Understanding Medicare Advantage and Part D Plans, Exams of Nursing

Download Understanding Medicare Advantage and Part D Plans and more Exams Nursing in PDF only on Docsity! AHIP Final Exam Test Review Questions and Answers Latest Update 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 a. He generally would pay only a per-prescription co-payment. Medicare covers all other costs. b. He generally would pay only a monthly premium. Medicare covers all other costs. c. He generally would pay only a monthly premium and deductible. Medicare covers all other costs. d. He generally would pay a monthly premium, annual deductible, and per- prescription cost- sharing. 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? 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. Correct: Mr. Gomez may receive health care services from any doctor allowed to bill Medicare, provided he shows the doctor the plan’s identification card, and the doctor accepts the PFFS’s payment terms and conditions. These terms may include balance billing up to 15% of the Medicare rate. b. If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor accepts Original Medicare. c. He may receive services from any physician, regardless of whether or not that physician participates in the plan or Original Medicare. d. If he enrolls in the PFFS plan and shows his card to a doctor who participates in Original Medicare, then that doctor is required to accept the plan’s terms and conditions, which could include balance billing. Feedback Source: Module 2, Slide - MA Plan Types Private Fee-for-Service (PFFS) Plans, MA Plan Types Private Fee-for-Service Plans (2 of 3) and MA Plan Types Private Fee-for-Service Plans (3 of 3). Feedback Source: Part 2, Slide -MA Plans and Dual Eligible Beneficiaries, continued and Slide - MA Plans and Dual Eligible Beneficiaries, continued Which of the following statement is/are correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III.An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV.Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. a. I, II, and III only b. II and III only c. I, II, and IV only Correct: MSAs may not have a network or may have a full or partial network of providers. MSAs cover Part A and Part B benefits after the deductible. All non- network providers must accept the same amount that Original Medicare would pay them as payment in full. This is the amount the enrollee will pay the provider before the deductible is met. d. I and II only Feedback Source: Module 2, Slide - MA Plan Types: Medical Savings Account (MSA) Plans. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? a. Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States. b. Mrs. Radford must be enrolled in both Medigap and Part A to enroll in a Medicare Advantage plan. c. Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, before being accepted and enrolled. d. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Correct: To be eligible to enroll in Medicare Advantage, an individual must be entitled (not enrolled) to Part A and enrolled in Part B. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost- sharing amounts and Mr. Greco would like to join that plan. What should you tell him? a. SNPs only serve individuals in long-term care facilities, so he cannot enroll. b. SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll. c. SNPs do not provide Part D prescription drug coverage, so if he does enroll, he should be aware that he will not have coverage for any medications he may need now or in the future. d. SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. Correct: Mr.Greco’s circumstances would not meet the eligibility criteria to qualify him for any of the SNPs. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility: SNPs, Medicare Advantage Eligibility: SNP Description (1 of 2) and Medicare Advantage Eligibility: SNP Description (2 of 2). Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him? a. Since SNPs don’t cover prescription drugs Mr. Sinclair should consider a different option. b. SNPs offer care from any doctor or hospital Mr. Sinclair would like to use and his costs will always be lower than in Original Medicare. c. SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. d. SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well. Correct: Chronic condition SNPs (C-SNPs) restrict enrollment and tailor services to individuals with chronic conditions, such as Mr. Sinclair. All SNPs include prescription drug coverage. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description (2 of 2). Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? a. Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage it must be a MSA-PD plan that includes drug coverage. b. Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage she must also enroll in a Medicare Supplement Plan (Medigap) F that covers the Medicare Part B deductible and includes both drug coverage. c. Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. Correct. MA MSA plans are prohibited from offering prescription drug coverage. If an MSA member wants prescription drug coverage, the member must enroll in a standalone PDP. d. Mrs. Chi is ineligible for a MA MSA plan because she is ineligible for Medicaid due to her income level. Feedback Source: Module 2, Slide - MA & Prescription Drugs, Slide - Medicare Advantage Eligibility: MSAs Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do? a. He will not need to do anything. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan. b. He must wait until the next Annual Election Period, at which time he can enroll in a Medicare Advantage plan. c. He will have to enroll in Part B. b.They are Medigap Supplemental plans that fill in the gaps not covered by Medicare. c. They are custodial long-term care plans for people with Medicare. d.They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Correct: There are coordinated care Medicare Advantage plans that include HMOs and PPOs. There are also Private-Fee-for-Service (PFFS), Medicare Savings Account (MSA), and Special Needs Plans (SNPs). Feedback Source: Module 2, Slide - Medicare Advantage Plans (Overview). Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him? a. C-SNP Correct: Because Daniel’s bronchitis is a chronic condition, a Chronic condition SNP would be most appropriate for him to enroll in. b. I-SNP c. D-SNP d. FIDE-SNP Feedback Source: Module 2, Slide - Medicare Advantage Eligibility, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description (2 of 2). What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? a. Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrict access through prior authorization. b. Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market. c. The Federal government establishes a set formulary, or list of covered drugs, each year that the Part D plans must use. Beneficiaries should consult the government’s list prior to deciding whether they wish to enroll in a Part D plan during that year. d. Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization. Correct: Part D plans are not required to cover all prescriptions on the market. But they have various methods to manage costs including formularies, cost- sharing tiers, step therapy, prior authorization and substitution. Feedback Source: Module 3, Slide - Part D Drug Management Tools. Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this? a. Mrs. Berkowitz can apply for any Medicare Advantage plan and, if it offers drug coverage, ask to have that element of the coverage eliminated, after which she can enroll in a stand- alone Medicare prescription drug plan in her service area. b. Mrs. Berkowitz can enroll in any Medicare Advantage plan, regardless of whether it offers drug coverage, and enroll in any stand-alone Medicare prescription drug plan. c. This is not a possibility. If Mrs. Berkowitz wants health coverage and drug coverage through a plan, she must purchase an MA-PD plan. d. If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. a. If a Part D benefit is offered through her plan she must enroll in this plan. b. Mrs. Lopez must first seek COBRA benefits under her husband’s plan before she can apply for Part D coverage. c. Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage. d. If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. Correct: Mrs. Lopez is enrolled in a Cost plan. This provides her with options as to how she secures Part D benefits. Beneficiaries enrolled in a Cost plan may obtain Part D benefits through their plan (if offered) or through a stand-alone Prescription Drug Plan (PDP). Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? a. Medicare prescription drug plans are required to include only a certain percentage of brand name drugs among those they cover. It may be possible that plans available in her area have opted not to include in their formularies the brand name drugs she needs. She may need to pay for this particular medication out of pocket. b. Medicare prescription drug plans are allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medications out of pocket. c. When medication costs exceed a certain threshold amount, which rises each year, a Medicare prescription drug plan is permitted to exclude coverage for all but the least expensive of the medications in a given category. Mrs. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives. d. Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs. Correct: Part D formularies must include at least two drugs in each therapeutic category whether or not generic versions are available. Mrs. Allen should be able to find a plan that covers the medications she needs. Feedback Source: Module 3, Slide - Covered Part D Drugs Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? a. Betsy, a grandmother from overseas who has overstayed her visa. b. Jose, a grandfather who was granted asylum and has worked in the United States for many years. Correct: Jose, having been granted asylum, is legally present in the United States thus meeting one of the criteria for Part D eligibility. c. Helena, an overseas college student who has overstayed her visa. d. Guy, who has illegally crossed the Canadian border. Feedback Source: Module 3, Slide - Medicare Part D Eligibility. Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her? a. She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan’s network. b. She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. c. She may fill one prescription out-of-network per year and it will be fully covered. Her second prescription will require her to pay the full cost out-of-pocket. d. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Correct: There are some circumstances that allow for enrollees to utilize a non- network pharmacy. However, these prescriptions are typically filled at a higher cost to these enrollees. Feedback Source: Module 3, Slide - Part D Pharmacy Networks. Mrs. McIntire is enrolled in her state’s Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen to her drug coverage? a. Medicaid will cover all drugs not covered under the Medicare Part D prescription drug plan into which Mrs. McIntire is enrolled. b. She will continue to obtain her drug coverage through Medicaid. c. She can expect that all her prescriptions will be automatically delivered on a mail-order basis as a requirement of the Medicare Part D program. d. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Correct: If a Medicaid beneficiary does not choose a Part D plan once they become eligible for Medicare, then Medicare will select one for them. Feedback Source: Module 3, Slide - Medicaid Drug Coverage. Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan’s formulary he takes several other medications. These include a prescription drug not on his plan’s formulary, over- the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say? a. None of the costs of Mr. Wingate’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. Correct: None of the costs of Mr. Wingate’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. If he receives an exception under which the plan covers the drug, it could count toward TrOOP. b.The cost of the prescription drugs that are not on his plan’s formulary as well as the cost of the drug(s) to reduce joint swelling from the Canadian pharmacy will count toward TrOOP but the other medications in question will not count toward TrOOP. c. The cost of the prescription drug that is not on his plan’s formulary will count toward TrOOP but the other medications in question will not count toward TrOOP. d.The cost of all medications bought within the United States not covered by his plan would count toward TrOOP. The cost of the Canadian bought medications would not count toward TrOOP. Feedback Source: Module 3, Slide - True Out-of-Pocket Costs? (TrOOP): What Counts and Slice - True Out-of-Pocket Costs (TrOOP): What is Excluded? c. Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. Correct: Part D plans must cover at least the Part D standard benefits or its actuarial equivalent. Part D plans are permitted to offer supplemental benefits that cover certain drugs not covered under Part D. Some Part D plans may offer these supplemental benefits for an additional monthly premium. d.The government bases its payments to Part D plans on the standard benefit model. For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries. Feedback Source: Module 3, Slide - Part D Plan Benefits. Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him? a. Mr. Carlini can keep Original Medicare, but if he does not sign up for an MA plan that includes prescription drug coverage, he will only be able to obtain prescription drug coverage through a Medigap plan. b. Mr. Carlini can obtain drug coverage through the Federal government’s fallback plans, which are designed to provide an alternative to privately sponsored Medicare Advantage plans. c. Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. Correct: Mr. Carlini can stay in Original Medicare and obtain prescription drug benefits through a stand-alone Part D plan. He does not have to enroll in a MA plan. d.To obtain prescription drug coverage, Mr. Carlini must enroll in an MA plan. The plan will cover his Part A and Part B services, as well as provide him with the desired prescription drug coverage. Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basic and Slide - Medicare Prescription Drug Eligibility Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him? a.As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding should begin, he can change his method of Part D premium payment and withholding will begin the month after his savings account is exhausted. b. In general, to pay his Part D premium, he only can have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals. c. During 2017, many people experienced significant problems with deductions from their Social Security check for their Part D premium. As a result, this method of payment is no longer an option for Part D premium payments. d. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Correct: Generally, a Part D beneficiary must stay with a premium payment option for the entire plan year. Feedback Source: Module 3, Slide - Part D Premiums Mr. Shultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has lost his employer group coverage within the last two weeks. How would you advise him? a. Mr. Schultz should immediately enroll in a Part D plan but he can expect to pay a premium penalty because he failed to enroll when first eligible. b. Mr. Schultz should seek to continue employer group coverage through COBRA because it is likely to have superior benefits at a more permanent solution. c. Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty. Correct: Mr. Schultz should enroll in a Part D plan, or otherwise obtain creditable drug coverage, before he has a 63-day break in order to avoid a premium penalty. d. Mr. Schultz can wait up to 180 days after the loss of his creditable employer group coverage before enrolling in a Part D plan without worrying payment a premium penalty. Feedback Source: Module 3, Slide - Employer Coverage of Drugs. Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. She currently does not have creditable coverage. What could you tell her about the implications of such a decision? a. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will be required to pay a higher premium during the first year that she is enrolled in the Medicare prescription drug program. After that point, her premium will return to the normal amount. b. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will have to pay a one-time penalty equal to 10% of the annual premium amount. c. If she does not sign up for a Medicare prescription drug plan, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications. d. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered. Correct: Most Individuals should sign up for Part D as soon as they are eligible to do so. Otherwise, they face a permanent premium penalty of 1% of the national average premium for each month the individual does not have Part D coverage. Beneficiaries who qualify for the low-income subsidy, however, are not subject to the late enrollment penalty. Feedback Source: Module 3, Slide - Part D Late Enrollment Penalty. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? a. The vitamins the Vaughns are taking will be covered under Part D because their physician suggested they should take vitamins, but the hair loss You will be holding a sales event soon, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation? a. Gifts of nominal retail value ($15 or less) Incorrect: This statement is incorrect because marketing representatives may offer gifts to sales event attendees provided they are of nominal value and are worth $15 or less. b. Gifts worth more than $15 but based on anticipated attendance will not exceed $15 per attendee. c. Two or more gifts whose combined value does not exceed $15. d. Gift cards or gift certificates of $15 or less that can be readily converted to cash. Feedback Source: Module 4, Slide - Gifts and Promotional Items. Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational? a. Yes. Whether or not an event has been advertised as “educational” or a “sales presentation,” discussing plan-specific information is impermissible. b.Yes. When an event has been advertised as “educational,” discussing plan-specific premiums is impermissible. Correct: Discussion or distribution of plan-specific information is prohibited at any educational event. c. No. This action is permissible. Handing out enrollment forms, on the other hand, would not be permissible. d. No. Attendees expect some “puffery” at any event on a product in which they may be potentially interested. Feedback Source: Module 4, Slide - Educational Events, Impermissible Activities. During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her? a. Tell her that Medicare or CMS (the Medicare agency) has approved and endorsed the plan. b. Tell her that the Medicare agency does not endorse or recommend any plan. Correct: Centers for Medicare and Medicaid Services (CMS), the government agency responsible for Medicare, does not endorse or recommend any of the Medicare Advantage (MA) plans it approves. Medicare beneficiaries should choose either Original Medicare or a MA plan based on their particular needs and circumstances. c. Tell her that Medicare recommends that beneficiaries enroll in a Medicare Advantage plan because it will serve her better than Original Medicare. d. Tell her that, because you represent a Medicare health plan, you therefore work for Medicare, and the information you offer her is a good basis of any decision she makes. Feedback Source: Module 4, Slide - Prohibited Practices: Marketing and Communications Material and Activities and Prohibited Practices: Examples. A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do? a. You must set an appointment for another time, at least 48 hours from the point when she walked into your office. b.You do not have to do anything. You may proceed with the discussion and enroll the individual if she so desires. c. Before speaking with the individual, you must inquire as to her eligibility for MA and Part D plans and then complete a scope of appointment form for the plans for which she is eligible. 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. Feedback Source: Module 4, Slide - Marketing Activities: Marketing in a Health Care Setting. 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 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. c. Your coworker is correct because employed agents have to follow a stricter set of rules than do independent agents, such as yourself. d.Your coworker is correct. You may use any marketing techniques that do not involve providing misinformation to potential enrollees. Feedback Source: Module 4, Slide - Applicability of Medicare Marketing and Communication Rules to Marketing Representatives. 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 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. b.You should plan to conduct sales presentations but must not accept enrollment forms. c. You should plan to answer questions and accept enrollment forms. d.You should plan to conduct sales presentations and accept enrollment forms. Feedback Source: Module 4, Slide - Marketing and Educational Events and Slide - Educational Events, Impermissible Activities. 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. 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: 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. Feedback Source: Module 4, Slide - Marketing Activities: Marketing in a Long-term Care Facility and Slide - Marketing Activities in a Health Care Setting: Example. Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. 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 enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong? a.Agent Armstrong needs to be licensed and appointed only in the state where ABC Health Plan is headquartered. b.