Understanding Medicare Coverage and Enrollment Options, Exams of Nursing

Download Understanding Medicare Coverage and Enrollment Options and more Exams Nursing in PDF only on Docsity! 1 / 17 AHIP Final Exam Questions and Answers (2025) (Verified Answers) 1. 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?: 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. 2.Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through massage therapy. She is concerned about whether or not Medicare will cover these items and services. What should you tell her?: Medicare does not cover massage therapy, or, in general, glasses or dentures. 3.Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance?: She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible. 4.Mr. Alonso receives some help paying for his two generic prescription drugs from his employer's retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him?: He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing. 5.Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has but replace 2 / 17 her existing Medigap plan with one that provides drug coverage. What should you tell her?: Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan. 6.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?: He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. 7.Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determi- nation that partially denied one of her claims for services. What advice would you give her?: Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. 8.Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because the 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?: 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. 9.Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representa- tive) about the length of an inpatient psychiatric hospital stay that Medicare will cover?: Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. 10.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 5 / 17 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. 21.Hank's Fish Store, Inc. is a small company with just 15 employees located in Florida. Hank, the store owner, has provided excellent health benefits to the store's workforce. William, one of the store's long-time employees, will soon be reaching age 65 and eligible for Medicare. William is in good health. He intends to remain an active full-time employee, working several years after becoming eligible for Medicare. What type(s) of retiree health benefit will Hank's Fish Store be able to offer William?: Hank's can continue to offer William the same employee health benefit plan, or, if William enrolls in Medicare Part B, it can enroll him in a Medicare Advantage plan that is offered to the public. 22.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?: He will have to enroll in Part B. 23.Mrs. Velasquez cares for her frail elderly mother, Maria, who lives in North Carolina. She is worried that without additional support, her mother will need to go into a nursing home. Mrs. Velasquez asks you if there is any Medicare plan that might allow her mother to remain in the community rather than going into a nursing home. How should you advise Mrs. Velasquez?: There are Programs of All-Inclusive Care for the Elderly (PACE) for frail elderly beneficiaries certified as needing a nursing home level of care but are able to live safely in the community at the time of enrolment. 24.Which of the following statement(s) is/are correct about a Medicare Sav- ings 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 6 / 17 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.: I, II, and IV only 25.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?: Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. 26.Mrs. Lyons is in good health, uses a single prescription, and lives indepen- dently 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?: 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. 27.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?: She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. 28.Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?: Mrs. Radford must be entitled to Part 7 / 17 A and enrolled in Part B to enroll in Medicare Advantage. 29.Mr. Kelly wants to know whether he is eligible to sign up for a private fee-for- service (PFFS) plan. What questions would you need to ask to deter- mine his eligibility?: You would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area. 30.Mr. Romero is 64, retiring soon, and considering enrollment in his em- ployer- 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?: He should compare the benefits in his em- ployer-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. 31.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?: She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. 32.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?: 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. 33.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 can enroll in a Medicare Advantage plan?: To join a Medicare Advantage plan, she also must enroll in Part B. 10 / In addition to drugs on his plan's formulary, he takes several other medications. These include a prescription drug not on his plan's for- mulary, 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.: 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. 44.What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?: 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 step therapy. 45.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?: 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. 46.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 11 / coverage that he will not need. What should you tell him?: 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. 47.Mr. Jacob understands that there is a standard Medicare Part D prescrip- tion 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, premi- ums, and cost sharing. How can you explain this to him?: 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. 