AHIP TRAINING MODULE 5

You are doing a sales presentation for Mrs. PECK. 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.

"If you're not in very good health, you will probably do better with a different product." PROHIBITED STATEMENT

You have a good meeting with Mr. CLAGGETT and he has selected a MA 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 CAN'T do which of the following?

?? Help him fill out any portion of the enrollment form OR Help him correct any information on the enrollment form if he makes a mistake. (you can correct the mistake but put your initials beside it)

BUSHMAN has two homes in different states and is concerned about restrictions on where she can get her medications.

?? Part D Rx plan use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states.

ROBERTS has Original Medicare and would like to enroll in a PFFS plan. ALL types of PFFS plans are available in her area. Which options could Mrs. ROBERTS consider before selecting a PFFS plan?

A (MA PD) PFFS plan that combines medical benefits and Part D Rx coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone Rx plan.

FERA is selling his home to move into a retirement facility new his daughter in a neighboring state. he has a stand-alone Rx plan and has learned it is not available where he is moving. He doesn't know what he should do.

Because he is moving outside of the service area, the plan must automatically disenroll him. He will have a SEP to select a new plan.

GOODMAN enrolled in an MA-PD plan during the AEP. In mid-January of the following year, she wants to switch back to Original Medicare and enroll in a stand-alone Rx plan.

During the MA Disenrollment period, from January 1-February 14, she may dis-enroll from the MA PD plan into Original Medicare and also may add a stand-alone Rx plan.

JOHNSON calls you to tell you she has not received her new plan ID card yet, but she needs to see a doctor. What can she expect to receive from the plan after the plan has received her enrollment form?

Evidence of plan membership, information on how to obtain services, and the effective day of coverage.

FORD enrolled in a MA only plan in mid November. On December 1, he calls you up and says that he has changed his mind and would like to enroll into a MA-PD plan. What enrollment rules would apply in this case?

He can make as many enrollment changes as he likes during the AEP and the last choice made prior to the end of the period will be the effective one as of January 1.

PINTOK is interested in joining a MA-PD plan and wants advice on which type would allow him to select or change his personal PCP.

He has a right to select or change his PCP from within the plan's network w/o interference.

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.

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

CHARLES, who is enrolled in a stand-alone Part D plan, receives the Part D low income subsidy and just received a letter from the SSA 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.

He qualifies for a SEP which begins the month he was notified of his loss and continues for two more months. This SEP allows him one opportunity to enroll into another PDP or an MA-PD.

SAUNDERS is entitled to Part A, but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a MA plan, what will he have to do?

He will HAVE to enroll in Part B.

GRANT has just entered his MA ICEP. What action could you help him take during this time?

He will have one opportunity to enroll in a MA plan.

BLOCK is currently enrolled in a MA plan that includes drug coverage. He found a stand-alone Medicare Rx 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 Rx plan in addition to his MA-PD plan.

If Mr. Block enrolls in the stand-alone Medicare Rx plan, he will be dis-enrolled from the MA plan.

GUNNER thought she was enrolling in a stand-alone PDP, but when she received her plan materials, she could out she was enrolled in a PFFS plan with drug coverage. She called her marketing representative for help.

If she believes she received misleading information, she must contact 1-800-MEDICARE and, if she qualifies for a SEP, she can select a new option, which could include a different MA plan, a PDP, or Original Medicare.

BROWN wants to enroll in a MA plan that does NOT include drug coverage and also enroll in a stand-alone Medicare Rx plan. Under what circumstances can she do this?

If the MA plan is a PFFS plan that does NOT offer drug coverage or a MSA, Mrs. Brown can do this.

GRACE was told he qualifies for a SEP, but he lost the paper that explains what he could do during the SEP.

If the SEP is for MA coverage, he will have one opportunity to change his MA coverage.

SCHMIDT is moving and a friend told her she might qualify for a SEP to enroll in a new MA plan. She contacted you to ask what a Special Election Period is.

