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 Comprehensive Solutions for Every Question Handpicked from Elite Universities Verified for Academic Excellence Mrs. Fields wants to know whether applying for the Part D low income subsidy will be worth the time to fill out the paperwork. What could you tell her? - -correct ans- -The Part D low income subsidy could substantially lower her overall costs. She can apply by contacting her state Medicaid office, or calling the Social Security Administration. Mr. Fitzgerald 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 ans- -He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means 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. 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. What could you tell her about the implications of such a decision? - -correct ans- -If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered. 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 ans- -In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Mrs. Fiore was in the Army for 35 years and is now retired. She has drug coverage through the VA. What issues might she consider with regard to whether to enroll in a Medicare prescription drug plan? - -correct ans- -She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the VA for the specific medications she needs and whether any additional benefits are worth the Part D premium costs. Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him? - - correct ans- -If the drug coverage he has is not 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 period to avoid the late enrollment penalty. Mr. Jenkins has coverage for medical services and medications through his employer's retiree plan. He is considering switching to a Medicare prescription drug plan because his retiree plan does not cover two important medications. What should he consider before making a change? - -correct ans- -If Mr. Jenkins drops his drug coverage through the retiree plan, he may not be able to get it back and he also may lose his medical health coverage. Since 1999, Mrs. Patel has had a Medigap policy that covers drugs. This year she received a letter from her Medigap insurer telling her that her Medigap drug coverage is not "creditable." She wants you to explain what this means and what she should do. What should you tell her? - - correct ans- -The letter is letting her know that her Medigap drug coverage is coverage that does not expect to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay. If she signs up for a Medicare prescription drug plan now, she may have to pay a premium penalty if her special enrollment period has expired. 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 with respect to her drug coverage? - -correct ans- - Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services' Marketing Guidelines to ensure he is compliant for which type of products? - -correct ans- -Medicare Advantage (MA) and Prescription Drug (PDP) plans Ordinarily, you obtain referrals from a third-party that initiates contact with potential clients and usually sets up appointments for you. How would the guidelines for marketing Medicare Advantage and Part D plans apply to this practice? - -correct ans- -Third parties may not make unsolicited calls, visits, or emails to Medicare beneficiaries in order to set up such appointments, or for any other reason related to the marketing of Medicare Advantage or Part D plans. You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To be in compliance with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plans? - - correct ans- -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. You have received an advertisement from a vendor who says they can provide you with an extensive list of publicly available e-mail addresses for individuals who are Medicare beneficiaries. In addition, one of your Medicare Advantage clients offered to share her e-mail address book with you so you could contact her Medicare-eligible friends. In considering these sources of leads, what rules must you be sure to abide by? - -correct ans- -You may send an e- mail to a beneficiary about Medicare Advantage plan information if the beneficiary provides his/her email address to the plan and agrees to receive e-mails from the plan. During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5-star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the correct statement to say to her? - -correct ans- -The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4-stars. During a sales presentation for a Private Fee-for-Service (PFFS) plan, which of the following points should you explain? - -correct ans- -That the beneficiary, not the plan, is responsible for the entire cost for services she obtains that are not medically necessary. Mr. Valesquez asked if the Private Fee-for-Service plan you have discussed is like Original Medicare or a Medigap supplement plan. What should you say about a Private Fee-for-Service (PFFS) plan to explain it to Mr. Valesquez? - -correct ans- -It is not Original Medicare and it works differently than a Medicare supplement plan. During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her? - -correct ans- - Tell her that the Medicare agency does not endorse or recommend any plan. 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 benefit package. What should you do to make sure your clients know about these pieces of information? - -correct ans- -You may present comparative information that has been created and approved by the Medicare agency (CMS), such as a print-out from the Medicare plan comparison website. You have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respect to meals? - - correct ans- -You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. Ordinarily, you provide clients who purchase various types of insurance products from you with a gift when they enroll and you let them know that they will receive it after their enrollment is complete. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan? - -correct ans- -You may not provide any gift or prize as an inducement to enroll. One of your colleagues argues that face-to-face meetings with potential enrollees should be required because they cannot make an appropriate decision with the minimal information that can be provided over the phone or in small brochures. How should you respond to this argument? - -correct ans- -This is incorrect. Brokers and agents cannot require face to face meetings in order to answer questions or enroll a Medicare beneficiary. Mr. Moreno's neighbor, Tom Smith, invited him to discuss Medicare Advantage (MA) and Part D plans that he sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Mr. Moreno tell agent Tom Smith about the kinds of food that can be provided to potential enrollees who attend the sales presentation? - -correct ans- -A meal cannot be provided, but light snacks would be permitted. Ordinarily, you provide clients who purchase various types of insurance products from you with a gift when they enroll and you let them know that they will receive it after their enrollment is complete. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan? - -correct ans- -You may not provide any gift or prize as an inducement to enroll. 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 at a cost of $200 to entertain attendees. Can he do this in a way that complies with guidance from the Medicare agency? - -correct ans- -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. You will be holding a sales event in the near future, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation? - -correct ans- -Gift cards or gift certificates of $15 or less that can be readily converted to cash. You are scheduled to give a sales presentation at a local senior center. At the beginning of the presentation, which of the following must you do? - -correct ans- -Clearly state that no obligation exists to enroll if a gift or prize is being offered. Ordinarily, you ask your clients for referrals to people they think would benefit from the products you offer. When selling Medicare Advantage or Part D products, how might you solicit referrals? - -correct ans- -You may solicit referrals from current MA and Part D enrollees and offer one thank you gift per member per year of less than $15, based on retail purchase price for the item, although you may not inform enrollees of the availability of the gift in your letter soliciting referrals. When soliciting referrals from current members of an MA or Part D plan, what may you do? - - correct ans- -You may request names and mailing addresses. to individuals who request information on how to contact you for further details on the plan(s) you represent. 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? - -correct ans- -You should tell your colleague no, because marketing representatives are not permitted to participate, in any way, in an educational event. Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual? - -correct ans- -The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. The Medicare agency has requested a list of contracted representatives from a Private Fee-for- Service (PFFS) plan that you represent. In this situation, what will the plan do? - -correct ans- - Plans will provide to the Medicare agency a complete list of all of their contracted representatives who are marketing PFFS products, and will authorize the agency to provide those names to state departments of insurance when they request it. With regard to the training you are currently taking, what involvement will CMS have in ensuring that it takes place? - -correct ans- -CMS will conduct oversight of plan training programs and plans must provide the agency with any information necessary for the agency to conduct such oversight. The Medicare agency requires all Medicare health plans that contract with marketing representatives to ensure that contracts address which of the following? - -correct ans- - Medicare health plans must include in all marketing representative contracts requirements to abide by all guidance from the Federal agency overseeing Medicare and all applicable state laws. Medicare health plans establish provisions in marketing representative contracts to ensure compliance with applicable laws and policies. If non-compliance occurs, CMS can penalize a plan in which of the following ways? - -correct ans- -CMS requires plan sponsors to create and complete a corrective action plan and may terminate a sponsor's contract. Mr. Quinn is a marketing representative who markets an MA plan. He is a very good speaker and was asked to make a presentation at a local event that was advertised as educational. He accepted the invitation and the MA plan reported the event to CMS. CMS' secret shopper attended the event and heard Mr. Quinn's sales presentation. Which of the following could CMS do? - -correct ans- -Require the MA plan to suspend marketing and enrollment for a period of time. Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted with regard to 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? - - correct ans- -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. Can marketing representatives request information from providers regarding Medicare beneficiaries with specific health conditions for marketing purposes? - -correct ans- -No, providers are legally prohibited from sharing such information Mrs. Weiss is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to? - -correct ans- -Yes. Mrs. Weiss must be entitled to Part A or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program. Mr. Saunders 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 ans- -He will have to enroll in Part B. Mr. Kelly wants to know whether he is eligible to sign up for a Private fee-for-service (PFFS) plan. What questions would you need to ask to determine his eligibility? - -correct ans- -You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if he lives in the PFFS plan's service area. Mr. Gonzalez is entitled to Part A, but has not yet enrolled in Part B. If he wants to enroll in a Private Fee-for-Service (PFFS) plan, what will he have to do? - -correct ans- -He will have to enroll in Part B prior to enrolling in the PFFS plan. Mrs. Brown 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 ans- -If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account, Mrs. Brown can do this. 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? - -correct ans- -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. 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 ans- -As long as she is able to 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. You are visiting with Mr. Tully and his daughter at her request. He has advanced Alzheimer's and is incapable of understanding the implications of choosing a Medicare Advantage or prescription drug plan. Can his daughter fill out the enrollment form and sign it for him? - -correct ans- -Mr. Tully's daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions. about turning it in. What should you tell him? - -correct ans- -You must tell him you are not permitted to take the form. If he sends the form directly to the plan, the plan will process the enrollment on the day the Annual Election Period begins. Mrs. Goodman enrolled in an MA-PD plan during the Annual Election Period. In mid-January of the following year, she wants to switch back to Original Medicare and enroll in a stand-alone prescription drug plan. What should you tell her? - -correct ans- -During the MA Disenrollment Period, from January 1 - February 14, she may disenroll from the MA-PD plan into Original Medicare and also may add a stand-alone prescription drug plan. Ms. Gardner is currently enrolled in an MA-PD plan. However, she wants to disenroll from the MA-PD plan and instead enroll in a Part D only plan and go back to Original Medicare. According to Medicare's enrollment guidelines, when could she do this? - -correct ans- -She may make such a change during the Annual Election Period that runs from Oct. 15 to December 7, or during the MA Disenrollment Period that runs from January 1 to February 14 of each year. 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 ans- -It is a time 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. Mr. Grace 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 ans- -If the SEP is for MA coverage, he will have one opportunity to change his MA coverage. Mrs. Gunner thought she was enrolling in a stand-alone PDP, but when she received her plan materials, she found out she was enrolled in a Private Fee-for-Service (PFFS) plan with drug coverage. She called her marketing representative for help. What should the marketing representative tell her? - -correct ans- -If she believes she received misleading information, she must contact 1-800-MEDICARE and, if she qualifies for a Special Enrollment Period, she can select a new option, which could include a different MA plan, a PDP, or Original Medicare Ms. Lee is enrolled in an MA-PD plan, but will be moving out of the plan's service area next month. She is worried that she will not be able to enroll in another plan available in her new residence until the Annual Election Period. What should you tell her? - -correct ans- -She is eligible for a Special Election Period that begins either the month before her permanent move, if the plan is notified in advance, or the month she provides notice of the move, and this period typically lasts an additional two months. Mr. Yoo's employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a Special Election Period. Mr. Yoo contacted you to find out more about what this means. What can you tell him? - -correct ans- -It means that he qualifies for a one-time opportunity to enroll into an MA-PD or Part D prescription drug plan. Mrs. Steeley has Original Medicare Parts A and B and has just qualified for her state's Medicaid program, so the state is now paying her Part B premium. Will gaining eligibility for this program affect her ability to enroll in a Medicare Advantage or Medicare Prescription Drug plan? - - correct ans- -Yes. Qualifying for this state program gives Mrs. Steeley access to a Special Election Period that allows her to make changes to her MA and/or Part D enrollment at any time. If Mr. Johnson gains the Part D low-income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan? - -correct ans- -He can enroll in or disenroll from a Part D plan at any time and the subsidy will apply to the plan he chooses. Mr. Charles, who is enrolled in a stand-alone Part D plan, receives the Part D low-income subsidy and just received a letter from the Social Security Administration informing him that he will no longer qualify for the subsidy? He is wondering if he can switch to a lower cost Part D plan. What should you tell him? - -correct ans- -He qualifies for a Special Election Period which begins the month he was notified of his loss and continues for two more months. This SEP allows him one opportunity to enroll into another PDP or an MA-PD. 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 ans- -Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment, but he should revaluate if he really wants to drop his employer coverage. You are completing a PFFS plan sale to Mr. Schmidt who is new to Medicare, and as you are finishing up, what should you tell him about next steps in the enrollment process? - -correct ans- -You need to get Mr. Schmidt's phone number and include it on the enrollment form because the plan must call him after you leave to ensure that he understood the nature of the PFFS plan he selected and to verify his intent to enroll. 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? - -correct ans- -Evidence of plan membership, information on how to obtain services, and the effective date of coverage. After a sales presentation, Mr. Brooks announces that he is ready to enroll in the plan you represent. He would like to know if he can have his plan premiums deducted from his Social Security check. What should you tell him? - -correct ans- -He may choose withholding from his Social Security check when he completes the enrollment form. Mrs. Austin 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? - -correct ans- -Coverage always begins on the first of July, or the first of January after a beneficiary enrolls, whichever comes first. Mr. Pintok is interested in joining a MA-PD plan and wants advice on which type would allow him to select or change his personal primary care physician. What can you tell him? - -correct ans- - He has a right to select or change his primary care provider from within the plan's network without interference. Mrs. Burton is in an MA-PD plan and was disappointed in 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 wouldn't continue to have to put up with such poor access to care. What could you tell her? - -correct ans- -She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment.