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! 1 / 18 AHIP PREP EXAM Questions and Answers Latest Updates 2024 GRADE A+ 1. 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?: Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. 2. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him?: In 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 the network). 3. ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees' information to market non- health related products such as life insurance and annuities. Which statement best describes ABC's obligation to its enrollees regarding marketing such products?: XXXIt must obtain a HIPAA complaint authorization from an enrollee that indicates the plan or plan sponsor may use their information for marketing purposes. 4. Mr. Yoo's employer has recently dropped comprehensive creditable pre- scription 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?: It means that he qualifies for a one-time opportunity to enroll in an MA-PD or Part D prescription drug plan. 5. 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 treatment. How much may Dr. Brennan charge?: Dr. Brennan can charge Mary Rogers no more than 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. 6. 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?: Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. 7. Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales presentation?: A meal cannot be provided, but light snacks would be permitted. 8. You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns?: Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facility. 9. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them?: 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 Vaughn's could look into that possibility. 10. Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescrip- tion drug plan. Under what circumstances can she do this?: If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. 2 / 18 11. Which of the following is/are most likely to be characterized as an invol- untary disenrollment from a Medicare Advantage (MA) plan? I. The enrollee dies. II. An SNP enrollee loses special needs status due to substantially improved health. III. It is determined that the member is not lawfully present in the United States. IV. The member enrolls in another plan during the Annual Open Enrollment period.: I, II, and III only 12. Ms. Brooks has an aggressive cancer and would like to k: Medicare covers hospice services and they will be available for her. 13. You are working several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do?: You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. 14. Which of the following statement 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.: I and II, only 15. 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?: 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. 16. Mr. Xi will soon turn age 65 and has come to you for advice as to what ser- vices are provided under Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to Medicare beneficiaries?: . Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots. 17. During a sales presentation in Ms. Sullivan's home, she tells you that she has heard about a type of Medicare health plan known as Private Fee-for-Ser- vice (PFFS). She wants to know if this would be available to her. What should you tell her about PFFS plans?: A PFFS plan is one of the various types of Medicare Advantage plans offered by private entities and she may enroll in one if it is available in her area. 18. You have come to Mrs. Midler's home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical records available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan. What should you do?: You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has one of the conditions that would qualify her for a special needs plan. 19. 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?: She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. 20. Mr. Johannsen is entitled to Medicare Part A and Part B. He gains the Part D low-income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan?: He qualifies for a special election period and can enroll in or disenroll from a Part D plan once during that period. 21. 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?: 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. 22. Mr. Moy's wife has a Medicare Advantage plan, but he wants to under- stand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. 5 / 18 47. 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?: 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. 48. Juan Perez, who is turning age 65 next month, intends to work for sev- eral 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?: 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. 49. 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?: Part 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. 50. Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving dis- ability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him?: After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. 51. Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health 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?: Medicare 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. 52. 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?: 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. 53. 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?: Mrs. 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. 54. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan sev- eral years ago. 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 open enrollment season?: She may remain in her ABC MA plan, enroll in 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. 55. Daniel is a middle-income Medicare beneficiary. He has chronic bronchi- tis, 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?: - C- SNP 56. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?: Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. 57. 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?: You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. 58. Mr. Romero is 64, retiring soon, and considering enrollment in his em- ployer-sponsored retiree group health plan 6 / 18 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 con- sidering signing up for it. What should you tell him?: 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. 59. Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-in- come 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?: Mrs. Chi may enroll in a MS MSA plan and remain in her current standalone Part D prescription drug plan. 60. Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him?: He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. 61. Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might af- fect her access to services since she receives some assistance for her health care costs from the State. What should you tell her?: Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state's Medicaid program. 62. Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him?: He 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. 63. 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 prescription drug plan. What should you tell him about this situation?: He could enroll either in one of the MA plans that include prescrip- tion 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. 64. 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?: They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. 65. 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?: He will have to enroll in Part B. 66. 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. What could you tell her about the implications of such a decision?: If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and 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. 67. 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?: 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. 68. Which of the following individuals is most likely to be eligible to enroll in a Part D Plan?: . Jose, a grandfather who was granted asylum and has worked in the United States for many years. 69. 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?: He could check with the manufacturers of his medications to see if they offer an assistance program to help people with 7 / 18 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. 70. 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. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan.: I, II, and III only 71. 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?: In general, he must select a single Part D premium payment mechanism that will be used throughout the year. 72. 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, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has lost his employer group coverage within the last two weeks. How would you advise him?: 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. 73. 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?: . Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. 74. 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?: 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. 75. 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?: 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. 76. 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 for- mulary, 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?: 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. 77. 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?: Standard Part D coverage would require payment of an annual de- ductible, and once past the catastrophic coverage threshold, the beneficiary pays whichever is greater of either the co-pays for generic and brand name drugs or coinsurance of 5%. 78. 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?: If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. 79. Mr. Jacob understands that there is a standard Medicare Part D prescrip- tion drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums,