Understanding Medicare Coverage and Enrollment, Exams of Advanced Education

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Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to Medicare beneficiaries? a. Medicare Part B generally provides prescription drug coverage. b. Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots. c. Medicare Part A generally covers medically necessary physician and other health care professional services. d. Benefits covered by Medicare Parts A and B include routine dental care, hearing aids, and routine eye care. - Correct Answer-b. Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots. (Beneficiaries enrolled in both Original Medicare (Parts A and B) have no cost-sharing for most preventive services. These services include immunizations such as annual flu shots.) Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him? a. Mr. Singh must leave Original Medicare to receive drug coverage. b. Part D prescription drug coverage can only be obtained by enrollment into a Medicare Advantage plan that also covers Part A and Part B services. c. 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. d. Mr. Singh can enroll in a stand-alone prescription drug plan and continue to be covered for Part A and Part B services through Original Fee-for-Service Medicare. - Correct Answer-d. Mr. Singh can enroll in a stand-alone prescription drug plan and continue to be covered for Part A and Part B services through Original Fee-for-Service Medicare. (Prescription drug coverage is available to those who enroll in a stand-alone Part D prescription drug plan and continue coverage under Original Medicare Part A and Part B.) Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern?

a. Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. b. Medigap plans are not sold by private companies and are a government insurance product. c. All costs not covered by Medicare are covered by some Medigap plans. d. If Mrs. Paterson applies during the Medigap open enrollment period, she will have to undergo a medical review to determine if she has a pre-existing condition that would increase the premium for a Medigap policy. - Correct Answer-a. Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. (Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles when Original Medicare determines that a benefit is medically necessary.) Mr. Diaz continued working with his company and was insured under his employer's group plan until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know how much he will have to pay. What should you tell him? a. The penalty will be a permanent 10% increase in his Part B premium for every 12- month period that passed during which he could have enrolled and did not. b. Mr. Diaz will pay a penalty, which will be a flat amount each year, paid during the first month of coverage. c. During the first year, he is covered under Part B, his premiums will be 10% higher than they otherwise would be, after which point they will return to normal. d. Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. - Correct Answer-d. Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. (Individuals with coverage based on their own current employment are not subject to the late enrollment penalty.) Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern? a. Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's disease so she will be eligible for Medicare. b. Eligibility for Medicare is based on whether or not a person has ever been employed by the federal government. If she or her husband were ever employed by the federal government, she can enroll in Medicare. c. Medicare is a program for people who have incomes and assets below specific limits, so you will have to find out her exact financial situation before telling her whether she can obtain Medicare coverage.

d. Medicare is a program for people of al - Correct Answer-a. Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's disease so she will be eligible for Medicare. (Individuals that meet these criteria may be eligible to participate in Medicare. It is not based on income.) Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline, who has only worked part-time for the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her? a. You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband's long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at the highest rate because her income over the last several years has exceeded $100,000. b. You should tell Madeline that she will need to pay premiums for Part A because of her short work history. You should also tell Madeline that she will pay Part B pr - Correct Answer-c. You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband's long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at more than the standard lowest rate but less than the highest rate due her substantial income. (Madeline will be able to enroll in premium-free Part A due to her husband's work record. She will pay a premium for Part B coverage based on her income level (her income-related monthly adjustment amount [IRMMA]). An income level of $100, would mean Mrs. Martinez would pay a premium more than the standard (lowest) amount but not at the highest level which looks at incomes above $500,000 for those filing individual income tax returns.) Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him? a. He may not sign-up for Medicare until he reaches age 62, the date he first becomes eligible for Social Security benefits. b. He may sign-up for Medicare at any time and coverage usually begins immediately. c. He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. d. He may sign-up for Medicare at any time however coverage usually begins on the sixth month after dialysis treatments start. - Correct Answer-c. He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start.

(Medicare coverage for individuals with ESRD typically begins on the fourth month after dialysis treatments start.) 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? a. Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program. b. Mr. Wu may still qualify for help in paying for Part D costs through the Federal Pharmaceutical Assistance Program. c. Mr. Wu may still qualify for help in paying for Part D costs through the local Office of the Aging. d. Mr. Wu has no alternative but to liquidate his remaining assets and apply for coverage through his state's Medicaid program. - Correct Answer-a. Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program. (A State Pharmaceutical Assistance Program may be able to provide assistance with prescription drug costs for those who are of limited means but do not qualify for the Part D low-income subsidy.) Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy? a. Medicare Supplemental Insurance would cover his long-term care services. b. Medicare Supplemental Insurance would cover all of his IRS approved health care expenditures not covered under Original Fee-for-Service (FFS) Medicare. c. Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover. d. Medicare Supplemental Insurance would cover his dental, vision and hearing services only. - Correct Answer-c. Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover. (Medicare Supplement Insurance (Medigap) helps to cover Part A and Part B cost- sharing in Original Medicare as well as possibly offering some services such as medical care when a beneficiary travels outside the United States.) Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-Service (FFS) Medicare? What could you tell him? a. Part D, which covers prescription drug services, is covered under Original Medicare.

b. Part A, which covers long term custodial care services, is covered under Original Medicare. c. Part C, which always covers dental and vision services, is covered under Original Medicare. d. Part A, which covers hospital, skilled nursing facility, hospice, and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare. - Correct Answer-d. Part A, which covers hospital, skilled nursing facility, hospice, and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare. (Original Medicare consists of Part A and Part B.) Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled nursing facility? a. Once she has expended her liquid assets, Medicare will cover 80% of Mrs. Shields long-term care costs. b. Medicare will cover Mrs. Shield's skilled nursing services provided during the first 20 days of her stay, after which she would have a copay until she has been in the facility for 100 days. c. Medicare will cover an unlimited number of days in a skilled-nursing facility, as long as a physician certifies that such care is needed. d. Mrs. Shields will have to apply for Medicaid to have her skilled nursing services covered because Medicare does not - Correct Answer-b. Medicare will cover Mrs. Shield's skilled nursing services provided during the first 20 days of her stay, after which she would have a copay until she has been in the facility for 100 days. (Mrs. Shields has experienced a long hospital stay, over the 3-day time period to qualify for skilled nursing and rehabilitative care benefits under Medicare.) Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her? a. Part D covers physician and non-physician practitioner services and the deductible has not changed this year, but the physician charges may go up. b. Part D covers hospital and home health services and the cost sharing has changed this year. c. Part D covers prescription drugs and she should look at her premiums, formulary, and cost-sharing among other factors to see if they have changed.

d. Part D covers long-term care services and she shouldn't worry because there has been no change in coverage. - Correct Answer-c. Part D covers prescription drugs and she should look at her premiums, formulary, and cost-sharing among other factors to see if they have changed. (Part D provides prescription drug coverage. Premiums, plan formularies, and cost- sharing, among other factors, may change from one plan year to another.) Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her? a. All individuals who are citizens and age 65 or over will be covered under Part A. b. Most individuals who are citizens and age 65 or over and wish to be covered under Part A must enroll in a Medicare Advantage Plan. c. Most individuals who are citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. d. Most individuals who are citizens and age 65 or over and are covered under Part A must pay a monthly premium for that coverage. - Correct Answer-c. Most individuals who are citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. (Most individuals who are citizens and age 65 or older may qualify for coverage either because they pay a monthly premium or because they paid Medicare taxes while working for a specific duration.) What impact, if any, will recent regulatory changes have upon Medigap plans? a. The Part A deductible is no longer covered under Medigap plans for all enrollees starting January 1, 2020. b. The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020. c. The Part B deductible will be covered for some newly eligible individuals depending on their financial status. d. The Part A deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020. - Correct Answer-b. The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020. (Starting January 1, 2020, Medigap plans sold to individuals who are newly eligible to Medicare will not be allowed to cover the Part B deductible. If an individual already had one of the plans before January 1, 2020, they will be able to keep their plan. If an individual was eligible for Medicare before January 1, 2020, but not yet enrolled, his or she may be able to purchase one of these plans.)

Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him? a. He became eligible for Medicare when his disability eligibility determination was first made. b. After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. c. Individuals who become eligible for such disability payments only have to wait 12 months before they can apply for coverage under Medicare. d. Individuals receiving such disability payments from the Social Security Administration continue to receive those payments but only become eligible for Medicare upon reaching age 65. - Correct Answer-b. After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. (Individuals with disabilities who are under age 65 are automatically enrolled in Medicare Parts A and B the month after they have received Social Security or Railroad Retirement disability benefits for 24 months.) 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? a. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan. b. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls his employer-sponsored coverage would continue to be the primary payor while Medicare would be consi - Correct Answer-a. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan. (small GHPs do not have to continue to offer their age 65 and over employees and their spouses the same benefits under the GHP as individuals under age 65. Nor do they have to offer such coverage under the same conditions as for individuals under age 65.) Mrs. Quinn recently turned 66 and decided after many years of work to begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn?

a. Part B primarily covers physician services. She will be paying a monthly premium and, with the exception of many preventive and screening tests, generally will have 20% coinsurance for these services, in addition to an annual deductible. b. She should disenroll if she does not want to pay the monthly premiums. There is no disadvantage in doing so. c. Part B will cover her dental and vision needs. d. She will need to pay no premiums for Part B as she qualifies for premium-free coverage due to the number of quarters she has worked. - Correct Answer-a. Part B primarily covers physician services. She will be paying a monthly premium and, with the exception of many preventive and screening tests, generally will have 20% coinsurance for these services, in addition to an annual deductible. (Medicare Part B primarily covers physician services. Enrollees pay a monthly premium based on their income level and have 20 percent coinsurance cost-sharing with the exception of preventive benefits.) Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met? What could you tell her? a. Original Medicare covers routine long-term custodial care. b. Original Medicare covers cosmetic surgery. c. Original Medicare covers routine dental care. d. Original Medicare covers ambulance services. - Correct Answer-d. Original Medicare covers ambulance services. (Original Medicare does cover ambulance services.) Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed? a. Tell prospect Jerry Smith that Medigap is simply a variation of a Medicare Advantage plan and the companies John represents offer more comprehensive coverage for a lower price. b. Tell prospect Jerry Smith that he should keep his Medigap plan but he should supplement his healthcare coverage by purchasing a Medicare Advantage plan that offers prescription drug coverage (MA-PD). c. Tell prospect Jerry Smith that he should drop his Medigap coverage and put those premium dollars toward the purchase of a standalone Part D prescription drug plan because he can always reactivate his Medigap policy on a guar - Correct Answer-d. Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage.

(Agent John Miller can help prospect Jerry select a standalone Part D prescription drug plan that complements his current Original Medicare and Medigap coverage. Alternatively, Agent Miller can suggest that Jerry drop his Medigap coverage and enroll in a MA-PD plan.) Anita Magri will turn age 65 in August 2020. Anita intends to enroll in Original Medicare Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel has told her about the Medigap Part F plan in which he is enrolled. It not only provides foreign travel emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What should you tell her? a. You are sorry to disappoint Anita but a Medigap Part F plan is no longer available to those who turn age 65 after January 1,2020. Anita might instead consider other Medigap plans that offer foreign travel benefits but do not cover the Part B deductible. b. You would be happy to help Anita enroll in a Medigap plan but before she can do so, she must also enroll in a Medicare Part D prescription drug plan. c. You are sorry to disappoint Anita but Medigap plans are no longer available to - Correct Answer-a. You are sorry to disappoint Anita but a Medigap Part F plan is no longer available to those who turn age 65 after January 1,2020. Anita might instead consider other Medigap plans that offer foreign travel benefits but do not cover the Part B deductible. (Individuals who attain age 65 on or after January 1, 2020 cannot purchase a Medigap plan that pays the Part B deductible. Generally, these are plans C, F, or high deductible F. Anita can still purchase a Medigap plan that provides foreign travel emergency benefits such as plan G.) Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid-February 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 Original Medicare. b. 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. c. 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. d. She must remain enrolled in her ABC MA plan unless the plan terminates. - Correct Answer-b. 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. (Mrs. Davenport has three clear choices: (1) remain in the ABC MA plan, (2) enroll in another MA plan in her service area, or (3) enroll in a Special Needs Plan (SPN) for persons suffering from ESRD if one is available in her area.)

