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

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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? a.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. b.Generally, employers prefer retirees to enroll in a stand-alone PDP, so he should consider that instead of the MA-PD. c.Generally, employers prefer retirees to have both the retiree group plan and the MA-PD plan to fill in the gaps, but he would be better off with just the MA-PD plan. d.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 suf - - correct ans- - d. 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?

a.Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage it must be a MSA-PD plan that includes drug coverage. b.Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. c.Mrs. Chi is ineligible for a MA MSA plan because she is ineligible for Medicaid due to her income level. d.Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage she must also enroll in a Medicare Supplement Plan (Medigap) F that covers the Medicare Part B deductible a - - correct ans- - b. Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? a.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). b.With any Medicare Advantage HMO, Mr. Kumar will be able to see any provider he likes, so long as that provider participates in Original Medicare. c.Mr. Kumar will be able to obtain routine care outside of the plan's service area but will pay a higher co-payment (except in an emergency). d.In Medicare Advantage HMO plans, services provided by primary care physicians are covered at 100%, but those of specialists are covered at 80%. - - 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). 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? a.They are Medigap Supplemental plans that fill in the gaps not covered by Medicare.

b.They are major medical policies but are only for low-income beneficiaries with Medicare. c.They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. d.They are custodial long-term care plans for people with Medicare. - - 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? a.He will not need to do anything. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan. b.As long as his employer offers coverage that is equivalent to Medicare's, he cannot enroll in Part B. c.He must wait until the next Annual Election Period, at which time he can enroll in a Medicare Advantage plan. d.He will have to enroll in Part B. - - correct ans- - d. He will have to enroll in Part B. 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? a.In general, Mrs. Ramos can obtain care from any provider who participates in Original Medicare but will have to pay the difference between the plan's allowed amount and the provider's usual and customary charge. b.In general, Mrs. Ramos will need a referral to see specialists. c.Mrs. Ramos should be aware that generally plan providers can decide, on a case-by-case basis, whether they will treat her. d.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. - - correct ans- - d. 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. 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? a.She must write to the plan and wait for a response and then, if she is still dissatisfied, she could file an appeal with her state Medicaid office requesting transfer to one of its managed care plans. b.She should not expect to get in to see her doctor any more quickly since she is a Medicare patient. c.She should call the doctor's office to complain since the plan cannot do anything about the doctor's schedule. d.She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. - - correct ans- - d. She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. 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? a.SNPs offer care from any doctor or hospital Mr. Sinclair would like to use and his costs will always be lower than in Original Medicare. b.SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. c.Since SNPs don't cover prescription drugs Mr. Sinclair should consider a different option. d.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. - - correct ans- - d. 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. 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? a.SNPs only serve individuals in long-term care facilities, so he cannot enroll. b.SNPs do not provide Part D prescription drug coverage, so if he does enroll, he should be aware that he will not have coverage for any medications he may need now or in the future. c.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. d.SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll. - correct ans- - c. 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. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? a.Medicare Advantage is designed to pick up where Original Medicare leaves off, covering those health care services that would not normally be covered by Original Medicare. b.Medicare Advantage is a health insurance program operated jointly by the states with the Federal government. c.Medicare Advantage is a new name for the Original Medicare program. d.Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. - - correct ans- - d. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. 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?

a.Dr. Brennan can charge the beneficiary the same cost-sharing as Original Medicare as long as she sends the claim to Medicare and not the plan. b.Dr. Brennan can charge Mary Rodgers more than the cost sharing specified in the PFFS plan's terms and conditions as long as she treats all beneficiaries the same. c.Dr. Brennan can charge Mary Rodgers no more than the cost sharing specified in the PFFS plan's terms and conditions of payment which may include balance billing up to 25% of the Medicare rate. d.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. - - correct ans- - d. 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. 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? a.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. b.If he enrolls in the PFFS plan and shows his card to a doctor who participates in Original Medicare, then that doctor is required to accept the plan's terms and conditions, which could include balance billing. c.He may receive services from any physician, regardless of whether or not that physician participates in the plan or Original Medicare. d.If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor acc - correct ans- - a. 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. 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?

a.C-SNP b.FIDE-SNP c. D-SNP d. I-SNP - - correct ans- - a. C-SNP Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? a.Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States. b.Mrs. Radford must be enrolled in both Medigap and Part A to enroll in a Medicare Advantage plan. c.Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, before being accepted and enrolled. d.Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.

