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 Final Exam |LATEST VERSION |NEW UPDATE |GUARANTEED PASS|2024-2025 |BEST STUDYING MATERIAL WITH 100+ QUESTIONS 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. - ANSWER d. Since Mr. Peters requested a description of the Part D plan, his agent must discuss both the Part D and the MA-PD plans and return after at least 48 hours to complete the Part D plan enrollment form with Mr. Peters. Question9 - ANSWER Marks: 1 - ANSWER 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? - ANSWER Choose one answer. - ANSWER - ANSWER a. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. - ANSWER b. As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding should begin, he can change his method of Part D premium payment and withholding will begin the month after his savings account is exhausted. - ANSWER c. During 2017, many people experienced significant problems with deductions from their Social Security check for their Part D premium. As a result, this method of payment is no longer an option for Part D premium payments - ANSWER d. In general, to pay his Part D premium, he only can have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals. Question10 - ANSWER Marks: 1 - ANSWER Since 2004 Ms. Eisenberg has had a Medigap plan that provides some 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? - ANSWER 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. 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 - ANSWER a. So long as the hospital or its physician staff don't object, marketing anywhere in the hospital is an acceptable practice. - ANSWER b. As long as the marketing activities are conducted in a way that does not target healthy beneficiaries, it does not matter where in the hospital these activities are carried out. - ANSWER c. Marketing in health care facilities is an acceptable practice, regardless of where it takes place. - ANSWER d. 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. Question15 - ANSWER Marks: 1 - ANSWER Mrs. Disraeli is enrolled in Original Medicare (Parts A and B) and a standalone Part D prescription drug plan. She has recently developed diabetes and has suffered from heart disease for several years. She has also recently learned that her area is served by a SNP for individuals suffering from such a combination of chronic diseases (C-SNP). Mrs. Disraeli is concerned however, that she will have few rights or protections if she enrolls in a C-SNP. How would you respond? - ANSWER Choose one answer. - ANSWER - ANSWER a. The SNP would select her primary care provider (PCP) but she could file a grievance within 90 days if the PCP proved incapable. - ANSWER b. Mrs. Disraeli would have substantial restrictions on obtaining emergency care and must use network facilities or be responsible for most emergency care costs. - ANSWER c. Enrollees, while able to select their primary care provider (PCP), do have substantial restrictions and financial responsibilities regarding emergency care whether obtained at in-network or out-of-network facilities. - ANSWER d. Enrollees in SNPs must have access to provider networks that include enough doctors, specialists, and hospitals to provide all covered services necessary to meet enrollee needs within reasonable travel time. Question16 - ANSWER Marks: 1 - ANSWER Mr. Lopez takes several high-cost prescription drugs. He would like to enroll in a standalone Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan can he enroll? - ANSWER Choose one answer. - ANSWER - ANSWER a. Medicare Advantage (MA) HMO-POS plan that does not include drug coverage. - ANSWER b. Medicare Advantage (MA) PPO that does not include drug coverage. - ANSWER c. Medicare Advantage (MA) HMO that does not include drug coverage. - ANSWER d. Private Fee-for-Service (PFFS) plan that does not include drug coverage. Question17 - ANSWER Marks: 1 - ANSWER If a beneficiary is enrolled in a stand-alone prescription drug plan and wants to keep that plan, what type of Medicare health plan could the individual also enroll 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. Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program. - ANSWER c. Mr. Wu may still qualify for help in paying for Part D costs through the Federal Pharmaceutical Assistance Program. - ANSWER d. Mr. Wu may still qualify for help in paying for Part D costs through the local Office of the Aging. Question22 - ANSWER Marks: 1 - ANSWER Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is interested in that product. She wants to be sure she also has coverage for prescription drugs. Would she be able to obtain drug coverage if she enrolled in the SNP? - ANSWER Choose one answer. - ANSWER - ANSWER a. Yes. All SNPs are required to provide Part D coverage for prescription drugs. - ANSWER b. Yes, but only if she qualifies for Part D prescription drug coverage under her state Medicaid program. 