Module 2 -Medicare Health Plans 20 Review Questions Flashcards
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.
Correct: Eligibility to enroll in a PFFS plan is based on entitlement to Medicare Part A and enrollment in Part B. In addition, to enroll in a specific PFFS plan, the individual must reside in the plan’s service area.
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.
Correct: 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.
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.
Correct: Ms. Gibson can enroll in a PPO without drug coverage. However, 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).
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.
Correct: The Social Security Administration will determine Juan’s eligibility for Medicare. If Juan is entitled to Part A and enrolled in Part B, he is generally eligible for enrollment in a Medicare Advantage plan.
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.
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?
C-SNP
-Because Daniel’s bronchitis is a chronic condition, a Chronic condition SNP would be most appropriate for him to enroll in.
Given that Daniel has chronic bronchitis, a Chronic Condition Special Needs Plan (C-SNP) would likely be the most appropriate for him1. These plans are designed to serve individuals with specific severe or disabling chronic conditions. They provide tailored healthcare services to help manage those conditions effectively.
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.
Correct: To be eligible to enroll in Medicare Advantage, an individual must be entitled (not enrolled) to Part A and enrolled in Part B.
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.
Correct: MSA enrollees must enroll in a stand-alone prescription drug plan (PDP) if they want prescription drug benefits.
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.
Correct: 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. 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.
The type of Medicare Advantage plans offered vary by employers. Therefore, beneficiaries should compare their employer’s retiree plan with other available plan options.
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.
Based on the information provided, Mr. Greco may not be eligible for a Medicare Advantage Special Needs Plan (SNP). SNPs are designed to provide targeted care and limit enrollment to special needs individuals. An individual must fit into one of the following groups to be eligible for a special needs plan:
-People who live in certain institutions (like nursing homes) or who require nursing care at home.
-People who are eligible for both Medicare and Medicaid.
-People who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease, HIV/AIDS, chronic heart failure, or dementia).
Since Mr. Greco is in excellent health, lives in his own home, and does not appear to have a specific chronic or disabling condition, he may not meet the eligibility requirements for an SNP.
Therefore, the correct answer would be:
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.
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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.
Correct: Medicare Advantage is a way of covering Original Medicare, Part A and Part B benefits, through private health insurance plans.
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.
Correct: MSAs may not have a network or may have a full or partial network of providers. MSAs cover Part A and Part B benefits after the deductible. All non-network providers must accept the same amount that Original Medicare would pay them as payment in full. This is the amount the enrollee will pay the provider before the deductible is met.
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.
Correct: 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.
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 an MA MSA plan and remain in her current standalone Part D prescription drug plan.
Correct. MA MSA plans are prohibited from offering prescription drug coverage. If an MSA member wants prescription drug coverage, the member must enroll in a standalone PDP.
