Understanding Medicare Coverage and Options, Exams of Nursing

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AHIP FINAL EXAM:QUESTIONS AND

ANSWERS LATEST UPDATE 2024

Mr.Davisis52yearsoldandhasrecentlybeendiagnosedwithend- stagerenaldisease(ESRD)andwillsoonbegindialysis.Heiswonderingif hecanobtaincoverageunderMedicare.Whatshouldyoutellhim? CorrectAns- Hemaysign- upforMedicareatanytimehowevercoverageusuallybeginson thefourth monthafterdialysistreatmentsstart. Juan Perez, who is turning age 65 next month, intends to work forseveralmoreyearsatSmallcap,Incorporated.Smallcaphasaworkforc eof15employeesandoffersemployer-sponsoredhealthcare coverage. Juan is a naturalized citizen and hascontributed to the Medicare system for over 20 years. Juan asks youif he will be entitled to Medicare and if he enrolls how that willimpacthisemployer- sponsoredhealthcarecoverage.Howwouldyourespond? CorrectAns- Juan is likely to be eligible for Medicareonce he turns age 65 and if he enrolls Medicare would become theprimarypayorofhishealthcareclaimsandSmallcapdoesnothaveto continue to offer him coverage comparable to those under age 65underitsemployer-sponsoredgrouphealthplan. Mr.Moy'swifehasaMedicareAdvantageplan,buthewantstoundersta ndwhatcoverageMedicareSupplementalInsuranceprovides since his health care needs are different from his wife'sneeds.Whatcouldyou tell Mr.Moy? CorrectAns- MedicareSupplementalInsurance wouldhelpcoverhisPartAandPartBdeductibles or coinsurance in Original Fee-for-Service (FFS)MedicareaswellaspossiblysomeservicesthatMedicaredoesnot cover. Mrs.Peňais66yearsold,hascoverageunderanemployerplan,and will retire next year. She heard she must enroll in Part B at thebeginningoftheyeartoensurenogapincoverage.Whatcanyoutellh er? CorrectAns- She may enroll at any time while she iscovered under her employer plan, but she will have a special eight- monthenrollmentperiodafterthelastmonthonheremployerplanthat differs from the standard general enrollment period, duringwhichshemayenrollinMedicarePartB. Mrs. Chen will be 65 soon, has been a citizen for twelve years, hasbeen employed full time, and paid taxes during that entire period.Sheisconcerned thatshewill notqualifyfor coverageunderpartAbecauseshewasnotbornintheUnitedStates.What shouldyoutellher? CorrectAns- Mostindividualswhoarecitizensandage

or over are covered under Part A by virtue of having paid Medicaretaxeswhileworking,thoughsomemaybecoveredasaresultof payingmonthlypremiums. Mrs.GonzalezisenrolledinOriginalMedicareandhasaMedigappolicy as well, but it provides no drug coverage. She would like tokeepthecoverageshehasbutreplaceherexistingMedigapplanwitho nethatprovidesdrugcoverage.Whatshouldyoutellher? CorrectAns- Mrs.GonzalezcannotpurchaseaMedigapplanthatcoversdrugs,butshe couldkeepherMedigappolicyandenrollinaPartDprescriptiondrugplan . Mrs.Westwearsglassesanddenturesandhasenjoyedconsiderablepainr elieffromarthritisthroughmassagetherapy.Sheisconcernedabout whether or not Medicare will cover these items and services.Whatshouldyoutellher? CorrectAns- Medicaredoesnot covermassagetherapy,or,ingeneral,glassesordentures. Mr.Patelisingoodhealthandispreparingabudgetinanticipationof his retirement when he turns 66. He wants to understand thehealthcare costs he might be exposed to underMedicareif he weretorequirehospitalizationasaresultofanillness.Ingeneralterms,w hat could you tell him about his costs for inpatient hospitalservices underOriginalMedicare? CorrectAns- UnderOriginalMedicare,there isasingledeductibleamount dueforthe first60days ofanyinpatient hospital stay, after which it converts into a per-daycoinsurance amount through day 90. After day 90, he would pay adaily amount up to 60 days over his lifetime, after which he wouldberesponsibleforallcosts. Ms.HendersonbelievesthatshewillqualifyforMedicareCoveragewhen sheturns65,withoutpayinganypremiums,becauseshehasbeenworkin gfor40yearsandpayingMedicaretaxes.Whatshouldyoutellher? CorrectAns- To obtain Part B coverage, she mustpayastandardmonthlypremium,thoughitishigherforindividuals withhigherincomes. Mr. Alonso receives some help paying for his two genericprescription drugs from his employer's retiree coverage, but hewantstocompareittoaPartDprescriptiondrugplan.Heasksyouwhat costs he would generally expect to encounter when enrollingintoastandardMedicarePartDprescriptiondrugplan.Whatsh ouldyoutellhim? CorrectAns- He generally would pay a monthlypremium,annualdeductible,andper-prescriptioncost- sharing. Ms.Mooreplanstoretirewhensheturns65inafewmonths.Sheisin excellent health and will have considerable income when sheretires.Sheisconcernedthatherincomewillmakeitimpossibleforhe r to qualify for Medicare. What could you tell her to address herconcern? CorrectAns- Medicareisaprogramforpeopleage65orolderandthoseunderage65wit

hcertaindisabilities,end- stagerenaldisease,andLouGehrig'sdiseasesoshewillbeeligibleforMed icare. Mr. Xi will soon turn age 65 and has come to you for advice as towhatservicesareprovidedunderOriginalMedicare.Whatshouldyou tell Mr. Xi that best describes the health coverage provided toMedicarebeneficiaries? CorrectAns- Beneficiaries under OriginalMedicarehavenocost- sharingformostpreventiveserviceswhichincludeimmunizationssucha sannualflushots. Mrs.DuarteisenrolledinOriginalMedicarePartsAandB.Shehasrecently reviewed her MedicareSummary Notice(MSN)anddisagrees with a determination that partially denied one of herclaimsforservices.Whatadvicewouldyougiveher? CorrectAns- Mrs. Duarte shouldfile an appealofthis initialdetermination within120daysofthedateshereceivedtheMSNinthemail. Mr.CapadonawouldliketopurchaseaMedicareAdvantage(MA)planand aMedigapplantopickupcostsnotcoveredbythatplan.Whatshouldyout ellhim? CorrectAns- ItisillegalforyoutosellMr.Capadonaa MedigapplanifheisenrolledinanMAplan,andbesides, Medigap only workswithOriginal Medicare. Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income.WhatcouldyoutellMrs.Parkthatmightbeofassistance? CorrectAns- SheshouldcontactherstateMedicaidagencytoseeifshequalifies foroneofseveralprogramsthatcan helpwithMedicarecostsforwhichsheisresponsible. Mr.Raineyisexperiencingparanoiddelusionsandhisphysicianfeels that he should be hospitalized. What should you tell Mr. Rainey(orhisrepresentative)aboutthelengthofaninpatientpsychiatric hospitalstaythatMedicarewillcover? CorrectAns- Medicarewill cover a total of 190 days of inpatient psychiatric care during Mr.Rainey'sentirelifetime. Mr. Schmidt would like to plan for retirement and has asked youwhat is covered under Original Fee-for-Service (FFS) Medicare? Whatcouldyoutell him? CorrectAns- Part A, which covershospital, skillednursingfacility,hospice,andhomehealthservices andPartB,whichcoversprofessionalservicessuchasthoseprovidedby adoctorarecoveredunderOriginalMedicare. AgentJohnMillerismeetingwithJerrySmith,anewprospect.Jerryis currently enrolled in Medicare Parts A and B. Jerry has alsopurchasedaMedicareSupplement(Medigap)planwhichhehashadf orseveralyears.However,theplandoesnotprovidedrugbenefits.Howw ouldyouadviseAgentJohnMillertoproceed? Correct Ans- Tell prospect Jerry Smith that he should consider adding astandalonePartDprescriptiondrugcoveragepolicytohispresentcover age.

