He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Mrs.DavenportenrolledintheABCMedicareAdvantage(MA)planseveralyears 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? ✓✓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. Mr.KumarisconsideringaMedicareAdvantageHMOandhasquestionsabouthis ability to access providers. What should you tell him?In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network).ur clients, Lauren Nichols, has heard about a Medica 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,whenhereceivedthebill,hewassurprisedtoseelargechargesinexcess 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? ✓✓You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Mr.Sinclairhasdiabetesandhearttroubleandisgenerallysatisfiedwiththecare he has received under Original Medicare, but he would like to know more about MedicareAdvantage Special Needs Plans (SNPs). What could you tell him? ✓✓SNPshavespecialprogramsforenrolleeswithchronicconditions,likeMr. Sinclair,andtheyprovideprescriptiondrugcoveragethatcouldbeveryhelpfulas well. Mr.Lopezhasheardthathecansignupforaproductcalled"MedicareAdvantage" but is not sure about what type of plan designs are available through this program. What should you tell himabout the types of health plans that are available through the Medicare Advantage program? ✓✓They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. whoisentitledtoPartAorenrolledunderPartBiseligibletoenrollinaMedicareprescripti ondrug plan. As long as Mrs. Mulcahyis entitled to Part A, she does notneed to enroll under Part B before enrolling in a prescription drug plan. WhattypesoftoolscanMedicarePartDprescriptiondrugplansusethataffectthe way their enrollees can access medications? ✓✓Part D plans do not have to coverall medications. As a result, their formularies, or lists of covered drugs, will varyfrom plan to plan. In addition, they can use cost containment techniques such astiered co-payments and prior authorization. All plans must cover at least the standard Part D coverage or its actuarial equivalent.Whichofthefollowingstatementsbestdescribessomeofthecostsa beneficiary would incur for prescription drugs under the standard coverage? ✓✓StandardPartDcoveragewouldrequirepaymentofanannualdeductible,and once past the catastrophic coverage threshold,thebeneficiarypays whicheverisgreaterofeithertheco- paysforgenericandbrandnamedrugsorcoinsuranceof5%. Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit,butwhenhelooksatinformationonvariousplansavailableinhisarea,he seesawiderangeinwhattheychargefordeductibles,premiums,andcostsharing. How can you explain this to him? ✓✓Medicare Part D drug plans may havedifferentbenefitstructures,but on average,they must allbe atleast asgood asthestandard model established by the government. Mr. Carlini has heard that Medicare prescription drug plans are only offered throughprivatecompaniesunder aprogramknownas Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up foranMAproduct,buthealsowantsprescriptiondrugcoverage.Whatshouldyou tell him? ✓✓Mr. Carlini can stay with Original Medicare and also enroll in aMedicare prescription drug plan through a private company that has contractedwith the government to provide only such drug coverage to eligible Medicarebeneficiaries. Whichofthefollowingindividualsismostlikelytobeeligibletoenroll inaPartD Plan? ✓✓Jose, a grandfather who was granted asylum and has worked in theUnited States for many years. Mr. Hutchinsonhasdrugcoveragethrough his former employer's retiree plan. He isconcernedaboutthePartDpremiumpenaltyifhedoesnotenrollinaMedicare Ifthedrugcoveragehehasisnotexpectedto prescriptiondrugplan,butdoesnotwanttopurchaseextracoveragethathewill not need. What should you tell him? pay,onaverage,atleastasmuchasMedicare'sstandardPartDcoverageexpectstopay, then he will need to enroll in Medicare Part D during his initial eligibilityperiod to avoid the late enrollment penalty. Mrs.McIntireisenrolledinherstate'sMedicaidplanandhasjustbecomeeligible for Medicare as well.What can she expect will happen to her drug coverage? ✓✓UnlessshechoosesaMedicarePart Dprescriptiondrugplanon herown,shewill be automatically enrolled in one available in her area. Mrs.BerkowitzwantstoenrollinaMedicareAdvantageplanthatdoesnotinclude drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Underwhatcircumstancescanshedothis? ✓✓IftheMedicareAdvantageplanisaPrivateFee-for-Service(PFFS)plan that doesnot offerdrug coverageoraMedicalSavings Account plan, Mrs. Berkowitz can do this. WhichofthefollowingstatementsaboutMedicarePartDarecorrect? I. PartDplansmustenrollanyeligiblebeneficiarywhoappliesregardlessofhealth status except in limited circumstances. II. Privatefee-for-service(PFFS)plansarenotrequiredtouseapharmacynetwork but may choose to have one. III. BeneficiariesenrolledinaMA-MedicalSavingsAccount(MSA)planmay only obtain Part D benefits through a standalone PDP. IV. BeneficiariesenrolledinaMA-PPOmayobtainPartDbenefitsthrougha standalone PDPor through their plan. I, II, and III only Mr. Torres has a small savings account. Hewouldlike topayfor his monthlyPart Dpremiumswithanautomaticmonthlywithdrawalfromhissavingsaccountuntil it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him? premiumpaymentmechanismthatwillbeusedthroughouttheyear. You will be holding a sales event soon, at which you would like to offer door prizestoattendees.UnderguidelinesfromtheMedicareagency,whattypesofgifts or prizes would not be allowed in this situation? $15orlessthatcanbereadilyconvertedtocash. Anotheragentworkingforyouragencyclaimsthatbecauseyouarenotemployed by the MedicareAdvantage plans that you represent, you are not subject to the Ingeneral,hemustselectasinglePartD Giftcardsorgiftcertificates of samemarketingrequirementsastheplansthemselves.Howshouldyourespondto such a statement?Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules. 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 meetwithyouonOctober15.Duringtheappointment,whatareyoupermittedto do?You may provide her with the required enrollment materials and take her completed enrollment application. 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 MedicareAdvantageproductsyourepresentcomparedtothoselivinginapartment complexes. How should you respond?This could be considered discriminatory activity and a prohibited practice. 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?You must have her signascopeofappointmentform,indicatingwhichproductsshewishestodiscuss. You may then proceed with the discussion. Yourfriend'smotherjustmovedtoanassistedlivingfacilityandheaskedifyou could present a program for the residents about the MA-PD plans you market. Whatcouldyoutellhim?Youappreciatetheopportunityandwouldbehappyto schedule an appointment with anyone at their request. Melissa Meadows is a marketing representative for Best Care which has recently introducedaMedicareAdvantageplanofferingcomprehensivedentalbenefitsfor $15 per month. Best Care has not submitted any potential posts to CMS for approval. Melissa would like to use the power of social media to reach potential prospects. What advice would you give her?As soon as CMS approves Best Care's social media posts, Agent Meadows could post a tweet stating that "Best CareoffersanarrayofMedicareAdvantagebenefitpackages.Onemightberight for you. Call me to find out more!" Agent Jennings makes a presentation on Medicare advertised as an educational event.AgentJenningsdistributesmaterialsthataresolelyeducational.However, Mr.Rockwell,age67,isenrolledinMedicarePartA,butbecausehecontinuesto work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice.What advice would you give Mr. Rockwell about special election periods (SEPs)?Mr. Rockwell is eligible for a SEPduetohisinvoluntarylossofcreditabledrugcoverage;theSEPbeginsinJune and ends on September 1- two months after the loss of creditable coverage. Mrs.YoungiscurrentlyenrolledinOriginalMedicare(PartsAandB),butshehas 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 AdamsisconsideringsuggestingthatheandMrs.Youngcompletetheapplication 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 advisingAgentAdams?This is a bad idea.Agents are generally prohibited from soliciting or accepting an enrollment form before the start of theAEP. 