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 - ANSWER a. Because he is moving outside of the service area, the plan must automatically disenroll him. He will have a special election period to select a new plan. - ANSWER b. Since he is moving before the Annual Election Period, he will need to continue using the prescription drug plan but should get his prescriptions filled through the plan's mail order service. - ANSWER c. He can keep his plan indefinitely because prescription drug plans must be available to all beneficiary's regardless of where they live. - ANSWER d. Since he is moving before the Annual Election Period, he should request an exception to continue using the plan for several more months until the AEP when he can enroll in a new plan. Question31 - ANSWER Marks: 1 - ANSWER 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? - ANSWER Choose one answer. - ANSWER - ANSWER a. He can call them to let them know that if they do not like their new plans, they can change back during the MA-OEP. - ANSWER b. He can e-mail them in January and ask them to let him know if they are not happy with their new plans. - 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 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 You are doing a sales presentation for Ms. Duarte and her son. Ms. Duarte has some cognitive impairment and her son informs you that he has power of attorney to make financial decisions for her. Can he execute the enrollment for her? - ANSWER Choose one answer. - ANSWER - ANSWER a. No, he cannot execute the enrollment for her. He must have a legal authorization, under state law that explicitly allows him to make health care decisions for his mother. - ANSWER b. Yes, he can execute the enrollment for her. A financial power of attorney is sufficient. - ANSWER c. Yes, he can execute the enrollment for her. He can do so because he is an immediate family member. No power of attorney is necessary. - ANSWER d. No, he cannot execute the enrollment for her. Only Ms. Duarte can sign the form, regardless of her mental capacities. Question37 - ANSWER Marks: 1 - ANSWER Mrs. Tanner is enrolled in a Medicare Advantage HMO that offers a point of service option. This allows Mrs. Tanner to do which of the following? - ANSWER Choose one answer. - ANSWER - ANSWER a. Mrs. Tanner can go to non-plan doctors without receiving prior approval for all services. - ANSWER b. Mrs. Tanner can go to non-plan doctors knowing that cost sharing will generally be the same as with network providers. - ANSWER c. Mr. Tanner can go to non-network doctors without worrying about a cap on the amount of out-of-network services she may receive. - ANSWER d. Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval. Question38 - ANSWER Marks: 1 - ANSWER 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? - ANSWER Choose one answer. - ANSWER - ANSWER a. Inpatient psychiatric services are not covered under Original Medicare. - ANSWER b. Medicare inpatient psychiatric coverage is limited to the same number of days covered for typical inpatient stays. - ANSWER c. Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. - ANSWER d. Medicare will cover, at its allowable amount, as many stays as are needed throughout Mr. Rainey's life, as long as no single stay exceeds 190 days. Question39 - 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 - 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 Eleanor takes several high-cost prescription drugs. She would like to enroll in a standalone Part D prescription drug plan that is available in her area. In what type of Medicare Health Plan can she enroll if she also wishes to enroll in the standalone Part D plan? - ANSWER Choose one answer. - ANSWER - ANSWER a. A Cost Plan only if it does not offer drug coverage. - ANSWER b. A MA PPO plan only if it does not offer drug coverage. - ANSWER c. A MA PPO plan that offers drug coverage if she chooses not to enroll in it. - ANSWER d. A Cost Plan that does not offer drug coverage or a Cost Plan that does offer drug coverage if she chooses not to enroll in it. Question44 - ANSWER Marks: 1 - ANSWER Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable income only sporadically. Her husband worked full-time throughout his long career. She has heard that to qualify for Medicare Part A she has to have worked and paid Medicare taxes for a sufficient time. What should you tell her? - ANSWER Choose one answer. - ANSWER - ANSWER a. She will have to obtain a job and work enough years to qualify for Medicare Part A. - ANSWER b. She will have to pay the monthly Part A premium in order to obtain the coverage. - ANSWER c. Because her husband paid Medicare taxes, and she rarely did, she will have to pay Part A premiums but will do so at a reduced rate. 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