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

Download Understanding Medicare Advantage and Part D Plans and more Exams Public Health in PDF only on Docsity! AHIP 2023 | 80 Questions With Solutions 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 may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. 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. 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. 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 - When possible, it is always the best option to have both the employer's plan and the MA- PD, so he would have no out-of-pocket expenses. 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 Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could you tell her? Correct Ans - Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services. Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollment in a Medicare Advantage plan (Part C). What should you advise her to do before she will be able to enroll in a Medicare Advantage plan? Correct Ans - To join a Medicare Advantage plan, she also must enroll in Part B. Which of the following statement(s) 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, II, and IV Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan? Correct Ans - All MSAs cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling in a separate prescription drug plan. Mrs. Walters is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Advantage (MA) plan? Correct Ans - She cannot enroll in an MA Medical Savings Account (MSA) plan 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? Correct Ans - She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her? Correct Ans - If she wants drug coverage and a PFFS plan, she could only enroll in a PFFS plan that includes Medicare prescription drug coverage 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 MA MSA plan and remain in her current standalone Part D prescription drug plan. 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 employer- sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employer-sponsored healthcare coverage. How would you respond? 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 Mrs. Fiore is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan? Correct Ans - She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution. 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. 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. 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. 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. 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. Mr. Schultz 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. Schultz 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. Roswell is a new Medicare beneficiary who has just retired from retail work. She is interested in selecting a Medicare Part D prescription drug plan. She takes a number of medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her? Correct Ans - Every Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90-day transition period. 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% 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. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him? Correct Ans - The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government 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. If you are to comply with Medicare's guidance regarding educational events, which of the following would be acceptable activities? Correct Ans - You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent. Agent Harriet Walker has recently begun marketing Medicare Advantage and related products aimed at meeting the needs of senior citizens. Client Mildred Jones has expressed interest in a Medicare Advantage plan. It is now the beginning of September. If you were in Agent Walker's position, what would you do? Correct Ans - 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. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan? Correct Ans - You may provide gifts or prizes to all potential enrollees during an event that does not exceed $15 in retail value. 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 for $200 to entertain attendees. Can he do this in a way that complies with guidance from the Medicare agency? Correct Ans - 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. You are meeting with Mrs. Hall in her home. On her scope of appointment form, she asked to discuss Medicare Advantage plans. During the meeting, she asks to discuss a stand-alone prescription drug plan. She is leaving the next day to visit her family for a week in another state, so it is important for her to make a decision before she leaves. What must happen before that additional discussion can take place? Correct Ans - Since Mrs. Hall specifically asked that you discuss the stand-alone Part D plan, you may do so, as long as she signs a new scope of appointment form first, indicating that she wants to discuss the Part D plan. BestCare Health Plan has received a request from a state insurance department in connection with the investigation of several marketing representatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response? Correct Ans - Cooperate with the state and supply requested information. You are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs. What should you keep in mind? Correct Ans - You may request RSVPs, but you are not permitted to require contact information. This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do? Correct Ans - You may go ahead and call them. Mrs. Kendrick is in good health, has worked for many years and is six months away from turning 65. She wants to know what she will have to do to enroll in a Medicare Advantage (MA) plan as soon as possible. What could you tell her? Correct Ans - She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B. Mrs. Johnson calls to tell you she has not received her new plan ID card yet, but she needs to see a doctor. What can she expect to receive from the plan after the plan has received her enrollment form? Correct Ans - Evidence of plan membership, information on how to obtain services, and the effective date of coverage. Mrs. Reynolds is in her Medicare initial coverage election period (ICEP) and the date of her entitlement to Part A and B has already occurred. Mrs. Reynolds has just signed up for a Medicare Advantage plan on the second of the month. She is leaving for vacation in two weeks and wants to know if her new coverage will start before she leaves. What should you tell her? Correct Ans - Typically, her coverage would begin on the first day of the next month, so she should not expect her coverage to begin before she leaves Ms. Thomas has worked for many years and is turning 68 in June. She is eligible for Medicare Part A and did not enroll for Part B when first eligible because she has insurance through her employer - Coffee Brew, Inc. She also did not enroll in Part D because she had creditable coverage. She would like to retire in June and enroll in a Medicare Advantage plan. She has been informed that her group coverage will end on her retirement effective