Understanding Medicare Advantage and Part D Plans, Exams of Nursing

Download Understanding Medicare Advantage and Part D Plans and more Exams Nursing in PDF only on Docsity! AHIP 2024 Final Exam Questions and Answers 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? - Answer a. 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. b. Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. - Answer Ms. Lopez is an independent agent under contract with MarketCo, a third-party marketing organization. MarketCo has a contract with BestCare health plan, a Medicare Advantage (MA) organization, to offer marketing services through its contracted agents and agencies. Ms. Lopez returns calls to individuals who contact MarketCo in response to its mailers promoting BestCare health plan. Which of the following best describes the responsibilities of Ms. Lopez? a. Ms. Lopez is considered a marketing representative of BestCare but is exempt from the marketing rules regarding approved call scripts because she works directly for MarketCo. b. Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. c. Ms. Lopez no longer needs to be concerned about state licensure since she is marketing an MA product subject to federal rules. d. Ms. Lopez needs to maintain state licensure, but because she is working for a third-party marketing organization she is exempt from CMS training requirements that apply to BestCare captive agents. 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? - Answer a. He can do this because the estimated number of attendees is based on the venue size and response rate and the value of the gift does not exceed $15. 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? - Answer b. 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. Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a meeting so that she can learn about Medicare and the products you represent. How should you respond? - Answer c. Tell Julia that you will meet with her to explain Medicare and should she be interested you can accept and submit an enrollment request, since this is an initial enrollment qualifying her for a special enrollment period. 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 The doctor may only collect from Mr. Rivera the cost sharing allowable under the state's Medicaid program.may the doctor collect from Mr. Rivera? - Answer The doctor may only collect from Mr. Rivera the cost sharing allowable under the state's Medicaid program. 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? - Answer Choose one answer. - Answer - Answer a. A PFFS plan is a type of Medicare Supplement plan and she may enroll in one if it is available in her area. - Answer b. A PFFS plan is exactly the same as Original Medicare, only offered by a private entity and she may enroll in one if it is available in her area. Choose one answer. - Answer - Answer a. The letter is to inform her that her Medigap drug coverage must be supplemented by purchasing coverage under a Part D plan. If she does not do so within 63 days, she will not be able to obtain Part D coverage at a later date. - Answer b. The letter is to inform her that the drug coverage offered through her Medigap plan does not offer drug coverage that is at 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. - Answer c. The letter is to inform her that her Medigap plan's coverage has been determined by the Federal government to be inadequate and the plan must therefore discontinue offering such coverage. Ms. Eisenberg will have to select a different Medigap plan if she wants drug coverage. - Answer d. The letter is to inform her that Medicare Part D prescription drug coverage is available, but there is no need for her to change her drug coverage since it is just as good as Part D. She may keep her current coverage through the Medigap plan. Question11 - Answer Marks: 1 - Answer Richard is a licensed agent who represents Spartan Health Plan and its Medicare Advantage (MA) plans. Richard has several clients who have recently come to him for help who are in their initial coverage election period (ICEP) and are interested in enrolling in one of Spartan Health Plan's MA plans. Alice will soon turn 65 and retire. Alice has coverage through Spartan Health Plan offered by her employer. Bob had health coverage through Spartan but dropped the coverage when he retired early to travel overseas. Bob, who has just turned age 65, is now back in the United States. Charlotte, who will turn 65 next month, has coverage through Athena Health plan - a company Richard also represents. Who qualifies for the opt-in simplified enrollment mechanism? - Answer Choose one answer. - Answer - Answer a. Alice because she will not have a break between her non-Medicare and Medicare coverage through Spartan Health Plan. - Answer b. Alice and Charlotte because each of them currently have health coverage and is in their initial coverage election period (ICEP). - Answer c. Alice and Bob because each of them has had coverage through Spartan Health Plan. - Answer d. Alice, Bob, and Charlotte because electronic health record interoperability will allow Richard to access any needed information for their applications. Question12 - Answer Marks: 1 - Answer Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year? - Answer Choose one answer. - Answer - Answer a. When a formulary change is in response to a drug's removal from the market. - Answer b. When the Part D plan can demonstrate to CMS that no enrollee has accessed the medication in the past six months, generally the plan can remove the drug from its formulary within the first 60 days of the year. - Answer c. Under no conditions can a Medicare Part D prescription drug plan reduce its coverage for a