Understanding Medicare Advantage and Part D Plans, Exams of Advanced Education

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Mr.Gomez notes that a Private Fee for Service (PFFS) plan avaliable in his area has an attractive preminum. 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? - Correct Answer-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. Mrs. Lee is discussing with you the possibility of enrolling in a Private Fee- for Service (PFFS) plan. As part of that discussion, what should you be sure to tell her? - Correct Answer-PFFS plans may choose to offer Part D benefits but are not required to do so. 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? - Correct Answer- 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 apart of the PPO network. Mr. McTaggert notes that a Private Fee for-Service (PFFS) plan avaliable in his area has an attractive premium. He wants to know what makes them different from an HMO or a PPO. What should you tell him? - Correct Answer-Enrollees in a PFFS plan can obtain care from any provider in the US who accepts Original Medicare, as long as the provider has a reasonable opportunity to access the plan's terms and conditions and agrees to accept them. 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? - Correct Answer-He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Mr. Sinclar has diabetes and heart trouble and is generally satisified with the care he has just received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him? - Correct Answer-SNPs have special programs from enrollees with chronic conditions, like Mr. Sinclair and they provide prescription drug coverage that could be very helpful as well. Mrs.Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs.Davenport have regarding her MA plan during the next open enrollment season? - Correct Answer-She may remain in her ABC MA plan or enroll in a

Special Needs Plan (SNP) for individuals sufferinf from ESRD if one is available in her area. 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 SNP is likely to be most appropriate for him? - Correct Answer-C-SNP 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 curreny HMO plan requires him to do. What should you tell him? - Correct Answer-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. 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? - Correct Answer- 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. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? - Correct Answer-In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers who have a contractual relationship with the plan (except in emergency or where care is unavailable within the network) Mr.Greco is in excellent health, lives in his own home, and has aa 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 costs sharing amounts and Mr. Greco would like to join that plan. What should you tell him? - Correct Answer- SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikelt to qualify and would not be able to enroll in the SNP. Dr. Elizabeth Brennan does not contract with the PFFS plan but she accepts the plan's terms and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan charge? - Correct Answer-Dr. Brennan can charge Mary Rodgers 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 percent of the Medicare rate. 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.Lee is discussing with you the possibility of enrolling in a Private Fee-for-Service (PFFS) plan. As part of that discussion, what should you be sure to tell her? - Correct Answer-PFFS plans may choose to offer Part D benefits but are not required to do so. Which of the following statements is correct about 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. Mr. Davies is turning 65 next month. He would like to enroll in a Medicare health plan but does not want to be limited in terms of where he obtains his care. What should you tell him about how a Medicare Cost Plan might fit his needs? - Correct Answer-Cost plan enrollees can choose to receive Medicare covered services under the plan's benefits by going to plan network providers and paying plan cost-sharing or may receive services from non-network providers and pay cost-sharing due under Original Medicare. 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, but he should revaluate if he really wants to drop his employer coverage. When soliciting referrals from current members of an MA or Part D plan, what may you do? - Correct Answer-Enrollment period (SEP) for both MA and 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 providing him with new MA and Part D options. Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of misusing or abusing frequently abused drugs? I. Identifying at risk individuals by using criteria that includes the number of opioid prescriptions the beneficiary has and the number of prescribers who have written those prescriptions. II. Locking an at-risk beneficiary into one pharmacy III. Locking an at-risk beneficiary into one prescriber

