Understanding Medicare Advantage and Part D Plans, Exams of Health sciences

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Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him? - - correct ans- - Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? - - correct ans- - 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). 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? - - correct ans- XXXIt must obtain a HIPAA complaint authorization from an enrollee that indicates the plan or plan sponsor may use their information for marketing purposes. Mr. Yoo's employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a Special election period. Mr. Yoo contacted you to find out more about what this means. What can you tell him? - - correct ans- - It means that he qualifies for a one-time opportunity to enroll in an MA-PD or Part D prescription drug plan.

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? - - correct ans- - 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. Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover? - - correct ans- - Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. 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? - - correct ans- - A meal cannot be provided, but light snacks would be permitted. 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 ans- - Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facility. 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 ans- 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. 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 ans- - If the Medicare Advantage plan is a Private

Feefor-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. Which of the following is/are most likely to be characterized as an involuntary 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. - - correct ans- - I, II, and III only Ms. Brooks has an aggressive cancer and would like to k - - correct ans- - Medicare covers hospice services and they will be available for her. You are working several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do? - - correct ans- - You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. 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. - - correct ans- - I and II, only

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? - - correct ans- - 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. Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to Medicare beneficiaries? - - correct ans- -. Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots. 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-Service (PFFS). She wants to know if this would be available to her. What should you tell her about PFFS plans? - - correct ans- - 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. 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? - - correct ans- - 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. 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? - - correct ans- - She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. 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? - - correct ans- - He qualifies

for a special election period and can enroll in or disenroll from a Part D plan once during that period. Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him? - correct ans- - If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy? - - correct ans- - Medicare Supplemental Insurance would help cover his Part A and Part B deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover. 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 marketing requirements as the plans themselves. How should you respond to such a statement? - - correct ans- - 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. You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA) plans you represent. Before you conduct such sales presentations, what must you do? - correct ans- - You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in-home presentation. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - - correct ans- - Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies.

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 ans- - Her daughter should come in November. Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members? - - correct ans- - Market non-health related items or services such as life insurance or annuities policies to current members as permitted following HIPAA Privacy Rules. Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that plan. What should you tell him? - - correct ans- - SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. Mrs. Mulcahy, age 65, 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 ans- - An individual 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. 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 ans- - This could be considered discriminatory activity and a prohibited practice. Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was disappointed with the service she received from her primary care physician because she was

told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she would not have to put up with such poor access to care. What could you tell her? - - correct ans- - She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. 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 ans- - 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. What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? - - correct ans- - Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization. Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him? - - correct ans- - It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare. 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 on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special election periods (SEPs)? - - correct ans- - Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends on September 1- two months after the loss of creditable coverage. 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 ans- - You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion.

Mr. Alonso receives some help paying 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 ans- - He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing. Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through massage therapy. She is concerned about whether or not Medicare will cover these items and services. What should you tell her? - - correct ans- -. Medicare does not cover massage therapy, or, in general, glasses or dentures. Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her? - - correct ans- - She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period after the last month on her employer plan that differs from the standard general enrollment period, during which she may enroll in Medicare Part B. 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 ans- - To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed? - - correct ans- - Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage.

Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? - - correct ans- Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs. Mr. Davis is 52 years old and has recently been diagnosed 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 ans- - He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has but replace her existing Medigap plan with one that provides drug coverage. What should you tell her? - - correct ans- - Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan. 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 ans- - She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible. 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 services. What advice would you give her? - - correct ans- - Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. 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

ans- - 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. Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of 15 employees and offers employersponsored 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? - correct ans- - 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 employersponsored group health plan. 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 ans- - 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. 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 ans- - After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. 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 ans- - 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. 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? - - correct ans- - 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. 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 ans- - 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. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In midFebruary 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?

• • correct ans- - 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. 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 ans- - C-SNP Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? - - correct ans- - Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? - - correct ans- - You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.

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 ans- - 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. Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? - - correct ans- - Mrs. Chi may enroll in a MS MSA plan and remain in her current standalone Part D prescription drug plan. 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 ans- - He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. 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 ans- - Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state's Medicaid program. 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? - - correct ans- - 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. 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 ans- He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. 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 ans- - They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do? - - correct ans- - He will have to enroll in Part B. 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? - - correct ans- - 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. 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 ans- - 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.

Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? - - correct ans- -. Jose, a grandfather who was granted asylum and has worked in the United States for many years. 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 ans- - He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. 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. - - correct ans- - I, II, and III only Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him? - - correct ans- - In general, he must select a single Part D premium payment mechanism that will be used throughout the year. 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? - correct ans- - 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. Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen to her drug coverage? - - correct ans- -. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Mr. 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 ans- - 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. 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 ans- - Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan's formulary he takes several other medications. These include a prescription drug not on his plan's formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say? - - correct ans- - 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.

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? - - correct ans- - Standard Part D coverage would require payment of an annual deductible, 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%. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her? - - correct ans- - If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. 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 ans- - Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. You have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respect to meals? - correct ans- - You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her? - - correct ans- - Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. Melissa Meadows is a marketing representative for Best Care which has recently introduced a Medicare Advantage plan offering comprehensive dental benefits for $15 per month. Best Care has not submitted any potential posts to CMS for approval. Melissa would like to use the power of social media to reach potential prospects. What advice would you give her? - - correct ans- - As soon as CMS approves Best Care's social media posts, Agent Meadows could post a tweet stating

that "Best Care offers an array of Medicare Advantage benefit packages. One might be right for you. Call me to find out more!" Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual? - - correct ans- - The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel? - - correct ans- - During the MA-OEP, Miguel can have one-on-one meetings with beneficiaries who have requested such meetings Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational? - - correct ans- - Yes. When an event has been advertised as "educational," discussing plan-specific premiums is impermissible. Next week you will be participating in your first "educational event" for prospective enrollees. To be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage? - - correct ans- - You should plan to ensure that the educational event is an informative event and must not conduct a sales presentation or distribute or accept enrollment forms at the event. 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 ans- - Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located.

You will be holding a sales event soon, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation? - - correct ans- - Gift cards or gift certificates of $15 or less that can be readily converted to cash. You are 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 ans- - You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score. However, you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing. During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her? - - correct ans- Tell her that the Medicare agency does not endorse or recommend any plan. 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 ans- - You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request. 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 on October

15. During the appointment, what are you permitted to do? - - correct ans- - You may provide her with the required enrollment materials and take her completed enrollment application. Mrs. Schmidt is moving and a friend told her she might qualify for a "Special election period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a special election

period is. What could you tell her? - - correct ans- - It is a period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically the Special election period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area. 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 ans- - You may correct this information as long as you add your initials and date next to the correction. Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? - - correct ans- - He will have one opportunity to enroll in a Medicare Advantage plan. Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Original 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 certain MA plans 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 ans- - 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 election period (SEP) A client wants to give you an enrollment application on October 1 before 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 ans- - You must tell him you are not permitted to take the form. If he sends the form directly to the plan, the plan will process the enrollment on the day the Annual Election Period begins. Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs.

Young complete the application together before she leaves. He will then submit the paper application before the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams? - - correct ans- - This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form before the start of the AEP. 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 ans- - His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility. 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 ans- - 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. Mr. and Mrs. Nunez attended one of your sales presentations. They've asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do? - - correct ans- - As long as she can do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time. Mrs. Margolis contacts you in August because she will become eligible for Medicare for the first time in November. She would like to meet and discuss plan choices with you. What advice should you give her? - - correct ans- - Tell her to wait until October to discuss plan choices with you so that you can share plan benefits for the current year as well as any changes for the following year that may impact her choice. Mr. White has Medicare Parts A and B with a Part D plan. Last year, he received a notice that his plan sponsor identified him as a "potential at-risk" beneficiary. This month, he started receiving assistance from Medicaid. He wants to find a different Part D plan that's more suitable to his current prescription drug needs. He believes he's entitled to a SEP since he is now a dual eligible.

Is he able to change to a different Part D plan during a SEP for dual eligible individuals? - - correct ans- - No. Once he is identified by the plan sponsor as a "potential at-risk" beneficiary, he cannot use the dual eligible SEP to change plans while this designation is in place. Mrs. Reeves is newly eligible to enroll in a Medicare Advantage plan and her MA Initial Coverage Election Period (ICEP) has just begun. Which of the following can she not do during the ICEP? - correct ans- - She can enroll in a Medigap plan to supplement the benefits of the MA plan that she's also enrolling in. 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 ans- - If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. Ms. Stein retired when she was 66 but did not enroll in Medicare Part B after her group coverage ended because she was healthy and thought her Part A benefit would cover catastrophic costs. Ms. Stein is now 72 and wants to get {art B because her doctors bill, lab tests and vaccines are getting very expensive. Ms. Stein will have to pay the monthly Part B premium plus an additional 10 percent for each 12 month period since her group coverage ended. This obligation will continue as long as she has Part B unless she qualifies for extra help with her Medicare bills. - correct ans- - Example Mr. O'Hare, who is 70 and does not have Part B, is retired, but he has health coverage through his wife's current employer. Mr. O'Hare decides to get Part B while the group coverage is in effect or within 8 months after his last month of group coverage, he can do so without incurring a late enrollment penalty. - - correct ans- - Example Ms. Smith wishes to buy a Medigap plan. She became Medicare eligible in June 2019. She tells her agent that she wants the most comprehensive coverage she can get that would also cover emergencies when she travels outside of the United States. Her agent wisely suggests Plan F without a deductible for her. - - correct ans- - Example