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 offersbettercoveragethanthatavailablethroughhisMA-PDplanandinaddition, hasalowpremium.Itwon'tcosthimmuch moreand,becausehehasthemeansto do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan.What should you tell him?If Mr. Block enrolls in the stand- alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. Mrs.ReevesisnewlyeligibletoenrollinaMedicareAdvantageplanandherMA Initial Coverage Election Period (ICEP) has just begun. Which of the following can shenot doduring the ICEP?Shecan enroll in aMedigap plan to supplement the benefits of the MAplan that she's also enrolling in. Mr.JohannsenisentitledtoMedicarePartAandPartB.HegainsthePartDlow- income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan?Hequalifiesforaspecialelectionperiodandcanenrollinordisenrollfrom a Part D plan once during that period. Mr.Yoo'semployerhasrecentlydroppedcomprehensivecreditableprescription drugcoveragethatwasofferedtocompanyretirees.ThecompanytoldMr.Yoo that, because he was affected by this change, he would qualify for a Special electionperiod.Mr.Yoocontactedyoutofindoutmoreaboutwhatthismeans. What can youtellhim?It means thathequalifies foraone-time opportunityto enroll in an MA-PD or Part D prescription drug plan. Mrs. Schmidt is moving and a friend told her she might qualify for a "Special electionperiod"toenrollinanewMedicareAdvantageplan.Shecontactedyouto ask what a special election period is. What could you tell her?It is a period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different MedicareAdvantage and/or Part D prescription drug plan. TypicallytheSpecialelectionperiodisbeneficiaryspecificandresultsfrom events, such as when the beneficiary moves outside of the service area. 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 choiceswithyou.Whatadviceshouldyougiveher?TellhertowaituntilOctober todiscuss plan choices with you so that you can shareplanbenefits forthecurrent year as well as any changes for the following year that may impact her choice. Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. Hewouldliketoknowhisoptionssincehehasdecidedtodrophisretireecoverage and is eligible for Medicare. What should you tell him?Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. Mrs.Kumarwouldlikeherdaughter,wholivesinanotherstate,tomeetwithyou duringtheAnnualElectionPeriodtohelphercompleteherenrollmentinaPartD plan. She asked you when she should have her daughter plan to visit. What could you tell her?Her daughter should come in November. Mr. Roberts is enrolled in an MAplan. He recently suffered complications followinghipreplacementsurgery.Asaresult,hehasspentthelastthreemonthsin Resthaven, a skilled nursing facility. Mr. Roberts is about to be discharged. What advice would you give him regarding his health coverage options?His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility. Mr.WhitehasMedicarePartsAandBwithaPartDplan.Lastyear,he receiveda noticethathisplansponsoridentifiedhimasa"potentialat-risk"beneficiary.This month,hestartedreceivingassistancefromMedicaid.Hewantstofindadifferent PartDplanthat'smoresuitabletohiscurrentprescriptiondrugneeds.Hebelieves 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 SEPfor dual eligible individuals?No. Once he is identifiedbytheplansponsorasa"potentialat-risk"beneficiary,hecannotusethe dual eligible SEPto change plans while this designation is in place. Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D.What could you tell him?He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he maymakeonePartDenrollmentchoice,includingenrollmentinastand-alonePart D plan or an MA-PD plan. A client wants to give you an enrollment application on October 1 before the beginningoftheAnnualElectionPeriodbecauseheisleavingonvacationfortwo weeks and does not want to forget about turning it in. What should you tell him? You musttellhimyou arenotpermittedtotaketheform.Ifhesendstheform directlyto theplan,theplan willprocess theenrollment on thedaytheAnnual Election Period begins. Mr.GarretthasjustenteredhisMAInitialCoverageElectionPeriod(ICEP).What action could you help himtake during this time?He will have one opportunity to enroll in a Medicare Advantage plan. You are meeting with Ms. Berlin and she has completed an enrollment form for a MA-PD plan you represent. You notice that her handwriting is illegible and as a result,thespellingofherstreetlooksincorrect.Sheasksyoutofillinthecorrected street name.What should you do?You may correct this information as long as you add your initials and date next to the correction. YouhavecometoMrs.Midler'shomeforasalespresentation.Atthebeginningof the presentation, Mrs. Midler tells you that she has a copy of her medical records available because shethinks this willhelpyou understand her needs.Shesuggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan.What should you do?You can only ask Mrs. Midlerquestionsaboutconditionsthataffecteligibility,specifically,whethershe has one of the conditions that would qualify her for a special needs plan. Mr.andMrs.Nunezattendedoneofyoursalespresentations.They'veaskedyouto come to their home to clear up a few questions. During the presentation, Mrs. Nunezfeelstiredandtellsyouthatherhusbandcanfinishthingsup.Shegoesto bed.At the end of your discussion, Mr. Nunez says that he wants to enroll both Rulearenotconsideredtobeprincipallyengagedindeliveringhealth care,and thus lines ofbusinessthat do not receivefederal fundingor administered under Title I of theACA, such as life insurance, do not fall under the scope of 1557. Section 1557 of theAffordable CareAct applies toall health programs and activitiesadministeredbyorreceivingfederalfinancialassistancefromHHS UnderSection1557,2020FinalRuleissuedduringtheTrumpAdministrationsex was initially defined as biologic sex only, meaning whether a person was determined to be male or female at birth. Which of the following would be considered permissible under Section 1557 and the 2020 Final Rule?Broker Mary Jones has recruited a diverse workforce. She encouragesheragentstoprospectthroughcommunity-basedmarketingandwithin their community of influence. Auxiliaryaidsandservicesmustbeprovidedtoindividualswithdisabilities,such as those suffering from vision or hearing impairments, free of charge, and in a timely manner.Auxiliary aids and services include which of the following: I. largeprintmaterials II. qualifiedsignlanguageinterpreters III. braillematerialsanddisplays IV. screenreadersoftwareI,II,III,and IV WhichentityenforcesSection1557forprogramsthatreceivefundingfromonare administered by HHS?The Office of Civil Rights (OCR) of HHS. Whichoftheseactionsismostlikelytobepermittedindealingwithapersonwith limited English proficiency?Allowing a child to interpret in an emergency. UnderACASection1557,ahealthplancannotdenycoveragetoLEPindividuals and is required to provide language assistance to them, free of charge. Forahealthplan,whatarethepossibleconsequencesofviolationsofACASection 1557?Loss of federal business and compensatory damages. WhichofthefollowingisNOTpotentiallyapenaltyforviolationofalawor regulation prohibiting fraud, waste, and abuse (FWA)?Deportation Whichofthefollowingrequiresintenttoobtainpaymentandtheknowledgethe actions are wrong?Fraud You are performing a regular inventory of the controlled substances in the pharmacy.Youdiscoveraminorinventorydiscrepancy.Whatshouldyoudo? Follow your pharmacy's procedures Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS)forthepurposeofpayment.Aspart ofthis job,you useaprocess to verify the data is accurate. Your immediate supervisor tells you to ignore the Sponsor'sprocessandtoadjustoraddriskdiagnosiscodesforcertainindividuals. What should you do?Report the incident to the compliance department (via compliance hotline or other mechanism) You are in charge of paying claims submitted by providers. You notice a certain diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize Doe Diagnostics' claims far exceed any other