Medicare Module 1

Several agents you work with are planning sales events in your area. One plans on giving door prizes worth $5, refreshments valued at $8 per anticipated attendee, and coupon books with discounts worth $10. Since no gift or prize exceeds the $15 limit he believes his plan is acceptable. What should you tell them

He can give away more than one gift during a single event, but the aggregate retail value cannot exceed $15.

BestCare Health Plan has received a request from a state insurance department in connection with the investigation of several marketing representatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response?

Agent Armstrong is an independent agent under contract with MarketCo, a third party marketing organization. MarketCo has a contract with BestChoice health plan, a Medicare Advantage organization, to offer marketing services through its contracted agents and agencies. Agent Armstrong returns calls to individuals who call MarketCo in response to its mailers promoting BestChoice health plan. Agent Armstrong is a marketing representative of BestChoice. Thus, he is obligated to comply with all marketing requirements, including those regarding using only approved call scripts.

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. How will Agent Chan be compensated under CMS rules?

Agents/brokers must be licensed in the State in which they do business, annually complete training and pass a test on their knowledge of Medicare and health and prescription drug plans, and follow all Medicare marketing rules. Agents/brokers are subject to rigorous oversight by their contracted health or drug plans and face the risk of loss of licensure with their State and termination with their contracted health or drug plans if they don't comply with strict rules related to selling to and enrolling Medicare beneficiaries in Medicare plans.

Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales presentation?

A meal CAN'T be provided, but light snacks would be permitted. Examples of foods that may be considered "light snacks" include: ▪ Fruit and raw vegetables ▪ Pastries and muffins ▪ Cookies or other small bite-size dessert items ▪ Crackers ▪ Cheese ▪ Chips ▪ Yogurt ▪ Nuts

Next week you will be participating in your first "educational event" for prospective enrollees. In order to be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage?

An agent attends a community-sponsored health fair, and hands out plan-specific benefits information including premium and/or copayment amounts; ▪ An agent participates in a health fair and hands out enrollment forms; ▪ An agent hands out only educational materials but gives a brief presentation that mentions plan-specific premiums and/or copayment amounts; ▪ An agent distributes business cards to attendees and asks them to call him about getting the best Medicare coverage representatives may NOT: ▪ Conduct sales presentations; ▪ Discuss or distribute plan-specific premiums, benefits, or materials including provider and pharmacy directories; ▪ Distribute or collect enrollment applications; ▪ Collect names/addresses of potential enrollees; ▪ Distribute or display business reply cards, scope of appointment forms, or sign up sheets; ▪ Attach business cards or plan/agent contact information to educational materials (business cards free of marketing information may be provided upon beneficiary request); ▪ Ask participants if they want information about a specific plan or limited number of plans; ▪ Set up personal sales appointments or get permission for an outbound call to the beneficiary; or ▪ Distribute or make available marketing materials.

ABC is a long-term care facility provider. What steps may it take to inform residents of the Medicare options available to them?

An institutionalized beneficiary has a continuous open enrollment period (OEPI) for purposes of changing enrollment in Medicare Advantage plans; this period does not end until two months after the month the beneficiary moves out of the institution. Medicare-Medicaid beneficiaries have a continuous special enrollment period that permits them to enroll in a MA, MAPD, PDP, or MMP (in applicable states and subject to state-specific eligibility rules) during any month. As previously noted this enrollment is only valid when executed by the beneficiary/legal representative or as State law allows. The Medicare Managed Care Manual Chapter 2 has a full description of the relevant special enrollment periods

Mrs. Goodman enrolled in an MA-PD plan during the Annual Election Period. In mid-January of the following year, she wants to switch back to Original Medicare and enroll in a stand-alone prescription drug plan. What should you tell her?