• • correct ans- - d. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. 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? a.Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state's Medicaid program. b.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. c.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.

d.Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. - - correct ans- - d. Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. 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? a.He can enroll in a Medicare Advantage plan if he has dropped Part B less than 90 days ago. b.He can enroll in a Medicare Advantage plan but it will pay only the benefits associated with Medicare Part A. c.He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. d.He is not eligible to enroll in a Medicare Advantage as a naturalized citizen. - - correct ans- - c. He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. 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? a.She must immediately drop her ABC MA plan and enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. b.She must immediately drop her ABC MA plan and enroll in Original Medicare. c.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. d.She must remain enrolled in her ABC MA plan unless the plan terminates. - - correct ans- - c. 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. 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? a.He could enroll in the MA-only plan and purchase a Medigap plan with drug coverage. b.He could enroll in the MA-only PPO plan and a stand-alone Medicare prescription drug plan. c.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. d.He cannot enroll in a stand- - - correct ans- - c. 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. Question text 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? a.You could remind him that he cannot do anything until the next Annual Election Period when he will have an opportunity to change plans. b.You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. c.You could reassure him that such charges are typical, but if he needs assistance in paying, he should apply to the state for Medicaid assistance. d.You could suggest he call th - - correct ans- - b. You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Question text

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. a.I, II, and III only b.I and II only c.I, II, and IV only d.II and III only - - correct ans- - c. I, II, and IV only Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? a.Betsy, a grandmother from overseas who has overstayed her visa. b.Helena, an overseas college student who has overstayed her visa. c.Guy, who has illegally crossed the Canadian border. d. Jose, a grandfather who was granted asylum and has worked in the United States for many years. -

• correct ans- - d. Jose, a grandfather who was granted asylum and has worked in the United States for many years. 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?

a.When medication costs exceed a certain threshold amount, which rises each year, a Medicare prescription drug plan is permitted to exclude coverage for all but the least expensive of the medications in a given category. Mrs. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives. b.Medicare prescription drug plans are required to include only a certain percentage of brand name drugs among those they cover. It may be possible that plans available in her area have opted not to include in their formularies the brand name drugs she needs. S - - correct ans- - d. 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. 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? a.The cost of the prescription drugs that are not on his plan's formulary as well as the cost of the drug(s) to reduce joint swelling from the Canadian pharmacy will count toward TrOOP but the other medications in question will not count toward TrOOP. b.None of the costs of Mr. Wingate's other medications would currently count - - correct ans- - b. 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. 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? a. Mrs. Berkowitz can apply for any Medicare Advantage plan and, if it offers drug coverage, ask to have that element of the coverage eliminated, after which she can enroll in a stand-alone Medicare prescription drug plan in her service area.

b. If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. c. Mrs. Berkowitz can enroll in any Medicare Advantage plan, regardless of whether it offers drug coverage, and enroll in any stand-alone Medicare prescription drug plan. d.This is not a possibility. If Mrs. Berkowitz wants health coverage and drug coverage through a plan, she must purchase an MA-PD plan. - - correct ans- - b. If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. 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? a.Mr. Vaughn's hair growth medication would only be covered under Part D if his balding resulted from an illness or was a side effect of a treatment such as chemotherapy. b.Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmetic purposes. c.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. d.The vitamins the Vaughns are taking will be covered under Part D because their physician suggested they should take vitamins, but the hair loss - - correct ans- - c. 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. 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?

a.He should drop the employer coverage and enroll in a Medicare prescription drug plan. Employer plans are almost always more costly for beneficiaries and most do not cover the same range of drugs available from a Medicare prescription drug plan. b.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. c.If he has any sort of employer coverage, regardless of the level of coverage, he will incur no penalty if he does not enroll in a Part D pl - - correct ans- - b. 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. 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? a.Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. b.She will continue to obtain her drug coverage through Medicaid. c. She can expect that all her prescriptions will be automatically delivered on a mail-order basis as a requirement of the Medicare Part D program. d.Medicaid will cover all drugs not covered under the Medicare Part D prescription drug plan into which Mrs. McIntire is enrolled. - - correct ans- - a. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Question text 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? a.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.

b.In general, he must select a single Part D premium payment mechanism that will be used throughout the year. c.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. d.During 2017, many people experienced significant problems with deduction - - correct ans- - b. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? a.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. b.The Federal government establishes a set formulary, or list of covered drugs, each year that the Part D plans must use. Beneficiaries should consult the government's list prior to deciding whether they wish to enroll in a Part D plan during that year. c.Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrict access through prior authorization. d.Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market. - - correct ans- - a. 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. 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? a.Standard Part D coverage would require payment of only fixed per-prescription co-payments. b.Standard Part D coverage would require payment of an annual deductible, fixed perprescription co-payments, and once catastrophic coverage begins, the plan covers 100% of all costs.

