Understanding Medicare Part A, Part B, and Part D Enrollment and Options, Exams of Nursing

Download Understanding Medicare Part A, Part B, and Part D Enrollment and Options and more Exams Nursing in PDF only on Docsity! AHIP FWA 2023 AHIP FWA 2023 (Modules 1-5, Nondiscrimination, FWA, Compliance) Exam Questions and Answers. Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met? What could you tell her? - Answer: Original Medicare covers ambulance services. Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him? - Answer: Mr. Singh can enroll in a stand-alone prescription drug plan and continue to be covered for Part A and Part B services through Original Fee-for-Service Medicare. 1 | P a g e AHIP FWA 2023 Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay, she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled nursing facility? - Answer: Medicare will cover Mrs. Shield's skilled nursing services provided during the first 20 days of her stay, after which she would have a copay until she has been in the facility for 100 days. Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline, who has only worked part-time for the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her? - Answer: You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband's long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at more than the standard lowest rate but less than the highest rate due her substantial income. 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? - Answer: Medicare does not cover massage therapy, or, in general, glasses or dentures. 2 | P a g e AHIP FWA 2023 Mr. Alonso receives some help paying for his two generic prescription drugs from his employer's retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him? - Answer: He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing. Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him? - Answer: Medicare covers the periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered. Mr. Diaz continued working with his company and was insured under his employer's group plan until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know how much he will have to pay. What should you tell him? - Answer: Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. What impact, if any, have recent regulatory changes had upon Medigap plans? - Answer: The Part B deductible is no longer covered for individuals newly eligible for Medicare starting January 1, 2020. 5 | P a g e AHIP FWA 2023 Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern? - Answer: *** Medigap plans help beneficiaries cover Original Medicare benefits, but they coordinate with Original Medicare 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? - Answer: 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. Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her? - Answer: She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period after the last month on her employer plan that differs from the standard general enrollment period, during which she may enroll in Medicare Part B. Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-income subsidy. Where might he turn for help with his 6 | P a g e AHIP FWA 2023 prescription drug costs? - Answer: Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program. 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? - Answer: 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. Mrs. Walters is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Advantage (MA) plan? - Answer: She cannot enroll in an MA Medical Savings Account (MSA) plan. Which of the following statement(s) 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. 7 | P a g e AHIP FWA 2023 alone prescription drug plan. What should you tell her? - Answer: She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her? - Answer: Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of 15 employees and offers employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employer- sponsored healthcare coverage. How would you respond? - Answer: Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan. Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr. Lombardi's area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare 10 | P a g e AHIP FWA 2023 prescription drug plan. What should you tell him about this situation? - Answer: He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but is not sure about what type of plan designs are available through this program. What should you tell him about the types of health plans that are available through the Medicare Advantage program? - Answer: They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. 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? - Answer: C-SNP Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug coverage. What should you tell her about obtaining drug coverage? - Answer: She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollment in a Medicare Advantage plan (Part C). What should you 11 | P a g e AHIP FWA 2023 advise her to do before she will be able to enroll in a Medicare Advantage plan? - Answer: To join a Medicare Advantage plan, she also must enroll in Part B. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? - Answer: Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. 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? - Answer: 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. Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could you tell her? - Answer: Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of- pocket limit on Part A and Part B services. All plans must cover at least the standard Part D coverage or its actuarial equivalent. Which of the following statements best describes some of the costs a beneficiary would incur for prescription drugs under the standard coverage? - Answer: Standard Part D coverage would require payment of an annual 12 | P a g e AHIP FWA 2023 Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him? - Answer: The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him? - Answer: He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. Mrs. Fiore is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan? - Answer: She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution. 15 | P a g e AHIP FWA 2023 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? - Answer: 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. Mr. Rice has is 68, actively working and has coverage for medical services and medications through his employer's group health plan. He is entitled to premium free Part A and thinking of enrolling in Part B and switching to an MA-PD because he is paying a very large part of his group coverage premium and it does not provide coverage for a number of his medications. Which of the following is NOT a consideration when making the change? - Answer: Mr. Rice's retiree plan is required to take him back if, within 63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his Medicare Part D plan. 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? - Answer: She may fill 16 | P a g e AHIP FWA 2023 prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Mr. Schultz 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. Schultz has lost his employer group coverage within the last two weeks. How would you advise him? - Answer: 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. Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for- Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan? - Answer: A Medicare Advantage Prescription Drug (MA-PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone prescription drug plan. Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. 17 | P a g e AHIP FWA 2023 for prior approval because it does not include information about the plans' benefits structures, cost-sharing, or information about measures or ranking standards. You are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs. What should you keep in mind? - Answer: You may request RSVPs, but you are not permitted to require contact information. Mr. Edwards, a marketing representative of the ACME Insurance Company, scheduled a marketing event and expects about 40 people to attend. He has hired a magician for $200 to entertain attendees. Can he do this in a way that complies with guidance from the Medicare agency? - Answer: He can do this because the estimated number of attendees is based on the venue size and response rate and the value of the gift does not exceed $15. By contacting plans available in your area, you have learned that the plan you represent has a significantly lower monthly premium than the others. Furthermore, you see that the plan you represent has a unique benefits package. What should you do to make sure your clients know about these pieces of information? - Answer: You may make comparisons between plans if you can support them by studies or statistical data and such comparisons are factually based. 20 | P a g e AHIP FWA 2023 This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do? - Answer: You may go ahead and call them. You plan to participate in an educational event sponsored by a large regional health care system. One of your colleagues suggests that you do a presentation on one of the Medicare Health plans you market and modify it to include information about preventive screening tests showcased at the event. How should you respond to your colleague's suggestion? - Answer: You should tell your colleague no, because participation in an educational event may not include a sales presentation. Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted concerning the marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise him concerning the type of scrutiny he will be under? - Answer: Organizations sponsoring Medicare health plans are responsible for the behavior of their contracted representatives and will be conducting monitoring activities to ensure compliance with all applicable federal law and guidance and plan policies. Furthermore, state agent licensure laws are not preempted and he must abide by their requirements. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan? - Answer: You may provide gifts or prizes to all potential enrollees during an event that does not exceed $15 in retail value. 21 | P a g e AHIP FWA 2023 While making an appointment to discuss Medicare Advantage (MA) and Part D plans with a potential enrollee, you are asked to describe other types of insurance products that your client might wish to purchase. What additional types of insurance can you present during the MA and Part D marketing appointment? - Answer: You can present only health care related lines of business but must obtain the beneficiary's permission to do so before the presentation occurs and document that you have obtained that permission. If you are to comply with Medicare's guidance regarding educational events, which of the following would be acceptable activities? - Answer: You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent. Alice is a marketing representative employed by a health plan. Betty is a captive agent of a health plan who markets to multiple plans and sponsors. Carl is a captive agent who markets to only one plan/sponsor. Denise is an independent agent who markets to different types of groups. Edward is an independent agent who markets only to employer and union groups. CMS marketing representative compensation rules generally apply to: - Answer: Betty and Denise, but not Alice (the employee) or Carl or Edward (to whom exceptions apply). You have set up an appointment for an in-home sales presentation with Mrs. Fernandez, who expressed interest in the Medicare plans you represent. In preparation for the sales presentation, what must you do? - Answer: Before 22 | P a g e AHIP FWA 2023 rating in customer service and care coordination with an overall performance rating of 4-stars. Ms. Claggett is sixty-six (66) years old. She has been covered under Original Medicare