Annual election period (October 15 - December 7) Medicare Advantage Disenrollment Period (January 1 - February 14) Beneficiaries may only enroll in or change plans at certain fixed times each year or under certain limited special circumstances. If the application does not include information supporting a permissible election period, plans must contact the beneficiary to decide if enrollment is permissible.MA and Part D Enrollment periods are:MA Initial Coverage Election Period (ICEP)Part D Initial Enrollment Period (IEP)MA and Part D Annual Election Period (AEP)MA and Part D Special Enrollment Periods (SEP)Open Enrollment Period for Institutionalized Individuals (OEPI)MA 45-Day Disenrollment Period (MADP)

Mr. Albert has heard about something called the Star Rating system for Medicare Advantage plans. He asks you to explain it to him since he is interested in enrolling in a plan that is newly available in his area. After you explain that it is way for consumers to judge plan performance, what else would you say?

Beneficiaries who live in the service area of a 5-star plan and are enrolled in an MA or PDP plan, or beginning in 2013, a Cost plan Beneficiaries who live in the service area of a 5-star plan, are enrolled in Original Medicare, and meet the eligibility requirements for Medicare Advantage or Part D plans The SEP is available each year beginning on December 8 and may be used once through November 30 of the following year. For example, the SEP for calendar year 2018 can be used from December 8, 2017 through November 30, 2018. Disenroll from an MA plan, PDP or Cost plan or leave Original Medicare Enroll in a 5-star MA plan, PDP or Cost plan Eligible individuals may enroll in a 5-star plan through 1-800-MEDICARE, Medicare.gov, or directly through the 5-star plan.

Ms. Levi often travels to visit relatives and is concerned that she may need emergency care outside of her plan's service area. What should you tell her about coverage of emergency care?

Cover the following services even when provided by non-network providers: • emergency services; • out-of-area urgently needed services; and • out-of-area renal dialysis. Have access to doctors, specialists and hospitals: Get emergency care when and where they need it. CMS may offer services through non-network providers at the in-network enrollee cost-sharing level.

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?

During individual appointments, marketing representatives may: ▪ Distribute plan materials such as an enrollment kit or marketing materials. ▪ Provide educational information. ▪ Provide and collect enrollment forms. During individual appointments, marketing representatives may not: ▪ Discuss plan options that were not agreed to in the Scope of Appointment. ▪ Market non-health care related products. ▪ Ask for referrals. Solicit/accept an enrollment request for a January 1st effective date prior to the start of the Annual Election Period on October 15 unless the beneficiary is entitled to another enrollment period (for example, an initial enrollment period or special enrollment period) Personal/Individual marketing appointments are defined by the intimacy of the appointments' location or format and typically take place in person at the beneficiary's home or a venue such as a library or coffee shop or via telephone call. All individual appointments ▪ Are considered sales/marketing events; ▪ Must meet sales/marketing event requirements; ▪ Must follow scope of appointment requirements (See following slides)

Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong?

Employed or independent agents/brokers must be state-licensed and follow all state appointment regulations in order to sell Medicare Advantage plans

Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare's efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment site, which of the following must Phiona consider?

Enrollment via the internet: CMS offers an on-line enrollment center through www.medicare.gov • Individuals can also enroll through: www.ssa.gov/medicare/apply.html • CMS on-line enrollment is disabled for MA and Part D plans with a low performer icon (LPI), which means the plan received less than 3 stars for three consecutive years. MA and Part D plans may offer CMS-approved online enrollment on the plan sponsor's website. MA organizations may develop and offer electronic enrollment mechanisms made available via an electronic device or secure internet website. A number of requirements apply to electronic enrollment mechanisms, including, but not limited to: Plan Sponsors must submit all materials, web pages, and images (e.g. screen shots) related to the electronic enrollment process for CMS approval.Individuals must be provided with all required pre-enrollment information (see module 4).The mechanism must comply with CMS' data security policies. Each individual must be advised at the beginning of the electronic enrollment process that he or she is completing an enrollment request.

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?

For MA and Part D plans the individual must Permanently reside in the service area of the plan. Submit a complete enrollment request (a legal representative may complete the enrollment request for the individual) Be fully informed of and agree to abide by the plan rules provided during the enrollment request. Be a U.S. citizen or lawfully present in the United States on or before the enrollment effective date. (CMS makes this determination

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

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 Rx plan, he will be dis-enrolled from the MA plan. Individuals' eligibility to enroll in a stand-alone PDP depends on how they receive their medical benefits. If enrolled in a Medicare coordinated care plan (HMO/PPO) or a PFFS plan that includes Part D drug coverage, the beneficiary may not be enrolled in a stand-alone PDP. Enrollment in a stand-alone PDP will result in automatic disenrollment from a Medicare coordinated care or PFFS plan that includes Part D coverage. Enrollees may be enrolled in a stand-alone PDP only if they are enrolled in: Original fee-for-service Medicare; Private Fee-for-Service (PFFS) plan without Part D drug coverage; Medical Savings Account (MSA) plan; or 1876 Cost plan.

You have had a good meeting with Mr. Claggett and he has selected a Medicare Advantage plan. He would like you to help him complete the enrollment application because he wants to make sure he gets into the right plan. You offer to help, but you tell him that you cannot do which of the following?

If enrollment is completed during a face-to-face interview, the plan representative should use the individual's Medicare card to verify the spelling of the name, sex, Medicare number; and Part A and Part B effective dates.

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. 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, 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 If you do not have a Medicare Advantage plan that includes Part D drug coverage, you must sign up for it separately. You should sign up for Medicare Part D at the same time that you enroll in Part B. Do not delay even if you do not take any prescription drugs regularly right now. If you wait until later to sign up, you will be charged extra on your premium for every month that you waited. The amount of the premium penalty changes every year.

Mrs. Reynolds just signed up for a Medicare Advantage plan on the second of the month. She is leaving for vacation in two weeks and wants to know if her new coverage will start before she leaves. What should you tell her?

Initial Coverage Election Period (ICEP) The ICEP begins three months immediately before the individual's first entitlement to both Medicare Part A and Part B and ends on the later of: The last day of the month preceding entitlement to both Part A and Part B, or;The last day of the individual's Part B initial enrollment period.The initial enrollment period for Part B is the seven (7)month period that begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends 3 months after the month of eligibility.

You work for a company that has marketed Medigap products for many years. The company has added Medicare Advantage and Part D plans and you will begin marketing those plans this fall. You are planning what materials to use to easily show the differences in benefits, premiums and cost sharing for each of the products. What do you need to do with your materials before using them for marketing purposes?

Marketing materials include any MA, MA-PD, section 1876 cost, or PDP plan or plan sponsor informational materials targeted to Medicare beneficiaries which: ▪ Promote the plan sponsor or any plan offered by the plan sponsor; ▪ Inform Medicare beneficiaries that they may enroll, or remain enrolled in a plan offered by the plan sponsor; ▪ Explain the benefits of enrollment or rules that apply to enrollees; or ▪ Explain how Medicare services are covered under the plan, including conditions that apply to such coverage. General audience materials such as brochures, direct mail, newspapers, magazines, television, radio, billboards, yellow pages or the Internet. ▪ Marketing representative scripts or outlines for telemarketing, enrollment or other presentations. ▪ Presentation materials such as slides and charts. ▪ Promotional materials such as brochures or leaflets, including materials for circulation by physicians, other providers, or third parties. ▪ Enrollee communications including rules; agreements; handbooks; contractual changes; changes in providers, premiums, or benefits; plan procedures; and wallet card instructions to enrollees. ▪ Social media (e.g., Facebook, Twitter, YouTube, etc.) posts that meet the definition of marketing materials, specifically those that contain plan-specific benefits, premiums, cost-sharing, or Star Ratings.

Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members?