IV. Increasing deductibles and copays for at-risk beneficiaries. - Correct Answer-FALSE Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawl 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-Any person who knowingly submits false claims to the Government is liable for five times the Governments damages caused by the violator plus a penalty. Mr. Chan is one of your clients and in excellent health. He is enrolled in a Medicare prescription drug plan rhat you represent. He recently heard about a Medication Therapy Management (MTM) program in which his friend is enrolled. What should you tell him? - Correct Answer-To be eligible for a MTM program, a Medicare beneficiary must have multiple chronic diseases, be taking multiple Part D prescription drugs, and likely to incur considerable drug costs Since 2004 Ms. Eisenberg has had a Medigap plan that provides soem drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her? - Correct Answer-The letter is to inform her that the drug coverage offered through her Medigap plan does not offer drug coverage that is a least comparable to that provided under the Medicare Part D prescription drug program. If she does not have such creditable coverage during periods when she is first eligible for the Part D program, she will face a premium penalty if she enrolls in a Part D plan at a later date 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 help beneficiaries cover coinsurance, co- payments, and/or deductibles for medically necessary services. Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for her services. What advice would you give her? - Correct Answer-Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. Mr. Alonso receives some help payinf for his two generic prescription drugs from his employer's retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him? - Correct Answer-He generally would pay a monthly premium, annual deductible, and per-prescription cost sharing. 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 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-They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when hr turns 56. He wants to understand the health care costs he might be expected if he were to require hospitalization as a result of an illness. In general terms, what could you tell him costs for impatient hospital services under Original Medicare? - Correct Answer-Under Original Medicare, there is a single deductible amount due for the first 60 days of any impatient hospital stay after which it converts into a per-day consurance amount through day 90. After day 90, he would pay a daily amount up to 50 days over his lifetime, after which he would be responsible for all costs. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplementsl Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy? - Correct Answer-Medicare Supplemental Insurance would help cover his Part A and Part B costs sharing in Original Fee for Service (FFS) Medicare as well as possibly some services that Medicare does not cover. 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? - Correct Answer-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. Agent Willis had several clients who disenrolled from the plans he represents during the AEP to try new Medicare Advantage plans. Agent Willis believes that the choices they made are not ideal for them and would like to get their business back during the Medicare Advantage Open Enrollment Period (MA-OEP). What can agent Willis do? - Correct Answer-He can call them to let them know that if they do not like their new plans, they can change back during the MA-CEP Mr. Hernandez is concerned that if he signs up for a Medicare Advantage plan, the health plan may, at some time in the future, reduce his benefits below what is available in Original Medicare. What should you tell him about his concern? - Correct Answer- Medicare Advantage plans must cover all benefits vailable under Medicare Part A and Part B. Many also cover Part D prescription drugs.

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 Answer- Part A, which covers hospital, skilled nursing facility, hospice, and the home health services, and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Health Plan before she starts looking specific plans. What could you tell her? - Correct Answer-Medicare Health Plans mau offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services. Mrs. Roberts has just received a new Medicare identity card in the mail. She is concerned that it is forgery since it does not have her Social Security number on it. What should you tell her? - Correct Answer-The card she received is valid, the change has been made to protect Medicare beneficiaries from identity theft and she should destroy her old card. 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 over age 65 are covered under Part A by virute of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. 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 wondering whether he can obtain coverage under Medicare. What should you tell him? - Correct Answer-After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. 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 penalty because he had continuous coverage under his employer's plan Mr. Denton is 52 years old and has recently been diagonosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him? - Correct Answer-He may sign up for Medicare at any time, however coverage usually begins on the fourth month after dialysis treatments start 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

Medicare taxes. What should you tell her? - Correct Answer-In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. 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 Answer-She should contact her state Medicaid agency to see if she qualifies forprograms that can help with Medicare costs for which she is responsible. Mrs. Pena is 66 years old, has coveerage under an employer plan and will retire next year. She heard she must enroll in Part B at the beginning of the yeear to ensure no gap in coverage. What can you tell her? - Correct Answer-She may enroll at any timr ehile she is covered under her employer plan, but she will have a special eight month enrollment period that differes from the standard general enrollment period, during which she may enroll in Medicare Part B Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollement in a Medicare health plan (Part C). What should you advise her to do before she will be able to enroll into a Medicare health plan - Correct Answer-In order to join a Medicare health plan, she also must enroll in Part B Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the part D low-income subsidy. Where might he turn for help with his prescription drug costs? - Correct Answer-Mr.Wu may still qualify for help in payinf Part D costs through his State Pharmaceutical Assistance Program For which of the following individuals would a Cost Plan be most appropriate? - Correct Answer-Ms. Baler who is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan premiums Which statement best describes PACE plans? - Correct Answer-It includes comprehensive medical and sovial service delivery systems using an interdisciplinary team approach in an adult day health center, supplemented by in-home and referral services 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 Health Plan? - Correct Answer-She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account plan 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 about a neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him? - Correct Answer-Beneficiaries should check with their employer or union group benefits adminstrator before changing plans to avoid losing the coverage they want to keep

