Understanding Medicare Supplemental Insurance and Medicare Advantage Plans, Exams of Nursing

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coverage

Medicare

Supplemental Insurance provides since his health care

needs are different from his wife's needs. What could

you tell Mr. Moy?correct answersMedicare

would help cover his Part A and Part B

deductibles or

coinsurance in Original Fee-for-

Service

(FFS) Medicare as well as

possibly some

services that Medicare does not

cover.

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?correct answersShe may enroll

at any time while

she

is

covered under her employer plan, but she will have a

special eight-month

enrollme

nt

standard general

enrollment period,

during which she may enroll in Medicare Part B.

time,

and

paid taxes during that entire period. She is concerned that she will not qualify

for

[Type here] [Type here] [Type here]

Mr. Moy's wife has a Medicare Advantage plan, but he wants to

understand what

Supplemental

Insurance

period after the last month on her employer plan that

differs from the

Mrs. Chen will be 65 soon, has been a citizen for twelve years, has

been employed full

you tell

her?correct answersMost individuals who are citizens and age 65

or over are

Part A by virtue of having paid Medicare taxes while

working, though

some may be

covered

as a result of paying monthly premiums.

Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well,

but it

her her?

correct

answersMrs. Gonzalez cannot purchase a Medigap plan that covers

drugs,

could keep her Medigap policy and enroll in a Part D prescription drug plan.

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 does

not

cover massage therapy, or, in general, glasses or dentures.

Mr. Patel is in good health and is preparing a budget in anticipation

of his retirement

whe

n

he turns 66. He wants to understand the health care costs he

might be exposed to

unde

r

Medicare if he were to require hospitalization as a result of an

illness. In genera

lterms,

what

could you tell him about his costs for inpatient hospital services

under Original Medicare?correct answersUnder 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

coverage under part A because she was not born in the United

States. What should covered

under

provides no drug coverage. She would like to keep the coverage she

has but replace existing Medigap plan with one that provides drug coverage. What

should you tell but

she

cover these items and services. What should you tell her?correct

answersMedicare

costs.

Ms. Henderson believes that she will qualify for Medicare Coverage when she

turns 65,

without paying any premiums, because she has been working for 40 years and

paying

she must

pay a

standard monthly premium, though it is higher for individuals with higher

incomes.

Mr. Alonso receives some help paying for his two generic prescription drugs

from his

plan.

into a

standard

MedicarePart D prescription drug plan. What should you tell him?correct

answersHe generally would pay a monthly premium, annual deductible, and

per-

prescription cost-sharing.

and will

have

considerable income when she retires. She is concerned that her income will

make it impossible for her to qualify for Medicare. What could you tell her to

address her concern?

correct answersMedicare is a program for people age 65 or older and those

under age 65

with certain disabilities, end-stage renal disease, and Lou Gehrig's disease so

she will be

eligible for Medicare.

provided

under

Original Medicare. What should you tell Mr. Xi that best describes the health

coverage

provided to Medicare

beneficiaries?

correct answersBeneficiaries under Original

Medicare

have no cost-

sharing for

most preventive services which

include

immunizations

such as

[Type here] [Type here] [Type here]

Medicare taxes. What should you tell her?correct answersTo obtain

Part B coverage,

employer's retiree coverage, but he wants to compare it to a Part D

prescription drug He asks you what costs he would generally expect to encounter

when enrolling

Ms. Moore plans to retire when she turns 65 in a few months. She is in

excellent health

Mr. Xi will soon turn age 65 and has come to you for advice as to

what services are

annual flu shots.

her

Medicare Summary Notice (MSN) and disagrees with a determination that

partially

one of her claims for services. What advice would

you give her?

correct answersMrs.

Duarte

should file an appeal of this initial determination within 120 days of the date

she received

the MSN in the mail.

Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a

Medigap plan

to pick up costs not covered by that plan.

What should you tell

him?

correct answersIt is illegal for you to sell Mr.

Capadona a

Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works

with

Original Medicare.

Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income.

What could you tell

Mrs

.

Park that might be of

assistance?

correct answersShe should contact her state

Medicaid

agency to see if she qualifies for one of several programs that can help with

Medicare costs

for which she is responsible.