Mr.Baueris49yearsold,buteighteenmonthsagohewasdeclareddisable dbytheSocialSecurityAdministrationandhasbeenreceiving disability payments. He is wondering whether he canobtaincoverageunderMedicare.Whatshouldyoutellhim? CorrectAns - Afterreceiving suchdisability payments for24months,hewillbeautomatically enrolledinMedicare,regardless ofage. Mr. Buck has several family members who died from differentcancers. He wants to know if Medicare covers cancer screening.Whatshouldyoutellhim? CorrectAns- Medicare covers theperiodicperformanceofarangeofscreeningteststhataremeantto provide early detection of disease. Mr. Buck will need to checkspecifictestsbeforeobtainingthem toseeiftheywillbecovered. Which of the following statement is/are correct about a MedicareSavingsAccount(MSA)Plans?

I. MSAs may have either a partial network, full network, or

nonetworkofproviders.

II. MSAplanscoverPartAandPartBbenefitsbutnotPartDprescri

ptiondrugbenefits.

III. AnindividualwhoisenrolledinanMSAplanisresponsibleforaminim

aldeductibleof$500indexedforinflation.

IV. Non-network providers must accept the same amount

thatOriginalMedicare wouldpaythem aspaymentin full. CorrectAns- I,II,andIVonly Mr.LombardiisinterestedinaMedicareAdvantage(MA)PPOplanthatyo u represent. It is oneofthree plansoperatedbythesameorganization in Mr. Lombardi's area. The MA PPO plan does notinclude drug coverage, but the other two plans do. Mr. LombardilikesthePPOplanthatdoesnotincludedrugcoverageandinte ndstoobtainhisdrugcoveragethroughastand- aloneMedicareprescription drug plan. What should youtellhimaboutthis plansthatincludeprescriptiondrugcoverageorOriginalMedicarewitha MedigapplanandstandalonePartDprescriptiondrugcoverage,butheca nnotenrollintheMA-onlyPPOplanandastand- aloneprescriptiondrugplan. Mrs.RamosisconsideringaMedicareAdvantagePPOandhasquestions aboutwhichproviders shecangotoforherhealth care.Whatshouldyoutellher? CorrectAns- Mrs.Ramoscanobtaincare from any provider who participates in Original Medicare, butgenerallywillhaveahighercost- sharingamountifsheseesaproviderwho/ thatisnotapartofthePPOnetwork. Mr. Romero is 64, retiring soon, and considering enrollment in hisemployer-

situation? CorrectAns-

HecouldenrolleitherinoneoftheMA

sponsoredretireegrouphealthplanthatincludesdrugcoveragewithno minalcopays.Heheardaboutaneighbor'sMA-PDplan that you represent and because he takes numerousprescriptiondrugs,heisconsideringsigningupforit.Whatsho uldyoutellhim? CorrectAns- Heshouldcompare thebenefitsinhisemployer-sponsored retiree group health plan with the benefits inhis neighbor's MA-PD plan to determine which one will providesufficientcoverageforhisprescriptionneeds. Dr. Elizabeth Brennan does not contract with the ABC PFFS plan butacceptstheplan'stermsandconditionsforpayment.MaryRodgersse esDr.Brennanfortreatment.HowmuchmayDr.Brennancharge? CorrectAns- Dr.BrennancanchargeMaryRogersnomorethanthecostsharingspecifi edinthePFFSplan'stermsandconditionofpayment which may include balance billing up to 15% of theMedicarerate. Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan availableinhis areahasan attractive premium. He wants toknow if hemustusedoctorsinanetworkashiscurrentHMOplanrequireshimtodo .What shouldyou tellhim? CorrectAns- He may receivehealth care services from any doctor allowed to bill Medicare, aslongasheshowsthedoctortheplan'sidentificationcardandthedoctor agreesto acceptthePFFSplan's paymenttermsandconditions,whichcouldincludebalancebilling. Mr. Wells is trying to understand the difference between OriginalMedicareandMedicare Advantage.What wouldbe the correctdescription? CorrectAns- MedicareAdvantageisawayofcoveringalltheOriginalMedicarebene fitsthroughprivatehealthinsurancecompanies.

Mrs.Chiisage75andenjoysacomfortablebutnotextremelyhigh- incomelevel.ShewishestoenrollinaMAMSAplanthatsheheardaboutfro mherneighbor.Shealsowantstohaveprescriptiondrugcoverage since her doctor recently prescribed several expensivemedications. Currently, she is enrolled in Original Medicare and astandalonePartDplan.HowwouldyouadviseMrs.Chi? CorrectAns - Mrs.Chimayenrollin aMAMSAplan andremainin hercurrentstandalonePartDprescriptiondrugplan. Daniel is a middle-income Medicare beneficiary. He has chronicbronchitis, putting him at severe risk for pneumonia. Otherwise, hehasnoproblemsfunctioning.WhichtypeofSNPislikelytobemostappr opriateforhim? CorrectAns-. C-SNP Mrs.Burtonisaretireewithsubstantialincome.Sheisenrolledinan MA- PD plan and was disappointed with the service she receivedfrom her primary care physician because she was told she wouldhavetowaitfiveweekstogetanappointmentwhenshewasfeelingi ll.Shecalledyoutoaskwhatshecoulddososhewouldnothavetoput upwithsuchpooraccesstocare.Whatcould you tellher? CorrectAns- She could file a grievance with her plan to complainaboutthelack oftimelinessingettinganappointment. Mr. Greco is in excellent health, lives in his own home, and has asizeable income from his investments. He has a friend enrolled in aMedicareAdvantageSpecialNeedsPlan(SNP).Hisfriendhasmentione dthattheSNPchargesverylowcost- sharingamountsandMr.Grecowouldliketojointhatplan.Whatshouldyo utellhim? CorrectAns- SNPslimitenrollmenttocertainsubpopulationsofbeneficiaries. Given his current situation, he is unlikely to qualifyandwouldnotbeabletoenrollintheSNP. Mrs. Radford askswhetherthereareanyspecial eligibilityrequirementsforMedicareAdvantage.Whatshouldyoutellhe r? CorrectAns- Mrs.RadfordmustbeentitledtoPartAandenrolledinPartBtoenrollinMe dicareAdvantage. Mrs.AndrewsaskedhowaPrivateFee-for- Service(PFFS)planmightaffectheraccesstoservicessinceshereceivess omeassistanceforherhealthcarecostsfromtheState.Whatshouldyoute llher? CorrectAns- Medicaid may provide additional benefits, butMedicaidwillcoordinatebenefitsonlywithMedicaidparticipating providers.