provider you reviewed. What should you do?Consult with your immediate supervisor for next steps or contact the compliancedepartment(viacompliancehotline,SpecialInvestigationsUnit[SIU], or other mechanism) Apersondropsoffaprescriptionforabeneficiarywhoisa"regular"customer.The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step?Call the prescriber to verify the quantity Wasteincludesanymisuseofresources,suchastheoveruseofservicesorother practices that directly or indirectly result in unnecessary costs to the Medicare Program.True Bribes or kickbacks of any kind for services that are paid under a Federal health careprogram(whichincludesMedicare)constitutefraudbythepersonmakingas well as the person receiving them.True TheseareexamplesofissuesthatshouldbereportedtoaComplianceDepartment: suspected fraud, waste, and abuse (FWA); potential health privacy violation, unethical behavior, and employee misconduct.True Abuseinvolvespaymentforitemsorserviceswhenthereisnolegalentitlementto that payment and the provider has not knowingly or intentionally misrepresented facts to obtain payment.True Waystoreportpotentialfraud,waste,andabuse(FWA)include: a. Maildrops b. SpecialInvestigativeUnits(SIUs) c. Tekephonehotlines d. Allofthe above e. In-personreportingtothecompliancedepartment/supervisorAlloftheabove Onceacorrectiveactionplanisstarted,thecorrectiveactionplanmustbe monitored annually to ensure they are effective.False Whataresomeofthepenaltiesforviolatingfraud,waste,andabuse(FWA)laws? a.Civil Monetary Penalties b.Imprisonment c.Alloftheabove d.ExclusionfromparticipationinallFederalhealthcareprogramsAllofthe above Any person who knowingly submits false claims to the Government is liable for fivetimestheGovernment'sdamagescausedbytheviolatorplusapenalty.False SomeofthelawsgoverningMedicarePartCandDfraud,waste,andabuse(FWA) includetheHealthInsurancePortabilityandAccountabilityAct(HIPAA),theFalse ClaimsAct theAnti-Kickback Statute, and the Health Care Fraud Statute.False Youcanhelppreventfraud,waste,andabuse(FWA)bydoingallthefollowing: Look for suspicious activity Conduct yourself in an ethical manner Ensureaccurateandtimelydataandbilling Ensure you coordinate with other payers Keepup to date with FWA policies and procedures, standards of conduct, laws, regulations,andtheCentersforMedicare&MedicaidServices(CMS)guidance Verify all information provided to youTrue AgentMarvinMillnerwantstoreachouttohiscurrentclientsforreferrals.What advice would you give to Marvin?Marvin should understand that under CMS guidelineshecannolongerprovidegifts,evenofminimalvalue,inexchangefor referrals. NOT SURE Mr.ChenhasheardaboutaMedicalSavingsAccount(MSA)butwantstoknowif it is just about saving money, or if he will get insurance coverage for his health care expenditures as well. What should you tell him?Under the Medicare Advantage program, a MSA plan involves the combination of a high deductible health plan and a savings account for health expenses. Medicare will make contributions to this savings account to help him pay his health care expenses while in the deductible. NOT SURE Ms. Lewis understands that Medicare prescription drug plans may use various methods to control the use of specific drugs. She has heard about a technique called"steptherapy"andiswonderingifyoucanexplainwhatthatis.Whatshould you tell her?Step therapy involves using one or more lower priced drugs before trying a more expensive drug when all are used to treat the same condition. Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is interested in that product. She wants to be sure she also has coverageforprescriptiondrugs.Wouldshebeabletoobtaindrugcoverageifshe enrolled in the SNP?Yes.All SNPs are required to provide Part D coverage for prescription drugs. AgentRoderickenrollsretireeMrs.Martinezinamedicalsavingsaccount(MSA) Medicarehealthplan.TheMSAplandoesnotofferprescriptiondrugcoverage,so Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation rules apply to this situation?This situation is considered a "dual enrollment," and CMS compensation rules are applied to the two plans at once and independently of each other. Mr. Olsen is concerned that a Medicare Advantage plan will not cover the same rangeofservicesthatwouldbecoveredunderOriginalfee-for-serviceMedicare. What should you tell him?Though their cost-sharing may differ from Original Medicare's,MedicareAdvantageplansarerequiredtocoverallservicescovered by original Medicare. Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recentlytoldherthatthereisanexcellentMedicareAdvantage(MA)planwitha five-star rating serving her area. On January 15 she comes to you for advice as to what options, if any, she has. What should you say regarding special enrollment periods(SEPs)?Mrs.WellingtoniseligibleforaSEPthatmaybeusedonceuntil November 30 to enroll in the five-star plan. Ms. Gardner is currently enrolled in an MA-PD plan. However, she wants to disenroll from the MA-PD plan and instead enroll in a Part D only plan and go backtoOriginalMedicare.AccordingtoMedicare'senrollmentguidelines,when could she do this?She may make such a change during theAnnual Election PeriodthatrunsfromOct.15toDecember7,orduringtheMAOpenEnrollment Period which takes place from January 1- March 31 of each year. Mr.Lopez,whoisfairlywell-offfinancially,wouldliketoenrollinaMedicare prescription drug plan you represent and simply give you a check to cover his premiums for the entire year.What should you tell him?Enrollees should pay using automatic withdrawal from a bank account or credit or debit card, direct monthly billing from the plan, or deductions from their Social Security check. Ms.Jensenhasheardabout"OriginalFee-for-ServiceMedicare"and"PrivateFee- for- Service" plans. She wants to know what the difference is if any. What should youtellher?PFFSplansareatypeofMedicareAdvantageplanofferedbyprivate companies. Ms.Bushmanhastwohomesindifferentstatesandisconcernedaboutrestrictions on where she can get her medications. What should you tell her?Part D prescription drug plansusenetworks ofpharmacies within theirserviceareas.She could look for a plan that maintains a network in both states. NOTSURE Whoismostlikelytobe eligibleto enrollina PartDprescriptiondrugplan?Ms. Daviswhoisentitled toPartAandhasjustenrolled in PartB.asalespresentation, your client asks you wh Mr.Lopeztakesseveralhigh-costprescriptiondrugs.Hewouldliketoenrollina standalonePartDprescriptiondrugplanthatisavailableinhisarea.Inwhattype of Medicare Health Plan can heenroll?Private Fee-for-Service(PFFS) plan that does not include drug coverage. If a beneficiary is enrolled in a stand-alone prescription drug plan and wants to keep that plan, whattype of Medicare health plan couldthe individual also enroll in,withoutbeingautomaticallydisenrolledfromthestand-aloneprescriptiondrug Mr.Singhcanenrollinastand-alone throughhisStatePharmaceuticalAssistanceProgram. Mr.WumaystillqualifyforhelpinpayingPartDcosts plan?The beneficiarycould enrollin a private fee-for-service (PFFS) plan that doesnotincludeprescriptiondrugcoverage;acostplan;oraMedicareMedical Savings Account (MSA) plan. Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr.Morenoaboutthekindsoffoodthatcanbeprovidedtopotentialenrolleeswho attend the sales presentation? be permitted Whichofthefollowingis/aremostlikelytobecharacterizedasaninvoluntary disenrollment from a Medicare Advantage (MA) plan? I. Theenrolleedies. II. AnSNPenrolleelosesspecialneedsstatusduetosubstantiallyimprovedhealth. III. ItisdeterminedthatthememberisnotlawfullypresentintheUnitedStates. IV. ThememberenrollsinanotherplanduringtheAnnualOpenEnrollment period. Mr.SinghwouldlikedrugcoveragebutdoesnotwanttobeenrolledinaMedicare Advantage plan. What should you tell him prescriptiondrugplanandcontinuetobecoveredforPartAandPartBservicesthrough Original Fee-for-Service Medicare. MadelineMartinezwaswidowedseveralyearsago.Herhusbandworkedformany years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline,whohasonlyworkedpart-timeforthelastthreeyears,willsoon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her? in Medicare Part A without paying monthly premiums due to her husband's longwork record and participation in the Medicare system. You should also tellMadelinethatshewillpayPartBpremiumsatmorethanthestandardlowestratebut less than the highest rate due her substantial income. Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualifyforthePartDlow-incomesubsidy.Wheremightheturnforhelpwithhis prescription drug costs? I,II,andIII only Amealcannotbeprovided,butlightsnackswould YoushouldtellMadelinethatshewillbeabletoenroll Shecouldenrollina EveryPartDdrugplanisrequiredtocoverasingleone- AdvantagePrescriptionDrug(MA-PD)PFFSplanthatcombinesmedicalbenefits AMedicare tellheraboutobtainingdrugcoverage? beabletopurchaseastand-aloneMedicarePartDprescriptiondrugplan. Mrs.ChoulikesaPrivateFee-for-Service(PFFS)planavailableinherareathat does not include drug coverage. She wants to enroll in the plan and enroll in a stand- alone prescription drug plan. What should you tell her? PFFSplanandastand-aloneMedicareprescriptiondrugplan. Mrs.Lyonsisingoodhealth,usesasingleprescription,andlivesindependentlyin her own home. She is attracted by the idea of maintaining control over a Medical SavingsAccount(MSA)butisnotsureiftheplanassociatedwiththeaccountwill fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan? coverPartAandPartBbenefits,butnotPartDprescriptiondrugbenefits,whichcould be obtained by also enrolling in a separate prescription drug plan. Mrs. Fiore is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) planthatincludescreditabledrug coverage. She is ready toturn65 and become Medicare eligible for the first time. What issues mightshe consideraboutwhethertoenrollinaMedicareprescriptiondrugplan? ShecouldcomparethecoveragetoseeiftheMedicarePartDplanoffersbetterbenefitsan dcoverage than the FEHB plan for the specific medications sheneeds and whetherany additional benefits are worth the Part D premium costs on top of her FEHBcontribution. Mrs.Roswellis anewMedicarebeneficiarywho has just retired fromretail work. SheisinterestedinselectingaMedicarePartDprescriptiondrugplan.Shetakesa number of medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her? monthfillofherexistingmedicationssometimeduringa90-daytransitionperiod. Mrs.RobertshasOriginalMedicareandwouldliketoenrollinaPrivateFee-for- Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan? ShecanenrollinthePPO,butshewillnot AllMSAs oraPFFSplanincombinationwithastand-aloneprescriptiondrugplan. andPartDprescriptiondrugcoverage,aPFFSplanofferingonlymedicalbenefits, Theextrahelpisavailabletobeneficiarieswhoseincomeandassetsdo Mrs.WaltersisentitledtoPart Aandhasmedicalcoveragewithout drug coverage throughanemployerretireeplan.SheisnotenrolledinPartB.Sincetheemployer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan.Will she be able to? Yes. Mrs.Walters must be entitled toPart A and/or enrolled in Part B to be eligible for coverage under the Medicareprescription drug program. Mrs.FieldswantstoknowwhetherapplyingforthePartDlow-incomesubsidy will be worth the time to fill out the paperwork.What could you tell her? Dlow-incomesubsidycouldsubstantiallylowerheroverallcosts.Shecanapplyby contacting her state Medicaid office or calling the Social SecurityAdministration. Oneofyourclients,LaurenNichols,hasheardaboutaMedicareconceptfromone of her neighbors called TrOOP. She asks you to explain it. What do you say? Dcatastrophiclimitandincludenotonlyexpensespaidbyabeneficiarybutalsoinsome instances drug manufacturer discounts. Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries withlimitedincome.Hewantstoknowwhetherhemightqualify.Whatshouldyou tell him? notexceedannuallimitsspecifiedbythegovernment. Mr. Rice is 68, actively working and has coverage for medical services and medications through his employer's group health plan. He is entitled to premium freePartAandthinkingofenrollinginPartBandswitchingtoanMA-PDbecause he is paying a very large part of his group coverage premium and it does not provide coverage for a number of his medications. Which of the following is NOT a consideration when making the change?Mr. Rice's retiree plan is required to take him back if, within 63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his Medicare Part D plan. Thisyearyouhavedecidedtofocusyoureffortsonmarketingtoemployergroup plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do?You may go ahead and call them. TrOOPstandsfortrueout-of-pocketexpensesthatcounttowardtheMedicarePart ThePart Alice is a marketing representative employed by a health plan. Betty is a captive agentofahealthplanwhomarketstomultipleplansandsponsors.Carlisacaptive agent who markets to only one plan/sponsor. Denise is an independent agent who markets to different types of groups. Edward is an independent agent who markets only to employer and union groups. CMS marketing representative compensation rulesgenerallyapplyto:Bettyand Denise,butnotAlice (the employee) or Carlor Edward (to whom exceptions apply). DuringasalespresentationtoMs.DaleyforaMedicareAdvantageplanthathasa 5-star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the best statement to say to her?The MedicareAdvantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4- stars. BestCare Health Plan has received a request from a state insurance department in connectionwiththeinvestigationofseveralmarketingrepresentativeslicensedby thestatewhosellMedicareAdvantageplans.Whataction(s)shouldBestCaretake in response?Cooperate with the state and supply requested information. You are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs.Whatshouldyoukeepinmind?YoumayrequestRSVPs,butyouarenot permitted to require contact information. You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To comply with requirements for marketing MedicareAdvantage and Part D plans, what must you do about contacting potential clients to market those plans?You will have to avoid calling any potentialclientunlessheorsheinitiatescontact withyouandspecificallyasksthat you give him or her a call. Monica is an agent focused on serving seniors eligible for Medicare. As she reviewsherrecords,sheistryingtodeterminewhichofthefollowingitemsare considered compensation. What do you tell her? I. Commissions II. Bonuses III. Mileagereimbursement IV. AwardsI,IIandIVonly insurancecanyoupresentduringtheMAandPartDmarketingappointment?You can present only health care related lines of business but must obtain the beneficiary's permissiontodo so beforethepresentation occurs anddocument that you have obtained that permission. Mr. Edwards, a marketing representative of the ACME Insurance Company, scheduledamarketingeventandexpectsabout40peopletoattend.Hehashireda magician for $200 to entertain attendees. Can he do this in a way that complies with guidance from the Medicare agency?He can do this because the estimated number of attendees is based on the venue size and response rate and the value of the gift does not exceed $15. Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard?Implying that only seniors can enrollinaMedicareAdvantageplanwhenmeetingwithMr.Hernandez,whois58 but qualifies for Medicare because he is disabled. Which of the following individuals has enrolled in a plan based on a fixed enrollmentperiod?Ben,whoenrollsinaMedicareAdvantageplanduringthe MedicareAdvantage Open Enrollment Period (MA OEP). Mr. Wilcox has been enrolled in Lexington Private Fee-for-Service (PFFS) Medicare Advantage Health Plan (Lexington) for several years. Recently, Mr. Wilcoxdecidedtospendtimewithhischildrenwholiveinanotherstatethatisnot in Lexington's service area. In the future, he may relocate near his children permanently. How does this move to another service area impact his PFFS MA coverage?LexingtoncanallowforMr.Wilcox'scontinuedenrollmentforupto12 months whether or not he is in a visitor/traveler (V/T) program since it is a PFFS plan. Miles is a licensed agent who represents Colgate Health and its Medicare Advantage (MA) plans. Miles has several clients who have recently come to him for help. They are in their initial coverage periods) (ICEP) and are interested in enrolling in one of Colgate Health's MA plans. Adam will soon turn 68 and