48.Who is most likely to benefit from the Medicare Prescription Payment Plan?: Kevin, who suffered a heart attack at the beginning of the year requiring him to take an expensive brand name blood thinner on a daily, as well as an equally expensive injectable cholesterol medication on a bi-weekly basis for which he incurs high out-of-pocket costs. 49.Mr. Rice is 68, actively working, and has coverage for medical services and medications through his employer's group health plan. He is entitled to premium free Part A and thinking of enrolling in Part B and switching to an MA-PD because he is paying a very large part of his group coverage premium, and it does not provide coverage for a number of his medications. Which of the following is NOT a consideration when making the change?: Mr. Rice's retiree plan is required to take him back if, within 63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his Medicare Part D plan. 50.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 several 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 12 / drugs that would be covered and asks what she should do. What should you tell her?: 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. 51.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?: 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. 52.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?: 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. 53.Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription to help to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them?: 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 Vaughns could look into that possibility. 54.Mr. Hildalgo complains to you that because he takes multiple expensive drugs, he has trouble paying his cost sharing for his prescription drugs, particularly at the beginning of the year during the deductible phase. He 15 / exclusively on 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?: This could be considered discriminatory activity and a prohibited practice. 65.Agent Jennings makes a presentation on Medicare advertised as an educa- tional event. Agent Jennings distributes materials that are solely educational. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as edu- cational?: Yes. When an event has been advertised as "educational," discussing plan-specific premiums is impermissible. 66.Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services (CMS) Communication and Marketing Guidelines to ensure he is compliant with which type of prod- ucts.: Medicare Advantage (MA) and Prescription Drug (PDP) plans. 67.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?: You should plan to ensure that the educational event is informative and must not conduct a sales presentation or distribute or accept enrollment forms at the event. 68.You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To comply with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plansl?: You will have to avoid calling any potential client unless he or she initiates contact with you and specifically asks that you give him or her a call. 69.If you are to comply with Medicare's guidance regarding educational events, which of the following would be acceptable activities?: You may dis- tribute business cards to individuals who request information on how to contact you for further details on 16 / the plan(s) you represent. 70.By contacting plans available in your area, you have learned that the plan you represent has a significantly lower monthly premium than the others. Furthermore, you see that the plan you represent has a unique benefits package. What should you do to make sure your clients know about these pieces of information?: You may make comparisons between plans if you can support them with studies or statistical data and such comparisons are factually based and referenced. 71.You have set up an appointment for an in-home sales presentation with Mrs. Fernandez, who expressed interest in the Medicare plans you represent. In preparation for the sales presentation, what must you do?: Before conducting the presentation, obtain and document having obtained her permission to visit, along with her interest in the specific products you will present. 72.Winthrop Brokerage wishes to place an advertisement in the local newspa- per that says: "We offer Medicare Advantage plans offered by AB Health and Top Choice Health. Contact us if you would like to learn more." Which of the following best describes the obligation(s) of Winthrop Brokerage regarding the advertisement?: Winthrop Brokerage does not need to submit the advertise- ment to CMS for prior approval because it does not include information about the plans' benefits structures, cost-sharing, or information about measures or ranking standards. 73.You are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs. What should you keep in mind?: You may request RSVPs, but you are not permitted to require contact information. 74.Your colleague works at a third-party marketing organization (TMO) and she said she did not need to take the Medicare training for brokers and agents or pass a test to market Medicare plans since her contract is with the TMO, not the plans that have the products she sells. What could you say to her?: You could tell her she is wrong, and 17 / that only agents selling employer/union group plans are permitted an exemption from testing, but some employer/union group plans may require testing to promote agent compliance with CMS marketing requirements. 75.You are meeting with Mrs. Hall in her home. On her scope of appointment form, she asked to discuss Medicare Advantage plans. During the meeting, she asked to discuss a stand-alone prescription drug plan. She is leaving the next day to visit her family for a week in another state, so she needs to decide before she leaves. What must happen before that additional discussion can take place?: Since Mrs. Hall specifically asked that you discuss the stand-alone Part D plan, you may do so, as long as she signs a new scope of appointment form first, indicating that she wants to discuss the Part D plan. 76.You plan to participate in an educational event sponsored by a large regional health care system. One of your colleagues suggests that you do a presentation on one of the Medicare Health plans you market and modify it to include information about preventive screening tests showcased at the event. How should you respond to your colleague's suggestion?: You should tell your colleague no, because marketing representatives are not permitted to participate, in any way, in an educational event. 