Module 5

Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to?

. Yes. Mrs. Walters must be entitled to Part A or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program.

Mrs. Pierce would like to enroll in a Medicare Cost plan that offers Part D prescription drug coverage. She comes to you for advice about when she can enroll in a plan you have previously discussed. What should you tell her?

Enrollment in Cost plans offering Part D coverage is available only during enrollment periods under the Part D program, and Cost plans must accept enrollments during these periods.

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? I. If a legal representative is completing an electronic enrollment request, he or she must first upload proof of his or her authority. II. All data elements required to complete an enrollment request must be captured. III. The mechanism must advise each individual at the beginning of the process that he or she is completing an actual enrollment request. IV. The mechanism must capture an accurate time and date stamp at the time the applicant enters the online site.

II and III only

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.

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?

She is eligible for a Special Election Period 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.

Mr. 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. He is currently enrolled in Original Medicare. What should you do?

Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins.

Ms. Gonzales decided to remain in Original Medicare (Parts A and B) and Part D during the Annual Enrollment Period (AEP). At the beginning of January, her neighbor told her about the Medicare Advantage (MA) plan he selected. He also told her there was an open enrollment period that she might be able to use to enroll in a MA plan. Ms. Gonzales comes to you for advice shortly after speaking to her neighbor. What should you tell her?

There is a MA Open Enrollment Period (OEP) that takes place between January 1 and March 31, but Ms. Gonzales cannot use it because eligibility to use the OEP is available only to MA enrollees.

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.

Which of the following individuals are likely to qualify for a special enrollment period (SEP) for either a MA and/or Part D due to a change of residence? I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan's service area.II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's service area.III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area where no Part D plan was available. IV. Henry makes a permanent move to a new state providing him with new MA and Part D options.

Which of the following individuals are likely to qualify for a special enrollment period (SEP) for either a MA and/or Part D due to a change of residence? I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan's service area.II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's service area.III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area where no Part D plan was available. IV. Henry makes a permanent move to a new state providing him with new MA and Part D options.

Ms. Claggett is sixty-six (66) years old. She has been covered under Original Medicare for the last six years due to her disability and has never been enrolled in a Medicare Advantage or a 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 Initial Enrollment Period" (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 Initial Enrollment Period applies to her situation?

a. 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.

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?

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

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?

a. 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. Kendrick is in good health, has worked for many years and is six months away from turning 65. She wants to know what she will have to do to enroll in a Medicare Advantage (MA) plan as soon as possible. What could you tell her?

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

Mr. 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. He is currently enrolled in Original Medicare. What should you do?

a. Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins.

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

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

Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirements several years ago. Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the first time. Unfortunately, Mrs. Ridgeway has found that many of her providers are not in the MA plan's network. She has come to you for advice? What should you tell her?

b. She qualifies for a special enrollment period (SEP) that will allow her to make a one-time election to return to Original Medicare and she also has a guaranteed eligibility period to rejoin her Medigap plan.

Mrs. Schneider 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 and she is considered a dual eligible. Will gaining eligibility for this program affect her ability to enroll in a Medicare Advantage or Medicare Prescription Drug plan?

c. Yes. Qualifying for this state program gives Mrs. Schneider access to a Special Enrollment Period that allows her to make changes to her MA and/or Part D enrollment during the first 9 months of each calendar year.

Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period (AEP). 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?

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

Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this?

d. If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this.

Mr. Garcia was told he qualifies for a Special Enrollment Period (SEP), but he lost the paper that explains what he could do during the SEP. What can you tell him?

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