has decidedtoretire.Bettyisabouttoturn65andhasalsodecidedtoretire.Adamand Betty both currently have coverage through Colgate Health. Charles had health coveragethrough Colgatebutdropped thecoveragewhenheretired earlyto travel to Europe. Charles has just turned age 65 and is now back in the United States. Diedre,whowillturn65nextmonth,currentlyhascoveragethroughDitmas Health - a company that Miles also represents. Who qualifies for the opt-in SinceMrs.JenkinshasMedicarePartAand simplifiedenrollmentmechanism?AdamandBettybecauseeachofthemwillnot have a break between theirnon-Medicareand Medicare coverage through Colgate Health Plan. Mr. Fitzgerald is selling his home to permanently move into a retirement facility nearhisdaughterinaneighboringstatebeforetheAnnualElectionPeriod.Hehas astand- aloneprescriptiondrugplan andhas learneditisnot availablewhereheis moving. He doesn't know what he shoulddo.What canyou tellhim?Becausehe is moving outside of the service area, the plan must automatically disenroll him. Hewillhaveaspecialelectionperiodtoselectanewplan. Mrs. Jenkins is enrolled in both Part A and Part B of Medicare. She has recently alsobecomeeligibleforMedicaidandwouldliketoenrollinaMA-PDplan.Since thisisherfirst experience with MedicareAdvantage, she is concerned that she will belocked intoaplanandunabletomakeanycoveragechangesforatleast ayearif not longer. What should you tell her? PartBandreceivesMedicaid,shehasaspecialelectionperiod(SEP)thatwillallow her to enroll or disenroll from an MA or MA-PD plan during the first 9months of each calendar year. Mr. Rodriguez is currently enrolled in a MA plan, but his plan doesn't sufficiently cover his prescription drug needs. He is interested in changing plans during the upcomingMAOpenEnrollmentPeriod.WhatarehisoptionsduringtheMAOEP? He can switch to a MA-PD plan. Mrs. Parker likes to handle most of her business matters through telephone calls. ShecurrentlyisenrolledinOriginalMedicarePartsAandBbuthasheardabouta Medicare Advantage plan offered by Senior Health from a neighbor. Mrs. Parker asks you whether she can enroll in Senior Health's MAplan over the telephone. Whatcantell her? I. Enrollmentrequestscanonlybemadeinface-to-faceinterviewsorbymail. II. Telephoneenrollmentrequestcallsmustberecorded. III. Telephonicenrollmentsmustincludeallrequiredelementsnecessaryto complete an enrollment. IV. Thesignatureelementmustbecompletedviacertifiedmail.IIandIII only Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period (AEP). On December 1, he calls you up and says that he has changedhismindandwouldliketoenrollintoaMA-PDplan.Whatenrollment ruleswouldapplyinthiscase?Hecanmakeasmanyenrollmentchangesashe likesduringtheAnnualElectionPeriodandthelastchoicemadepriortotheendof the period will be the effective one as of January 1. Ms.Thomas has worked for manyyears andisturning68inJune.She is eligible for Medicare Part A and did not enroll for Part B when first eligible because she hasinsurancethroughheremployer-CoffeeBrew,Inc.Shealsodidnotenrollin Part D because she had creditable coverage. She would like to retire in June and enroll in a Medicare Advantage plan. She has been informed that her group coverage will end on her retirement effective date. How would you advise Ms. Thomas?Ms.ThomascanenrollinPartBwithoutalatepenaltyatanytimesheis still covered byheremployergroup and8 months afterherlastmonth ofemployer group coverage without a penalty. However, because she wants to enroll in a MA plan afterretirement,sheshould makesureherPart Bcoverageis effectiveintime to use the Medicare Advantage/Part D special election period for individuals changing from employer group coverage to enroll in a MA plan or MA-PD. The SEP begins while she has employer group coverage and will last until 2 months after the month after the month her employer coverage ends. If she wants Part D coverage sheshouldenroll in an MA-PD or a PDP (depending onhowshe decides to receive her PartAand B benefits) during this time. Mr.Liuturns65onJune19.HehasneverpreviouslyqualifiedforMedicaresohis first Medicare eligibility date will be by June 1. Mr. Liu's ICEP and Part D IEP begin March 1 and end on September 30. He wants prescription drug coverage with his PartAand Part B benefits. What advice can you provide him?He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to PartA. Ms. Claggett is sixty-six (66) years old. She has been covered under Original Medicare for the last six years due to her disability and has never been enrolled in aMedicareAdvantageoraPartDplanbefore.ShewantstoenrollinaPartDplan. Sheknowsthatthereissuchathingasthe"PartDInitialEnrollmentPeriod"(IEP) and has concluded that, since she has never enrolled in such a plan before, she should be eligible to enroll under this period. What should you tell her about how the Part D Initial Enrollment Period applies to her situation?Ms. Claggetthas had two IEPs and missed them both. The first occurred three months before and three monthsafterthemonthwhenshewasfirstentitledtoPartAORenrolledinPartB. Because she was eligible for Medicare before age 65, Ms. Claggett had a second IEP based on turning age 65, which has also expired. Ms.O'DonnelllearnedaboutanewMA-PDplanthatherneighborsuggestedand that you represent. She plans to switch from her old MAHMO plan to the new legalauthorization,understatelawthatexplicitlyallowshimtomakehealthcare decisions for his mother. Agent Willis had several clients who disenrolled from the plans he represents duringthe AEP to enroll in Medicare Advantage plansthat arecompetitorsof his. Agent Willisbelievesthat the choicestheymade are notideal for themand would like to get their business back during the Medicare Advantage Open Enrollment Period (MA-OEP).What can agentWillis do?He can call themto let themknow thatiftheydonotliketheirnewplans,theycanchangebackduringtheMA-OEP. DuringasalespresentationinMs.Sullivan'shome,shetellsyouthatshehasheard about a type of Medicare health plan known as Private Fee-for-Service (PFFS). Shewantstoknowifthiswouldbeavailabletoher.Whatshouldyoutellherabout PFFS plans?APFFS plan is one of the various types of MedicareAdvantage plans offered by private entities and she may enroll in one if it is available in her area. Mrs.SanchezlivesinastatelocatednearCanada.Shehasrecentlybecomeeligible for Medicare and is considering enrollment in Part D prescription drug coverage. One of her friends has told her that she needs to be aware of something called TrOOP.What should you tell her when she asks you aboutTrOOP?TrOOPare out- of-pocket costs that count toward the annual out-of-pocket threshold to move intocatastrophiccoverageandgenerallyincludetheannualdeductible(s)andcosts for drugs on the plan's formulary purchased at a plan's participating pharmacy. In some instances, amounts not directly paid by the enrollee (like manufacturer discounts) count toward TrOOP. Mr.PolanskilikesthecostofanHMOplanavailableinhisareabutwouldliketo beabletovisitoneortwodoctorswhoaren'tparticipatingproviders.Hewantsto know if the Point of Service (POS) option available with some HMOs will be of anyhelp inthis situation.What should you tellhim?The POS option might be a good solution for him as it will allow him to visit out-of-network providers, generallywithoutprior approval. However, he shouldbe awarethatitislikelyhe will have to pay higher cost-sharing for services from out-of-network providers. Mr. Landry is approaching his 65th birthday. He has signed up for Medicare Part A,buthedidnotenrollinPartBbecausehehasemployer-sponsoredcoverageand intends to keep working for several more years. But he is considering enrolling in PartDprescriptiondrugcoveragebecausehebelievesitissuperiortohisemployer plan. How would you advise him?Mr. Landry is eligible for Part D since he has PartA,andhisinitialenrollmentperiod(IEP)forPartDwillcontinueforthree months after his 65th birthday. Youhave decided tofocusondoingin-home presentations tomarket the Medicare Advantage(MA)plansyourepresent.Beforeyouconductsuchsalespresentations, what must you do?You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in-home presentation. This year you decide