Mr. Rainey is experiencing paranoid delusions and his physician feels that he

should be hospitalized. What should you tell Mr. Rainey (or his representative)

about the length of an

inpatient psychiatric hospital stay that Medicare will

cover?correct

answersMedicare

will

cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire

lifetime.

Mr. Schmidt would like to plan for retirement and has asked you what is

covered under

Original Fee-for-Service (FFS) Medicare? What could you tell him?

correct answersP

art

A,

which covers hospital, skilled nursing facility, hospice, and home health

services and Part B,

which covers professional services such as those provided by a doctor are

covered under

Original Medicare.

Agent John Miller is meeting with Jerry Smith, a new prospect.

Jerry is currently

enrolled

in

Medicare Parts A and B. Jerry has also purchased a Medicare

Supplement

(Medigap)

plan

Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has

recently reviewed denie

d

drug benefits. How

would you advise Agent John Miller to

proceed?correct a

nswersTell prospect Jerry

Smith that

he should consider adding a standalone Part D prescription drug coverage

policy to his

present coverage.

Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by

the

Social Security Administration and has been receiving disability payments. He is

him?

correct

ans

wersAfter receiving such disability payments for 24

months, he will be

automatically enrolled in Medicare, regardless of age.

Mr. Buck has several family members who died from different

cancers. He wants to

Medicare covers cancer screening.

What should you tell him?correct answersMedicare covers the periodic

performance of

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.

Which of the following statement

is/are

correct about a Medicare Savings

Account (MSA)

Plans?

I.

An individual who is

enrolled in an

MSA plan is

responsible for a minimal deductible of

$500 indexed for inflation.

Non-network providers must accept the same amount that Original Medicare would pay

them as payment in full.correct answersI, II, and IV only

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

likes the PPO

plan that does not include drug coverage and intends to

obtain his drug

coverage

through a

stand-alone Medicare prescription drug plan. What

should you tel

lhim about this

situation?

[Type here] [Type here] [Type here]

which he has had for several years. However, the plan does

not provide

wondering whether he can obtain coverage under Medicare. What

should you tell

know

if

a

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.

plan does not include drug coverage, but the other two plans do.

Mr. Lombardi

correct answersHe 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.

Mrs. Ramos is considering a Medicare Advantage PPO and has questions about

which

providers she can go to for her health care. What should you

tell her?corre

ct

answersMrs.

[Type here] [Type here] [Type here]

Ramos can obtain care from any provider who participates in Original Medicare,

but

generally will have a higher cost-sharing amount if she sees a provider who/that

is not a part

of the PPO network.

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

abou

t

[Type here] [Type here] [Type here]

prescription a neighbor's MA-PD plan that you represent and because he

takes numerous

drugs, he is considering signing up for it. What should

you tell him?

correct answersHe

should

[Type here] [Type here] [Type here]

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.

Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the

plan's

terms and conditions for payment. Mary Rodgers sees Dr. Brennan for much

treatment. How

may Dr. Brennan charge?

correct

answersDr. Brennan can charge Mary Rogers no

more than

[Type here] [Type here] [Type here]

the cost sharing specified in the PFFS plan's terms and condition of payment

which may

include balance billing up to 15% of the Medicare rate.

Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available

in his area has

an

[Type here] [Type here] [Type here]

current

HMO plan requires him to do. What should

you tell him?

correct answersHe may

receive

health care services from any doctor allowed to bill Medicare, as long as he

shows the

doctor the plan's identification card and the doctor agrees to accept the PFFS

plan's

payment terms and conditions, which could include balance billing.

Medicare

Advantage. What would be the correct

description?correct

answersMedicare

Advantage is a

way of covering all the Original Medicare benefits through private health

insurance

companies.

Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income

level. She

wishes to enroll in a MA MSA plan that she heard about from her

neighbor. She also

wants

to

expensive medications. Currently, she is enrolled in Original Medicare and a

standalone

How would you advise

Mrs. Chi?

correct answersMrs. Chi may enroll in a MA MSA

plan and

remain in her current standalone Part D prescription drug plan.

