QUESTIONS UNIT 2 Flashcards
B, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. B 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.
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 who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network).
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.
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 higher cost-sharing amount if she sees a provider who/that is not a part of the PPO network.
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.
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 would be obtained by also enrolling in a separate prescription drug plan.
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?
She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan.
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.
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.
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?
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.
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
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?
They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.
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. 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. 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 to the plan’s identification card and the doctor agrees to accept the PFFS plan’s payment terms and conditions, which could include balance billing.