Mr.Castillo,anaturalizedcitizen,previouslyenrolledinMedicarePartB buthasrecentlystopped payinghisPart Bpremium.Mr. Castillo is still covered by Part A. He would like to enroll in aMedicareAdvantage(MA)planandisstillcoveredbyPartA.Whatshoul dyoutellhim? CorrectAns- He is not eligible to enroll in aMedicareAdvantageplanuntil here-enrollsinMedicarePartB. Mrs.DavenportenrolledintheABCMedicareAdvantage(MA)plansever al years ago. In mid-February of 2021, her doctor confirms adiagnosisofend- stagerenaldisease(ESRD).WhatoptionswillMrs.Davenporthaveregar dingherMAplanduringthenextopenenrollmentseason? CorrectAns- ShemayremaininherABCMAplan, enroll in another MA plan in her service area, or enroll in aSpecialNeedsPlan(SNP)forindividualssufferingfromESRDifoneisava ilableinherarea. Mr.KumarisconsideringaMedicareAdvantageHMOandhasquestionsab outhisabilitytoaccessproviders.Whatshouldyoutellhim? CorrectAns- InmostMedicareAdvantageHMOs,Mr.Kumarmust generallyobtainhisservicesonlyfromproviderswithintheplan's network (except in an emergency or where care is unavailablewithin the network).ur clients, Lauren Nichols, has heard about aMedica Mr.Barkerenjoysacomfortableretirementincome.Herecentlyhadsurge ryandexpectedthathewouldhavecertainservicesanditemscovered by the plan with minimal out-of-pocket costs because hisMA-PD coverage hasbeenverygood. However,when hereceivedthebill,hewassurprisedtoseelargechargesinexcessofhism aximum out-of-pocket limit that included some services and itemshe thought would be fully covered. He called you to ask what hecould do?Whatcouldyoutellhim? CorrectAns- You can offer toreviewthe plans appealprocessto helphimaskthe plan to reviewthecoveragedecision. Mr.Sinclairhasdiabetesandhearttroubleandisgenerallysatisfiedwitht hecarehehasreceivedunderOriginalMedicare,buthewouldliketoknow moreaboutMedicareAdvantageSpecialNeedsPlans(SNPs).Whatcould youtellhim? CorrectAns- SNPshavespecialprograms for enrollees with chronic conditions, like Mr. Sinclair, andthey provide prescription drug coveragethat couldbeveryhelpfulaswell. Mr. Lopez has heard that he can sign up for a product called"MedicareAdvantage"butisnotsureaboutwhattypeofplandesig nsareavailablethroughthisprogram.Whatshouldyoutell

him about the types of health plans that are available through theMedicare Advantage program?Correct Ans-They are MedicarehealthplanssuchasHMOs,PPOs,PFFS,andMSAs. Mr. Sanchez has just turned 65 and is entitled to Part A but has notenrolledinPartBbecausehehascoveragethroughanemployerplan. If hewants toenrollinaMedicareAdvantage plan,whatwillhe havetodo? CorrectAns- HewillhavetoenrollinPartB. Mr. Zachow has a condition for which three drugs are available. Hehas tried two but had an allergic reaction to them. Only the thirddrugworksforhimanditisnotonhisPartDplan'sformulary.Whatcou ldyoutellhimtodo? CorrectAns- Mr. Zachowhasaright torequest a formulary exception to obtain coverage for his Part Ddrug.Heorhisphysiciancouldobtainthestandardizedrequestformont heplan'swebsite,fillitout,andsubmitittohisplan. Mr. Bickford did not quite qualify for the extra help low- incomesubsidyundertheMedicarePartDPrescriptionDrugprograma ndhe is wonderingif there isanyotheroption hehas forobtaininghelpwithhisconsiderabledrugcosts.Whatshouldyoutell him? CorrectAns- He could check with the manufacturers of hismedications toseeif theyofferanassistance programtohelppeoplewithlimitedmeanstoobtainthemedicationsth eyneed. Alternatively, he could check to see whether his state has apharmacyassistanceprogramtohelphimwithhisexpenses. Mr. and Mrs. Vaughn both take a specialized multivitaminprescription each day. Mr. Vaughn takes a prescription for helping toregrow hishair.Theyareanxiousto have their Medicareprescriptiondrugplancoverthesedrugneeds.Whatshouldyou tellthem? CorrectAns- Medicareprescriptiondrugplansarenotpermitted to cover the prescription medications the Vaughns areinterestedinunderPartDcoverage,however,plansmaycoverthemas supplementalbenefitsandtheVaughn'scouldlookintothatpossibility. Mr. Wingate is a newly enrolled Medicare Part D beneficiary and oneofyourclients.Inadditiontodrugsonhisplan'sformularyhetakessev eral other medications. These include a prescription drug not onhis plan's formulary, over-the-counter medications for colds andallergies,vitamins,anddrugsfromanInternet- basedCanadianpharmacy to promote hair growth and reduce joint swelling. Hisneighbor recently told him about a concept called TrOOP and heasks you if any of his other medications could count toward TrOOPshould he everreach the Part Dcatastrophiclimit. What shouldyou

say? CorrectAns- None of the costs of Mr. Wingate's othermedicationswouldcurrentlycounttowardTrOOPbuthemaywishto ask his plan for an exception to cover the prescription not on itsformulary. Ms.EdwardsisenrolledinaMedicareAdvantageplanthatincludespresc riptiondrugplan(PDP)coverage.Sheistravelingandwishesto fill two of the prescriptions that she has lost. How would youadviseher? CorrectAns- She may fill prescriptions for covereddrugsatnon- networkpharmacies,butlikelyatahighercostthanpaidatanin- networkpharmacy. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. Shehasrecentlylostcreditablecoveragepreviouslyavailablethroughh erhusband'semployer.SheisinterestedinenrollinginaMedicarePartDp rescriptiondrugplan(PDP).Whatshouldyoutellher? CorrectAns- If a Part D benefit is offered through her plan shemaychoosetoenrollinthatplanorastandalonePDP. Mrs. Allen has a rare condition for which two different brand namedrugsaretheonlyavailabletreatment.Sheisconcernedthatsincen ogenericprescriptiondrugisavailableandthesedrugsareveryhighcost, shewillnotbeableto find a MedicarePartDprescriptiondrug plan that covers either one of them. What should you tell her?CorrectAns- Medicareprescriptiondrugplansare required tocover drugs in each therapeutic category. She should be able toenroll in a Medicare prescription drug plan that covers themedicationssheneeds. Mrs. Quinn has just turned 65, is in excellent health and has arelativelyhighincome.Sheusesnomedicationsandseesnoreasontosp endmoneyonaMedicareprescriptiondrugplanifshedoesnot need the coverage. She currently does not have creditablecoverage. What could you tell her about the implications of such adecision? CorrectAns- IfshedoesnotsignupforaMedicareprescriptiondrugplanassoonasshei seligibletodoso,andifshedoes sign up at a later date, her premium will be permanentlyincreasedby1%ofthenationalaveragepremiumforevery monththatshewasnotcovered. Mr.ShultzwasstillworkingwhenhefirstqualifiedforMedicare.Atthatti me,hehademployergroup coverage thatwascreditable. During his initial Part D eligibility period, he decided not to enrollbecausehewassatisfiedwithhisdrugcoverage.Itisnowayearlater andMr.Shultzhaslosthisemployergroupcoveragewithinthelasttwowe eks.Howwouldyouadvisehim? CorrectAns- Mr.