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

likely to be

most

appropriate for him?correct

answers.

C-SNP

was

disappointed with the service she received from her primary

care physician

because

she

was told she would have to wait five weeks to get an

appointment when

she was feeling

ill.

She called you to ask what she could

do so she w

ould not have to put up with

such poor

attractive premium. He wants to know if he must use doctors in a

network as his

Mr. Wells is trying to understand the difference between Original

Medicare and

have prescription drug coverage since her doctor recently

prescribed several Part D

plan.

SNP

is

Mrs. Burton is a retiree with substantial income. She is enrolled in an

MA-PD plan and

access to care. What could you tell her?correct answersShe could file a

grievance with her

plan to complain about the lack of timeliness in getting an appointment.

Mr. Greco is in excellent health, lives in his own home, and has a sizeable

income from his investments. He has a friend enrolled in a Medicare Advantage

Special Needs Plan (SNP). His

friend has mentioned that the SNP charges very low cost-

sharing amounts

and Mr.

Greco

answersSNPs limit enrollment

to

certain subpopulations of beneficiaries. Given

his

qualify and would not be able to enroll in the SNP.

Mrs. Radford asks whether there are any special eligibility requirements for

Medicare Advantage. What should you tell her?correct answersMrs.

Radford must be entitled to

and enrolled in Part B to enroll in Medicare Advantage.

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?correct answersMedicaid may provide additional

benefits, but

Medicaid will coordinate benefits only with Medicaid participating providers.

recently

stopped paying his Part B premium. Mr. Castillo is still covered by

Part A. He

enroll in a Medicare Advantage (MA) plan and is still

covered by Part A.

What should you

tell

him?correct answersHe is not eligible to enroll in

a Medicare

Advantage plan until

he re-

enrolls in Medicare Part B.

In

mid-February of 2021, her doctor confirms a diagnosis of end-stage

renal disease

(ESRD

).

What options will Mrs. Davenport have regarding her MA plan

during the next

ope

n

[Type here] [Type here] [Type here]

would like to join that plan. What should you tell

him?correct current situation, he is

unlikely to

Part

A

Mr. Castillo, a naturalized citizen, previously enrolled in Medicare

Part B but has would like

to

Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan

several years ago.

another

MA plan in her service area, or enroll in a Special Needs

Plan (SNP) for

individuals

suffering

from ESRD if one is available in her area.

ability to

access

providers. What should you tell him?correct answersIn most Medicare

Advantage HMOs, Mr. Kumar must generally obtain his services

only from providers within the plan's network (except in an

emergency or where care is unavailable within

clients, Lauren Nichols, has heard about a Medica

Mr. Barker enjoys a comfortable retirement income. He recently

had surgery and

expecte

d

minimal out-of-

However, when he

received

the bill, he was surprised to see large charges in

excess of

that included some services and items he

thought

would be fully covered. He called

you to

ask what he could do? What could

you tell

him?correct answersYou can offer to

review the

plans appeal process to help

him ask

the plan to review the coverage

decision.

enrollment season?correct answersShe may remain in her ABC MA

plan, enroll in

Mr. Kumar is considering a Medicare Advantage HMO and has

questions about his

the

network).ur

that he would have certain services and items covered by

the plan with pocket costs because his MA-PD coverage has been

very good.

his maximum out-of-

pocket limit

has

received

under Original Medicare, but he would like to know more about Medicare

Advantage Special Needs Plans (SNPs). What could you tell him?correct

answersSNPs have special programs for enrollees with chronic

conditions, like Mr. Sinclair, and they

prescription drug coverage that could be very helpful as well.

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

shoul

d

Medicare

Advantage program?correct answersThey are Medicare health

plans such as

PFFS, and MSAs.

Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in

Part B

because he has coverage through an employer plan. If he wants to enroll in a

Medicare

Advantage plan, what will he have to do?correct answersHe will have to enroll

in Part B.

Mr. Zachow has a condition for which three drugs are available. He

has tried two but

had

an

allergic reaction to them. Only the third drug works for him and

it is not on his

Part D

plan's

formulary. What could you tell him to do?correct answersMr.

Zachow has

a right to

request

physician could

obtain the standardized request form on the plan's

website, fill it out, plan.

Mr. Bickford did not quite qualify for the extra help low-income

subsidy under the

Medicar

e

option he has for

obtaining help

with his considerable drug costs. What should you tell him?

correct answersHe could check with the manufacturers of his

medications to see if

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

[Type here] [Type here] [Type here]

Mr. Sinclair has diabetes and heart trouble and is generally satisfied

with the care he

provid

e

you tell him about the types of health plans that are available

through the HMOs,

PPOs,

a formulary exception to obtain coverage for his Part D

drug. He or his and submit it to

his

Part D Prescription Drug program and he is wondering if

there is any other

they offer

an

to help him with his expenses.

Vaughn

their

Medicare them?

correct

answersMedicare

prescription drug plans are not permitted to cover the however, plans may

cover them as supplemental benefits and the Vaughn's could

look

Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your

clients. In

include

a

prescription drug not on his plan's formulary, over-the-counter

medications for

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?correct answersNone

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.

plan

(PDP) coverage. She is traveling and wishes to fill two of the

prescriptions that she

How would you advise her?correct answersShe may fill

prescriptions for

covered drugs

at

non-network pharmacies, but likely at a higher cost than

paid at an in-

network

pharmacy.

Mr. and Mrs. Vaughn both take a specialized multivitamin

prescription each day. Mr. takes a prescription for helping to regrow his hair. They are

anxious to have prescription drug plan cover these drug needs. What

should you tell

prescripti

on medications the Vaughns are interested in under Part

D coverage,

into that

possibility.

addition to drugs on his plan's formulary he takes several other

medications. These colds

and

Ms. Edwards is enrolled in a Medicare Advantage plan that includes

prescription drug has

lost.

Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently

lost

interested in

enrolling in a Medicare Part D prescription drug plan (PDP). What

should

correct answersIf a Part D benefit is offered through her

plan she may

choose to

enroll in

that plan or a standalone PDP.

Mrs. Allen has a rare condition for which two different brand name drugs are the

only

available treatment. She is concerned that since no generic

prescription drug is

availabl

e

and these drugs are very high cost, she will not be able to find a

Medicare Part

D

prescription drug plan that covers either one of them. What

should you tel

lher?

correct

answersMedicare prescription drug plans are required to

cover drugs in

each

therapeutic

category. She should be able to enroll in a Medicare

prescription drug

plan that covers

the

medications she needs.

Mrs. Quinn has just turned 65, is in excellent health and has a relatively high

income. She

uses no medications and sees no reason to spend money

on a Medicare

prescription

drug

plan if she does not need the coverage. She currently

does not have

creditable

coverage.

[Type here] [Type here] [Type here]

creditable coverage previously available through her husband's

employer. She is you tell

her?

decision?correct answersIf she

does

not

sign up for a Medicare prescription

drug plan will be permanently

increased by 1%

of the national average premium for every month

Mr. Shultz was still working when he first qualified for

Medicare. At that time, he had

employer group coverage that was creditable. During his initial Part D

eligibility period,

decided not to enroll because he was satisfied with his drug

coverage. It is now a

year

later

weeks. How would

you advise him?correct answersMr. Schultz should

enroll in a Part D

day break in coverage in order to avoid a premium penalty.

Mrs. Mulcahy, age 65, is concerned that she may not qualify for

enrollment in a

Medicar

e

enrolled under

Medicare Part B. What should you tell her?correct

answersAn individual

Part A or enrolled under Part B is eligible to enroll in

a Medicare

prescription drug

plan. As

long as Mrs. Mulcahy is entitled to Part A, she

does not need

to enroll under Part B

before

What could you tell her about the implications

of such a as soon as she is eligible to

do so, and if she does sign up at a later date, her

premium

that she was not

covered.

he

and Mr. Shultz has lost his employer group coverage within

the last two plan before he has

a 63-

prescription drug plan because, although she is entitled to Part

A, she is not

who is entitled

to

enrolling in a prescription drug plan.

What types of tools can Medicare Part D prescription drug plans use that affect

the way

cover all

medications. As a

result, their formularies, or lists of covered drugs, will vary co-payments

and prior authorization.

