AHIP Q AND A 169 Flashcards
Edward IP suffered from serious kidney disease. As a result. Edward became eligible for Medicare coverage due to end-stage renal disease (ESRD). A close relative donated their kidney and Edward successfully underwent transplant surgery 12 months ago. Edward is now age 50 and asks you if his Medicare coverage will continue, what should you say?
Individuals eligible for Medicare based on ESRD generally lose eligibility 36 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward may, however, remain enrolled in Part B but solely for coverage of immunosuppressive drugs if he has no other health care coverage that would cover the drugs.
Mildred Savage enrolled in Allcare Medicare Advantage plan several years ago. Mildred recently learned that she is suffering from inoperable cancer and has just a few months to live. She would like to spend these final months in hospice care. Mildred’s family asks you whether hospice benefits will be paid for under the Allcare Medicare Advantage plan. What should you say?
Mildred may remain enrolled in Allcare and make a hospice election. Hospice benefits will be paid for by Original Medicare under Part A and Allcare will continue to pay for any non-hospice services.
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?
Mr. Diaz will not pay any penalty because he had continuous coverage under his employer’s plan.
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?
Medicare Supplemental Insurance would help cover his Part A and Part B deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.
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?
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.
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?
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.
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?
After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.
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?
Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots.
Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her?
She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period after the last month on her employer plan that differs from the standard general enrollment period, during which she may enroll in Medicare Part B.
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.
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?
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.
Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65, without paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her?
To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes.
To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes.
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.
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?
Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage.
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?
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.
Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him?
It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare.
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.
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?
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.
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?
Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program.
Shirly Thomas was enrolled in Medicaid during the Public Health Emergency (PHE). This coverage has recently been terminated due to the end of the PHE. While Shirley was enrolled in Medicaid, she missed an opportunity to enroll in Medicare and now wants Part B. Which of the following statements best describes Shirley’s ability to now enroll in Medicare Part B?
Shirley is eligible for a Special Enrollment Period (SEP) for up to six months after the termination of her Medicaid coverage. Under this SEP, Shirley can choose retroactive coverage back to the date of termination from Medicaid or coverage beginning the month after the month of enrollment.
Anthony Boniface turned 65 in 2023. He was not receiving Social Security or Railroad Retirement Benefits on his 65th birthday. He was interested in obtaining Medicare coverage and is eligible for premium-free Part A. Before he could enroll in Medicare, his entire area was impacted by a hurricane causing massive flooding and severe wind damage. The Federal government declared this to be a natural disaster which has recently ended. During this period Anthony’s initial enrollment period expired. Anthony asks you how he can now obtain Medicare coverage. What should you say?
Anthony is eligible for a special enrollment period (SEP) because he missed an enrollment period due to the impact of the Federally declared disaster. This SEP will allow Anthony to enroll in Part B up to six months after the end of the emergency declaration. Anthony may enroll in premium-free Part A at any time and his Part A coverage will be retroactive for up to 6 months.
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?
All MSAs cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling in a separate prescription drug plan.
Mrs. 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?
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.
Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan that includes drug coverage with nominal copays. He heard about a neighbor’s MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him?
He should compare the benefits in his employer-sponsored retiree group health plan with the benefits in his neighbor’s MA-PD plan to determine which one will provide sufficient coverage for his prescription needs.
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?
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.
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.
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?
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.
Juan Hernandez is turning 65 next month, Juan legally entered the United States over twenty years ago but is not a citizen. Since his entry into the country, Juan has worked at Smallcap Incorporated and contributed to the Medicare system. Juan suffers from diabetes. He will soon retire and asks you if he can enroll in a Medicare Advantage plan that you represent. How would you respond?
Juan is eligible to enroll in a Medicare Advantage as long as he is entitled to Part A and enrolled in Part B. Juan should go to the Social Security website to enroll in Medicare Part A and B if he has not done so already. Once he is enrolled, he can choose a Medicare Advantage plan.
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 A and enrolled in Part B to enroll in Medicare Advantage.
Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him?
You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.
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.
Which of the following statement(s) is/are correct about a Medicare Savings Account (MSA) Plans?
I. MSAs may have either a partial network, full network, or no network of providers.
II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits.
IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full.
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?
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.
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?
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?
Explain this
C-SNP
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?
He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B.
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.
Mrs. Wang 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?
Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part A and Part B services.
Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description?
Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies.
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 determine 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.
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.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him?
In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan’s network (except in an emergency or where care is unavailable within the network).
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?
If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered.
Mr. 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?
The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government.
Charles McCarthy is a Medicare beneficiary who suffers from diabetes. Mr. McCarthy is considering enrollment in a MA-PD plan that you represent. He asks you whether his insulin costs will be covered. What should you say?
Mr. McCarthy’s insulin costs for a one-month supply cannot be more than $35 in any coverage phase under the prescription drug plan beginning in 2023.
Mrs. Imelda Diaz is a Medicare beneficiary enrolled in a MA-PD plan you represent. Her neighbor recently suffered from a painful case of shingles. Mrs. Diaz hopes to avoid such an illness through vaccination. She asks you whether the cost of shingles vaccination will be covered under the plan you represent. What should you say?
Yes, there is no cost sharing for the shingles vaccine even in the deductible phase of her prescription drug plan because it is an adult vaccine recommended by the Advisory Committee on Immunization Practices (AICP).
Mr. Schultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Schultz has lost his employer group coverage within the last two weeks. How would you advise him?
Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty.
Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan?
A Medicare Advantage Prescription Drug (MA-PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone prescription drug plan.
Which of the following individuals is most likely to be eligible to enroll in a Part D Plan?
Jose, a grandfather who was granted asylum and has worked in the United States for many years.
Correct: Jose, having been granted asylum, is legally present in the United States thus meeting one of the criteria for Part D eligibility.
Jose, a grandfather who was granted asylum and has worked in the United States for many years.
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.
Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to?
Yes. Mrs. Walters must be entitled to Part A and/or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program.
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?
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.
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?
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.
Mrs. McIntire is enrolled in her state’s Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen to her drug coverage?
Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.
Mrs. Cantwell is enrolled in a prescription drug plan. She has heard about something called True-Out-Pocket costs or “TrOOP” and asks you if any of the following count toward reaching the catastrophic coverage phase. What do you say?
I. Her annual PDP deductible
II. A drug manufacturer’s discount for brand name drugs after her initial coverage period
Mrs. Fiore is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan?
She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution.
Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this?
If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this.
Mr. 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?
In general, he must select a single Part D premium payment mechanism that will be used throughout the year.
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.
Mrs. Fields wants to know whether applying for the Part D low-income subsidy will be worth the time to fill out the paperwork. What could you tell her?
The Part D low-income subsidy could substantially lower her overall costs. She can apply by contacting her state Medicaid office or calling the Social Security Administration.
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.
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.
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?
If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP.
Agent Daniel Webber has properly set up a sales appointment to meet with client Edward Young at Agent Webber’s office. At the agreed upon appointment time, Mr. Young arrives with his elderly neighbor - Clara Burton, who wants to learn about her Medicare Advantage options. What should Agent Daniel Webber do?
After executing a scope of appointment (SOA) with Clara Burton, meet with Edward Young and Clara Burton to discuss their Medicare Advantage options.
Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you on October 15. During the appointment, what are you permitted to do?
You may provide her with the required enrollment materials and take her completed enrollment application.
You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns?
Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider’s facility.
You are working several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do?
You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event.
Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel?
During the MA-OEP, Miguel can have one-on-one meetings with beneficiaries who have requested such meetings.
Wendy Park becomes eligible for Medicare for the first time in July. With the help of Agent James Chan, she enrolls in FeelBetter Medicare Advantage plan with an effective date of July 1st. Which statement best describes how Agent Chan may be compensated under CMS rules?
FeelBetter will pay Agent Chan initial year compensation for July through December. The renewal amounts will be paid starting in January if Ms. Park remains enrolled the following year.