It is a time period, outside of the AEP, when a Medicare beneficiary can select a new or different MA and/or Part D Rx plan. Typically the SEP is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area.

YOO's employer has recently dropped comprehensive creditable Rx coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a SEP. Mr. Yoo contacted you to find out more about what this means.

It means that he qualifies for a one-time opportunity to enroll into an MA-PD or Part D Rx plan.

CLAGGETT is 66 years old. She has been covered under both Parts A and B of Original Medicare for the last six years due to her disability, has never been enrolled in a MA or Part D plan before. She wants to enroll in a Part D plan. She knows that there is such a thing as the Part D IEP and has concluded that, since she has never enrolled in such a plan before, she should be eligible to enroll under this period. What should you tell her about how the Part D IEP applies to her situation?

It occurs three months before and three months after the month when a beneficiary meets the eligibility requirements for Part B, so she will NOT be able to use it as a justification for enrolling in a Part D plan now.

CHEN is enrolled in his employer's group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare.

Mr. Chen can disenroll from his employer sponsored coverage to elect a MA or Part D plan within two months of his disenrollment , but he should revaluate if he really wants to drop his employer coverage.

LEE is enrolled in a 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 and AEP.

She is eligible for a SEP that begins either the month before her permanent move, if the plan is notified in advance, or the month she provides notice of the move, and this period typically lasts an additional two months.

KENNY is six months away from turning 65. She wants to know what she will have to do to enroll in a MA plan as soon as possible. What could you tell her?

She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and B.

GARDNER is currently enrolled in an MA-PD plan. However, she wants to disenroll from the MA-PD plan and instead enroll in a Part D only plan and go back to Original Medicare. According to Medicare's enrollment guidelines, when could she do this?

She may make such a change during the AEP that runs from Oct. 15 to Dec. 7th, or during the MA Disenrollment period that runs from January 1 to February 14 of each year.

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 AEP. However, she wants to make sure she does not end up paying premiums for two plans.

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

ANDERSON is a very organized individual and has filled out and brought to you an enrollment form on October 10 for a new plan available January 1 next year. What should you do?

Tell Mr. Anderson that you CAN'T accept any enrollment forms until the AEP begins.

MURPHY has been very ill and has been in the hospital multiple times this year. She is concerned that her expenses have reached the max out of pocket costs and now her SNP will disenroll her.

There is NO limit on the expenses a plan can incur on behalf of any one beneficiary and a plan sponsor may NOT end a member's enrollment just because of high costs, so she should not be concerned.

AUSTIN just signed up for a MA 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.

Typically her coverage would begin on the first day of the NEXT month, so she should NOT expect her coverage to begin before she leaves.

STEELEY has Original Medicare Parts A and B and has just qualified for her state's Medicaid program, so the state is now paying her Part B premium. Will gaining eligibility for this program affect her ability to enroll in a MA or Medicare Rx plan?

YES. Qualifying for this state program gives Mrs. Steeley access to a SEP that allows her to make changes to her MA and/or Part D enrollment at any time.

WEISS is entitled to Part A and has medical coverage w/o drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does NOT cover Rx's, she want to enroll in a Medicare Rx plan. Will she be able to?

Yes, Mrs. WEISS MUST be entitled to part A or enrolled in Part B to be eligible for coverage under the Medicare Rx program.

You are meeting with Mrs. 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 have come to Mrs. BROWN's home for a sales presentation. At the beginning of the presentation, Mrs. Brown tells you that she has a copy of her medical record available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan.

You can only ask Mrs. Brown questions about conditions that affect eligibility, specifically, whether she has end stage renal disease or one of the conditions that would qualify her for a special needs plan.

A client wants to give you an enrollment application prior to the beginning of the AEP 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 AEP begins.

You are completing a PFFS plan sale to Mr. SCHMIDT 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.

JOHNSON gains the Part D low income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan?

he can enroll in or disenroll from a Part D plan at any time and the subsidy will apply to the plan he chooses.