given drug at any point during the year. - Answer d. If the Medicare prescription drug plan can show that reducing coverage early in the year will result in savings for the Part D plan and the Medicare program, generally the plan may make such a change. Question13 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer - Answer a. You may only contact the retirees after the employer has notified them that they will be receiving a call. - Answer b. You may call them but must record every call. - Answer c. You may go ahead and call them. - Answer d. You may not make any unsolicited contact with Medicare beneficiaries. The employer will have to tell its retirees to call you. Question14 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer Choose one answer. - Answer - Answer a. The beneficiary could only choose a Medicare Medical Savings Account (MSA) plan. - Answer b. The beneficiary could only stay in a stand-alone prescription drug plan if he or she has original fee-for-service Medicare - Answer c. The beneficiary could enroll in a private fee-for-service (PFFS) plan that does not include prescription drug coverage; an 1876 cost plan; or a Medicare Medical Savings Account (MSA) plan - Answer d. The beneficiary could only choose an 1876 Cost Plan. Question18 - Answer Marks: 1 - Answer Mrs. Sanchez lives in a state located near Canada. She has recently become eligible for Medicare and is considering enrollment in Part D prescription drug coverage. One of her friends has told her that she needs to be aware of something called TrOOP. What should you tell her when she asks you about TrOOP? - Answer Choose one answer. - Answer - Answer a. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include the annual deductible(s) and costs for drugs on the plan's formulary purchased at a plan's participating pharmacy. In some instances, amounts not directly paid by the enrollee (like manufacturer discounts) count toward TrOOP. - Answer b. TrOOP is calculated on a cumulative basis and consists of the sum of an enrollee's out-of- pocket deductibles from the date of his or her enrollment in Part D plus outlays for over-the-counter drugs. - Answer c. TrOOP is calculated on an annual basis and consists of an enrollee's out-of-pocket deductible plus any amounts paid on behalf of an enrollee by Medicaid. - Answer d. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include, in addition to the annual deductible, costs for drugs not on the Part D plan's formulary and drugs purchased outside the United States. Question19 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer - Answer a. Yes, but Mrs. Walters must drop the employer coverage prior to enrolling in a Medicare prescription drug plan. - Answer b. No. Mrs. Walters will have to enroll in Part B in order to qualify for enrollment into the Medicare prescription drug program. - Answer c. No. As long as her employer offers coverage that is equivalent to that available through Medicare, Mrs. Walters cannot enroll in a Medicare prescription drug plan. - Answer d. Yes. Mrs. Walters must be entitled to Part A or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program. Question20 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer - Answer a. A PFFS plan offering only medical benefits or a PFFS Medigap Supplemental Insurance plan. - Answer b. 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. - Answer c. A stand-alone prescription drug plan in combination with a PFFS plan or a PFFS Medigap Supplemental Insurance plan. - Answer d. 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 PFFS Medigap Supplemental Insurance plan. Question21 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer - Answer a. Mr. Wu has no alternative but to liquidate his remaining assets and apply for coverage through his state's Medicaid program. - Answer b. All that she needs to do is meet state licensure requirements moving forward. - Answer c. Melanie will need to do nothing to continue receiving renewal fees since the initial sale was made when she met all requirements. - Answer d. Melanie must remain trained, tested, licensed, and appointed, regardless of whether she is actively selling MA products. Question25 - Answer Marks: 1 - Answer Agent Chan is conducting a sales presentation on senior issues where he hopes to enroll some attendees in the Medicare Advantage (MA) plans he represents. What action(s) may Agent Chan take during the event? - Answer Choose one answer. - Answer - Answer a. Sell personal information obtained as part of a raffle to a third-party marketeer. - Answer b. Discuss plan specific information such as premiums and benefits. - Answer c. Indicate that in order participate attendees must provide their contact information. - Answer d. Conduct free health screenings as part of the event. Question26 - Answer Marks: 1 - Answer Mr. Decaro has looked at Medicare prescription drug plans available in his area and noted a wide range in premiums. He thought that all the drug plans were required to offer the same standard benefits and would like you to explain why there is such a range in premiums. What should you tell him? - Answer Choose one answer. - Answer - Answer a. Medicare permits plans that have the highest quality services to reduce their premiums below the standard amount in order to increase their market share. This accounts for the variation in premium amounts. - Answer b. Some prescription drug plans may have higher operating costs and/or may offer enhanced coverage in return for an additional premium amount. He could look at plan designs to see if one of the enhanced plans would serve his needs better than a plan based on the standard design. - Answer c. The premiums differ because some plans intend to market to sicker beneficiaries and have set their premiums to reflect expected greater costs. - Answer d. All drug plans must offer exactly the same coverage model. The difference in premium is a result of the differing financial estimates of the companies offering the plans. Question27 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer - Answer a. Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. - Answer b. Mrs. Duarte should file an appeal of this initial determination within 90 days of the date she received the MSN in the mail. If she still disagrees with Medicare Administrative Contractor's (MAC's) further decision she should request a reconsideration by a qualified independent party within 10 days. - Answer c. Mrs. Duarte has no right to appeal this determination since her claim has been partially paid. - Answer d. Mrs. Duarte should request a reconsideration of the decision by a qualified independent party within 60 days of the date she received the MSN in the mail. Question28 - Answer Marks: 1 - Answer Ms. Hernandez has marketed several different types of insurance products in her home state and has typically sought approval of her materials from her State Department of Insurance. What would you advise her regarding seeking such approval for materials she uses to market Medicare Advantage plans? - Answer Choose one answer. - Answer - Answer a. Obtaining approval of her materials from the State Department of Insurance is a good practice and she should continue it with materials for the Medicare health plans she represents. - Answer b. Materials for marketing Medicare health plans to individuals are subject to Medicare's uniform national requirements. They do not need to be reviewed by the state, but the company she represents must obtain approval from the Medicare agency (CMS) for any materials she uses. - Answer c. Materials need only be reviewed and approved by the company(s) she represents. - Answer d. States often volunteer to review marketing materials on behalf of the Medicare agency. She should check with her Department of Insurance to see if such a review is available and would satisfy CMS requirements. - Answer c. He can send them information about the MA-OEP along with a flyer on the plans he represents. - Answer d. He can wait until October and send them information about the plans he represents. Question32 - Answer Marks: 1 - Answer Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available 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? - Answer Choose one answer. - Answer - Answer a. If offered, beneficiaries can select a stand-alone Part D prescription drug plan (PDP) with an HMO or a PPO, but not with a PFFS plan. - Answer b. Enrollees in a PFFS plan can obtain care from any provider in the U.S. 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. - Answer c. PFFS plans are the same as Medicare supplement plans and he may obtain care from any provider in the U.S. - Answer d. If a PFFS enrollee shows his/her card when obtaining services from a provider who participates in Original Medicare, then that provider is required to accept the plan's terms and conditions. Question33 - Answer Marks: 1 - Answer This year you decide to focus your efforts on marketing to employer and union groups. Which of the following statements best describes what you can and cannot do in order to stay in compliance? - Answer Choose one answer. - Answer - Answer a. You do not need to complete a scope of appointment, but CMS can ask you to reconstruct one if there is a subsequent employee complaint. - Answer b. You can make unsolicited contacts but you cannot cross-sell other products. - Answer c. You do not need to take an annual test, but you must not provide potential enrollees with more than light snacks at presentations. - Answer d. You are not required to submit communication and marketing materials specific only to those employer plans to CMS at the time of use, but CMS may request and review copies if employee complaints occur. Question34 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer - Answer a. Tell the client that she cannot speak to her until after open enrollment begins on January 1st of the following year. - Answer b. 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. - Answer c. Solicit and complete the enrollment application in September and wait until the open enrollment date to submit it so that the client does not purchase a plan through another agent. - Answer d. Tell the client that she should also consider non-health products (such as cash value life insurance) to meet some of her health needs and offer to submit a life insurance application to see if client Jones is insurable. Question35 - Answer Marks: 1 - Answer Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him? - Answer Choose one answer. - Answer - Answer a. Part D prescription drug coverage can only be obtained by enrollment into a Medicare Advantage plan that also covers Part A and Part B services. - Answer b. 