Mr. Young is interested in switching to a PFFS plan because his primary care physicial (PCP) no longer participates in his HMO. His PCP is not in the PFFS plan's network. Mr. Young should ccall his PCP beford he enrolls to make wure she is willing to see patients enrolled in the PFFS plan. - correct ans- - Example Mr. Walsh is a Qualified Medicare Beneficiary (QMB). He enrolls in a Medicare Advantage HMO. Mr. Walsh goes to his primary care doctor to receive a Medicare covered service. The normal copayment is $25.00. The doctor may only collect from Mr. Walsh any minimal cost sharing allowable under the state Medicaid program. - - correct ans- - Example Mr. Page is enrolled in a MA PPO. He did nor choose Part D coverage through the PPO. Now he wishes to enroll in a stand-alone PDP. Mr. Page cannot enroll in a PDP because he can only get Part D coverage through his PPO. - - correct ans- - Example Ms. Smith is enrolled in a PDP. She wishes to enroll in an MA MSA plan. Ms. Smith can remain enrolled in her PDP because MSA plans do not offer Part D coverage. - - correct ans- - Example Ms. Singh just become eligible for Medicare. However, she is not eligible for premium-free Part A. She has chosen not to pay the premium to obtain Part A but will enroll in Part B. She asks her broker whether she can get coverage for her prescription drugs as well. Her broker correctly advises her that she is eligible to enroll in Part D and any choose among the free-standing PDPs available in the area in which she lives. - - correct ans- - Example Mr. Bradley has Medicare FFS with a PDP. The PDP offers excellent low-cost coverage for the prescription drugs Mr. Bradley takes, and he would like to remain enrolled in it. However, Mr. Bradley is interested in enrolling in a Medicare Advantage plan to obtain additional coverage of the Medicare out-of-pocket amounts. To accommodate Mr. Bradley's wishes, his broker should help Mr. Bradley explore PFFS plans that do not include Part D and MSAs. - - correct ans- - Example Ms. James is enrolled in a PDP with no monthly premium. She takes 3 prescription drugs with a total cost of $4000 annually. Ms. Baker pays $1360 for her drugs ($4000 (total drug cost) - $480 (deductible) = $3520 x .25 (initial coverage cost sharing percentage) = $880 + $480 (deductible) =

$1360. - - correct ans- - Example Mr. Bingham is enrolled in a PDP with a $0 deductible and a $50 per month premium. His copayment for generic drugs is $5 and for a brand name is $25. Mr. Bingham takes several maintenance drugs. Two are generic and two are brand names. Mr. Bingham's annual drug cost is $1320. (2 generic drugs = $10/mo.) + (2 brand name drugs = $50/mo.) x 12 months = $720. In addition, Mr Bingham will pay $600 in premiums per year ($50 x 12 months). - - correct ans- Example Mr. Reynolds takes several formulary drugs which have a total cost of $4000 per year. He uses a Health Reimbursement Arrangement (HRA) funded by his employer to pay his deductible and cost-sharing. Only the manufacturer discount for brand anme drugs purchased in the coverage gap count towards TrOOP (i.e. 70% of the cost of those drugs). No costs that Mr. Reynolds pays for with HRA funds count. - - correct ans- - Example To address her acid reflux, Ms. Lopez has been taking a formulary drug and an over-the-counter medication. Only the amount Ms. Lopez pays for the formulary drug counts toward Ms. Lopez's out-of-pocket costs. - - correct ans- - Example Mr. Russell did not sign up for Part D when he first became eligible because he had creditable coverage through his employer. Mr. Russell retired two years ago and lost his prescription drug coverage on the date he officially retired. He can no longer afford his prescription drugs and has approached a broker about enrolling in a Part D plan. His broker advised him that the advertised premiums for the plans he is considering could be substantially increased because he has not had creditable coverage for two years and might be subject to a late enrollment penalty of 24%. His broker wisely directed him to the Social Security Administration (SSA) to see if he is eligible for the low-income subsidy. The SSA confirmed his eligibility allowing him to avoid the financial penalty. - - correct ans- - Example Mr. Smith did not enroll in Part B or D when he became eligible because he had comprehensive health and drug coverage through his wife's employer. As a result of divorce, he lost eligibility for employer payment for the coverage and chose not to pay the COBRA premiums because they were too high. He enrolled in a Part B immediately upon losing the employer coverage, but 6 months later has realized that it does not cover his substantial drug costs. He is interested in