to focus your efforts on marketing to employer and union groups.Whichofthefollowingstatementsbestdescribeswhatyoucanandcannot doinorder tostayincompliance?You arenot requiredtosubmitcommunication and marketing materials specific only to those employer plans to CMS at the time of use, but CMS may request and review copies if employee complaints occur. Agent Chanis conducting a sales presentation on senior issueswhere he hopesto enrollsomeattendeesintheMedicareAdvantage(MA)plansherepresents.What action(s) mayAgent Chan take during the event?Discuss plan specific information such as premiums and benefits. Ms.Hernandezhasmarketedseveraldifferenttypesofinsuranceproductsinher home state and has typically sought approval of her materials from her State Department of Insurance. What would you advise her regarding seeking such approvalformaterialssheusestomarketMedicareAdvantageplans?Materials need only be reviewed and approved by the company(s) she represents. Mr. Lee was intending to enroll in MaxCare's Medicare Advantage plan this year. However, due to his current medical condition, his daughter Debbie has been appointedashislegalrepresentativeoverbothhealthandfinancialmatters.Debbie wouldliketo ensure thather fatherisstill ableto enrollin MaxCare'splan,but she isunsurewhat herroleistohelp with his enrollment request.Whatadvicecan you give her?Legal representatives are only permitted to submit a paper enrollment request. ??????????? LastyearAgentMelanieMeyersmarketedandenrolledseveralclientsinMedicare Advantage (MA) health plans. This year she has decided to focus on non-MA products.WhatadvicewouldyougiveMelanieifshewishestocontinuetoreceive renewal fees?Melanie must remain trained, tested, licensed, and appointed, regardless of whether she is actively selling MAproducts. Alice is enrolled in a MA-PD plan. She makes a permanent move across the countryand wonderswhatheroptions are for continuing MA-PD coverage. What wouldyousaytoherinregardtoaspecialenrollmentperiod(SEP)?Sheislikely to qualify for a SEP. She can choose an effective date of up to three months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than the date of her permanent move. Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. Hewouldliketoknowhisoptionssincehehasdecidedtodrophisretireecoverage and is eligible for Medicare. What should you tell him?Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. Mr.KumarisconsideringaMedicareAdvantageHMOandhasquestionsabouthis ability to access providers. What should you tell him?In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network). 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?XXXIt must obtain a HIPAAcomplaint authorizationfromanenrolleethatindicatestheplanorplansponsormayusetheir information for marketing purposes. Mr.Yoo'semployerhasrecentlydroppedcomprehensivecreditableprescription drugcoveragethatwasofferedtocompanyretirees.ThecompanytoldMr.Yoo that, because he was affected by this change, he would qualify for a Special electionperiod.Mr.Yoocontactedyoutofindoutmoreaboutwhatthismeans. What canyou tell him?It meansthat hequalifiesforaone-timeopportunityto enroll in an MA-PD or Part D prescription drug plan. Dr.ElizabethBrennandoesnotcontractwiththeABCPFFSplanbutacceptsthe plan's terms and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan charge?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. YouhavecometoMrs.Midler'shomeforasalespresentation.Atthebeginningof the presentation, Mrs. Midler tells you that she has a copy of her medical records available because shethinks this willhelpyou understand her needs.Shesuggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan.What should you do?You can only ask Mrs. Midlerquestionsaboutconditionsthataffecteligibility,specifically,whethershe has one of the conditions that would qualify her for a special needs plan. Ms.EdwardsisenrolledinaMedicareAdvantageplanthatincludesprescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her?She may fill prescriptionsforcovereddrugsatnon-networkpharmacies,butlikelyatahigher cost than paid at an in-network pharmacy. Mr.JohannsenisentitledtoMedicarePartAandPartB.HegainsthePartDlow- income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan?Hequalifiesforaspecialelectionperiodandcanenrollinordisenrollfrom a Part D plan once during that period. Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need.Whatshould you tellhim?If thedrug coveragehehasis notexpected to pay,onaverage,atleastasmuchasMedicare'sstandardPartDcoverageexpectsto pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Mr.Moy'swifehasaMedicareAdvantageplan,buthewantstounderstandwhat coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy?Medicare Supplemental Insurance would help cover his Part A and Part B deductibles or coinsuranceinOriginalFee-for-Service(FFS)Medicareaswellaspossiblysome services that Medicare does not cover. Anotheragent working foryouragencyclaims that becauseyou arenot employed by the Medicare Advantage plans that you represent, you are not subject to the samemarketingrequirementsastheplansthemselves.Howshouldyourespondto such a statement?Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules. Youhave decided tofocusondoingin-home presentations tomarket the Medicare Advantage(MA)plansyourepresent.Beforeyouconductsuchsalespresentations, what must you do?You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in-home presentation. Mr. Wells is trying to understand the difference between Original Medicare and MedicareAdvantage. What would be the correct description?Medicare AdvantageisawayofcoveringalltheOriginalMedicarebenefitsthroughprivate health insurance companies. Mrs.Kumarwouldlikeherdaughter,wholivesinanotherstate,tomeetwithyou duringtheAnnualElectionPeriodtohelphercompleteherenrollmentinaPartD plan. She asked you when she should have her daughter plan to visit. What could you tell her?Her daughter should come in November. Plan sponsors may undertake the following marketing activities with current MedicareAdvantageplanmembers?Marketnon-healthrelateditemsorservices such as life insurance or annuities policies to current members as permitted following HIPAA Privacy Rules. Mr.Grecoisinexcellenthealth,livesinhisownhome,andhasasizeableincome from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friendhas mentioned that the SNP charges verylow cost- sharing amounts andMr.Greco wouldliketo jointhatplan.What should youtell him?SNPs limit enrollmenttocertainsubpopulations ofbeneficiaries.Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. 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 notenrolledunderMedicarePartB.Whatshouldyoutellher?Anindividualwho is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescriptiondrugplan.AslongasMrs.MulcahyisentitledtoPartA,shedoesnot need to enroll under Part B before enrolling in a prescription drug plan. One of your colleagues argues that it is better to focus your time and energy exclusivelyinneighborhoodswithsingle-familyhomes.Hefurtherarguesthat their older owners are more likely to have higher incomes and purchase the MedicareAdvantageproductsyourepresentcomparedtothoselivinginapartment complexes. How should you respond?This could be considered discriminatory activity and a prohibited practice. Mrs.Burtonisaretireewithsubstantialincome.SheisenrolledinanMA-PDplan 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?She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D.What could you tell him?He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he maymakeonePartDenrollmentchoice,includingenrollmentinastand-alonePart D plan or an MA-PD plan. WhattypesoftoolscanMedicarePartDprescriptiondrugplansusethataffectthe way their enrollees can access medications?Part D plans do not have to cover all medications.Asaresult,theirformularies,orlistsofcovereddrugs,willvaryfrom plan to plan. In addition, they can use cost containment techniques such as tiered co- payments and prior authorization. Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered bythat plan.What should you tell him? It is illegal for you to sellMr. Capadona aMedigapplanifheis enrolledinanMA plan, and besides, Medigap only works with Original Medicare. Mr.Rockwell,age67,isenrolledinMedicarePartA,butbecausehecontinuesto work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice.What advice would you give Mr. Rockwell about special election periods (SEPs)?Mr. Rockwell is eligible for a SEPduetohisinvoluntarylossofcreditabledrugcoverage;theSEPbeginsinJune and ends on September 1- two months after the loss of creditable coverage. A Medicare beneficiary has walked into your office and requested that you sit downwithheranddiscussheroptionsundertheMedicareAdvantageprogram. offers employer-sponsored healthcare coverage. Juan is a naturalized citizen and hascontributedtotheMedicaresystemforover20years.Juanasksyouifhewill be entitled to Medicare and if he enrolls how that will impact his employer- sponsored healthcare coverage. How would you respond?Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would becometheprimarypayorofhishealthcareclaimsandSmallcapdoesnothaveto continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan. Mr. Schmidt would like to plan for retirement and has asked you what is covered underOriginalFee-for-Service(FFS)Medicare?Whatcouldyoutellhim?PartA, 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. Mr.Baueris49yearsold,buteighteenmonthsagohewasdeclareddisabledbythe Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him?After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern?Medicare is a program for people age 65 or olderandthoseunderage65withcertaindisabilities,end-stagerenaldisease,and Lou Gehrig's disease so she will be eligible for Medicare. Mr. Buck has several family members who died from different cancers. He wants toknowifMedicarecoverscancerscreening.Whatshouldyoutellhim?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. Mrs. Ramos is considering a Medicare Advantage PPO and has questions about whichprovidersshecangotoforherhealthcare.Whatshouldyoutellher?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. Mrs.DavenportenrolledintheABCMedicareAdvantage(MA)planseveralyears 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?She may remain in herABC MAplan, 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. Danielisamiddle-incomeMedicarebeneficiary.Hehaschronicbronchitis,putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. WhichtypeofSNPislikelytobemostappropriateforhim?C-SNP Mrs. Radford asks whether there are any special eligibility requirements for MedicareAdvantage.Whatshouldyoutellher?Mrs.Radfordmustbeentitledto PartAand enrolled in Part B to enroll in MedicareAdvantage. 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,whenhereceivedthebill,hewassurprisedtoseelargechargesinexcess 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?You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Mr. Romero is 64, retiring soon, and considering enrollment in his employer- sponsored retiree group health plan that includes drug coverage with nominal copays.Heheardaboutaneighbor'sMA-PDplanthatyourepresentandbecause he takes numerous prescription drugs, he is considering signing up for it. What should you tell him?Heshouldcomparethebenefitsinhisemployer-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. Mrs.Chiisage75andenjoysacomfortablebutnotextremelyhigh-incomelevel. She wishes to enroll in a MAMSAplan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribedseveralexpensivemedications.Currently,sheisenrolledinOriginal MedicareandastandalonePartDplan.HowwouldyouadviseMrs.Chi?Mrs. Chi may enroll in a MS MSAplan and remain in her current standalone Part D prescription drug plan. Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recentlystoppedpayinghisPartBpremium.Mr.CastilloisstillcoveredbyPartA. HewouldliketoenrollinaMedicareAdvantage(MA)plan andisstill covered by PartA. What should you tell him?He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her accesstoservicessinceshereceivessomeassistanceforherhealthcarecostsfrom the State. What should you tell her?Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state's Medicaid program. 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?He may receivehealthcareservicesfromanydoctorallowedtobillMedicare,aslongashe 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. Mr.LombardiisinterestedinaMedicareAdvantage(MA)PPOplanthatyou represent. It is one of three plans operated by the same organization in Mr. Lombardi's area. The MA PPO plan does not include drug coverage, but the other twoplansdo.Mr.LombardilikesthePPOplanthatdoesnotincludedrugcoverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan.What should you tell him about this situation?He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. Mr.Lopezhasheardthathecansignupforaproductcalled"MedicareAdvantage" but is not sure about what type of plan designs are available through this program. What should you tell himabout the types of health plans that are available through the MedicareAdvantage program?They are Medicare health plans such as HMOs,PPOs,PFFS,andMSAs. Mr.Sanchezhasjustturned65andisentitledtoPartAbuthasnotenrolledinPart B because he has coverage through an employer plan. If he wants to enroll in a MedicareAdvantage plan, what willhehave to do?He willhave to enrollin Part B. Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling.HisneighborrecentlytoldhimaboutaconceptcalledTrOOPandheasks you if any of his other medications could count toward TrOOP should he ever reachthePartDcatastrophiclimit.Whatshouldyousay?NoneofthecostsofMr. Wingate'sothermedicationswouldcurrentlycounttowardTrOOPbuthemaywish to ask his plan for an exception to cover the prescription not on its formulary. All plans must cover at least the standard Part D coverage or its actuarial equivalent.Whichofthefollowingstatementsbestdescribessomeofthecostsa beneficiary would incur for prescription drugs under the standard coverage? Standard Part D coverage would require payment of an annual deductible, and oncepastthecatastrophiccoveragethreshold,thebeneficiarypayswhicheveris greaterofeithertheco-paysforgenericandbrandnamedrugsorcoinsuranceof 5%. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previouslyavailable through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What shouldyoutellher?IfaPartDbenefitisofferedthroughherplanshemaychoose to enroll in that plan or a standalone PDP. Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit,butwhenhelooksatinformationonvariousplansavailableinhisarea,he seesawiderangeinwhattheychargefordeductibles,premiums,andcostsharing. Howcan you explainthis to him?Medicare Part Ddrugplans mayhavedifferent benefit structures,but on average,they must all be at least as good as the standard model established by the government. You have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respect to meals?You may provide light snacks, but a Thanksgivingstylemealwouldbeprohibited,regardlessofwhoprovidesorpays for the meal. AgentMartinezwishes to solicit MedicareAdvantageprospectsthrough e-mail andasksyouforadviceastowhetherthisispossible.Whatshouldyoutellher? Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. Melissa Meadows is a marketing representative for Best Care which has recently introducedaMedicareAdvantageplanofferingcomprehensivedentalbenefitsfor $15 per month. Best Care has not submitted any potential posts to CMS for approval. Melissa would like to use the power of social media to reach potential prospects. What advice would you give her?As soon as CMS approves Best Care's social media posts, Agent Meadows could post a tweet stating that "Best CareoffersanarrayofMedicareAdvantagebenefitpackages.Onemightberight for you. Call me to find out more!" Anotheragentyouknowhasengagedinmisconductthathasbeenverifiedbythe plan she represented. What sort of penalty might the plan impose on this individual?The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. 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 adviceshould you give Miguel?DuringtheMA-OEP,Miguel can haveone-on-onemeetingswithbeneficiarieswhohaverequestedsuchmeetings 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 prohibitedactivityataneventthathasbeenadvertisedaseducational?Yes.When an event has been advertised as "educational," discussing plan-specific premiums is impermissible. 