c.Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap. d.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%. - - correct ans- - d. 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%. 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? a.She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. b.She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. c.She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan's network. d.She may fill one prescription out-of-network per year and it will be fully covered. Her second prescription will require her to pay the full cost out-of-pocket. - - correct ans- - b. 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. 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? a.Mr. Schultz can wait up to 180 days after the loss of his creditable employer group coverage before enrolling in a Part D plan without worrying payment a premium penalty. b.Mr. Schultz should seek to continue employer group coverage through COBRA because it is likely to have superior benefits at a more permanent solution. c.Mr. Schultz should immediately enroll in a Part D plan but he can expect to pay a premium penalty because he failed to enroll when first eligible.

d.Mr. Schultz should enroll in a Part D plan before he has a 63-day brea - - correct ans- - d. 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. 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. a.I, II, III, and IV b.I, II, and III only c.I and II only d.I only - - correct ans- - b. I, II, and III only 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? a.If a Part D benefit is offered through her plan she must enroll in this plan. b.If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. c.Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage. d.Mrs. Lopez must first seek COBRA benefits under her husband's plan before she can apply for Part D coverage. - - correct ans- - b.If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP.

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? a.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. b.Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication. c.Mr. Zachow will have to wait until the Annual Election Period when he can switch Part D plans. In the meantime, he will have to pay for his drug out of pocket. d.Mr. Zachow could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him. - - correct ans- - a. Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan. Mrs. 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? a.To qualify for enrollment into a Medicare prescription drug plan, Mrs. Mulcahy must be entitled to Part A and enrolled under Part B. She should contact her local Social Security office and decide to enroll in Part B prior to selecting a prescription drug plan. b.Like all Medicare beneficiaries, Mrs. Mulcahy will be automatically enrolled in a Medicare prescription drug plan when she turns 65. She will have a six-month window during which she can select a plan other than the one into which she has been automatically enrolled. c.As long as Mrs. Mulcahy is 65, eligibility for a Medicare prescription drug plan is not dependent on entitlement to Part A or enrollment under Part B, so she should not - - correct ans- - d. 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. 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?

a.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. b.To obtain prescription drug coverage, Mr. Carlini must enroll in an MA plan. The plan will cover his Part A and Part B services, as well as provide him with the desired prescription drug coverage. c.Mr. Carlini can obtain drug coverage through the Federal government's fallback plans, which are designed to provide an alternative to privately sponsored Medicare Advant - - correct ans- - a. 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. 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? a.He should look into the possibility of purchasing his medications through the internet from offshore pharmacies. b.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. c.The only option available is to reduce his income so that he can qualify for the Part D extra help or wait until next year to see if the annual limits change. d.He should contact his neighbors and family members and let them know that any contributions they - - correct ans- - b. 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. 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?

a.If she does not sign up for a Medicare prescription drug plan, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications. b.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, she will have to pay a one-time penalty equal to 10% of the annual premium amount. c.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 b - - correct ans- - c. 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. 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? a.The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval. b.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. c.The government bases its payments to Part D plans on the standard benefit model. For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries. d.The Part D standard model's importance is that it is the only type of plan i - - correct ans- - b. 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. 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?

a.Agent Armstrong needs to be licensed and appointed only in the state where ABC Health Plan is headquartered. b.Agent Armstrong needs to be licensed and appointed only in his state of residence. c.Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located. d.Agent Armstrong needs to be licensed and appointed only in the state where XYZ Agency is headquarte - - correct ans- - c. Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located. 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? a.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. b.Your coworker is correct. You are subject only to marketing requirements issued by your state department of insurance. c.Your coworker is correct. You may use any marketing techniques that do not involve providing misinformation to potential enrollees. d.Your coworker is correct because employed agents have to follow a stricter set of rules than do independent agents, such as yourself. - - correct ans- - a. 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. 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? a.This is not a discriminatory activity since this is merely a widely recommended sales practice.