enrolling in Part D. He is not eligible for a low-income penalty. Mr. Smith will pay a premium penalty of 1% for each month he was without creditable coverage. - - correct ans- - Example Mr. Patterson recently moved out of the service area of his MA-PD and had to enroll in a new MA- PD plan. One if the drugs that Mr. Patterson was prescribed is not on the new plan's formulary. When Mr. Patterson's current supply of the drug runs out, he can get at least another month of his drug covered as long as he requests a refill within 90 days of his new coverage. If Mr. Patterson wishes to see if the plan will continue coverage of this drug, he should work with his prescribing physician to request a formulary exception. - - correct ans- - Example Mr. Cooley changed PDPs during open enrollment. When he went to have his prescription refilled, he was informed that the drug he takes is subject to step therapy requirements under his new PDP plan (that is, a requirement to try a lower-cost drug first, before his drug would be covered). Mr. Cooley can get at least a one-month refill of his drug covered without trying the lower-cost drug as long as it is within 90 days of his change in coverage. - - correct ans- - Example Agent Watson hands out flyers for his Insurance agency at a senior expo. The brochures state that his agency can help seniors find the health plan that is correct for them and lists the eight different Medicare Advantage organizations with which his agency contracts. The flyer also includes a telephone number that beneficiaries can call if they would like additional information. This activity is communication only and not marketing. - - correct ans- - Example Agent King is employed by an agency under contract with HealthMax health plan, a Medicare Advantage organization that offers plans in multiple states. The agency maintains a website marketing the Medicare Advantage plans with which it has contracts. Agent King follows up with individuals who request more information about HealthMax via the agency's website and tries to persuade them to enroll in HealthMax. Agent King is a marketing representative of HealthMax. Thus, he must be licensed and appointed in every state in which beneficiaries to whom he markets HealthMax are located. He may not submit enrollment applications or receive commissions for enrollees residing in states in which he is not licensed and appointed. - - correct ans- - Example

Agent Jackson is involved in a health fair that offers a raffle. After the fair, Agent Jackson takes the telephone numbers on the raffle entries and calls each individual to see if they would be interested in discussing MA plans. Agent Jackson has violated the prohibition on unsolicited contacts. - - correct ans- - Example Agent Lopez's aunt tells him that her neighbor was recently telling her that she was having trouble understanding her Medicare choices and wanted to know if it made sense to enroll in an MA plan. His aunt offers the neighbor's telephone number, but agent Lopez gives his aunt his card and says that the neighbor should call him. Agent Lopez has wisely avoided marketing an unsolicited call based on a referral. - - correct ans- - Example The Super Agency puts out pretzels, chips, cookies, and soda during its marketing seminar to promote the MA plans it represents. Such food offerings qualify as light snacks, which may be offered at marketing events. - - correct ans- - Example To promote an early morning marketing seminar, Super Agency provides pastries, muffins, bagels, cream cheese, yogurt, fruit, juice, and coffee. Super Agency has bundled several items that might have been considered snacks as a continental berakfast (i.e., a meal), which is prohibited at a marketing event, but allowable at an educational event if they meet nominal value requirements.

• • correct ans- - Example If an agency wishes to place an ad in a newspaper that says "We sell Medicare Advantage plans offered by BestHealth and TopChoice. Contact us if you would like to learn more," the ad would not be subject to CMS review/approval requirements. (It does not include marketing content such as inforamtion about the plans's benefit structure or cost sharing or information about measuring or ranking standards). - - correct ans- - Example Agent Snyder is excited about the 2022 Medicare Advantage plan that will be offered by FabulousCare. She would like to send out a tweet stating, "Call me to learn more about FabulouCare's Medicare Advantage Plan offering comprehensive dental benefits at only $10 per