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 Answer-Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participatinf providers 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? - Correct Answer-He could enroll in one of the MA plans that include perscription drug coverage or a Medigap plan and a stand-alone prescription drug plan Mr. Rivera has Qualified Medicare Beneficiary (QMB) eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) PPO plan. Later he sees an out-of-network doctor to receive a Medicare covered service. How much may the doctor collect from Mr. Rivera? - Correct Answer-The doctor may only collect from Mr.Rivera the cost sharing allowable under the state's Medicaid program. 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 Mrs. Chou likes a PFFS plan available in her area that does not offer 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. Mrs. Mulcahy is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her? - Correct Answer-Everyone who is entitled to 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 enrolling in a prescription drug plan Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll and 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 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 - Correct Answer-I, II, and III only Mrs. Lopez is enrolled in a Medicare Advantage cost plan. 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 standalone PDP Which of thr following statements about Medicare Part D are correct I. Part D plans must enroll any eligible beneficiary who applies regarldess of health status II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network 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 - Correct Answer-I, II,and III only Mr. Jacob understands that there is a standard Medicare Part D prescription 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 and cost sharing. How can you explain this to him? - Correct Answer-Medicare Part D drug plans may have different benefit structures but on average they must all be at least as good as good as the standard model established by the government 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? - Correct Answer-Medicare prescription drug plans are not permitted to cover the prescription medication the Vaughns are interested in under Part D coverage, however plans may cover them as 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 her prescriptions hat she has lost. How would you advise her? - Correct Answer-She may fill prescriptiond for covered drugs at non-network pharmacies but likely at a higher cost than paid at an in- network pharmacy All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a beneficiary incur for prescription drugs in 2018 under the standard coverage? - Correct Answer-Standard Part D coverage would require payment of an annual deductible of $435, 25% cost sharing between $435 and $4020 , and once

through the catastrophic coverafe threshold, the beneficiary pays either co-pays for generic and brand name drugs or co-insurance of 5% whichever is greater Which types of tools can Medicare Part D prescription drug plans use that affects the way their enrollees can access medication? - Correct Answer-Part D plans do not have to cover all medications. As aresult, their formularities, 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 prior authorization 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 Answer-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. Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year? - Correct Answer-Whena formulary change is in response to a drug's removal from the market 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 Mrs. Roswell is a new Medicare beneficiary and is interested in selecting a Medicare Part D prescription drug plan. She takes a number of medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her? - Correct Answer-Every Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90 day transition day period Mr. Shapiro gets by on a very small 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 avaliable to beneficiaries whose income and assets do not exceed annual limits specified by the government 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. 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 Answer-The Part D low income subsidy could substancially lower her overall costs she can apply by contacting her state Medicaid office or calling the Social Security Adminstration 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 with expenses 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 Answer-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 Answer-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 needs to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Mr. Rice 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 Answer-If Mr. Rice drips 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 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 Answer-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. 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. How would you advise him? - Correct Answer-Mr. Shultz should enroll in a Part D plan before he has a 63 day break in coverage in order to avoid a premium penalty 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 Answer-Medicare Advantage (MA) and Prescription Drug (pdp) Plans Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same requirements as the plans themselves. How should you respond to such a statement? - Correct Answer-Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules Your colleague works at a third-party marketing organization (TMO) and she said she did not need to take the Medicare training for brokers and agents or pass a test to market Medicare plans since her contract is with the TMO, not the plans that have the products she sells. What could you say to her? - Correct Answer-You could tell her she is wrong and that only agents selling employer/ union group plans are permitted an exemption from testing but some employer/union group plans are require testing to promote agent compliance with CMS marketing requirements You work for a company that has marketed Medigap products for many years. The company has added Medicare Advantage and Part D plans and you will begin marketing those plans this fall. You are planning what materials to use to easily show the differences in benefits, premiums, and cpst sharing for each of the products. What do you need to do with your materials before using them for marketing purposes? - Correct Answer-You must submit your materials to the plan you represent so CMS can review and approve the materials to ensure they are accurate Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong? - Correct Answer-Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC, MA plans are located You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation? - Correct Answer-YUou will not be able to represent any