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 apply to the Medicare Advantage plan, which will include a medical review, prior to being accepted and enrolled. c. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. d. Mrs. Radford must be enrolled in both Medigap and Part A to enroll in a Medicare Advantage plan. - Correct Answer-c. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. (To be eligible to enroll in Medicare Advantage, an individual must be entitled (not enrolled) to Part A and enrolled in Part B.) 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 should not expect to get in to see her doctor any more quickly since she is a Medicare patient. b. 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. 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 appointme - Correct Answer-d. She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. (Enrollees or their representatives may file a grievance if they experience problems with their health care services, such as timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item.) 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 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.

b. 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. c. 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. d. 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. - Correct Answer-a. 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. (Because Dr. Brennan accepts the plan's terms and conditions for payment, she is permitted to charge this amount.) 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 Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. b. They are custodial long-term care plans for people with Medicare. c. They are major medical policies but are only for low-income beneficiaries with Medicare. d. They are Medigap Supplemental plans that fill in the gaps not covered by Medicare. - Correct Answer-a. They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. (There are coordinated care Medicare Advantage plans that include HMOs and PPOs. There are also Private-Fee-for-Service (PFFS), Medicare Savings Account (MSA), and Special Needs Plans (SNPs).) 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? a. She could enroll in the PFFS plan and a Medigap plan that offers drug coverage, but not in a stand-alone Medicare prescription drug plan. b. She could enroll in a PFFS plan, but not in a stand-alone drug plan. c. She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. d. If she wants drug coverage and a PFFS plan, she could only enroll in a PFFS plan that includes Medicare prescription drug coverage. - Correct Answer-c. She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. (An individual enrolled in a MA PFFS plan that does not include a Part D benefit may enroll in a stand-alone Part D prescription drug plan. This is true even if the organization offers another PFFS plan under the same MA contract that includes a Part D benefit.)

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? a. 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. b. All beneficiaries enrolled in an MSA set-aside the MSA funds on a pre-tax basis in addition to paying their Part B premium. c. MSA enrollees may only receive covered health care services from a limited panel of network providers because otherwise, some providers may charge more than Original Medicare rates. d. For enrollees in an MSA, after the annual d - Correct Answer-a. 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. (MSA enrollees must enroll in a stand-alone prescription drug plan (PDP) if they want prescription drug benefits.) Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? a. In Medicare Advantage HMO plans, services provided by primary care physicians are covered at 100%, but those of specialists are covered at 80%. b. In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network). 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. 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. - Correct Answer-b. In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network). (In most Medicare Advantage HMOs, as a general rule, an enrollee must obtain services only from providers who have a contractual relationship with the plan. An exception is made for emergency care.) 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 but it will pay only the benefits associated with Medicare Part A. b. He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. c. He is not eligible to enroll in a Medicare Advantage as a naturalized citizen. d. He can enroll in a Medicare Advantage plan if he has dropped Part B less than 90 days ago. - Correct Answer-b. He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. (In order to enroll in a Medicare Advantage (MA) plan, an individual must be entitled to Part A and enrolled in Part B. Mr. Castillo is covered by Plan A but no longer enrolled in Medicare Part B so he cannot enroll in MA plan until he re-enrolls in Part B.) 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 have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well. b. Since SNPs don't cover prescription drugs Mr. Sinclair should consider a different option. c. SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. d. 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. - Correct Answer-a. 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. (Chronic condition SNPs (C-SNPs) restrict enrollment and tailor services to individuals with chronic conditions, such as Mr. Sinclair. All SNPs include prescription drug coverage.) 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 a number of 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 suggest he call the doctor who performed the surgery to complain about the costs and ask for a discount on the charges.