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?You should plan to ensurethattheeducationaleventisaninformativeeventandmustnotconducta sales presentation or distribute or accept enrollment forms at the event. AgentArmstrongisemployedbyXYZAgency,whichisundercontractwithABC Health Plan, a Medicare Advantage (MA)planthat offers plansin multiplestates. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enrollinABCplans.Whatstatementbestdescribesthemarketingandcompliance rules that apply toAgentArmstrong?AgentArmstrong needs to be licensed and Giftcardsorgiftcertificates of appointedineverystateinwhichbeneficiariestowhomhemarketsABCMAplans are located. You will be holding a sales event soon, at which you would like to offer door prizestoattendees.UnderguidelinesfromtheMedicareagency,whattypesofgifts or prizes would not be allowed in this situation? $15orlessthatcanbereadilyconvertedtocash. 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?You will not be able to represent any Medicare Advantageor Part Dplanuntil you complete the training and achieve an adequatescore.However,youwillnothavetotakeatestifyouexclusivelymarket employer/union group plans and the companies do not require testing. Duringasalespresentation,yourclientasksyouwhethertheMedicareagency recommendsthatshesignupforyourplanorstayinOriginalMedicare.What should you tell her?Tell her that the Medicare agency does not endorse or recommend any plan. Yourfriend'smotherjustmovedtoanassistedlivingfacilityandheaskedifyou could present a program for the residents about the MA-PD plans you market. Whatcouldyoutellhim?Youappreciatetheopportunityandwouldbehappyto schedule an appointment with anyone at their request. 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 meetwithyouonOctober15.Duringtheappointment,whatareyoupermittedto do?You may provide her with the required enrollment materials and take her completed enrollment application. Mrs. Schmidt is moving and a friend told her she might qualify for a "Special electionperiod"toenrollinanewMedicareAdvantageplan.Shecontactedyouto ask what a special election period is. What could you tell her?It is a period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different MedicareAdvantage and/or Part D prescription drug plan. TypicallytheSpecialelectionperiodisbeneficiaryspecificandresultsfrom events, such as when the beneficiary moves outside of the service area. 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 offersbettercoveragethanthatavailablethroughhisMA-PDplanandinaddition, hasalowpremium.Itwon'tcosthimmuch moreand,becausehehasthemeansto do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan.What should you tell him?If Mr. Block enrolls in the stand- alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit,butwhenhelooksatinformationonvariousplansavailableinhisarea,he seesawiderangeinwhattheychargefordeductibles,premiums,andcostsharing. How can you explain this to him?Part D plans must cover at least the Part D standard benefits or its actuarial equivalent. They are not required to offer the standard plan. Questiontext Mr. Torres has a small savings account. Hewouldlike topayfor his monthlyPart Dpremiumswithanautomaticmonthlywithdrawalfromhissavingsaccountuntil it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him?In general, he must select a single Part D premium payment mechanism that will be used throughout the year. WhichofthefollowingstatementsaboutMedicarePartDarecorrect? I. PartDplansmustenrollanyeligiblebeneficiarywhoappliesregardlessofhealth status except in limited circumstances. II. Privatefee-for-service(PFFS)plansarenotrequiredtouseapharmacynetwork but may choose to have one. III. BeneficiariesenrolledinaMA-MedicalSavingsAccount(MSA)planmay only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalonePDPorthroughtheirplan.BeneficiariesenrolledinanMA-PPOmay not obtain Part D benefits through a standalone PDP or through their plan. They must obtain them through their plan by enrolling in an MA-PD. 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, sheis not enrolledunderMedicarePartB.Whatshould you tellher?Mrs.Mulcahycan enrollinPartDbecausesheisentitledtoPartA.TherulesforPartDaredifferent from those that apply to eligibility for MedicareAdvantage (Part C). Individuals entitled to Part A and/or enrolled in Part B are eligible to enroll in Part D. In contrast,toenrollinanMAplananindividualmustbeeligibleforPartAand enrolled in Part B. Mr. Hutchinsonhasdrugcoveragethrough his former employer's retiree plan. He isconcernedaboutthePartDpremiumpenaltyifhedoesnotenrollinaMedicare prescription drug plan, but does not want to purchase extra coverage that he will not need.What should you tell him?To avoid a late enrollment penalty, Mr. Hutchinsonmusthave"creditable"coverage.Ifhedoesnot,hemustenrollin MedicarePart Dduring his initial eligibilityperiod to avoid alateenrollment penalty. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previouslyavailable through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What shouldyoutellher?IfaPartDbenefitisofferedthroughherplanshemaychoose to enroll in that plan or a standalone PDP. Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan's formulary he takes several other medications. These include a prescription drug not on his plan's formulary, over- the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling.HisneighborrecentlytoldhimaboutaconceptcalledTrOOPandheasks you if any of his other medications could count toward TrOOP should he ever reachthePartDcatastrophiclimit.Whatshouldyousay?NoneofthecostsofMr. Wingate'sothermedicationswouldcurrentlycounttowardTrOOPbuthemaywish to ask his plan for an exception to cover the prescription not on its formulary. Mr.ShultzwasstillworkingwhenhefirstqualifiedforMedicare.Atthattime,he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has lost his employer group coverage within the last two weeks. How would you advise him?Mr. Schultz shouldenrollinaPartDplanbeforehehasa63-daybreakincoverageinorderto avoid a premium penalty. Mr.Bickforddidnotquitequalifyfortheextrahelplow-incomesubsidyunderthe 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 shouldyoutellhim?Hecouldcheckwiththemanufacturersofhismedicationsto seeiftheyofferanassistanceprogramtohelppeoplewithlimitedmeanstoobtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. She currently does not have creditable coverage. What could you tell her about the implications of such a decision?If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, her premiumwillbepermanentlyincreasedby1%ofthenationalaveragepremiumfor every month that she was not covered. Ms.EdwardsisenrolledinaMedicareAdvantageplanthatincludesprescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her?She may fill prescriptionsforcovereddrugsatnon-networkpharmacies,butlikelyatahigher cost than paid at an in-network pharmacy. Mr. Zachow has a condition for which three drugs are available. He has tried two buthadanallergicreactiontothem.Onlythethirddrugworksforhimanditisnot on his Part Dplan's formulary.What could you tell himto do?Mr. Zachow has a righttorequestaformularyexceptiontoobtaincoverageforhisPartDdrug.Heor his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan. WhattypesoftoolscanMedicarePartDprescriptiondrugplansusethataffectthe way their enrollees can access medications?Part D plans do not have to cover all medications.Asaresult,theirformularies,orlistsofcovereddrugs,willvaryfrom plan to plan. In addition, they can use cost containment techniques such as tiered co- payments and prior authorization. Mrs.McIntireisenrolledinherstate'sMedicaidplanandhasjustbecomeeligible for Medicare as well.What can she expect will happen to her drug coverage? UnlessshechoosesaMedicarePartDprescriptiondrugplanonherown,shewill be automatically enrolled in one available in her area. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr.Vaughntakesaprescriptionforhelpingtoregrowhishair.Theyareanxiousto