Marketing materials include any MA, MA-PD, section 1876 cost, or PDP plan or plan sponsor informational materials targeted to Medicare beneficiaries which: ▪ Promote the plan sponsor or any plan offered by the plan sponsor; ▪ Inform Medicare beneficiaries that they may enroll, or remain enrolled in a plan offered by the plan sponsor; ▪ Explain the benefits of enrollment or rules that apply to enrollees; or ▪ Explain how Medicare services are covered under the plan, including conditions that apply to such coverage.

You are doing a sales presentation for Mrs. Pearson. You know that the Medicare marketing guidelines prohibit certain types of statements. Apply those guidelines to the following statements and identify which would be prohibited.

Marketing representatives cannot say: ▪ The government wants you to join a Medicare health plan because it helps them. ▪ I am certified by Medicare to sell this plan. ▪ If your doctor accepts Medicare, she accepts this plan. ▪ There are no limits on services. ▪ We cover all drugs without restrictions. ▪ If you don't like this plan, you can stop paying your premium and return to original Medicare anytime. ▪ It is better to choose a different company if you are sick. ▪ (Name of plan) is the best Medicare plan you can buy. ▪ Medicare Advantage plans are the same as Medigap plans. ▪ You should opt out of MMP enrollment because everyone knows you will get a higher quality care through a Medicare Advantage plan.

Ordinarily, you provide clients who purchase various types of insurance products from you with a gift when they enroll and you let them know that they will receive it after their enrollment is complete. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?

Marketing representatives may offer gifts to potential enrollees if they attend a marketing presentation as long as the gifts are of nominal value and provided regardless of enrollment and without discrimination. ▪ Gifts are of nominal value if an individual item is worth $15 or less (based on retail purchase price of the item); ▪ When more than one gift is offered, the combined value of all items must not exceed $15; ▪ Gifts must not be in the form of cash or other monetary reward, even if their worth is less than $15. Cash gifts include charitable contributions on behalf of an attendee and those gift certificates or gift cards that can be readily converted to cash. ▪ There is an exception where state law requires that the gift certificate or gift card must be convertible to cash and the cash value is no more than $2.00. ▪ If the gift is one large one that is enjoyed by all attending an event, the total cost must be $15 or less when divided by the estimated attendance. Anticipated attendance may be used, but must be based on venue size, response rate, or advertisement circulation. Plan sponsors must include a disclaimer on all marketing materials promoting a prize or drawing or any promise of a free gift that there is no obligation to enroll in the plan.Plan sponsors must track and document promotional activities and items given to current enrollees during the year. Plan sponsors and their marketing representatives may not willfully structure pre-enrollment activities with the intent to give people more than $75 per year.

You would like to market an MA plan at a neighborhood pharmacy. What should you keep in mind to comply with the marketing requirements for MA plans?

Marketing representatives may: Engage in marketing activities (i.e., conduct sales presentations and distribute and accept enrollment applications) in common areas of health care settings, for example: At a hospital or nursing home - in a cafeteria, community or recreational room, or conference room;At a retail pharmacy, in areas away from the pharmacy counter.Marketing representatives must NOT:Engage in marketing activities in areas where patients receive health care services, for example: In the area where a beneficiary waits for health care or pharmacy services, exam rooms, dialysis center treatment areas, or hospital patient rooms.Marketing that is prohibited in health care settings is prohibited during and outside of normal business hours.

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?

Marketing representatives should contact plan sponsor regarding the appropriateness of the food products provided and must ensure that items provided could not be reasonably considered a meal and/or that multiple items are not being "bundled" and provided as if a meal. Examples of foods that may be considered "light snacks" include: ▪ Fruit and raw vegetables ▪ Pastries and muffins ▪ Cookies or other small bite-size dessert items ▪ Crackers ▪ Cheese ▪ Chips ▪ Yogurt ▪ Nuts

Mr. Carter, who is enrolled in a stand-alone Part D plan, receives the Part D low-income subsidy and just received a letter from the Social Security Administration informing him that he will no longer qualify for the subsidy? He is wondering if he can switch to a lower cost Part D plan. What should you tell him?

