AHIP TEST

Able, Baker, and Charles are engaged in the marketing to and enrollment of beneficiaries into Medicare health plans. Mr. Able is an independent agent paid directly by a health plan. Ms. Baker is an independent agent paid through a field marketing organization (FMO). Mr. Charles is an independent agent paid for his work by a third-party marketing organization (TMO). How do the CMS compensation rules apply to these three agents?

Able is subject to CMS compensation rules because he is paid directly by a health plan. Agents Baker and Charles are not because they are paid by third parties.

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.

Melissa Meadows is a marketing representative for Best Care which has recently introduced a Medicare Advantage plan offering comprehensive dental benefits for $15 per month. Best Care has not submitted any potential posts to CMS for approval. Melissa would like to use the power of social media to reach potential prospects. What advice would you give her?

Agent Meadows should post a tweet telling readers to contact her directly to learn more about Best Care's comprehensive dental benefits at only $15 per month.

Ms. Gates has recently become dually eligible for Medicare and Medicaid. She is very concerned about how this will affect her prescription drug coverage. What should you tell her?

As a dual eligible beneficiary, her Part D drugs will be covered by Medicare once she is enrolled in a Part D plan. If she doesn't select a plan, Medicare will select a plan for her. (Not Verified as correct answer)

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.

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.

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

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.

Hector Hernandez is an independent agent. Hector sells plans on behalf of three Medicare Advantage organizations that offer a total of 10 plans but does not represent all Medicare Advantage organizations offering plans that are available in his area. Which of the following statements best describes any steps Hector is required to take?

During the first minute of a sales call, Hector must use a disclaimer that says "I do not represent every plan available in your area. I represent 3 organizations that offer 10 plans in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all your options."

Edna, Felix, George, and Harriet are Medicare beneficiaries. Edna lives in an area that has suffered from major flooding that has been declared a major disaster by both the Federal government and her state. As a result of dealing with the flooding issues and being evacuated from her home, Edna missed her chance to enroll in MA during her Initial Coverage Election Period. Felix lives in an area with a Medicare Advantage plan with a 4-star rating that he would like to join. George dropped his Medigap policy six months ago when he first enrolled in a Medicare Advantage plan. He now wants to return to Original Medicare. Harriet has recently developed diabetes and would like to enroll in a Medicare Advantage plan that focuses on care for those with that disease. Which, if any, of these individuals would qualify for a special election period (SEP)?

Edna would qualify for a SEP because government officials have declared a major disaster for her area and she did not enroll in MA during her ICEP due to the emergency. George would qualify for an SEP because he enrolled in Medicare Advantage (MA) plan for the first time and would now like to return to Original Medicare within the first 12 months of his enrollment. Harriet would also qualify for a SEP to enroll in a C-SNP because she has developed a chronic condition. Felix would not qualify for a SEP since he seeks to enroll in a 4-star not a 5-star MA plan.

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.

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.

Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D. What could you tell him?

He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may make one Part D enrollment choice, including enrollment in a stand-alone Part D plan or an MA-PD 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.

Mr. Johannsen is entitled to Medicare Part A and Part B. He gains the Part D low-income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan?

He qualifies for a special election period and can enroll in or disenroll from a Part D plan once during that period.

Mr. Lopez, who is fairly well-off financially, would like to enroll in a Medicare prescription drug plan you represent and simply give you a check to cover his premiums for the entire year. What should you tell him?

He will need to mail in his payment with his enrollment form.

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 III. The off formulary drug her doctor prescribed but she pays for because the plan denied her exception request IV. Her over-the-counter (OTC) allergy medication.

I and II only

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.

I, II, and III only

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. 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

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.

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. 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. 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.

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.

Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her?

Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided.

Mary Samuels recently suffered a stroke while visiting her daughter and grandchildren. As a result, Mary has been admitted to a rehabilitation hospital where she is expected to reside for several months. The rehabilitation hospital is located outside the geographic area served by her current Medicare Advantage (MA) plan. What options are available to Mary regarding her health plan coverage?

Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA 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.

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. Landry is approaching his 65th birthday. He has signed up for Medicare Part A, but he did not enroll in Part B because he has employer-sponsored coverage and intends to keep working for several more years. But he is considering enrolling in Part D prescription drug coverage because he believes it is superior to his employer plan. How would you advise him?

Mr. Landry is eligible for Part D since he has Part A, and his initial enrollment period (IEP) for Part D will continue for three months after his 65th birthday.

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.

You are visiting with Mr. Tully and his daughter at her request. He has advanced Alzheimer's and is incapable of understanding the implications of choosing a Medicare Advantage or prescription drug plan. Can his daughter fill out the enrollment form and sign it for him?

Mr. Tully's daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has a durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions.

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.

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.

You are doing a sales presentation for Ms. Duarte and her son. Ms. Duarte has some cognitive impairment and her son informs you that he has power of attorney to only make financial not health care decisions for her. Can he execute the enrollment for her?

No, he cannot execute the enrollment for her. He must have a legal authorization, under state law that explicitly allows him to make health care decisions for his mother.

Mr. White has Medicare Parts A and B with a Part D plan. Last year, he received a notice that his plan sponsor identified him as a "potential at-risk" beneficiary. This month, he started receiving assistance from Medicaid. He wants to find a different Part D plan that's more suitable to his current prescription drug needs. He believes he's entitled to a SEP since he is now a dual eligible. Is he able to change to a different Part D plan during a SEP for dual eligible individuals?

No. Once he is identified by the plan sponsor as a "potential at-risk" beneficiary, he cannot use the dual eligible SEP to change plans while this designation is in place.

Sal D'Angelo is new to the Medicare marketplace having previously been focused on life insurance and disability income protection products. He intends to conduct an educational seminar during the AEP at a local hotel and then invite those who attend to a subsequent marketing meeting to discuss the benefits of next year's plans. How would you advise Sal?

Sal should book the marketing meeting in the same hotel on the same day 1 hour apart for the convenience of those who attend and wish to learn more about the Medicare Advantage plans he represents. (Not verified as correct answer)

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. 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.

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.

When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice would you give her?

She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA 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.

Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual?

The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract.

Torie Jones is a new marketing representative. Torie asks you for advice as to what topics must be discussed with a Medicare beneficiary prior to enrollment in a Medicare Advantage (MA-PD) plan. What should you say?

Torie, there are many required questions and topics regarding beneficiary needs to be discussed prior to enrollment in an MA plan. These include information regarding primary care providers and specialists whether they are in the plan network, whether or not a beneficiary's current prescriptions are covered as well as premiums, benefits, and costs of health care services. (Not verified as correct Answer)

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).

Your friend's mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him?

You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request.

You have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respect to meals?

You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal.

A client wants to give you an enrollment application on October 1 before the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him?

You must tell him you are not permitted to take the form. If he sends the form directly to the plan, the plan will process the enrollment on the day the Annual Election Period begins.

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.

Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same marketing requirements as the plans themselves. How should you respond to such a statement?

Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules.