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Medicare Agent & Broker Certification
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A prospective beneficiary asks an agent if plan XYZ has an urgent care benefit and if so, what the benefit includes. Where would the agent find this information for plan XYZ? - ✔✔Evidence of Coverage Because the beneficiary asked if plan XYZ has an urgent care benefit and what the benefit includes. If the beneficiary only wanted to know if plan XYZ has an urgent care benefit, the answer would be Summary of Benefits & Evidence of Coverage. If a beneficiary who is enrolled in an HMO tells you that she wants to see a specialist, you should tell her: - ✔✔You will likely need a referral from your primary care physician (PCP) to see a specialist. If you see your specialist without this referral, the plan may not pay for your visit. Because the beneficiary is enrolled in an HMO, she should work with her PCP prior to seeing a specialist (except in an emergency). True or False? Once a beneficiary is enrolled in an MA plan and has paid his plan-specific monthly premium, he no longer needs to pay his Part B premium. - ✔✔False
Beneficiaries are required to continue paying their Part B premium (unless they receive Extra Help) in addition to any plan-specific premium. Define: Medicare Part A - ✔✔Part A of Medicare covers hospital inpatient care, some SNF care, and home health and hospice care Define: Medicare Part B - ✔✔Part B of Medicare covers physician services, outpatient hospital care, lab tests, mental health services, some preventative services, and medical equipment considered medically necessary to treat a disease or condition Define: Medicare Part C - ✔✔Part C of Medicare provides an option for beneficiaries to receive private health plan coverage in lieu of Original Medicare Define: Medicare Part D - ✔✔Part D of Medicare provides prescription drug benefit Mrs. Doe will turn 65 at the end of March and signed up for an MA plan in January during her Initial Coverage Election Period (ICEP). When will her coverage begin? - ✔✔On March 1 The ICEP coverage begins the first day of the month of entitlement to Medicare Part A and Part B, OR the first of the month following the month the enrollment request was made (if after entitlement has occurred).
the plan won't take effect until January 1. However, if you don't like the plan after you enroll, you have until March 1 to switch back to Original Medicare." Following the presentation, the agent assists a couple in filling out an enrollment form for Acme's Traditional HMO plan, and tells the couple that she will "hold on to it" until the October 15 enrollment date. What is inaccurate? - ✔✔The agent is not allowed to accept an enrollment prior to October 15 The presenter provided incorrect Medicare Advantage Disenrollment Period (MADP) information Although agents may assist beneficiaries in completing their forms, an agent may not accept, collect, or take possession of completed enrollment forms before October 15 and may not encourage beneficiaries to mail the enrollment form to the plan prior to October
- Further, although the agent provided the correct dates for the AEP (October 15 - December 7), she misstated the window for which a beneficiary may disenroll and revert back to Original Medicare. In 2015, the MADP is January 1 - February 14. Mrs. Doe has decided to file a grievance because she feels that she was treated with disrespect while communicating with a plan's customer services representative (CSR). What is the first step Mrs. Doe should take to file a grievance? - ✔✔Contact the plan in writing or by telephone to file a grievance is the first step. An appeal is intended to handle different circumstances involving coverage decisions or organizational determinations.
True or False? For all MA plans, an enrollee that chooses to join a PDP will be automatically disenrolled from his/her current plan. - ✔✔FALSE A person who is enrolled in an MSA or an MA-PFFS plan without drug coverage and is joining a PDP will not be automatically disenrolled from the MSA or MA-PFFS plan. To disenroll, the beneficiary must call 1- 800 - MEDICARE or submit a written disenrollment request to the plan. A person enrolled in any MA coordinated care plan (HMO, PPO), or an MAPFFS plan that includes drug coverage, who is joining a PDP will be automatically disenrolled from their current plan upon enrolling in a PDP. A plan may end an enrollee's membership if... - ✔✔The enrollee is away from the service area for more than 6 months The enrollee does not stay continuously enrolled in Medicare Part A or Part B The enrollee is no longer eligible for the plan's SNP category A plan may end an enrollee's membership for any of the reasons listed (involuntary disenrollment), so long as the enrollee is part of a plan for which the rule applies. True or False? A state insurance department would like to investigate a sales agent that they suspect is violating Medicare marketing regulations. The plan does not need to allow the investigation because the agent is licensed and has followed the guidelines to date - ✔✔FALSE
At a formal marketing event that occurred on December 1st, an agent provided information on the MA/MA-PD plans available from Acme Health Plan, and noted that compared to all other plans in the area, Acme has the largest network of doctors available and is also the most well liked. At the Agent and Broker Training & Testing Guidelines 12 end of the presentation, the agent told the beneficiaries that if they do not sign up for coverage today, they will likely lose their opportunity to do so. Are these actions appropriate? - ✔✔No. The agent made unsubstantiated absolute statements and also inappropriately pressured beneficiaries into enrolling. Plans may not use absolute superlatives (e.g., we are the best), unless they are substantiated with supporting data provided to CMS as part of the marketing review process or they are used in logos/taglines. Additionally, plans are prohibited from using "scare tactics" or pressuring beneficiaries into enrolling. A beneficiary enrolled into Acme Health Plan in 2012 as an initial enrollment and has remained in the plan since. How much should Acme pay in CY2015 to the agent that facilitated the enrollment? - ✔✔Up to 50% of CY2015 fair market value Renewal compensation should be paid up to 50% of the current fair market value (FMV), regardless of whether the member is new to the organization or not. The initial rate when the member first entered the plan will no longer be utilized to determine the renewal rate.
A beneficiary enrolls into Acme Health Plan in November 2014 as an initial enrollment. Assuming the beneficiary remains enrolled in the plan in 2015, in what month does their first renewal cycle begin? - ✔✔January 2015 The compensation year is January through December. "Rolling years" are not permitted. In this example, the beneficiaries first initial year ends December 31, 2014 and their first renewal year would be January 1, 2015 through December 31, 2015. If a beneficiary makes a plan change to a plan offered by another organization, and the new organization doesn't use agent and brokers, what happens to the payment? - ✔✔The new organization would not make payments and the initial plan would have to recoup for the number of months the member was not in the plan. When a switch happens across organizations, and the new organization doesn't use agents and brokers, the new MA organization would not make payments. The initial plan would have to recoup for the number of months the member was not in the plan. Mr. Smith, an agent with ACME Health Plan, is giving a sales presentation and wants to provide some food for his guests. What can Mr. Smith provide? - ✔✔Snacks such as cheese and crackers Meals (either provided or subsidized) are prohibited at marketing events where plan-specific benefits are discussed and plan materials are distributed. Refreshments and light snacks are permitted, however agents and brokers should use their best judgment on the appropriateness of
When an agent is with a potential enrollee and they request information during a meeting that is outside the Scope of Appointment, the agent may fill in a new scope of appointment and then proceed with providing that information