Medicaid: help with health care costs. Medicare Savings Program: help paying for the Medicare Part B premium and, in some cases, deductibles and coinsurance. Part D low-income subsidy: help paying for prescription drug coverage. The State Medicaid office will check eligibility for this and other programs such as the Medicare Savings Program. Persons interested in Part D help only may call the Social Security Administration (SSA) at 1-800-772-1213 or apply online at www.ssa.gov/prescriptionhelp. Supplemental Security Income (SSI) benefits: help with cash for basic needs. You also may apply through SSA.

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?

Medicare Advantage HMO or PPO may only obtain Part D benefits through their plan. They may not enroll in a standalone PDP. (Employer group plan enrollees may have additional choices.)

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?

Medicare Advantage HMO or PPO may only obtain Part D benefits through their plan. They may not enroll in a standalone PDP. (Employer group plan enrollees may have additional choices.) MA MSA may only obtain Part D benefits through a standalone PDP.MA PFFS plan that offers Part D coverage may only obtain Part D benefits through that plan. If the PFFS plan does not offer Part D coverage, the beneficiary may enroll in a standalone PDP. Cost plan may obtain Part D benefit through their plan (if offered) or through a standalone PDP. Medicare-Medicaid plan may only receive Part D benefits through that plan. PACE plan may only receive Part D benefits through that plan.

Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern?

Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services

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 over age 65 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. 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. 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 be charged a lower co-payment if she goes to one of the plan's preferred providers. Preferred Provider Organizations (PPOs), local and regional; PPO enrollees generally may get care from any provider in the U.S. who accepts Medicare, but will pay less if they go to one of the "preferred" providers in the PPO's network. PPOs must have a maximum limit on member out-of pocket costs for network providers of not greater than $6,700 per year and an aggregate limit on network and non-network costs of $10,000. Enrollees do not need a referral to see an out-of-network provider, but may be encouraged to contact the plan to be sure the service is medically necessary and will be covered. Regional PPOs are PPOs that serve an entire region, made up of one or more states.

Mr. Gonzalez is entitled to Part A, but has not yet enrolled in Part B. If he wants to enroll in a Private Fee-for-Service (PFFS) plan, what will he have to do?

PFFS options available to beneficiaries may include: Enrolling in a PFFS plan offering only Medicare A/B benefits and not obtaining Part D coverage; Enrolling in a PFFS plan that combines Medicare A/B and Part D prescription drug benefits (MAPD plan); or Enrolling in a PFFS plan offering Medicare A/B benefits and enrolling in a stand-alone Part D prescription drug plan (PDP). Individuals enrolled in a PFFS plan receive their Medicare benefits through the plan. PFFS is not the same as Original Medicare. PFFS is not a Medicare supplement, Medigap, or a Medicare Select policy

Mr.Lopez, who is fairly well off, 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?

Part D enrollees have three options for paying their Part D premium. (1) Automatic electronic monthly mechanism, such as withdrawal from their checking or savings bank account or automatic deduction from their credit or debit card; (2) Direct monthly billing from the plan; or (3) Automatic deduction from their monthly Social Security Administration (SSA) benefit check. • Typically it takes 2-3 months for SSA withholding to begin or end. • When withholding begins, it will be for the 2-3 months of premiums owed. • If a beneficiary is considering this option, he/she should call the plan first. Generally the beneficiary must stay with the premium payment option for the entire year.

Which of the following is a correct statement about state laws as they pertain to marketing representatives?

Plans are responsible for ensuring compliance with Medicare rules by their marketing representatives. Plan marketing representatives include: ▪ individuals employed by a plan and ▪ individuals or entities under contract to the plan through a direct or downstream contract ▪ This would include brokers and agents (contracting directly with the plan or through an agency or other entity), third party marketing organizations (TMOs) such as a field marketing organizations (FMOs), general agents (GAs), or other marketing contractors).