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. - Answer c. Mr. Singh must leave Original Medicare to receive drug coverage. - Answer d. Mr. Singh will have to enroll in Medicaid if he wishes to obtain prescription drug coverage through some means other than a Medicare Advantage plan. Question36 - Answer Marks: 1 - Answer Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug coverage. What should you tell her about obtaining drug coverage? - Answer Choose one answer. - Answer - Answer a. She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. - Answer b. She can enroll in the PPO and purchase drug coverage through a Medigap plan. - Answer c. She can enroll in the PPO and purchase drug coverage through a stand-alone Medicare Part D prescription drug plan. - Answer d. She can enroll in the PPO and if she decides that she wants drug coverage, she will be able to drop her PPO at any time in favor of a Medicare Advantage plan that includes such drug coverage. Question40 - Answer Marks: 1 - Answer Mr. Olsen is concerned that a Medicare Advantage plan will not cover the same range of services that would be covered under Original fee-for-service Medicare. What should you tell him? - Answer Choose one answer. - Answer - Answer a. Medicare Advantage plans are required to create a benefits package that results in roughly equivalent costs and may exclude coverage for some items and services that are covered under Part A and/or Part B of Original Medicare. - Answer b. Though their cost-sharing may differ from Original Medicare's, Medicare Advantage plans are required to cover all services covered by original Medicare. - Answer c. Medicare Advantage plans are required to cover services mandated under health care reform and applicable state law, which may differ from the Original Medicare package of benefits. - Answer d. Medicare Advantage plans differ from Original Medicare in that they are required to cover any service ordered by a physician. Question41 - Answer Marks: 1 - Answer Ms. Brooks has an aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her? - Answer Choose one answer. - Answer - Answer a. The Federal government facilitates competition between hospice programs to lower the price of their services for Medicare beneficiaries, but does not offer coverage for hospice services through the Medicare program. - Answer b. Medicare does not cover hospice services. Hospice services are only available through state Medicaid programs, if the state offers such coverage. - Answer c. Hospice services are currently only offered under a limited demonstration project. Whether they will eventually become available nationally depends on the outcomes of the demonstration. - Answer d. Medicare covers hospice services and they will be available for her. Question42 - Answer Marks: 1 - Answer Which of the following statements is correct about the appeal and grievance processes? - Answer I. Enrollees have a right to obtain a review (appeal) of certain decisions about prescription drug coverage. - Answer II. The grievance process is used for reviews of coverage decisions on plan benefits. - Answer III. Plans must provide a link to the Medicare.gov website where an enrollee can enter a complaint. - Answer IV. Enrollees have a right to file complaints (sometimes called grievances) about the quality of their care. - Answer Choose one answer. - Answer - Answer a. II and IV only - Answer b. I, III, and IV only - Answer c. I and III only - Answer d. I and II only Question43 - Answer Marks: 1 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer - Answer a. The neighbors may not provide a meal, but light snacks would be permitted. - Answer b. Any type of meal or food is allowed, as long as it is available to the general public and not just to those who are eligible to enroll in the plans. - Answer c. The neighbors may not provide anything to either eat or drink during the sales presentation. - Answer d. Any meal is allowed, as long as it is valued at less than $15. Question47 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer - Answer a. Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state's Medicaid program. - Answer b. Medicaid will cover all of her PFFS out-of-pocket costs and Medicaid providers will accept amounts paid by the PFFS plan as payment in full. - Answer c. Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. - Answer d. If Mrs. Andrews joins a PFFS plan, the State will not cover any of her medical expenses because she will be using only Medicare providers. Question48 - Answer Marks: 1 - Answer Alice is enrolled in a MA-PD plan. She makes a permanent move across the country and wonders what her options are for continuing MA-PD coverage. What would you say to her in regard to a special enrollment period (SEP)? - Answer Choose one answer. - Answer - Answer a. She is unlikely to qualify for a SEP but will be automatically covered by Original Medicare and a standalone Part D prescription drug plan. - Answer b. She is likely to qualify for a SEP. She can choose an effective date of up to three months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than the date of her permanent move. - Answer c. She is likely to qualify for a SEP. She can choose an effective date of up to six months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than 30 days prior to the date of her move. - Answer d. She is unlikely to qualify for a SEP and should remain on her current plan, relying on her current plan's out-of-network benefits. Question49 - Answer Marks: 1 - Answer Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him? - Answer Choose one answer. - Answer - Answer a. He is eligible for the Part D prescription drug benefit because he is entitled to Part A and he does not have to be enrolled in Part B. - Answer b. He need not be entitled to Part A or enrolled in Part B to be eligible for the Part D prescription drug benefit. He must only be aged 65 to qualify for enrollment in Part D, so he can go ahead and enroll in a Part D prescription drug plan. - Answer c. He will have to enroll in Part B before he can enroll in a Part D prescription drug plan. - Answer d. He does not have to enroll in Part B but, must pay a penalty for his failure to do so when he first turned 65. After that, he can enroll in a Part D prescription drug plan. Question50 - Answer Marks: 1 - Answer 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? - Answer Choose one answer. - Answer