Medicare Advantage or Part D plan until you complete the training and achieve an adequate score, although you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing You are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs. What should you keep in mind? - Correct Answer-You may request RSVPs, but you are not permitted to require contact information Next week you will be participating in your first "educational event" for prospective enrollees. In order 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 a social event and must not conduct a sales presentation or distribute or accept enrollment forms at the event. If you are to be in compliance 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 Which of the following is a correct statement about state laws as they pertain to marketing representatives - Correct Answer-Medicare health plans must comply with requests for information from state insurance departments investigating complaints about a marketing representative Youare working with a number of plans and community or organizers to sponsor an educational event. When putting together advertisements for this event, what should you do? - Correct Answer-You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event 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 Answer-You should tell your colleague no because participation in an educational event may not include a sales presentation. 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 this sales presentation, what must you do? - Correct Answer-Prior to conducting the presentation, obtain and document having obtained her permission to visit with interest in the specific products you will present. Agent Mary Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational in nature. 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" discussingplan- specific premiums is impermissible 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 appointment? - 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 Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you October 15. During the appointment, what are you permitted to do? - Correct Answer-You may provide her with the required enrollment materials and take her completed enrollment application 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 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 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 Ordinarily, you obtain referrals from a theid 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 Answer-Third parties may not make unsolicited calls to potential Medicare enrollees in order to set up such appointments, or for any other reason related to the marketinf of Medicare Advantage or Part D plans. Agent Martinez wishes to solicit Medicare Advantage prospects through the e-mail and asks you for advice as to whether this is possible. What should you tell her? - Correct Answer-Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided You are meeting with Mrs. Hall in her home. On herscope of appointment forms, she asked to discuss Medicare Advantage plans. During the meeting she asks to discuss a stand-alone prescription drug plan. She is leaving the next day to visit her family for a

week in another state so it is important for her to make a decision before she leaves. What must happen before that additional discussion can take place? - Correct Answer- Since Mrs. Hall specifically asked that you discuss the stand-alone Part D plan, you may do so as long as she signs a new scope of appointment first indicating that she wants to discuss the Part D 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 Answer-Tell her that the Medicare agency does not endorse or reccoment any plan Winthrop Brokerage wishes to place an advertisement in the local newspaper that says "We offer Medicare Advantage plans offered by AB Health and Top Choice Health. Contact us if you would like to learn more." Which of the following best describes the obligation(s) of Winthrop Brokerage regarding this advertisement? - Correct Answer- Winthrop Brokerage deos not need to submit the advertisement to CMS for approval because it does not include information about the plans' benefit structure, cost-sharing or information about measures or ranking standards 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 Answer-You may make comparisons between plans if you can support them by studies or statistical data and such comparisons are factually based ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees' protected health information (PHI) to market non-health related products such as life insurance and annuities. To do so it must obtain authorization from the enrollees. Which statement best describes the authorization process? - Correct Answer-Authorization may be obtained by directing a beneficiary to a website to provide consent as long as the website includes a mechanism for an electronic signature that is valid under applicable law 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 Answer-You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal 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 do not exceed $15 in retail value

One of your colleagues argues that it is better to focus your time and energy exclusively in 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 a discrimatory activity and a prohibited practice 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 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 Answer-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 $ Mr. Murphy is an agent. A neighbor invited him to discuss the Medicare Advantage (MA) and Part D plans he sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Mr. Murphy tell his neighbor about the kinds of food that can be provided to potential enrollees who attend the sales presentation? - Correct Answer-The neighnors may not provide a meal, but light snacks would be permitted. 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 Answer-Clearly, state that no obligations exist to enroll if a gift or prize is being offered. 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 Answer-Gift cards or gift certificates of $15 or less that can be readily converted to cash. You would like to market an 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 upir table, make marketing presentations, and accept enrollment applications only in common areas outside of where the patient waits for services from the pharmacists. You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her

concerns? - Correct Answer-Tell her that Meicare guidelines allow you to conduct marketing activities in common areas of a provider's facility Several agents with whom you work with are planning a sales event in your area. One agent plans on giving door prizes worth $5, refreshments valued at $8 per anticipated attendeel and coupon books with discounts worth $10. Since no gift or prize exceeds the $15 limit he believes his plan is acceptable. What should you tell him? - Correct Answer-He can give away more than one gift during a single event, but the aggregate retail value cannot exceed $ Your friend's mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him? - Correct Answer-You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request You have sought permission from a hospital to place brochures for your product in their gift shop and cafeteria. The hospital administration expresses some hesitation about allowing marketing in a health care facility. What should you tell them? - Correct Answer-Marketing in health care facilities is an acceptable practice, as long as it takes place in common areas where patients are not receiving or waiting to receive health care Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members? - Correct Answer-Market non-Medicare health related products such as dental insurance, to current memebers as permitted by HIPAA Privacy Rules 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 Answer-The plan may withhold commision, require retraining, report the misconduct to a state department of insurance or terminate the contract This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do? - Correct Answer-You may go ahead and call them We purchased books on health maintenance that we plan to give away to anyone attending one of our marketing presentations, regardless of whether they enroll in our plan. Becaue we purchased many these books, we were able to buy them at a cost of $14.99 per book. However, on the inside jacket the retail price is shown at $19.99. May we give these books away at our marketing presentation? - Correct Answer-No. The retail purchase price of the book is $19.99 which exceeds CMS's definition of nominal value

BestCare Health Plan has received a request from a state insurance department in connection with the investigation of several marketing representatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response? - Correct Answer-Cooperate with the state and supply requested information Medicare health plans establish provisions in marketinf 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 Answer-CMS requires plan sponsors to create and complete a corrective action plan and may terminate a sponsor's contract 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 Answer-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 a marketing representative take people to a casino or sponsor a bingo night at which the enrollee's earnings may exceed the $15 nominal value limit? - Correct Answer-No. The total value of the winnings may not exceed $15 and the winnings cannot be in cash or an item that may be readily converted to cash Listed below are some possible promotional items to encourage potential enrollees to attend marketing presentations. Are these types of promotions permissible?

• Light snacks (no meals)
• Day Trips
• Magazine Subscriptions
• Event Tickets
• Coupon Book (total value of discounts is less than $15) - Correct Answer-Yes. All these promotional items are permissible if thry are offered to everyone who attends the event, regardless of whether they can enroll and as long as the gifts have a retail value of $15 or less per marketing event. Cash gifts are prohitbited, including gift certificates and gift cards that can be readily converted into cash, regardless of the dollar amount Monica is an agent focused on serving seniors eligible for Medicare. As she reviews her records, she is trying to determine which of the following items are considered compensation. What do you tell her? I. Commissions II. Bonuses III. Mileage reimbursement IV. Referral fees - Correct Answer-I, II, and IV only

Can marketing representatives use providers to identify Medicare beneficiaries with certain illness or diseases for marketing purposes? - Correct Answer-No, not unless each individual has ocmpleted a HIPAA authorization that explicitly gives the provider authorization to disclose the individual's health care information for purposes of marketing (which is highly unlikely) Wendy Park becomes eligible for Medicare for the first time in July. With the help of Agent James Chan, she enrolls in FeelBetter Medicare Advantage plan with an effective date of July 1st. How will Agent Chan be compensated under CMS rules? - Correct Answer-FeelBetter will pay Agent Chan initial year compensation for the months of July through December. Renewal amounts will be paid starting in Januaray if Ms. Park remains enrolled the following year Alice is a marketing representative employed by a health plan. Betty is a captive agent of a health plan who markets to multiple plans and sponsors. Carl is a captive agent who markets to only one plan/sponsor. Denise is an independent agent who markets to different types of groups. Edward is an independent agent who markets only to employer and union groups. CMS marketing representative compensation rules generally apply to: - Correct Answer-Betty and Denise, but not Alice (the employee) or Carl or Edwards (to whom exceptions apply) Agent Lopez helps Ralph to enroll in Top Choice Medicare Advantage plan during the Annual Open Enrollment Period. Ralph's effective emrollment date is January 1st. Ralph disenrolls on February 12th because he did not understand that the plan did not cover services furnished by serveral of his longtime providers. Which of the following statements best describes the impact of Ralph's action upon Agent Lopez's compensation - Correct Answer-Agent Lopez'a entire compensation must be recouped because Ralph disenrolled within three months of enrollment Agent Higgins helps Mrs.O'Malley to entoll in AB Medicare Advantage (MA) plan during the annual Open Enrollment Period. Mrs.O'Malley's effective enrollment date is January 1st. Subsequently, Mrs.O'Malley disenrolls, on February 12th following a move outside the plan's service area. What impact will this have on Agent Higgins compensation? - Correct Answer-AB MA plan does not have to recoup Agent Higgins' compensation because she has moved away from its service area. Mrs. Walters 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 Answer-Yes Mrs. Walters must be entitled to Part A or enroll in Part B to be eligible for coverage under the Medicare presciption drug program. Mr. Sanchez 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 Answer-He will have to enroll in Part B

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 Answer-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. Berkowitz can do this 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 Answer-He will have to enroll in Part B prior to enrolling in a MA plan. 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 Answer-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. 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 Answer-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. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? - Correct Answer-He will have one opportunity to enroll in a Medicare Advantage plan Which of the following individuals is most likely to be eligible toin a Medicare Advantage or Part D Plan? - Correct Answer-Jose, a grandfather who was granted asylum and has worked in the United States for many years. Mrs. Kendrick 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 Roadmap to Enrollment Periods - Correct Answer-- Annual enrollment/disenrollment periods:

• Annual election Period (October 15- December 7) *Medicare Advantage Open Enrollment Period (MA-OEP) (January 1- March 31)

• Enrollment periods based on special circumstances:

• Initial election periods when beneficiary first eligible for Medicare
  • New beneficiaries who enroll in Medicare Advantage also have an MA-OEP that starts the month of entitlement to Part A and Part B.

• Special enrollment periods (SEPs) when special circumstances arise
• Continual open enrollment for institutionalized individuals

Ms. Claggett is sixty-six (66) years old. She has been covered under both Parts A and B of Original Medicare for the last six years due to her disability, has never been enrolled in a Medicare Advantage or a Part D plan before. She wants to enroll in a Part D plan. She knows that there is such a thing as the "Part D Initial Enrollment Period" 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-It occurs three months before and three months after the month when a beneficiary meets the eligibility requirements for Part B, so she will not be able to use it as justification for... Mr. Ford enrolled in an MA-only plan in mid November. On December 1, he calls you up and says that he has changed his mind and would like to enroll into an 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 prior to the end of the period will be the effective one as of January 1 Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D. What could you tell him? - Correct Answer-He is currently in the Part D Initial Enrollment Period (IEP), and during this time, he may make one Part D enrollment choice, including enrollment in a stand-alone Part D plan or an MA-PD plan When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice would you give her? - Correct Answer-She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA plan Mrs. Kumar would like her daughter, who lives in another state, to meet with you during the Annual Election Period to help her complete her enrollment in a Part D plan. She asked you when she should have her daughter plan to visit. What could you tell her? - Correct Answer-Her daughter should come in November Mrs. Goodman enrolled in a 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 Answer- During the MA Open Enrollment Period from January 1- March 31, she may disenroll from the MA-PD plan into Original Medicare and also may add a stand-alone prescription drug plan. A client want to give you an enrollment application on October 1 prior to the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him? - Correct Answer-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. 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 January 1 next year. What should you do? - Correct Answer-Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins. Ms. Gonzales decided to remain in Original Medicare (Parts A and B) and Part D during the Annual Enrollment Period (AEP). At the beginning of January, her neighbor told her about the Medicare Advantage (MA) plan he selected. He also told her there was an open enrollment period that she might be able to use to enroll in a MA plan. Mrs. Gonzales comes to you for advice shortly after speaking to her neighbor. What should you tell her? - Correct Answer-There us a MA Open Enrollment Period (OEP) that takes place between Januaray 1 and March 31, but Ms. Gonzales cannot use it because eligibility to use the OEP is available only to MA enrollees. 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 prior 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 prior to the start of the AEP. 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 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 Enrollment Period is beneficiary specific and results from events such as when the beneficiary moves outside of the service area. 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. Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Orifinal Medicare (Parts A and B) and a Part D prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard that there are certain MA plans that might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him? - Correct

Answer-If there is a special needs plan (SNP) in Mr. Wendt's area that specializes in caring for individuals with diabetes, he may enroll in the SNP at any time under a special enrollment period (SEP). 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 Answer-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. Rockwell, age 67, is enrolled in Medicare Part A, but because he continues to work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice that his employer is cutting back on prescription drug benefits, and as of June his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special enrollment periods (SEPs)? - Correct Answer-Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends on Septermber 1- two months agter the loss of creditable coverage. Which of the following individuals are likely to qualify for a special enrollment period (SEP) for both MA and 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, providing him with new MA and Part D options. - Correct Answer-II, III, and IV only If Mr. Johannsen gains the Part D low-income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan? - Correct Answer-He qualifies for a special enrollment period and can enroll in or disenroll from a Part D plan and the subsidy will apply to the plan he chooses. Mrs. Schneider 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 Answer-Yes. Qualifying for this state program gives Mrs. Schneider access to a Special Enrollment Period that allows her to make changes to her MA and/or Part D enrollment during the first 9 months of each calendar year beginning 2019. Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirements 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 out 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 enrollment 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. 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 Answer-It means that he qualifies for a one-time opportunity to enroll in an MA- PD or Part D prescription drug plan Mr. Roberts is enrolled in an MA plan. He recently suffered complications following hip replacement surgery. As a result, he has spent the last three months in Resthaven, a skilled nursing facility. Mr. Roberts is about to be discharged. What advice would you give him regarding his health coverage options? - Correct Answer-His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility. Mary Samuels recently suffered a stroke while visiting her daughter and grandchildren. As a result, Mary has been admitted to a rehabilitation hospital where she is expected to reside for several months. The rehabilitation hospital is located outside the geographic area served by her current Medicare Advantage (MA) plan. What options are available to Mary regarding her health plan coverage? - Correct Answer-Mary may make an unlimited number of enrollment requests and may disenroll from her current MA plan. 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 the Part D program, and Cost plans must accept enrollments during these periods. Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare's efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment site, which of the following must Phiona consider? I. If a legal representative is completing an electronic enrollment request, he or she must first upload proof of his or her authority. II. All data elements required to complete an enrollment request must be captured. III. The process must include a clear and distinct step that requires the applicant to activate an "Enroll Now" or "I Agree" type of button or tool. IV. The mechanism must capture an accurate time and date stamp at the time the applicant enters the online site. - Correct Answer-II and III only

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 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 meeting with Ms. Berlin and she has completed an enrollment form for a MA- PD plan you represent. You notice that her handwriting is illegible and as a result, the spelling of her street looks incorrect. She asks you to fill in the corrected street name. What should you do? - Correct Answer-You may correct this information as long as you add your initials and date next to the correction. 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 Answer-Mr. Tully's daughter can do so only, if she is authorized under state law as a court appointed legal guardian, has a durable power of attorney for healthcare decisions, or is authorized under state surrogate consent laws to make health decisions. You are doing a sales presentation for Mrs. Pearson. You know that Medicare marketing guidelines prohibit certain types of statements. Apply those guidelines to the following statements and identify which would be prohibited. - Correct Answer-"If you're not in very good health, you would probably do better with a different product." Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He found a stand-alone Medicare prescription drug plan in his area that offers better coverage than that available through his MA-PD plan and in addition has a low premium. It won't cost him much more and, because he has the means to do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan. What should you tell him? - Correct Answer-If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard? - Correct Answer-Implying that only seniors can enroll in a Medicare Advantage plan when meeting with Mr. Hernandez who is 58, but qualifies for Medicare because he is disabled. 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 record 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