Agent Mark Andrews would like to employ technology to facilitate the growth of his Medicare Advantage (MA) practice. What step(s) would you recommend that Mark take?

Plans/Part D Sponsors must submit to CMS social media (e.g.,Facebook, Twitter, YouTube, LinkedIn, Scan Code, or QR Code)posts that meet the definition of marketing materials, specifically those that contain plan-specific benefits, premiums, cost-sharing,or Star Ratings. Social media posts are subject to marketing requirements, such as those related to testimonials. Generally disclaimers are not required unless a communication written for social media has the potential to be disseminated via other mediums, such as youtube.Plans/Part D Sponsors must not include content on social/electronic media that discusses plan-specific benefits, premiums, cost-sharing, or Star Ratings for products offered in the next contract year prior to October 1.

Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him?

Preventive & screening services

Ms. O'Donnell learned about a new MA-PD plan that her neighbor suggested and that you represent. She plans to switch from her old MA HMO plan to the new MA-PD plan during the Annual Election Period. However, she wants to make sure she does not end up paying premiums for two plans. What can you tell her?

She only needs to enroll in the new MA-PD plan and she will automatically be disenrolled from her old MA plan

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?

Skilled nursing and rehabilitative care only after a three day hospital stay, up to 100 days in a benefit period (as defined by Medicare). In 2017, beneficiaries pay $164.50 coinsurance for days 21-100 each benefit period.Inpatient psychiatric care (up to 190 lifetime days) Part A does not cover custodial or long-term care Cost-sharing may differ for enrollees of Medicare

Mrs. Lenard is enrolled in a Medicare Cost plan. Recently the cost plan has transitioned to a Medicare Advantage (MA) contract, and Mrs. Lenard has been told that she has been subject to "deemed enrollment." What does this mean?

Some cost plans transitioning to MA contracts will have "deemed" or facilitated enrollment. That is, unless a cost plan enrollee opts out, he/she will be automatically enrolled in an MA plan offered by the same organization.Individuals subject to deemed enrollment will be notified by CMS and the plan and given the opportunity to choose another option.

Mr. Decaro has looked at Medicare prescription drug plans available in his area and noted a wide range in premiums. He thought that all the drug plans were required to offer the same standard benefits and would like you to explain why there is such a range in premiums. What should you tell him?

Some prescription drug plans may have higher operating costs and/or may offer enhanced coverage in return for an additional premium amount. He could look at plan designs to see if one of the enhanced plans would serve his needs better than a plan based on the standard design. Part D enrollees have three options for paying their Part D premium. (1) Automatic electronic monthly mechanism, such as withdrawal from their checking or savings bank account or automatic deduction from their credit or debit card; (2) Direct monthly billing from the plan; or (3) Automatic deduction from their monthly Social Security Administration (SSA) benefit check. • Typically it takes 2-3 months for SSA withholding to begin or end. • When withholding begins, it will be for the 2-3 months of premiums owed. • If a beneficiary is considering this option, he/she should call the plan first. Generally the beneficiary must stay with the premium payment option for the entire year.

What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have upon Medigap plans?

The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020.The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will make changes to Medigap plans effective 2020. Specifically, for individuals newly eligible to Medicare, the Part B deductible cannot be covered. Therefore, Plans C and F will no longer be an option for newly eligible individuals starting January 1, 2020. However, individuals who already have Plans C and F will be able to keep their current versions of the plans and individuals eligible for Medicare prior to January 1, 2020, can purchase the current version of Plans C and F on or after January 1, 2020

Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug mid-way through the year?

When a new generic drug for the same condition becomes available or when the FDA or manufacturer withdraws the drug from the market, a brand name drug can be replaced.

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?