SchultzshouldenrollinaPartD planbeforehe hasa63- daybreakincoverageinordertoavoidapremiumpenalty. Mrs. Mulcahy, age 65, is concerned that she may not qualify forenrollmentinaMedicareprescriptiondrugplanbecause,althoughsh e is entitled to Part A, she is not enrolled under Medicare Part B.Whatshouldyoutellher? CorrectAns- An individual who isentitled to Part A or enrolled under Part B is eligible to enroll in aMedicareprescriptiondrugplan.AslongasMrs.Mulcahyisentitledto Part A, she does not need to enroll under Part B before enrollinginaprescriptiondrugplan. WhattypesoftoolscanMedicarePartDprescriptiondrugplansusethata ffecttheway their enrolleescanaccessmedications? CorrectAns - PartDplansdonothavetocoverallmedications.Asaresult, their formularies, or lists of covered drugs, will vary fromplan to plan. In addition, they can use cost containment techniquessuchastieredco- paymentsandpriorauthorization. AllplansmustcoveratleastthestandardPartDcoverageoritsactuarial equivalent. Which of the following statements bestdescribes some of the costs a beneficiary would incur forprescriptiondrugsunderthestandardcoverage? CorrectAns- StandardPartDcoveragewouldrequire paymentofanannualdeductible, andoncepastthe catastrophiccoverage threshold,thebeneficiary pays whichever is greater of either the co-pays forgeneric and brand namedrugsor coinsuranceof5%. Mr. Jacob understands that there is a standard Medicare Part Dprescription drug benefit, but when he looks at information onvariousplansavailableinhisarea,heseesawiderangeinwhattheychar gefordeductibles,premiums,andcostsharing.Howcanyou explain this to him? CorrectAns- MedicarePartDdrugplansmay have different benefit structures, but on average, they must allbeatleastasgoodasthestandardmodelestablishedbythegovernmen t. Mr.CarlinihasheardthatMedicareprescriptiondrugplansareonlyoffer edthrough private companies underaprogramknown asMedicareAdvantage(MA),notbythegovernment.HelikesOriginalMe dicareanddoesnotwanttosignupforanMAproduct,buthealsowantspre scriptiondrugcoverage.Whatshouldyoutellhim? CorrectAns- Mr. Carlinican staywithOriginal Medicare andalsoenroll in a Medicare prescription drug plan through a privatecompanythat hascontractedwith the governmenttoprovide onlysuchdrug coveragetoeligibleMedicarebeneficiaries.

Which of the following individuals is most likely to be eligible toenrollin aPart DPlan? CorrectAns- Jose, a grandfather who wasgrantedasylumandhasworkedintheUnitedStatesformanyyears. Mr.Hutchinsonhasdrugcoveragethroughhisformeremployer'sretireep lan.HeisconcernedaboutthePartDpremiumpenaltyifhedoes not enrollinaMedicare prescriptiondrugplan,but doesnotwant to purchase extra coverage that he will not need. What shouldyoutellhim? CorrectAns- Ifthedrugcoveragehehasisnotexpectedtopay,onaverage,atleastasmu chasMedicare'sstandard Part D coverage expects to pay, then he will need to enrollinMedicarePartDduringhisinitialeligibilityperiodtoavoidthelate enrollmentpenalty. Mrs.McIntireisenrolledinherstate'sMedicaidplanandhasjustbecome eligible for Medicare as well. What can she expect willhappentoherdrugcoverage? CorrectAns- UnlessshechoosesaMedicare Part D prescription drug plan on her own, she will beautomaticallyenrolledinoneavailableinherarea. Mrs.BerkowitzwantstoenrollinaMedicareAdvantageplanthatdoesnoti ncludedrugcoverageandalsoenrollinastand- aloneMedicareprescriptiondrugplan.Underwhatcircumstancescansh edothis? CorrectAns- IftheMedicareAdvantageplanisaPrivateFee-for-Service (PFFS)plan thatdoes not offerdrugcoverageoraMedical SavingsAccountplan, Mrs.Berkowitz candothis. WhichofthefollowingstatementsaboutMedicarePartDarecorrect?

I. PartDplansmustenrollanyeligiblebeneficiarywhoappliesregar

dlessofhealthstatusexceptinlimitedcircumstances.

II. Private fee-for-service(PFFS)plansarenot

requiredtouseapharmacynetworkbutmaychoosetohaveone.

III. BeneficiariesenrolledinaMA-

MedicalSavingsAccount(MSA)planmayonlyobtainPartDbenefitsthro ughastandalonePDP.IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefitsthroughastandalonePDPorthroughtheirplan. CorrectAns- I,II,andIIIonly Mr. Torres has a small savings account. He would like to pay for hismonthly Part D premiums with an automatic monthly withdrawalfromhissavingsaccountuntilitisexhausted,andthenhavehi spremiumswithheldfromhis SocialSecuritycheck.Whatshouldyoutellhim? CorrectAns- Ingeneral,hemustselectasinglePartDpremiumpaymentmechanismth atwillbeusedthroughouttheyear.

You will be holding a sales event soon, at which you would like tooffer door prizes to attendees. Under guidelines from the Medicareagency, what types of gifts or prizes would not be allowed in thissituation? CorrectAns- Gift cards or gift certificates of $15 orlessthatcanbereadilyconvertedtocash. Anotheragentworkingforyouragencyclaimsthatbecauseyouarenote mployedbytheMedicareAdvantageplansthatyourepresent,you are not subject to the same marketing requirements as theplansthemselves.Howshouldyourespondtosuchastatement? CorrectAns- Your coworker is not correct. Marketing on behalf ofaplan isconsideredmarketingbytheplanandrequiresthatallcontractedande mployedagentscomplywithallMedicaremarketingrules. Mrs. Lu isturning65in November andcalled to ask foryourhelpdecidingonaMedicareAdvantageplan.Sheagreedtosigna scopeof appointment form and meet with you on October 15. During theappointment,whatare youpermittedtodo? CorrectAns- Youmay provide her with the required enrollment materials and takehercompletedenrollmentapplication. Oneofyourcolleaguesarguesthatitisbettertofocusyourtimeandenerg yexclusivelyinneighborhoodswithsingle-familyhomes.He further argues that their older owners are more likely to havehigherincomesandpurchasetheMedicareAdvantageproductsyou represent compared to those living in apartment complexes. Howshouldyourespond? CorrectAns- This could be considereddiscriminatoryactivityandaprohibitedpractice. A Medicare beneficiary has walked into your office and requestedthat you sit down with her and discuss her options under theMedicareAdvantageprogram.Beforeengaginginsuchadiscussion, whatshouldyoudo? CorrectAns- Youmusthavehersignascopeofappointmentform,indicatingwhichprod uctsshewishestodiscuss.Youmaythenproceedwiththediscussion. Yourfriend'smotherjustmovedtoanassistedlivingfacilityandheaskedi fyoucouldpresentaprogramfortheresidentsabouttheMA- PDplansyoumarket.Whatcouldyoutellhim? CorrectAns- You appreciate the opportunity and would be happy to schedule anappointmentwithanyoneattheirrequest. MelissaMeadowsisamarketingrepresentativeforBestCarewhichhasre centlyintroduceda Medicare Advantageplan offering

comprehensive dental benefits for $15 per month. Best Care has notsubmittedanypotentialpoststoCMSforapproval.Melissawouldliket ousethepowerofsocialmediatoreachpotentialprospects. Whatadvicewouldyougiveher? CorrectAns- As soon as CMSapprovesBestCare'ssocialmediaposts,AgentMeadowscouldpo sta tweet stating that "Best Care offers an array of MedicareAdvantagebenefitpackages.Onemightberightforyou.Callm etofindoutmore!" AgentJenningsmakesapresentationonMedicareadvertisedasaneduc ationalevent.AgentJenningsdistributesmaterialsthataresolely educational. However, she gives a brief presentation thatmentionsplan- specificpremiums.Isthisaprohibitedactivityataneventthathasbeenad vertisedaseducational? CorrectAns- Yes.When an event has been advertised as "educational," discussingplan- specificpremiumsisimpermissible. AgentMartinezwishestosolicitMedicareAdvantageprospectsthroug h e- mailandasksyouforadviceastowhetherthisispossible.Whatshouldy outellher? CorrectAns- Marketingrepresentatives may initiate electronic contact through e-mail butanopt- outprocessmustbeprovided. MiguelSanchezisarelativelynewagentwhohascometoyouforadviceast owhathecandoduringtheMedicareAdvantageOpenEnrollmentPeriod( MA-OEP).WhatadviceshouldyougiveMiguel? CorrectAns- During the MA-OEP, Miguel can have one-on- onemeetings withbeneficiaries who haverequestedsuchmeetings. ABCisaMedicareAdvantage(MA)plansponsor.Itwouldliketouseits enrollees'information to marketnon-health relatedproductssuchaslifeinsuranceandannuities.Whichstatementbe stdescribesABC'sobligationtoitsenrolleesregardingmarketingsuchpr oducts? CorrectAns- It must obtain a HIPAA complaintauthorization from an enrollee that indicates the plan or plansponsormay usetheirinformationformarketing purposes. Youhaveapproachedahospitaladministratoraboutmarketinginher facility. The administrator is uncomfortable with the suggestion.Howcouldyouaddressherconcerns? CorrectAns- Tell her thatMedicareguidelines allowyou toconduct marketing activities incommonareasofaprovider'sfacility. Duringasalespresentation, yourclientasks you whethertheMedicareagencyrecommendsthatshesignupforyourplano rstayinOriginalMedicare.Whatshouldyoutellher? CorrectAns- Tell

herthattheMedicareagencydoesnotendorseorrecommendanyplan. Agent Armstrong is employed by XYZ Agency, which is undercontractwithABCHealthPlan,aMedicareAdvantage(MA)planthat offers plans in multiple states. XYZ Agency maintains a websitemarketing the MA plans with which it has contracts. AgentArmstrongfollowsupwithindividualswhorequestmoreinformati onabout ABC MA plans via the website and tries to persuade them toenroll in ABC plans. What statement best describes the marketingandcompliancerulesthatapplytoAgentArmstrong? CorrectAns

AgentArmstrongneedstobelicensedandappointedineverystateinwh ichbeneficiariestowhomhemarketsABCMAplansarelocated. You havebeenprovidinga pre- Thanksgivingmealduringsalespresentations in November for many years and your clients lookforwardtoattendingthisannualevent.WhenmarketingMedicareAd vantage and Part D plans, what are you permitted to do withrespecttomeals? CorrectAns- Youmayprovidelightsnacks,buta Thanksgiving style meal would be prohibited, regardless of whoprovidesorpaysforthemeal. Nextweek youwill beparticipating inyourfirst"educational event"for prospective enrollees. To be sure that you do not violate any ofthe applicable guidelines, in what activities should you plan toengage? CorrectAns- You should plan to ensure that theeducational event is aninformative event andmust not conductasalespresentationordistribute oraccept enrollmentformsat theevent. You are workingseveralplans andcommunityorganizationstosponsoraneducationalevent.Whenputt ingtogetheradvertisementsforthisevent,whatshouldyoudo? CorrectAns- You mustensurethatthe advertisementsindicate it isaneducational event, otherwise it will be considered a marketingevent. Anotheragentyouknowhasengagedinmisconductthathasbeenverified bythe plan sherepresented.Whatsortof penaltymighttheplanimposeonthisindividual? CorrectAns- The plan maywithhold commission, require retraining, report the misconduct to astatedepartmentofinsuranceorterminatethecontract. YouareseekingtorepresentanindividualMedicareAdvantageplananda nindividualPartDplaninyourstate.Youhavecompletedthe

requiredtrainingforeachplan,butyoudidnotachieveapassingscoreont he tests thatcame afterthetraining.What can youdo inthissituation? CorrectAns- You will not be able to represent anyMedicareAdvantageorPartDplanuntilyoucompletethetrainingand achieveanadequatescore.However,youwillnothavetotakeatest if you exclusively market employer/union group plans and thecompaniesdonotrequiretesting. Plansponsorsmayundertakethefollowingmarketingactivitieswithcurr entMedicareAdvantageplanmembers? CorrectAns- Marketnon-health related items or services such as life insurance orannuities policiesto currentmembersas permittedfollowingHIPAAPrivacyRules. Mr. Rockwell, age 67, is enrolled in Medicare Part A, but because hecontinues to work and is covered by an employer health plan, he hasnot enrolled in Part B or Part D. He receives a notice on June 1 thathisemployeriscuttingbackonprescriptiondrugbenefitsandthataso fJuly1hiscoveragewillnolongerbecreditable.Hehascometoyou for advice. What advice would you give Mr. Rockwell aboutspecialelectionperiods(SEPs)? CorrectAns- Mr. Rockwell iseligible foraSEPduetohisinvoluntarylossofcreditabledrugcoverage; the SEP begins in June and ends on September 1- twomonthsafterthelossofcreditablecoverage. Mrs.YoungiscurrentlyenrolledinOriginalMedicare(PartsAandB),butsh ehasbeenworkingwithAgentNeilAdamsintheselectionofaMedicareAd vantage(MA)plan.Itismid-September,andMrs. Young is going on vacation. Agent Adams is considering suggestingthatheandMrs.Youngcompletetheapplicationtogetherbef oreshe leaves. He will then submit the paper application before thestartoftheannualenrollment period (AEP).Whatwould you sayIfyouwereadvisingAgentAdams? CorrectAns- Thisisabadidea.Agents are generally prohibited from soliciting or accepting anenrollmentformbeforethestartoftheAEP. Mr. Block is currently enrolled in a Medicare Advantage plan thatincludes drug coverage. He found a stand-alone Medicareprescriptiondrugplanin his areathat offersbettercoveragethanthatavailablethroughhisMA- PDplanandinaddition,hasalowpremium. It won't cost him much more and, because he has themeans to doso,hewishestoenrollin the stand-aloneprescriptiondrugplaninadditiontohisMA- PDplan.Whatshouldyoutellhim? CorrectAns- If Mr. Block enrolls in the stand-alone Medicareprescription drug plan, he will be disenrolled from the MedicareAdvantageplan.

Mrs.ReevesisnewlyeligibletoenrollinaMedicareAdvantageplanandhe rMAInitialCoverageElectionPeriod(ICEP)hasjustbegun. WhichofthefollowingcanshenotdoduringtheICEP? CorrectAns

ShecanenrollinaMedigapplantosupplementthebenefitsoftheMApl anthatshe'salsoenrollingin. Mr.JohannsenisentitledtoMedicarePartAandPartB.HegainsthePart D low-income subsidy. How does that affect his ability to enrollordisenrollinaPartDplan? CorrectAns-He qualifies for aspecial election period and can enroll in or disenroll from a Part Dplanonceduringthatperiod. Mr.Yoo'semployerhasrecentlydroppedcomprehensivecreditablepres criptiondrug coveragethat wasoffered tocompanyretirees. The company told Mr. Yoo that, because he was affected by thischange, he would qualify for a Special election period. Mr. Yoocontacted you to find out more about what this means. What canyoutellhim? CorrectAns- It means thathe qualifies foraone-timeopportunitytoenrollinanMA- PDorPartDprescriptiondrugplan. Mrs.Schmidtismovingandafriendtoldhershemightqualifyfora"Specia lelectionperiod"toenrollina newMedicareAdvantageplan.Shecontactedyoutoaskwhat aspecial election periodis. Whatcouldyoutellher? CorrectAns- Itisaperiod,outsideoftheAnnualElectionPeriod,whenaMedicarebenefi ciarycanselectanewordifferentMedicareAdvantageand/ orPartDprescriptiondrugplan.TypicallytheSpecialelectionperiodisben eficiaryspecificandresultsfromevents,suchaswhenthebeneficiarymov esoutsideoftheservicearea. Mrs.MargoliscontactsyouinAugustbecauseshewillbecomeeligible for Medicare for the first time in November. She would liketomeetanddiscussplanchoiceswithyou.Whatadviceshouldyougiv eher? CorrectAns- Tell her to wait until October to discussplan choices with you so that you can share plan benefits for thecurrentyearaswellasanychangesforthefollowingyearthatmayimp actherchoice. Mr. Chen is enrolled in his employer's group health plan and will beretiring soon. He would like to know his options since he hasdecidedtodrophisretireecoverage and iseligibleforMedicare. Whatshouldyoutellhim? CorrectAns- Mr.Chencandisenrollfrom his employer-sponsored coverage to elect a MedicareAdvantageorPartDplanwithin2monthsofhisdisenrollmen t.

Mrs. Kumar would like her daughter, who lives in another state, tomeet with you during the Annual Election Period to help hercomplete her enrollment in a Part D plan. She asked you when sheshouldhaveherdaughterplantovisit.Whatcouldyoutellher? CorrectAns- HerdaughtershouldcomeinNovember. Mr. Roberts is enrolled in an MA plan. He recently sufferedcomplicationsfollowinghipreplacementsurgery.Asa result,hehasspentthe lastthreemonthsinResthaven,askillednursingfacility.Mr.Robertsisab outtobedischarged.Whatadvicewouldyougivehimregardinghishealth coverageoptions? CorrectAns- Hisopen enrollment period as an institutionalized individual willcontinue for two months after the month he moves out of thefacility. 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 receivingassistance fromMedicaid.He wantstofindadifferentPart D planthat's more suitable to his current prescription drug needs. Hebelieveshe'sentitledtoaSEPsinceheisnowadualeligible.Isheable to change to a different Part D plan during a SEP for dualeligibleindividuals? CorrectAns- No.Onceheisidentifiedbytheplansponsorasa"potentialat- risk"beneficiary,hecannotusethedualeligibleSEPtochangeplanswhil ethisdesignationisinplace. Mr.Ziegleristurning65nextmonthandhasaskedyouwhathecando, and when he must do it, with respect to enrolling in Part D.Whatcouldyoutell him? CorrectAns- He is currently in the PartD Initial EnrollmentPeriod (IEP)and, duringthistime, hemay makeone Part D enrollment choice, including enrollment in a stand- alonePartDplanoranMA-PDplan. A client wants to give you an enrollment application on October 1before the beginning of the Annual Election Period because he isleavingonvacationfortwoweeksanddoesnotwanttoforgetabout turningitin.Whatshouldyoutellhim? CorrectAns- Youmusttellhimyouarenotpermittedtotaketheform.Ifhesendstheform directlytotheplan,theplanwillprocesstheenrollmentonthedaytheAnnu alElectionPeriodbegins. Mr. Garrett has just entered his MA Initial Coverage Election Period(ICEP).Whatactioncouldyouhelphimtakeduringthistime? CorrectAns- HewillhaveoneopportunitytoenrollinaMedicareAdvantageplan.

You are meeting with Ms. Berlin and she has completed anenrollmentformforaMA- PDplanyourepresent.Younoticethatherhandwritingisillegibleandasa result,thespellingofherstreetlooksincorrect.Sheasksyoutofillinthecor rectedstreetname. Whatshouldyoudo? CorrectAns- You may correct thisinformationaslongasyouaddyourinitialsanddatenexttothecor rection. YouhavecometoMrs.Midler'shomeforasalespresentation.Atthebegin ningofthepresentation,Mrs.Midlertellsyouthatshehasacopyofhermed icalrecordsavailablebecause shethinks this willhelpyouunderstandherneeds.Shesuggeststhatyouwillknowwhich questionstoaskheraboutherhealthstatusinordertobestassistherinsel ectingaplan.Whatshouldyoudo? CorrectAns- YoucanonlyaskMrs.Midlerquestionsaboutconditionsthataffecteligibil ity, specifically, whether she has one of the conditions thatwouldqualifyherforaspecialneedsplan. Mr. and Mrs. Nunez attended one of your sales presentations.They've asked you to come to their home to clear up a fewquestions.Duringthepresentation,Mrs.Nunezfeelstiredandtellsy outhatherhusbandcanfinishthingsup.Shegoestobed.Attheend ofyourdiscussion,Mr.Nunez saysthathe wantsto enrollbothhimselfandhiswife.Whatshouldyoudo? CorrectAns- Aslongasshecan doso,only Mrs. Nunez can signherenrollmentform. Mrs.Nunezwillhave to wake upto sign herformordoso at anothertime. When Myra first became eligible for Medicare, she enrolled inOriginalMedicare(PartsAandB).Sheisnow67andwillturn68onJuly 1. She would now like to enroll in a Medicare Advantage (MA)planandapproachesyouaboutheroptions.Whatadvicewouldyoug iveher? CorrectAns- SheshouldremaininOriginalMedicareuntil the annual election period running from October 15 toDecember7,duringwhichshecanselectanMAplan. Mr.Wendtsuffersfromdiabeteswhichhasgottenprogressivelyworse during the last year. He is currently enrolled in OriginalMedicare(PartsAandB)andaPartDprescriptiondrugplanand didnotenrollinaMedicareAdvantage(MA)planduringthelastannualo pen enrollment period (AEP) which has just closed. Mr. Wendt hasheard certain MA plans might provide him with more specializedcoverage for his diabetes and wants to know if he must wait untilthe next annual open enrollment period (AEP) before enrolling insuchaplan.Whatshouldyoutellhim? CorrectAns- Ifthereisa

specialneedsplan(SNP)inMr.Wendt'sareathatspecializesincaringfori ndividualswithdiabetes,hemayenrollintheSNPatanytimeunderaspeci alelectionperiod(SEP) Since2004Ms.EisenberghashadaMedigapplanthatprovidessome drug coverage. She has recently received a letter from herMedigap carrierinformingherthat herdrugcoverage isnot"creditable."Shewantstoknowwhatthismeans.Whatshouldyoutel lher? CorrectAns- The letter is to inform her that the drugcoverageofferedthroughherMedigapplandoesnotofferdrugcover age thatis atleast comparable tothat providedundertheMedicarePartDprescriptiondrugprogram.Ifshedoes nothavesuchcreditablecoverageduringperiodswhensheisfirsteligiblef orthe Part D program, she will face a premium penalty if she enrolls inaPartDplanatalaterdate. Mr. Cole has been a Medicaid beneficiary for some time, andrecently qualified for Medicare as well. He is concerned aboutchangesinhiscost-sharing.Whatshouldyoutellhim? CorrectAns

HeshouldknowthatMedicaidwillpaycostsharingonlyforservices providedbyMedicaidparticipatingproviders. Mrs. Wu was primarily a homemaker and employed in jobs thatprovided taxable income only sporadically. Her husband worked full-time throughout his long career. She has heard that to qualify forMedicarePartAshehastohaveworkedandpaidMedicaretaxesforasu fficienttime.Whatshouldyoutellher? CorrectAns- SinceherhusbandpaidMedicare taxesduringthe entire time hewasworking, she will automatically qualify for Medicare Part A withouthavingtopayanypremiums. A Medicare beneficiary has walked into your office and requestedthat you sit down with her and discuss her options under theMedicareAdvantageprogram.Beforeengaginginsuchadiscussion, whatshouldyoudo? CorrectAns- Youmusthavehersignascopeofappointmentform,indicatingwhichprod uctsshewishestodiscuss.Youmaythenproceedwiththediscussion. Mr. Perry is entitled to Medicare Part A but has not yet enrolled inPart B, even though he is 69 years old. He would like to enroll in aMedicarePartD prescription drugplan but isconcernedthathe willhave to sign up for Part B as well in order to qualify for enrollmentina Part Dplan.Whatshouldyoutellhim? CorrectAns- Hedoesnot have to enroll in Part B but, must pay a penalty for his failure todo so when he first turned 65. After that, he can enroll in a Part Dprescriptiondrugplan.

Mr.NguyenunderstandsthatMedicareprescriptiondrugplanscanuseaf ormularyorlistofcovereddrugs.Heissuspiciousabouthowplansestabli shtheseformularies.Whatshouldyoutellhim? CorrectAns- Formularies must be developed with input frompharmacists,doctors,andotherexperts. ACASection1557rulesfordisabilityconcern CorrectAns- Policiesandprocedures,physicalaccess,andcommunication. Under ACA Section 1557, a health plan premium sold through astateexchangemay,basedonanindividual'sage, CorrectAns- chargehigherpremiums. WhichofthefollowingstatementsbestdescribesSection1557oftheAff ordableCareAct(ACA)? CorrectAns- Section 1557incorporatesearliercivilrightsprotectionsinregardtorace,color, nationalorigin,disability,ageandsex. WhichMedicareprogramsarecoveredbyACASection1557? CorrectAns- PartsA,C,andD,butnotB. AsaresultofviolationsofACASection1557nondiscriminationrules , CorrectAns- a healthplan may revoke an agentorbroker'sappointmentwiththehealthplan. Whichofthefollowingstatements bestdescribesthescopeofoperationssubjecttoSection1557underthe 020FinalRule? CorrectAns- Health insurers under the 2020 Final Rule are notconsideredtobeprincipallyengagedindeliveringhealthcare,andth uslinesofbusinessthatdonotreceive federal funding oradministeredunderTitleIoftheACA,suchaslifeinsurance,donotfallu nderthescopeof1557. Section1557oftheAffordableCareActappliesto CorrectAns- allhealthprogramsandactivitiesadministeredbyorreceivingfederalfi nancialassistancefromHHS UnderSection1557,2020FinalRuleissuedduringtheTrump

Administration sexwas initiallydefined Correct Ans-

asbiologicsexonly,meaningwhetherapersonwasdetermi

bemaleorfemaleatbirth. Which of the following would be considered permissible underSection1557andthe2020FinalRule? CorrectAns- BrokerMaryJoneshasrecruiteda diverse workforce. She encouragesher agents

toprospectthroughcommunity- basedmarketingandwithintheircommunityofinfluence. Auxiliaryaidsandservicesmustbeprovidedtoindividualswithdisabiliti es,suchas thosesufferingfromvision orhearingimpairments,freeofcharge,andinatimelymanner.Auxiliary aidsandservicesincludewhichofthefollowing:

I. largeprintmaterials

II. qualifiedsignlanguageinterpretersII

I.braillematerialsanddisplays IV.screenreadersoftware CorrectAns- I,II,III,andIV Which entity enforces Section 1557 for programs that receivefundingfromonareadministeredbyHHS? CorrectAns- TheOfficeofCivilRights(OCR)ofHHS. Whichof theseactions ismostlikely tobe permittedin dealing witha personwithlimited Englishproficiency? CorrectAns- Allowingachildtointerpretinanemergency. UnderACASection1557,ahealthplan CorrectAns- cannot denycoveragetoLEPindividualsandisrequiredtoprovidelanguageassi stancetothem,freeofcharge. For a health plan, what are the possible consequences of violationsof ACA Section 1557?Correct Ans-Loss of federal business andcompensatorydamages. Which of the following is NOT potentially a penalty for violation of alaw orregulationprohibitingfraud, waste,and abuse(FWA)? CorrectAns- Deportation Which of the following requires intent to obtain payment and theknowledgetheactionsarewrong? CorrectAns- Fraud Youareperforminga regularinventoryofthecontrolledsubstancesin the pharmacy. You discover a minor inventory discrepancy. Whatshouldyoudo? CorrectAns- Followyourpharmacy's procedures YourjobistosubmitariskdiagnosistotheCentersforMedicare&Medicaid Services(CMS)forthepurposeofpayment.Aspartofthisjob,youuseapro cesstoverifythedataisaccurate.Yourimmediatesupervisortellsyoutoig noretheSponsor'sprocessandtoadjustoraddriskdiagnosiscodesforcer tainindividuals.Whatshouldyoudo? CorrectAns- Report the incident to the compliancedepartment(viacompliancehotlineorothermechanism)

You are in charge of paying claims submitted by providers. Younoticeacertaindiagnosticprovider("DoeDiagnostics")requestedas ubstantialpaymentforalargenumberofmembers.Manyoftheseclaims are for a certain procedure. You review the same type ofprocedureforotherdiagnosticprovidersandrealizeDoeDiagnostics'cl aimsfarexceed anyother provider youreviewed. Whatshouldyoudo? CorrectAns- Consult with your immediatesupervisorfornextstepsorcontactthecompliancedepartme nt(viacompliance hotline, Special Investigations Unit [SIU], or othermechanism) Apersondropsoffaprescriptionforabeneficiarywhoisa"regular"custom er. The prescription is for a controlled substance with aquantity of