77.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: Gift cards or gift certificates of $15 or less that can be readily converted to cash. 78.When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?: You may provide gifts or prizes to all potential enrollees during an event that does not exceed $15 in retail value. 79.You would like to market a MA plan at a neighborhood pharmacy. What should you keep in mind to comply with the marketing requirements for MA plans?: You must set 20 / can switch to a MA-PD plan. 89.Ms. Lee is enrolled in an MA-PD plan but will be moving out of the plan's service area next month. She is worried that she will not be able to enroll in another plan available in her new residence until the Annual Election Period. What should you tell her?: She is eligible for a special election period (SEP) that begins either the month before her permanent move, if the plan is notified in advance, or the month she provides notice of the move, and this period typically lasts an additional two months. 90.Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He found a stand-alone Medicare prescription drug plan in his area that offers better coverage than that available through his MA-PD plan and in addition, has a low premium. It won't cost him much more and, because he has the means to do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan. What should you tell him?: If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. 91.Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard certain MA plans might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him?: If there is a special needs plan (SNP) in Mr. Wendt's area that specializes in caring for individuals with diabetes, he may enroll in the SNP at any time under a special election period (SEP). 92.Mr. Yoo's employer has recently dropped comprehensive creditable pre- scription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a special election period. 21 / Mr. Yoo contacted you to find out more about what this means. What can you tell him?: It means that he qualifies for a one-time opportunity to enroll in an MA-PD or Part D prescription drug plan. 93.Ms. Claggett is sixty-six (66) years old. She has been covered under Original Medicare for the last six years due to her disability and has never been enrolled in a Medicare Advantage or a Part D plan before. She wants to enroll in a Part D plan. She knows that there is such a thing as the "Part D Initial Enrollment Period" (IEP) and has concluded that, since she has never enrolled in such a plan before, she should be eligible to enroll under this period. What should you tell her about how the Part D Initial Enrollment Period applies to her situation?: Ms. Claggett has had two IEPs and missed them both. The first occurred three months before and three months after the month when she was first entitled to Part A OR enrolled in Part B. Because she was eligible for Medicare before age 65, Ms. Claggett had a second IEP based on turning age 65, which has also expired. 94.Ms. Thomas has worked for many years and is turning 68 in June. She is eligible for Medicare Part A and did not enroll for Part B when first eligible because she has insurance through her employer - Coffee Brew, Inc. She also did not enroll in Part D because she had creditable coverage. She would like to retire in June and enroll in a Medicare Advantage plan. She has been informed that her group coverage will end on her retirement effective date. How would you advise Ms. Thomas?: Ms. Thomas can enroll in Part B without a late penalty at any time she is still covered by her employer group and 8 months after her last month of employer group coverage without a penalty. However, because she wants to enroll in a MA plan after retirement, she should make sure her Part B coverage is effective in time to use the Medicare Advantage/Part D special election period for individuals changing from employer group coverage to enroll in a MA plan or MA-PD. The SEP begins while she has employer group coverage and will last until 2 months after the month after the month her employer coverage ends. If she wants Part D 22 / coverage she should enroll in an MA-PD or a PDP (depending on how she decides to receive her Part A and B benefits) during this time. 95.Mr. Garcia was told he qualifies for a special election period (SEP), but he lost the paper that explains what he could do during the SEP. What can you tell him?: If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage. 96.Mrs. Schmidt is moving and a friend told her she might qualify for a "special election period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a special election period is. What could you tell her?: It is a period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically, the special election period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area. 97.Mrs. Kendrick is in good health, has worked for many years, and is six months away from turning 65. She wants to know what she will have to do to enroll in a Medicare Advantage (MA) plan as soon as possible. What could you tell her?: She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B. 98.Which of the following individuals has enrolled in a plan based on a fixed enrollment period?: Ben enrolls in a Medicare Advantage plan during the Medicare Advantage Open Enrollment Period (MA OEP). 99.Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage fol- lowing her retirement several years ago. Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the first time. Unfortunately, Mrs. Ridgeway has found that many of her providers are not in the MA plan's network. She has come to you for advice. What should you tell her?: She qualifies for a special election period (SEP) that will allow her to make a one-time election to return to Original Medicare and she also has a guaranteed eligibility