d. You could reassure him that such charges are - Correct Answer-b. You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. (Medicare Advantage (MA) plan enrollees have a right to obtain a review (appeal) to certain decisions about health care payment, coverage of services, or prescription drug coverage. Medicare health plans must provide enrollees with a written description of the appeals process.) 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? a. State Medicaid programs do not coordinate any of their coverage with Medicare Advantage plans. b. She can submit any bills she has for co-payments under Medicare to the state's Medicaid program and they will always be fully covered. c. She cannot enroll in an MA Medical Savings Account (MSA) plan. d. If a provider accepts her Medicare Advantage plan coverage, that provider is legally obligated to also accept her Medicaid coverage, so she does not need to worry about finding providers who participate in both Medicare and Medicaid. - Correct Answer-c. She cannot enroll in an MA Medical Savings Account (MSA) plan. (Mrs. Walters is a dual-eligible. Dual eligible beneficiaries may enroll in any type of MA plan except a MA Medical Savings Account (MSA) plan.) 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? a. Medicare Advantage Plans are not permitted to offer any benefits beyond those available under the Original Medicare program and must have the same maximum out- of-pocket limit on Part A and Part B services as FFS Medicare. b. Medicare Advantage Plans do not necessarily have to cover all of the Original Medicare Part A and Part B services but must include a maximum out-of-pocket limit. c. All Medicare Advantage Plans offer cost-sharing that is lower than Original Medicare for all Part A and Part B covered services, but the maximum out-of-pocket limit is higher than in Original Medicare. d. Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, - Correct Answer-d. 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. (Some Medicare Advantage Plans offer extra benefits that Original Medicare does not cover. Also, Original Medicare does not have a maximum out-of-pocket limit.)

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? a. She can enroll in the PPO and purchase drug coverage through a stand-alone Medicare Part D prescription drug plan. b. She can enroll in the PPO and purchase drug coverage through a Medigap plan. c. She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. d. She can enroll in the PPO and if she decides that she wants drug coverage, she will be able to drop her PPO at any time in favor of a Medicare Advantage plan that includes such drug coverage. - Correct Answer-c. She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. (If a beneficiary enrolls in a MA plan that is an HMO or PPO plan that does not include Part D coverage, the beneficiary cannot join a standalone Prescription Drug Plan (PDP).) Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? a. Medicare Advantage is a new name for the Original Medicare program. b. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. c. Medicare Advantage is a health insurance program operated jointly by the states with the Federal government. d. 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. - Correct Answer-b. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. (Medicare Advantage is a way of covering Original Medicare, Part A and Part B benefits, through private health insurance plans.) 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. Mrs. Ramos should be aware that generally plan providers can decide, on a case-by- case basis, whether they will treat her. b. 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. c. In general, Mrs. Ramos will need a referral to see specialists. 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 Answer-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. (MA-PPO enrollees may seek care from any provider who accepts Medicare. However, enrollees are typically responsible for higher cost-sharing payments if their provider is out-of-network.) 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. If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor accepts Original Medicare. b. 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. 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 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 - Correct Answer-b. He may receive health care services from any doctor allowed to bill Medicare, as long as he shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing. (Mr. Gomez may receive health care services from any doctor allowed to bill Medicare, provided he shows the doctor the plan's identification card, and the doctor accepts the PFFS's payment terms and conditions. These terms may include balance billing up to 15%of the Medicare rate.) 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. D-SNP b. FIDE-SNP c. C-SNP d. I-SNP - Correct Answer-c. C-SNP (Because Daniel's bronchitis is a chronic condition, a Chronic condition SNP would be most appropriate for him to enroll in.) 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 Answer-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.Greco's circumstances would not meet the eligibility criteria to qualify him for any of the SNPs.) 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? a. To enroll in a Medicare Advantage plan, she need only be entitled to Part A, so she does not need to take any further steps. b. In order to join a Medicare Advantage plan, she must be enrolled in Parts A, B, and D. c. Since she is age 65 she may enroll in any Medicare Advantage plan, regardless of whether she is entitled to Part A or Part B coverage. d. In order to join a Medicare Advantage plan, she also must enroll in Part B. - Correct Answer-d. In order to join a Medicare Advantage plan, she also must enroll in Part B. (Eligibility to enroll in a Medicare Advantage plan requires entitlement to benefits under Part A and enrollment in Part B.) 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 and II only b. I, II, III, and IV c. I only d. I, II, and III only - Correct Answer-d. I, II, and III only

(Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. Also, private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. Additionally, beneficiaries enrolled in an MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP.) Mr. Shultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has lost his employer group coverage within the last two weeks. How would you advise him? a. Mr. Schultz should seek to continue employer group coverage through COBRA because it is likely to have superior benefits at a more reasonable price. b. 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. c. 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. d. Mr. Schultz should enroll in a Part D plan before he has a 63-day - Correct Answer-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. (Mr. Schultz should enroll in a Part D plan, or otherwise obtain creditable drug coverage, before he has a 63-day break in order to avoid a premium penalty.) 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 off-shore pharmacies. b. He should contact his neighbors and family members and let them know that any contributions they make toward his drug expenses will be tax deductible. 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 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 - Correct Answer-d. 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. (Some pharmaceutical manufacturers operate programs that assist low-income individuals. In addition, some states have assistance programs specifically for their

residents. Some of the state programs are "qualified" and count toward TrOOP and some do not.) 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. 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. b. The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval. c. The Part D standard model's importance is that it is the only type of plan into which low-income beneficiaries can enroll and still receive any extra help for which they may qualify. d. 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 t - Correct Answer-a. 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. (Part D plans must cover at least the Part D standard benefits or its actuarial equivalent. Part D plans are permitted to offer supplemental benefits that cover certain drugs not covered under Part D. Some Part D plans may offer these supplemental benefits for an additional monthly premium.) 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. 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. b. Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmetic purposes. c. 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. d. The vitamins the Vaughns are taking will be covered under Part D because their physician suggested they should take vitamins, but the ha - Correct Answer-a. 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.

(Even if Mr. Vaughn's balding was the result of illness or a side effect of chemotherapy, by law Part D plans are not permitted to provide coverage for cosmetic purposes.) 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. As long as 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 plan when first eligible. b. 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. c. 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 t - Correct Answer-c. 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. (To avoid a late enrollment penalty, Mr. Hutchinson must have "creditable" coverage. If he does not, he must enroll in Medicare Part D during his initial eligibility period to avoid a late enrollment penalty.) 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. In order 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. b. Mr. Carlini can keep Original Medicare, but if he does not sign up for an MA plan that includes prescription drug coverage, he will only be able to obtain prescription drug coverage through a Medigap plan. 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 Advantage plans. d. - Correct Answer-d. 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. Carlini can stay in Original Medicare and obtain prescription drug benefits through a stand-alone Part D plan. He does not have to enroll in a MA 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? a. The extra help is available only to Medicare beneficiaries who are enrolled in Medicaid. He should apply for coverage under his state's Medicaid program to access the extra help with his drug costs. b. The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. c. He must apply for the extra help at the same time he applies for enrollment in a Part D plan. If he missed this opportunity, he will not be able to apply for the extra help again until the next annual enrollment period. d. The government pays a per-beneficiary dollar amount to the Medicare Part D prescription drug plans, to offset premiums - Correct Answer-b. The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. (If a beneficiary has limited income and resources, they may qualify for a low-income subsidy (LIS) to cover all or part of the Part D plan premium and cost-sharing. Beneficiary income may not exceed 150 percent of the Federal Poverty Level (FPL). Assets may not exceed a limited amount also specified by the government.) 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 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. b. 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. 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, - Correct Answer-a. 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. (Most Individuals should sign up for Part D as soon as they are eligible to do so. Otherwise, they face a permanent premium penalty of 1% of the national average premium for each month the individual does not have Part D coverage. Beneficiaries who qualify for the low-income subsidy, however, are not subject to the late enrollment penalty.)