160. This beneficiary normally receives a quantity of 60,not 160. You review the prescription and have concerns aboutpossibleforgery.Whatisyournextstep? CorrectAns- Call theprescribertoverifythequantity Waste includes any misuse of resources, such as the overuse ofservices or other practices that directly or indirectly result inunnecessarycoststotheMedicareProgram. CorrectAns- True Bribesorkickbacksofanykindforservicesthat arepaid underaFederal health care program (which includes Medicare) constitutefraudbythepersonmakingaswellasthepersonreceivingthe m. CorrectAns- True These areexamplesofissuesthatshould bereportedtoaComplianceDepartment:suspectedfraud,waste,andab use(FWA);potentialhealthprivacyviolation,unethicalbehavior,andem ployeemisconduct. CorrectAns- True Abuseinvolvespaymentforitemsorserviceswhenthereisnolegalentitle mentto that paymentandthe providerhasnot knowinglyorintentionallymisrepresentedfacts to obtainpayment. CorrectAns

• True Ways to report potential fraud, waste, and abuse (FWA) include:a.Maildrops b.SpecialInvestigativeUnits(SIUs)c .Tekephonehotlines d.Alloftheabove e.In-personreportingto thecompliancedepartment/supervisor CorrectAns- Alloftheabove

Onceacorrectiveactionplanisstarted,thecorrectiveactionplanmust be monitored annually to ensure they are effective.CorrectAns- False Whataresomeofthepenaltiesforviolatingfraud,waste,andabuse(FW A)laws? a.CivilMonetaryPenalties b.Imprisonment c.Alloftheabove d.Exclusionfrom participationinallFederalhealthcareprograms CorrectAns- Alloftheabove AnypersonwhoknowinglysubmitsfalseclaimstotheGovernmentisliab leforfivetimestheGovernment'sdamagescausedbytheviolatorplusap enalty. CorrectAns- False SomeofthelawsgoverningMedicarePartCandDfraud,waste,andabuse (FWA) include the Health Insurance Portability andAccountability Act (HIPAA), the False Claims Act the Anti-KickbackStatute, and theHealthCareFraudStatute. CorrectAns- False You can help prevent fraud, waste, and abuse (FWA) by doing all thefollowing: Lookforsuspiciousactivity Conduct yourself in an ethical mannerEnsureaccurateandtimelydataandbill ingEnsureyoucoordinatewithotherpayers Keep up todatewithFWApoliciesand procedures, standardsofconduct,laws,regulations,andtheCentersforMedicare&M edicaidServices(CMS)guidance Verifyallinformationprovidedtoyou CorrectAns- True Youareperforminga regularinventoryofthecontrolledsubstancesin the pharmacy. You discover a minor inventory discrepancy. Whatshouldyoudo? CorrectAns- Followyourpharmacy's procedures You work for a Sponsor. Last month, while reviewing a Centers forMedicare&MedicaidServices(CMS)monthlyreport,youidentifiedm ultiple individuals not enrolled in the plan but for whom theSponsorispaid.Youspoketoyoursupervisorwhosaiddon'tworryab out it. This month, you identify the same enrollees on the reportagain.Whatshouldyoudo? CorrectAns- Although youknowaboutthe Sponsor's non-retaliationpolicy, you are stillnervousaboutreporting— tobesafe,yousubmitareportthroughyourcompliance department'sanonymoustipline toavoididentification

You discover an unattended email address or fax machine in youroffice receiving beneficiary appeals requests. You suspect no one isprocessingtheappeals.Whatshouldyoudo? CorrectAns- Contact your compliance department (via compliance hotline orothermechanism) Asalesagent,employedbytheSponsor'sfirst- tier,downstream,orrelatedentity(FDR),submittedanapplicationforpr ocessingandrequested two things: 1) to back-date the enrollment date by onemonth,and2)towaiveallmonthlypremiumsforthebeneficiary. Whatshouldyoudo? CorrectAns- Process the applicationproperly(withouttherequestedrevisions)— informyoursupervisorandthecomplianceofficeraboutthesalesagent' srequest Waystoreportacomplianceissueinclude: a.In-person reportingto the compliancedepartment/supervisorb.ReportontheSponsor'swebsite c.Telephonehotlines d.Alloftheabove CorrectAns- Alloftheabove Compliance is the responsibility of the Compliance Officer,ComplianceCommittee,andUpperManagementonly. CorrectAns

• False Whatis thepolicyofnon-retaliation? CorrectAns- Protectsemployees,whoingoodfaithreportsuspectednon- compliance MedicarePartsCandDsponsorsarenotrequiredtohaveacompli anceprogram. CorrectAns- False Ataminimum,aneffectivecomplianceprogramincludesfourcorerequi rements. CorrectAns- False Correctingnon-compliance CorrectAns- Protectsenrollees, avoids recurrence of same non-compliance, and promotesefficiency TheseareexamplesofissuesthatcanbereportedtoaComplianceDepar tment:suspectedfraud,waste,andabuse(FWA),potentialhealth privacy violation, and unethical behavior/employeemisconduct. CorrectAns- True Once a corrective action plan begins addressing non-compliance forfraud, waste, and abuse (FWA) committed by a Sponsor's employeeorfirst- tier,downstream,orrelatedentity's(FDR's)employee,

ongoingmonitoringofthecorrectiveactionsisnotnecessary. CorrectAns- False StandardsofConductarethesameforeveryMedicarePartsCandDsponso r. CorrectAns- False Whataresomeoftheconsequencesfornon- compliance,fraudulent,orunethicalbehavior? a.Exclusion fromparticipatingkinallFederalhealth careprogramsb.Terminationofemployment c.Disciplinaryaction d.Alloftheabove CorrectAns- Alloftheabove Ms.LeviisconsideringenrollmentinaMedicareAdvantageHMOplan offered in her area. Ms. Levi often travels to visit relatives andisconcernedthatshemayneedemergencycareoutsideofherplan'sse rvicearea. What shouldyoutellherabout coverage ofemergencycare? CorrectAns- Plansarerequiredtocoverout-of- networkemergencycare. Ms. Morris will turn 65 on June 10th. She has never previouslyqualifiedforMedicare.SheisentitledtoMedicarePartAandint endstoenrollinPart B.She wantstoknow if sheiseligible toenrollinaMedicareAdvantageplanthatincludesprescriptiondrugcov erage.What do you tellher? CorrectAns- Ms.Morriscanenroll in an MA-PD plan now since her initial election period (IEP) forPartDprescriptiondrugcoverageandinitialcoverageperiodareoccur ringtogetherbeginningMarch1standendingSeptember30th. AgentMarvinMillnerwantstoreachouttohiscurrentclientsforreferral s.WhatadvicewouldyougivetoMarvin? CorrectAns- MarvinshouldunderstandthatunderCMSguidelineshecannolonger provide gifts, even of minimal value, in exchange forreferrals.NOTSURE Mr.ChenhasheardaboutaMedicalSavingsAccount(MSA)butwants to know if it is just about saving money, or if he will getinsurance coverage for his health care expenditures as well. Whatshouldyoutellhim? CorrectAns- UndertheMedicareAdvantageprogram,aMSAplaninvolvesthecombina tionofahighdeductiblehealthplanandasavingsaccountforhealthexpen ses.Medicarewillmakecontributionstothissavingsaccounttohelphimp ayhishealthcareexpenseswhileinthedeductible.NOTSURE