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. c.Agent Armstrong needs to be licensed and appointed only in his state of residence. d.Agent Armstrong needs to be licensed and appointed only in the state where XYZ Agency is headquartered. Feedback Source: Module 4, Slide - Requirement to act as Plan Marketing Representative and Slide - Marketing Representatives - State Licensure Case Study Melissa Meadows is a marketing representative for Best Care which has recently introduced a Medicare Advantage plan offering comprehensive dental benefits for $15 per month. Best Care has not submitted any potential posts to CMS for approval. Melissa would like to use the power of social media to reach potential prospects. What advice would you give her? a.Agent Meadows should post a tweet telling readers to contact her directly to learn more about Best Care’s comprehensive dental benefits at only $15 per month. b. Despite the terms of her contract forbidding the use of social media, Agent Meadows could send out a tweet stating that “Best Care offers a Medicare Advantage benefit package offering the lowest cost comprehensive dental benefit package available. Call me direct to learn more.” because the content does not contain any plan-specific information about benefits, premiums, cost-sharing, or Star Ratings. c. Due to cybersecurity dangers, social media cannot be used in the promotion of Medicare Advantage products. d.As soon as CMS approves Best Care's social media posts, Agent Meadows could post a tweet stating that“Best Care offers an array of Medicare Advantage benefit packages. One might be right for you. Call me to find out more!” Correct: Best Care must submit marketing materials, including social media posts to CMS for approval before the plan or its agents may begin posting such marketing content. Feedback Source: Module 4, Slide - Use of Social Media to Market and Slide - Social Media Example. Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her? a. While unsolicited contacts may be made through print media such as direct mail, marketing representatives may not initiate electronic contact. b. Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. 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 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 Mrs. Reeves is newly eligible to enroll in a Medicare Advantage plan and her MA Initial Coverage Election Period (ICEP) has just begun. Which of the following can she not do during the ICEP? a. She can choose to enroll in a MA-PD plan, provided that her Part D initial election period and MA ICEP occur at the same time. b. She can compare various MA plan options and select one to enroll in. c. During her ICEP, she can make an enrollment choice and change that choice during her MA Open Enrollment Period (MA OEP) that follows her election. d. She can enroll in a Medigap plan to supplement the benefits of the MA plan that she’s also enrolling in. Correct: MA ICEP is not an opportunity to enroll in a Medigap plan. Also, Medigap does not supplement MA plan benefits; it is meant to supplement Original Medicare. Feedback Source: Part 5, Enrollment Periods MA ICEP, continued. Mr. Yoo’s employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a Special election period. Mr. Yoo contacted you to find out more about what this means. What can you tell him? a. It means that he will have a one time opportunity to enroll in a Medigap policy with drug coverage. b. It means that he will be able to enroll in a state-funded pharmacy assistance program for retirees that will cover 80 percent of his drug costs. c. It means that he will be able to purchase continued drug coverage from the insurer that had provided it to the company retirees, but that he will not have to pay the entire premium himself. d. It means that he qualifies for a one-time opportunity to enroll in an MA-PD or Part D prescription drug plan. Correct. Beneficiaries eligible for Part D who involuntarily lose creditable prescription drug coverage have a special election period (SEP) allowing them to enroll in a prescription drug plan or MA-PD plan. During the SEP, he has one opportunity to drop, add or change his Part D coverage. Feedback Source: Part 5, Slide – Typical SEPs – Involuntary Loss of Creditable Drug Coverage and Slide – Enrollment Periods – SEPs, Limitations 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. 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 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. d.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. 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 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. 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. b.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. 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.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. Feedback Source: Part 5, Slide – Who May Complete the Enrollment Form? Mr. Rockwell, age 67, is enrolled in Medicare Part A, but because he continues to work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special election periods (SEPs)? a. Mr. Rockwell is eligible for a SEP that begins in June and ends three months later, during which he may enroll, disenroll, and reenroll in Part D plans, with his last selection considered binding. b. Mr. Rockwell is eligible for a SEP that begins three months before the month in which he receives notice of loss of creditable coverage and ends three months after that month. c. Mr. Rockwell must wait until the next annual election period (AEP) to sign up for Part D prescription drug coverage. d. Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends on September 1- two months after the loss of creditable coverage. Correct. His eligibility for a SEP is due to his involuntary loss of creditable drug coverage. The SEP begins the month he was advised of the loss of coverage (i.e. June), and it ends 2 months after the loss of creditable coverage (i.e. September). Feedback Source: Part 5, Slide – Typical SEPs – Involuntary Loss of Creditable Drug Coverage. 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. Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? a. He will have one opportunity to enroll in a Medicare Advantage plan. Correct: During the ICEP, he is permitted to make one enrollment choice. Once the enrollment is effective, the ICEP is used. However, individuals choosing a MA plan during their ICEP have a MA-OEP following their election through the last day of the 3rd month of entitlement. b. If he has a disability, he must enroll in Original Fee-for-Service Medicare during the MA Initial Coverage Election Period. c. He may change or drop MA plans, but may not drop drug coverage. d. He will have a nine month period during which he may enroll in as many Medicare Advantage plans as he chooses, with the last enrollment being the effective one. Feedback Source: Module 5, Slide - Enrollment Periods: MA Initial Coverage Election Period (ICEP) and Slide – Enrollment Periods MAICEP, continued You are meeting with Ms. Berlin and she has completed an enrollment form for a MA-PD plan you represent. You notice that her handwriting is illegible and as a result, the spelling of her street looks incorrect. She asks you to fill in the corrected street name. What should you do? a. You may correct the information since it was a simple mistake. You do not need to do anything further to the application form. b. Under no circumstances may you make corrections to information a beneficiary has provided. Review of enrollment forms is the sole responsibility of the plan sponsor. c. You may correct this information as long as you add your initials and date next to the correction. Correct. A marketing representative may correct information on the enrollment form after verifying an individual’s information. The representative must either add his/her initials to the correction or create a separate “correction” sheet, which he/she signs and dates. d.You may correct the information, but she will need to write a brief statement indicating she authorized you to make the change. Feedback Source: Part 5, Slide – Who May Complete the Enrollment Form? Marketing Representative Participation. You have come to Mrs. Midler’s home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical records available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan. What should you do? a. You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has one of the conditions that would qualify her for a special needs plan. Correct. Marketing representatives may ask health screening questions during the completion of an enrollment request if they are necessary to determine eligibility to enroll in a SNP. b. If she brings up the topic of her health, you can ask Mrs. Midler as many questions as she is willing to answer, so you can determine which plan is most suitable for her health needs. c. You can initiate a detailed discussion of all of Mrs. Midler’s health conditions only to better understand her situation and to advise her to choose a different plan if she is experiencing significant health problems. d.You cannot, under any circumstances, ask Mrs. Midler any health-related questions. Feedback Source: Part 5, Slide - Enrollment Discrimination Prohibitions 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 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 Feedback Source: Module 4, Slide - Applicability of Medicare Marketing and Communication Rules to Marketing Representatives. 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 could be considered discriminatory activity and a prohibited practice. Correct: Marketing representatives must not engage in any activity that would be considered discriminatory 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 is not a discriminatory activity since it is based on the incomes of likely prospects and not based on race or gender. Feedback Source: Module 4, Slide - Prohibited Practices: Marketing and Communications Materials and Activities. Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her? a. 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. b. While unsolicited contacts may be made through print media such as direct mail, marketing representatives may not initiate electronic contact. 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 but an opt-out process must be provided. 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. Feedback Source: Module 4, Slide - Permitted Contracts and Slide - General Audience Marketing. 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 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. b.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. c. 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. d.You appreciate the opportunity and would ask the facility to provide enrollment applications for the MA-PD plans you represent. Feedback Source: Module 4, Slide - Marketing Activities: Marketing in a Long-term Care Facility and Slide - Marketing Activities in a Health Care Setting: Example. 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 withdrawing commissions, retraining, termination, and reporting agent termination to a state department of insurance. c. Plans do not impose penalties. Instead, the Medicare agency has specific authority to fine such individuals for each violation. 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 only ensure that the advertisement is factually accurate. b.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. c. Plans may not participate in advertising such an event. All advertising must be done by community organizations. d.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 Feedback Source: Module 4, Slide - Educational Events and Slide - Marketing and Educational Events. 