b.This is not a discriminatory activity since it is based on the incomes of likely prospects and not based on race or gender. c.This could be considered discriminatory activity, but it is not a prohibited practice. d.This could be considered discriminatory activity and a prohibited practice. - - correct ans- - d. This could be considered discriminatory activity and a prohibited practice. 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? a.You should plan to conduct sales presentations and accept enrollment forms. b.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. c.You should plan to conduct sales presentations but must not accept enrollment forms. d.You should plan to answer questions and accept enrollment forms. - - correct ans- - b. 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. 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? a.Two or more gifts whose combined value does not exceed $15. b.Gifts worth more than $15 but based on anticipated attendance will not exceed $15 per attendee. c.Gift cards or gift certificates of $15 or less that can be readily converted to cash. d.Gifts of nominal retail value ($15 or less) - - correct ans- - c. Gift cards or gift certificates of $15 or less that can be readily converted to cash. 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?

a.Tell her that, because you represent a Medicare health plan, you therefore work for Medicare, and the information you offer her is a good basis of any decision she makes. b.Tell her that Medicare recommends that beneficiaries enroll in a Medicare Advantage plan because it will serve her better than Original Medicare. c.Tell her that the Medicare agency does not endorse or recommend any plan. d.Tell her that Medicare or CMS (the Medicare agency) has approved and endorsed the plan. - correct ans- - c. Tell her that the Medicare agency does not endorse or recommend any plan. 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? a.Before speaking with the individual, you must inquire as to her eligibility for MA and Part D plans and then complete a scope of appointment form for the plans for which she is eligible. b.You must set an appointment for another time, at least 48 hours from the point when she walked into your office. c.You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. d.You do not have to do anything. You may proceed with the discussion and enroll the individual if she so desires. - - correct ans- - c. You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. You 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? a.You will have to repeat the tests in three months, but may begin enrolling beneficiaries while you are waiting. b.You will have to attend one of several remedial training events sponsored by the Medicare agency before being allowed to retake the test.

c.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. d.Your name will be registered with the Medicare agency by the plans you are seeking to represent and you will be u - - correct ans- - c. 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. 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? a.The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. b. Her name will be reported to a publicly accessible database and could be advertised in local newspapers. c. Plans must immediately terminate their contracts with such individuals. d.Plans do not impose penalties. Instead, the Medicare agency has specific authority to fine such individuals for each violation. - - correct ans- - a. The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. 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? a.You may provide her with the required enrollment materials and take her completed enrollment application. b.You may leave enrollment kits for several MA plans and offer to discuss a Medigap and Part D prescription drug plan she might like. c.You may leave an enrollment kit and discuss a new life insurance product she might like.

d.You may begin her enrollment application and require her to provide names of any of friends who may be interested in enrolling before completing her application. - - correct ans- - a. You may provide her with the required enrollment materials and take her completed enrollment application. Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members? a. Market non-health related items such as accident-only plans without the need for obtaining a HIPAA compliant authorization form from an enrollee. b. Market contact information lists of current members to third-party vendors of ancillary health products as permitted by Dodd-Frank legislation. c. Market non-health related items or services such as life insurance or annuities policies to current members as permitted following HIPAA Privacy Rules. d. Market non-Medicare health-related products, such as financial planning, to current members as permitted by Dodd-Frank legislation. - - correct ans- - c. Market non-health related items or services such as life insurance or annuities policies to current members as permitted following HIPAA Privacy Rules. 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? a. You appreciate the opportunity and your friend would just need to complete scope of appointment forms on behalf of all the residents who would like to attend. b.You appreciate the opportunity and would ask the facility to provide enrollment applications for the MA-PD plans you represent. c. You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request. d.You appreciate the opportunity and will ask the facility to provide a plan brochure and enrollment application in every resident's room before the meeting to promote interest in the event. - - correct ans- - c. You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request.

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? a.Marketing representatives may initiate electronic contact through e-mail and as long as an email is opened marketing representatives may also follow-up with unsolicited telephone calls. b.Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. c.While unsolicited contacts may be made through print media such as direct mail, marketing representatives may not initiate electronic contact. d.Marketing representatives may only use internet pop-up ads providing plan-specific information that have been approved by CMS when soliciting prospects through electronic means of communication. - - correct ans- - b. Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. 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? a.As long as the meal is paid for by another person or entity, you are permitted to invite your clients and their friends to partake of the meal at your sales presentation. b.You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. c.There is no limitation on meals. You may continue to provide your Thanksgiving style meal, to any individual, in any manner you see fit. d.You may offer meals to existing enrollees of the plan(s) you represent, but potential enrollees may not have a meal. - - correct ans- - b. You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. 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?