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 all medications bought within the United States not covered by his plan would count toward TrOOP. The cost of the Canadian bought medications would not count toward TrOOP. 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 t - Correct Answer-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. Correct: 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. If he receives an exception under which the plan covers the drug, it could count toward TrOOP. 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. 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. b. 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. c. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. d. As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding - Correct Answer-c. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. (Generally, a Part D beneficiary must stay with a premium payment option for the entire plan year.) 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 may choose to enroll in that plan or a standalone PDP. b. If a Part D benefit is offered through her plan she must enroll in this plan. 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 Answer-a. If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. (Mrs. Lopez is enrolled in a Cost plan. This provides her with options as to how she secures Part D benefits. Beneficiaries enrolled in a Cost plan may obtain Part D benefits through their plan (if offered) or alternatively through a stand-alone Prescription Drug Plan (PDP).) One of your clients, Lauren Nichols, has heard about a Medicare concept from one of her neighbors called TrOOP. She asks you to explain it. What do you say? a. TrOOP stands for true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include only expenses paid directly by a Medicare Part D beneficiary. b. TrOOP refers to true out-of-pocket expenses paid by a Part D beneficiary for non- prescription over-the-counter (OTC) drugs and vitamins that are not covered by his or her plan. c. TrOOP stands for true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances drug manufacturer discounts. d. TrOOP refers to true out-of-pocket expenses paid by drug manufacturers on behalf of Medicare Part D beneficiaries. - Correct Answer-c. TrOOP stands for true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances drug manufacturer discounts. (TrOOP takes into account not only expenditures by a Part D beneficiary but can also includes expenses not paid by a beneficiary such as drug manufacturer discounts.) 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 may use varying co-payments for brand name and generic drugs, but they may not restrict access through 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, but they are required to cover all prescription medications on the market.

d. 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. - Correct Answer-d. 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. (Part D plans are not required to cover all prescriptions on the market. But they have various methods to manage costs including formularies, cost-sharing tiers, step therapy, prior authorization and substitution.) 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 will need to enroll in a Special Needs Plan to obtain coverage for his medication. b. 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. c. 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. d. 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. - Correct Answer-d. 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. (Formulary exception requests can be used to request coverage of a drug not on a Part D plan's formulary or to cover a formulary drug at a lower cost formulary.) 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 prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. b. 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. c. She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. d. 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. - Correct Answer-a. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy.

(There are some circumstances that allow for enrollees to utilize a non-network pharmacy. However, these prescriptions are typically filled at a higher cost to these enrollees.) Mrs. Mulcahy 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 make arrangements to enroll in Part B prior to selecting a prescription drug plan. b. 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. c. 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 duri - Correct Answer-b. 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. (Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan.) 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? a. 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. b. She should use an existing prescription drug coverage to get as large a supply of her existing drugs as possible, and then pick new drugs that are covered under her Medicare plan's formulary. c. The Medicare Part D drug plan is required to offer her coverage of the exact same drugs that she is currently stabilized on, so she does not need to be concerned abo - Correct Answer-a. 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. (Mrs. Roswell is a new enrollee. Those initially enrolling in Part D, those switching plans, and current enrollees affected by formulary changes must receive coverage of a single one-month fill of their non-formulary drugs.)