Understanding Medicare Advantage and Part D Plans, Exams of Nursing

Download Understanding Medicare Advantage and Part D Plans and more Exams Nursing in PDF only on Docsity! AHIP FINAL EXAM CERTIFICATION NEWEST ACTUAL EXAM 2025 QUESTIONS AND DETAILED CORRECT ANSWERS (VERIFIED ANSWERS) | VERIFIED 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. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. Correct Answer I, II, and IV only Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? Correct Answer Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan? Correct Answer All MSAs cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling in a separate prescription drug plan. Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was disappointed with the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she would not have to put up with such poor access to care. What could you tell her? Correct Answer She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? Correct Answer Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. the MA-only PPO plan and a stand-alone prescription drug plan. Mrs. Wang 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? Correct Answer Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part A and Part B services. Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her? Correct Answer She could enroll in a PFFS plan and a stand-alone Medicare 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? Correct Answer There are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit 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 Answer You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. 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? Correct Answer She cannot enroll in an MA Medical Savings Account (MSA) plan. 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? Correct Answer The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? Correct Answer Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs. 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. Correct 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. What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? Correct Answer Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and step therapy. Mrs. Mulcahy, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan 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? Correct 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. Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him? Correct Answer Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription to help to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? Correct Answer Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughns could look into that possibility. Mr. Hildalgo complains to you that because he takes multiple expensive drugs, he has trouble paying his cost sharing for his prescription drugs, particularly at the beginning of the year during the deductible phase. He is happy with his plan and does not want to change. However, he said he had heard about a new program called the Medicare Prescription Payment Plan and asked whether it might help. What do you tell him? Correct Answer The Medicare Prescription Payment Plan helps spread out beneficiary cost-sharing payments but does not decrease the total amount owed. 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 Answer In general, he must select a single Part D premium payment mechanism that will be used throughout the year. One of your clients, Lauren Nichols, has heard about a Medicare concept from one of her neighbors called TrOOP. She asks you to explain it. What do you say? Correct Answer TrOOP stands for true out-of-pocket costs that count toward the Medicare Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances amounts paid by or through qualified State Pharmaceutical Assistance Programs. 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 Answer Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her? Correct Answer If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. Mrs. Hernandez is one of your clients. She has read that there is a new program that may help her manage prescription drug costs. What do you tell her about the Medicare Prescription Payment Plan? Correct Answer Part D enrollees can opt into the Medicare Prescription Payment Plan at the beginning of the plan year or any point during the year. Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated What could you tell her? Correct Answer Part D covers prescription drugs and she should look at her premiums, formulary, and cost-sharing among other factors to see if they have changed. 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 Answer Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to Medicare beneficiaries? Correct Answer Beneficiaries under Original Medicare have no cost-sharing for most preventive services. Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him? Correct 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. Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her? Correct Answer Most individuals who are citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. Mrs. Quinn recently turned 66 and decided after many years of work to retire and begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she had been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn? Correct Answer Part B primarily covers physician services. She will be paying a monthly premium and, except for many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible. 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 because of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? Correct 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. What impact, if any, have recent regulatory changes had on Medigap plans? Correct Answer The Part B deductible is no longer covered for individuals newly eligible for Medicare starting January 1, 2020. 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? Correct Answer Medigap plans do not cover Original Medicare benefits, but they coordinate with Original Medicare coverage. 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? Correct Answer Original Medicare covers ambulance services. Ms. Brooks has aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her? Correct Answer Medicare covers hospice services, and they will be available for her. 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? Correct Answer Mr. Diaz will not pay any Answer The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4 stars. A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do? Correct Answer You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. 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 appointments? Correct 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. One of your colleagues argues that it is better to focus your time and energy exclusively on neighborhoods with single-family homes. He further argues that their older owners are more likely to have higher incomes and purchase the Medicare Advantage products you represent compared to those living in apartment complexes. How should you respond? Correct Answer This could be considered discriminatory activity and a prohibited practice. Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational? Correct Answer Yes. When an event has been advertised as "educational," discussing plan-specific premiums is impermissible. Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services (CMS) Communication and Marketing Guidelines to ensure he is compliant with which type of products. Correct Answer Medicare Advantage (MA) and Prescription Drug (PDP) plans. Next week you will be participating in your first "educational event" for prospective enrollees. To be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage? Correct Answer You should plan to ensure that the educational event is informative and must not conduct a sales presentation or distribute or accept enrollment forms at the event. You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To comply with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plansl? Correct Answer You will have to avoid calling any potential client unless he or she initiates contact with you and specifically asks that you give him or her a call. If you are to comply with Medicare's guidance regarding educational events, which of the following would be acceptable activities? Correct 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. 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? Correct Answer You may make comparisons between plans if you can support them with studies or statistical data and such comparisons are factually based and referenced. 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? Correct Answer Before conducting the presentation, obtain and document having obtained her permission to visit, along with her interest in the specific products you will present. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan? Correct Answer You may provide gifts or prizes to all potential enrollees during an event that does not exceed $15 in retail value. You would like to market a MA plan at a neighborhood pharmacy. What should you keep in mind to comply with the marketing requirements for MA plans? Correct Answer You must set up your table, make marketing presentations, and accept enrollment applications only in common areas outside of where the patient waits for services from the pharmacist. Agent Harriet Walker has recently begun marketing Medicare Advantage and related products aimed at meeting the needs of senior citizens. Client Mildred Jones has expressed interest in a Medicare Advantage plan. It is now the beginning of September. If you were in Agent Walker's position, what would you do? Correct Answer Inquire whether the client qualifies for a special enrollment period, and if not, solicit an enrollment application once the annual open enrollment election period begins on October 15th. Which of the following individuals are likely to qualify for a special election period (SEP) for either a MA and/or Part D due to a change of residence? I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan's service area. II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's service area. III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area where no Part D plan was available. IV. Henry makes a permanent move to a new state providing him with new MA and Part D options. Correct Answer II, III, and IV only. Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him? Correct Answer Mr. Chen can disenroll from his employer- sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. Mr. Liu turns 65 on June 19. He has never previously qualified for Medicare so his first Medicare eligibility date will be June 1. Mr. Liu's ICEP and Part D IEP begin on 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? Correct Answer He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to Part A. Mr. and Mrs. Nunez attended one of your sales presentations. They've asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do? Correct Answer As long as she can do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time. 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 on January 1 next year. He is currently enrolled in Original Medicare. What should you do? Correct Answer Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins. Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period (AEP). On December 1, he calls you up and says that he has changed his mind and would like to enroll in a MA-PD plan. What enrollment rules would apply in this case? Correct Answer He can make as many enrollment changes as he likes during the Annual Election Period and the last choice made before the end of the period will be the effective one as of January 1. Mrs. Pierce would like to enroll in a Medicare Cost plan that offers Part D prescription drug coverage. She comes to you for advice about when she can enroll in a plan you have previously discussed. What should you tell her? Correct Answer Enrollment in Cost plans offering Part D coverage is available only during enrollment periods under "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? Correct 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. 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? Correct 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. Mr. Garcia was told he qualifies for a special election period (SEP), but he lost the paper that explains what he could do during the SEP. What can you tell him? Correct Answer If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage. Mrs. Schmidt is moving and a friend told her she might qualify for a "special election period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a special election period is. What could you tell her? Correct Answer It is a period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically, the special election period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area. 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? Correct Answer She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B. Which of the following individuals has enrolled in a plan based on a fixed enrollment period? Correct Answer Ben enrolls in a Medicare Advantage plan during the Medicare Advantage Open Enrollment Period (MA OEP). Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirement several years ago. Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the first time. Unfortunately, Mrs. Ridgeway has found that many of her providers are not in the MA plan's network. She has come to you for advice. What should you tell her? Correct Answer She qualifies for a special election period (SEP) that will allow her to make a one-time election to return to Original Medicare and she also has a guaranteed eligibility period to rejoin her Medigap plan. Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application before the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams? Correct Answer This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form before the start of the AEP.