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. 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. 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.The request for authorization may include a brief synopsis of non-health related content. Feedback Source: Module 4, Slide - Required Practices: Marketing & Non-Health Activities. Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. 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 enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong? a.Agent Armstrong needs to be licensed and appointed only in his state of residence. b.Agent Armstrong needs to be licensed and appointed only in the state where ABC Health Plan is headquartered. c.Agent Armstrong needs to be licensed and appointed only in the state where XYZ Agency is headquartered. 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? c. 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. d. This is a good idea. This locks Mrs. Young into a plan and protects Agent Adams’ commission. Feedback Source: Part 5, Slide – Enrollment Periods - Annual Election Period and Slide – Enrollment Periods Annual Election Period, Timeframe for Submitting Enrollment Forms Question 2 Correct Question text You have come to Mrs. Midler’s home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical records available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan. What should you do? a. If she brings up the topic of her health, you can ask Mrs. Midler as many questions as she is willing to answer, so you can determine which plan is most suitable for her health needs. b. You can initiate a detailed discussion of all of Mrs. Midler’s health conditions only to better understand her situation and to advise her to choose a different plan if she is experiencing significant health problems. c. You cannot, under any circumstances, ask Mrs. Midler any health-related questions. d. You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has one of the conditions that would qualify her for a special needs plan. Correct. Marketing representatives may ask health screening questions during the completion of an enrollment request if they are necessary to determine eligibility to enroll in a SNP. Feedback Source: Part 5, Slide - Enrollment Discrimination Prohibitions. Question 3 Correct Question text 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. 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. He must first enroll in a Medicare Part D plan, before enrolling in a Medicare Advantage plan. d. He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may only enroll in an MA-PD plan. Feedback Source: Part 5,Slide - Enrollment Periods: Part D Initial Enrollment Period (IEP). Question 6 Correct Question text 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. c. Tell her you can meet with her immediately to discuss plan options for the following plan year only. d. 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. Correct: 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. Feedback Source: Module 5, Slide – Enrollment Periods – Annual Election Period, Timeframes for Submitting Enrollment Forms, continued and Slide – Timeframes for Submitting Enrollment Forms, continued. Question 7 Correct Question text 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) Question text Mr. Rockwell, age 67, is enrolled in Medicare Part A, but because he continues to work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special election periods (SEPs)? a. Mr. Rockwell is eligible for a SEP that begins in June and ends three months later, during which he may enroll, disenroll, and reenroll in Part D plans, with his last selection considered binding. b. Mr. Rockwell must wait until the next annual election period (AEP) to sign up for Part D prescription drug coverage. c. Mr. Rockwell is eligible for a SEP that begins three months before the month in which he receives notice of loss of creditable coverage and ends three months after that month. d. Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends on September 1- two months after the loss of creditable coverage. Correct. His eligibility for a SEP is due to his involuntary loss of creditable drug coverage. The SEP begins the month he was advised of the loss of coverage (i.e. June), and it ends 2 months after the loss of creditable coverage (i.e. September). Feedback Source: Part 5, Slide – Typical SEPs – Involuntary Loss of Creditable Drug Coverage. Question 10 Correct Question text 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. 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 PD plan. c. He can enroll in a different plan or disenroll from his current plan during the next Annual Election Period. d. He can apply the subsidy amount to his existing plan immediately, but he cannot enroll in a different plan. 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. Question 14 Correct Question text 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 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. 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 send it to the plan for immediate processing, although the enrollment will not become effective until January 1. d. 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) Feedback Source: Part 5, Slide -Enrollment Periods: Annual Election Period, Timeframe for Submitting Enrollment Forms Question 15 Correct Question text Mr. Yoo’s employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a Special election period. Mr. Yoo contacted you to find out more about what this means. What can you tell him?