Who is eligible for a SEP based on change of residence? MA and Part D enrollees who move out of their existing plan's service area, or who have new options available to them as a result of a permanent move. Beneficiaries who have moved into a plan service area from a location where there was no Part D plan available (e.g. overseas) qualify for an SEP just for Part D election purposes MA eligible and Part D eligible beneficiaries who experience certain qualifying events are allowed an SEP Timeframes for SEPs are variable, however, most begin on the first day of the month in which the qualifying event occurs and last for a total of three months. The SEP ends when the individual utilizes their SEP to make an allowed change, or the time period expires, whichever comes first. Where appropriate, SEPs allowing changes to MA coverage are coordinated with those allowing changes in Part D coverage.

If Mr. Johannsen gains the Part D low-income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan?

Who is eligible for a SEP based on gaining eligibility for Part D LIS? Non-dual beneficiaries who qualify for LIS but do not receive Medicaid benefits When does the SEP take place? Begins on the month the individual becomes eligible for LIS. Continues as long as he or she is eligible for LIS. What can beneficiaries do during the SEP? Enroll in or disenroll from a PDP or MA-PD plan at any time Who is eligible for a SEP based on loss of eligibility for Part D LIS? (1) Beneficiaries who lose their LIS eligibility because they are no longer deemed eligible for the following calendar year. (2) Beneficiaries who lose their LIS eligibility during the year outside of the annual redetermination process.When does the SEP take place? Group 1: January 1 - March 31 Group 2: Begins the month beneficiaries are notified and continues for two months. What can be done during the SEP? Enroll in or disenroll from a PDP or MA-PD plan. Example: Ms. Perry is awarded LIS. CMS facilitates her enrollment into a PDP, effective October 1st. She decides she would rather be enrolled in another PDP or an MA-PD plan and submits a request in November. She does so using this SEP and her enrollment is effective December 1st.

You are meeting with Ms. Berlin and she has completed an enrollment form for a MA-PD plan you represent. You notice that her handwriting is illegible and as a result, the spelling of her street looks incorrect. She asks you to fill in the corrected street name. What should you do?

You may correct this information as long as you add your initials and date next to the correction

You are completing a PFFS plan sale to Mr. West who is new to Medicare, and as you are finishing up, what should you tell him about next steps in the enrollment process?

You need to get Mr. Schmidt's phone number and include it on the enrollment form because the plan must call him after you leave to ensure that he understood the nature of the PFFS plan he selected and to verify his intent to enroll

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 participation in an educational event may not include a sales presentation

You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation?

You will NOT be able to represent any MA or Part D plan until you compete the training and achieve an adequate score, although you will NOT have to take a test if you exclusively market employer/union group plans and the companies do not require testing.

Mr. Rivera has QMB-Plus eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later in the year, Mr. Rivera needs dentures, a service only covered under Medicaid. What action would you recommend he take in order to have this cost covered?

has QMB-Plus eligibility. She has decided to enroll in a Medicare Advantage plan. Ms. Jones can receive all Medicare covered services through her Medicare Advantage plan cost sharing. However, in order to receive coverage of services that are only covered under Medicaid, for example, dentures, she must go to a Medicaid provider or obtain the services through a Medicaid managed care plan if she is enrolled in one Categories of dual eligible beneficiaries and out-of pocket costs that must be paid by Medicaid: QMB Plus - Medicare Part A and Part B premiums; cost sharing for Part A & Part B benefits; Full Medicaid benefits.When a dual eligible individual enrolls in an MA plan, if the individual has coverage for Part A and B cost sharing, they will not have to pay more than the cost sharing that would apply under Medicaid. This rule applies to all types of Medicare Advantage plans, including dual eligible SNPs. Dual eligible beneficiaries may enroll in any type of MA plan except an MA MSA. Some MA plans, known as dual eligible Special Needs Plans, are tailored to dual eligible individuals, depending on the category (see prior slide) to which they belong.