Which of

the

following statements best describes some of the costs a

beneficiary would incur for prescription drugs under the

standard coverage?correct answersStandard Part

catastrophic coverage threshold, the beneficiary pays whichever is greater of

either the

brand name drugs or coinsurance of 5%.

benefit, but

when he looks at information on various plans available in

his area, he sees you explain this to him?correct

answersMedicare Part D drug plans may have different

on average, they must all be at least as good as

the standard

model established by

the

government.

Mr. Carlini has heard that Medicare prescription drug plans are only

offered through

privat

e

companies under a program known as Medicare Advantage

(MA), not by the

governme

nt.

product, but he also

wants prescription drug coverage. What should you tell

him?correct

stay with Original Medicare and also enroll in a

Medicare

prescription drug plan

through a

private company that has contracted

with the

government to provide only

such drug

[Type here] [Type here] [Type here]

their enrollees can access medications?correct answersPart D plans

do not have to from plan

to plan. In addition, they can use cost containment techniques

such as tiered

All plans must cover at least the standard Part D coverage or its

actuarial equivalent.

D

coverage would require payment of an annual deductible, and

once past the co-pays for generic

and

Mr. Jacob understands that there is a standard Medicare Part D

prescription drug a wide range

in what they charge for deductibles, premiums, and cost

sharing. How can benefit structures,

but

He likes Original Medicare and does not want to sign

up for an MA answersMr. Carlini

can

coverage to eligible Medicare beneficiaries.

Plan? correct

answersJose, a grandfather who was granted asylum and has

worked in

States for many years.

Mr. Hutchinson has drug coverage through his former employer's retiree plan.

He is

prescription

drug plan, but does not want to purchase extra coverage

that he will not

need. What

should

expected to pay, on

average,

at least as much as Medicare's standard Part D coverage expects to pay, then

he will need to enroll in Medicare Part D

during his initial eligibility penalty.

Mrs. McIntire is enrolled in her state's

Medicaid plan and has just become eligible for

Medicare as well. What can she expect will happen to her drug coverage?

correct

answersUnless she chooses a Medicare Part D prescription drug plan

on her own, she

will

be

automatically enrolled in one available in her area.

Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not

include drug

coverage and also enroll in a stand-alone Medicare prescription drug plan.

Under what

circumstances can she do this?correct answersIf the Medicare

Advantage plan is a

Privat

e

Fee-for-Service (PFFS) plan that does not offer drug

coverage or a Medica

lSavings

Account

Which of the following individuals is most likely to be eligible to

enroll in a Part D the

United

concerned about the Part D premium penalty if he does not enroll

in a Medicare

you tell him?correct answersIf the drug coverage

he has is not

period to avoid the late

enrollment

plan, Mrs. Berkowitz can do this.

Which of the following statements about Medicare Part D are

correct?

Part D plans must enroll any eligible beneficiary who applies regardless

of health circumstances.

Private fee-for-service (PFFS) plans are not required to use a pharmacy

network but III. Beneficiaries enrolled in a MA-Medical Savings Account

(MSA) plan may only obtain

standalone PDP.

IV. Beneficiaries enrolled in a MA-PPO may obtain Part D

benefits through a standalone

plan.correct answersI, II, and III only

Mr. Torres has a small savings account. He would like to pay for his monthly

Part D

premiums with an automatic monthly withdrawal from his savings account until

it is

exhausted, and then have his premiums withheld from his Social Security

check. What should you tell him?correct answersIn general, he must select a

single Part D premium

payment mechanism that will be used throughout the year.

You will be holding a sales event soon, at which you would like to offer door

prizes to

attendees. Under guidelines from the Medicare agency, what types of gifts

or prizes

not be allowed in this situation?correct answersGift cards or gift certificates of

$15 or less that can be readily converted to cash.

Another agent working for your agency claims that because you are

not employed by

th

e

Medicare Advantage plans that you represent, you are not

subject to the same

marketin

g

[Type here] [Type here] [Type here]

status except

in limited

may choose to

have one. Part D benefits

through a

PDP or

through their

woul

d