date. How would you advise Ms. Thomas? Correct Ans - Ms. Thomas can enroll in Part B without a late penalty at any time she is still covered by her employer group and 8 months after her last month of employer group coverage without a penalty. However, because she wants to enroll in a MA plan after retirement, she should make sure her Part B coverage is effective in time to use the Medicare Advantage/Part D special election period for individuals changing from employer group coverage to enroll in a MA plan or MA-PD. The SEP begins while she has employer group coverage and will last until 2 months after the month after the month her employer coverage ends. If she wants Part D coverage she should enroll in an MA-PD or a PDP (depending on how she decides to receive her Part A and B benefits) during this time. Mrs. Parker likes to handle most of her business matters through telephone calls. She currently is enrolled in Original Medicare Parts A and B but has heard about a Medicare Advantage plan offered by Senior Health from a neighbor. Mrs. Parker asks you whether she can enroll in Senior Health's MA plan over the telephone. What can tell her? Correct Ans - II and III only Mrs. Jenkins is enrolled in both Part A and Part B of Medicare. She has recently also become eligible for Medicaid and would like to enroll in a MA-PD plan. Since this is her first experience with Medicare Advantage, she is concerned that she will be locked into a plan and unable to make any coverage changes for at least a year if not longer. What should you tell her? Correct Ans - Since Mrs. Jenkins has Medicare Part A and Part B and receives Medicaid, she has a special election period (SEP) that will allow her to enroll or disenroll from an MA or MA-PD plan during the first 9 months of each calendar year. Ms. Claggett is sixty-six (66) years old. She has been covered under Original Medicare for the last six years due to her disability and has never been enrolled in a Medicare Advantage or a Part D plan before. She wants to enroll in a Part D plan. She knows that there is such a thing as the "Part D Initial Enrollment Period" (IEP) and has concluded that, since she has never enrolled in such a plan before, she should be eligible to enroll under this period. What should you tell her about how the Part D Initial Enrollment Period applies to her situation? Correct Ans - Ms. Claggett has had two IEPs and missed them both. The first occurred three months before and three months after the month when she was first entitled to Part A OR enrolled in Part B. Because she was eligible for Medicare before age 65, Ms. Claggett had a second IEP based on turning age 65, which has also expired. You work for Caring Health, a Medicare Advantage (MA) plan sponsor. Recently, Mrs. Garcia has completed an enrollment application for a plan offered by Caring Health, which is waiting for a reply from CMS indicating whether or not Mrs. Garcia's enrollment has been accepted. Once CMS replies, how long does Caring Health have to notify Mrs. Garcia that her enrollment has been accepted and in what format? Correct Ans - The plan has 10 calendar days to notify Mrs. Garcia in writing. Ms. O'Donnell learned about a new MA-PD plan that her neighbor suggested and that you represent. She plans to switch from her old MA HMO plan to the new MA-PD plan during the Annual Election Period. However, she wants to make sure she does not end up paying premiums for two plans. What can you tell her? Correct Ans - She only needs to enroll in the new MA-PD plan and she will automatically be disenrolled from her old MA plan Mr. Robinson was quite ill recently and forgot to pay his monthly premium for his MA-PD plan. He is worried that he will lose his coverage now when he needs it the most. He is certain his plan will disenroll him because that is what happened to a friend of his in a similar type of plan. What can you tell Mr. Robinson about his situation? Correct Ans - Plan sponsors have the option to do nothing when a plan member does not pay their premiums or disenroll the member after a grace period and notice. 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) Which of the following individuals has enrolled in a plan based on a fixed enrollment period? Correct Ans - Ben, who enrolls in a Medicare Advantage plan during the Medicare Advantage Open Enrollment Period (MA OEP). Mr. Liu turns 65 on June 19. He has never previously qualified for Medicare so his first Medicare eligibility date will be by June 1. Mr. Liu's ICEP and Part D IEP begin March 1 and end on September 30. He wants prescription drug coverage with his Part A and Part B benefits. What advice can you provide him? Correct Ans - He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to Part A. Mr. Rodriguez is currently enrolled in a MA plan, but his plan doesn't sufficiently cover his prescription drug needs. He is interested in changing plans during the upcoming MA Open Enrollment Period. What are his options during the MA OEP? Correct Ans - He can switch to a MA-PD plan Mr. Anderson is a very organized individual and has filled out and brought to you an enrollment form on October 10 for a new plan available January 1 next year. He is currently enrolled in Original Medicare. What should you do? Correct Ans - Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins. Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period (AEP). On December 1, he calls you up and says that he has changed his mind and would like to enroll into a MA-PD plan. What enrollment rules would apply in this case? Correct Ans - He can make as many enrollment changes as he likes during the Annual Election Period and the last choice made prior to the end of the period will be the effective one as of January 1. Miles is a licensed agent who represents Colgate Health and its Medicare Advantage (MA) plans. Miles has several clients who have recently come to him for help. They are in their initial coverage period9s) (ICEP) and are interested in enrolling in one of Colgate Health's MA plans. Adam will soon turn 68 and has decided to retire. Betty is about to turn 65 and has also decided to retire. Adam and Betty both currently have coverage through Colgate Health. Charles had health coverage through Colgate but dropped the coverage when he retired early to travel to Europe. Charles has just turned age 65 and is now back in the United States. Diedre, who will turn 65 next month, currently has coverage through Ditmas Health - a company that Miles also represents. Who qualifies for the opt-in simplified enrollment mechanism? Correct Ans - Adam and Betty because each of them will not have a break between their non-Medicare and Medicare coverage through Colgate Health Plan. Mr. Wilcox has been enrolled in Lexington Private Fee-for-Service (PFFS) Medicare Advantage Health Plan (Lexington) for several years. Recently, Mr. Wilcox decided to spend time with his children who live in another state that is not in Lexington's service area. In the future, he may relocate near his children permanently. How does this move to another service area impact his PFFS MA coverage? Correct Ans - Lexington can allow for