for the last six years due to her disability and has never been enrolled in a Medicare Advantage or a Part D plan before. She wants to enroll in a Part D plan. She knows that there is such a thing as the "Part D Initial Enrollment Period" (IEP) and has concluded that, since she has never enrolled in such a plan before, she should be eligible to enroll under this period. What should you tell her about how the Part D Initial Enrollment Period applies to her situation? - Answer: Ms. Claggett has had two IEPs and missed them both. The first occurred three months before and three months after the month when she was first entitled to Part A OR enrolled in Part B. Because she was eligible for Medicare before age 65, Ms. Claggett had a second IEP based on turning age 65, which has also expired. Mr. Wilcox has been enrolled in Lexington Private Fee-for-Service (PFFS) Medicare Advantage Health Plan (Lexington) for several years. Recently, Mr. Wilcox decided to spend time with his children who live in another state that is not in Lexington's service area. In the future, he may relocate near his children permanently. How does this move to another service area impact his PFFS MA coverage? - Answer: Lexington can allow for Mr. Wilcox's continued enrollment for up to 12 months whether or not he is in a visitor/traveler (V/T) program since it is a PFFS plan. Mrs. Parker likes to handle most of her business matters through telephone calls. She currently is enrolled in Original Medicare Parts A and B but has heard about a 25 | P a g e AHIP FWA 2023 Medicare Advantage plan offered by Senior Health from a neighbor. Mrs. Parker asks you whether she can enroll in Senior Health's MA plan over the telephone. What can tell her? I. Enrollment requests can only be made in face-to-face interviews or by mail. II. Telephone enrollment request calls must be recorded. III. Telephonic enrollments must include all required elements necessary to complete an enrollment. IV. The signature element must be completed via certified mail. - Answer: II and III only Mrs. Reynolds is in her Medicare initial coverage election period (ICEP) and the date of her entitlement to Part A and B has already occurred. Mrs. Reynolds has just signed up for a Medicare Advantage plan on the second of the month. She is leaving for vacation in two weeks and wants to know if her new coverage will start before she leaves. What should you tell her? - Answer: Typically, her coverage would begin on the first day of the next month, so she should not expect her coverage to begin before she leaves. Mr. Fitzgerald is selling his home to permanently move into a retirement facility near his daughter in a neighboring state before the Annual Election Period. He has a stand-alone prescription drug plan and has learned it is not available where he is moving. He doesn't know what he should do. What can you tell him? - Answer: 26 | P a g e AHIP FWA 2023 Because he is moving outside of the service area, the plan must automatically disenroll him. He will have a special election period to select a new plan. Mrs. Kendrick is in good health, has worked for many years and is six months away from turning 65. She wants to know what she will have to do to enroll in a Medicare Advantage (MA) plan as soon as possible. What could you tell her? - Answer: She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B. Ms. Thomas has worked for many years and is turning 68 in June. She is eligible for Medicare Part A and did not enroll for Part B when first eligible because she has insurance through her employer - Coffee Brew, Inc. She also did not enroll in Part D because she had creditable coverage. She would like to retire in June and enroll in a Medicare Advantage plan. She has been informed that her group coverage will end on her retirement effective date. How would you advise Ms. Thomas? - Answer: Ms. Thomas can enroll in Part B without a late penalty at any time she is still covered by her employer group and 8 months after her last month of employer group coverage without a penalty. However, because she wants to enroll in a MA plan after retirement, she should make sure her Part B coverage is effective in time to use the Medicare Advantage/Part D special election period for individuals changing from employer group coverage to enroll in a MA plan or MA- PD. The SEP begins while she has employer group coverage and will last until 2 months after the month after the month her employer coverage ends. If she wants Part D coverage she should enroll in an MA-PD or a PDP (depending on how she decides to receive her Part A and B benefits) during this time. 27 | P a g e AHIP FWA 2023 Mr. Anderson is a very organized individual and has filled out and brought to you an enrollment form on October 10 for a new plan available January 1 next year. He is currently enrolled in Original Medicare. What should you do? - Answer: Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins. Mrs. Johnson calls to tell you she has not received her new plan ID card yet, but she needs to see a doctor. What can she expect to receive from the plan after the plan has received her enrollment form? - Answer: Evidence of plan membership, information on how to obtain services, and the effective date of coverage. Miles is a licensed agent who represents Colgate Health and its Medicare Advantage (MA) plans. Miles has several clients who have recently come to him for help. They are in their initial coverage period9s) (ICEP) and are interested in enrolling in one of Colgate Health's MA plans. Adam will soon turn 68 and has decided to retire. Betty is about to turn 65 and has also decided to retire. Adam and Betty both currently have coverage through Colgate Health. Charles had health coverage through Colgate but dropped the coverage when he retired early to travel to Europe. Charles has just turned age 65 and is now back in the United States. Diedre, who will turn 65 next month, currently has coverage through Ditmas Health - a company that Miles also represents. Who qualifies for the opt-in simplified enrollment mechanism? - Answer: Adam and Betty because each of them will not have a break between their non-Medicare and Medicare coverage through Colgate Health Plan. 30 | P a g e AHIP FWA 2023 Mr. Rodriguez is currently enrolled in a MA plan, but his plan doesn't sufficiently cover his prescription drug needs. He is interested in changing plans during the upcoming MA Open Enrollment Period. What are his options during the MA OEP? - Answer: He can switch to a MA-PD plan. Which of the following individuals has enrolled in a plan based on a fixed enrollment period? - Answer: Ben, who enrolls in a Medicare Advantage plan during the Medicare Advantage Open Enrollment Period (MA OEP). Mr. Liu turns 65 on June 19. He has never previously qualified for Medicare so his first Medicare eligibility date will be by June 1. Mr. Liu's ICEP and Part D IEP begin March 1 and end on September 30. He wants prescription drug coverage with his Part A and Part B benefits. What advice can you provide him? - Answer: He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to Part A. You work for Caring Health, a Medicare Advantage (MA) plan sponsor. Recently, Mrs. Garcia has completed an enrollment application for a plan offered by Caring Health, which is waiting for a reply from CMS indicating whether or not Mrs. Garcia's enrollment has been accepted. Once CMS replies, how long does Caring Health have to notify Mrs. Garcia that her enrollment has been accepted and in what format? 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. 31 | P a g e AHIP FWA 2023 Rockwell about special election periods (SEPs)? - Answer: The plan has 10 calendar days to notify Mrs. Garcia in writing. Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is interested in that product. She wants to be sure she also has coverage for prescription drugs. Would she be able to obtain drug coverage if she enrolled in the SNP? - Answer: Maybe. Some SNPs offer Part D coverage for prescription drugs and some do not. Mr. Lopez, who is fairly well-off financially, would like to enroll in a Medicare prescription drug plan you represent and simply give you a check to cover his premiums for the entire year. What should you tell him? - Answer: Enrollees should pay using automatic withdrawal from a bank account or credit or debit card, direct monthly billing from the plan, or deductions from their Social Security check. Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her? - Answer: The letter is to inform her that the drug coverage offered through her Medigap plan does not offer drug coverage that is at least comparable to that provided under the Medicare Part D prescription drug program. If she does not have such creditable coverage during periods when she is first eligible for the Part D program, she will face a premium penalty if she enrolls in a Part D plan at a later date. 32 | P a g e AHIP FWA 2023 administered under Title I of the ACA, such as life insurance, do not fall under the scope of 1557. Which entity enforces Section 1557 for programs that receive funding from on are administered by HHS? - Answer: The Office of Civil Rights (OCR) of HHS. Which of the following would be considered permissible under Section 1557 and the 2020 Final Rule? - Answer: Broker Mary Jones has recruited a diverse workforce. She encourages her agents to prospect through community-based marketing and within their community of influence. Which of these actions is most likely to be permitted in dealing with a person with limited English proficiency? - Answer: Allowing a child to interpret in an emergency. Under ACA Section 1557, a health plan - Answer: cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge. Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this job, you use a process to verify the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain individuals. What should you do? - Answer: Report the incident to the compliance department (via compliance hotline or other mechanism) 35 | P a g e AHIP FWA 2023 You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do? - Answer: Follow your pharmacy's procedures. Which of the following requires intent to obtain payment and the knowledge the actions are wrong? - Answer: Fraud You are in charge of paying claims submitted by providers. You notice a certain diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize Doe Diagnostics' claims far exceed any other provider you reviewed. What should you do? - Answer: Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or other mechanism) A person drops off a prescription for a beneficiary who is a "regular" customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step? - Answer: Call the prescriber to verify the quantity Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud, waste, and abuse (FWA)? - Answer: Deportation 36 | P a g e AHIP FWA 2023 Any person who knowingly submits false claims to the Government is liable for five times the Government's damages caused by the violator plus a penalty. - Answer: False (it's 3 times) What are some of the penalties for violating fraud, waste, and abuse (FWA) laws? - Answer: All of the above Ways to report potential fraud, waste, and abuse (FWA) include: - Answer: All of the above Once a corrective action plan is started, the corrective action plan must be monitored annually to ensure they are effective. - Answer: False Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly or intentionally misrepresented facts to obtain payment. - Answer: True Waste includes any misuse of resources, such as the overuse of services or other practices that directly or indirectly result in unnecessary costs to the Medicare Program. - Answer: True These are examples of issues that should be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA); potential health privacy violation, unethical behavior, and employee misconduct. - Answer: True 37 | P a g e