Study

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.

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

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 thirdparty marketing organization (TMO). How do the CMS compensation rules apply to these three agents?

All three are treated as independent agents under CMS compensation rules.

ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees' protected health information to market non-health related products such as life insurance and annuities. To do so it must obtain authorization from the enrollees. Which statement best describes the authorization process?

Authorization may be obtained by directing a beneficiary to a website to provide consent as long as the website includes a mechanism for an electronic signature that is valid under applicable law.

Mr. Katz reached the Part D coverage gap in August last year. His prescriptions have not changed, he is keeping the same Part D plan and the benefits, cost-sharing, and coverage of his drugs are all the same as last year. He asked what to expect for this year about his out-of-pocket costs. What could you tell him?

Because he reached the coverage gap last year, he will probably reach it again this year close to the same time.

Mrs. Disraeli is enrolled in Original Medicare (Parts A and B) and a standalone Part D prescription drug plan. She has recently developed diabetes and has suffered from heart disease for several years. She has also recently learned that her area is served by a SNP for individuals suffering from such a combination of chronic diseases (C-SNP). Mrs. Disraeli is concerned however, that she will have few rights or protections if she enrolls in a C-SNP. How would you respond?

Enrollees in SNPs must have access to provider networks that include enough doctors, specialists, and hospitals to provide all covered services necessary to meet enrollee needs within reasonable travel time.

Mr. Edwards, a marketing representative of the ACME Insurance Company, scheduled a marketing event and expects about 40 people to attend. He has hired a magician at a cost of $200 to entertain attendees. Can he do this in a way that complies with guidance from the Medicare agency?

He can do this, because the estimated number of attendees is based on the venue size and response rate and the value of the gift does not exceed $15.

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

Which of the following statements is correct about the appeal and grievance processes?

I, III, and IV only

Mr. Rice has coverage for medical services and medications through his employer's retiree plan. He is considering switching to a Medicare prescription drug plan because his retiree plan does not cover two important medications. What should he consider before making a change?

If Mr. Rice drops his drug coverage through the retiree plan, he may not be able to get it back and he also may lose his medical health coverage.

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.

Ms. Hernandez has marketed several different types of insurance products in her home state and has typically sought approval of her materials from her State Department of Insurance. What would you advise her regarding seeking such approval for materials she uses to market Medicare Advantage plans?

Materials for marketing Medicare health plans to individuals are subject to Medicare's uniform national requirements. They do not need to be reviewed by the state, but the company she represents must obtain approval from the Medicare agency (CMS) for any materials she uses.

Mr. Rockwell, age 67, is enrolled in Medicare Part A, but because he continues to work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special enrollment periods (SEPs)?

Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends September 1 - two months after the loss of creditable coverage.

Ms. Lopez is an independent agent under contract with MarketCo, a third-party marketing organization. MarketCo has a contract with BestCare health plan, a Medicare Advantage (MA) organization, to offer marketing services through its contracted agents and agencies. Ms. Lopez returns calls to individuals who contact MarketCo in response to its mailers promoting BestCare health plan. Which of the following best describes the responsibilities of Ms. Lopez?

Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts.

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 make financial 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. Schmidt would like to plan for retirement and has asked you what is covered under Original Feefor-Service (FFS) Medicare? What could you tell him?

Part A, which covers hospital, skilled nursing facility, hospice and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare.

Mr. Polanski likes the cost of an HMO plan available in his area, but would like to be able to visit one or two doctors who aren't participating providers. He wants to know if the Point of Service (POS) option available with some HMOs will be of any help in this situation. What should you tell him?

The POS option might be a good solution for him as it will allow him to visit out-ofnetwork providers, generally without prior approval. However, he should be aware that it is likely he will have to pay higher cost-sharing for services from out-of-network providers.

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.

One of your colleagues argues that it is better to focus your time and energy exclusively in neighborhoods with single family homes. He further argues that their older owners are more likely to have higher incomes and purchase the Medicare Advantage products you represent compared to those living in apartment complexes. How should you respond?

This could be considered discriminatory activity and a prohibited practice.

Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application prior the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams?

This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form prior to the start of the AEP.

Mr. Jenkins is interested in enrolling in a Medicare cost plan and has sought your advice. What would you tell him?

Cost plans are required to be open to enrollment at least 30 days per year, and many are open for enrollment all year. So open enrollment will be dependent on the plan he chooses.

Mr. Gonzalez is entitled to Part A, but has not yet enrolled in Part B. If he wants to enroll in a Medicare Advantage (MA) plan, what will he have to do?

He will have to enroll in Part B prior to enrolling in a MA plan.

Which statement best describes PACE plans?

It includes comprehensive medical and social service delivery systems using an interdisciplinary team approach in an adult day health center, supplemented by in-home and referral services.

Agent Chan is conducting a sales presentation on senior issues where he hopes to enroll some attendees in the Medicare Advantage (MA) plans he represents. What action(s) may Agent Chan take during the event?

Discuss plan specific information such as premiums and benefits.

Who is most likely to be eligible to enroll in a Part D prescription drug plan?

answer: Ms. Davis who recently turned age 65 and is eligible for Part A and has just enrolled in Part B.

Mr. Nguyen understands that Medicare prescription drug plans can use a formulary, or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him?

. Formularies must be developed with input from pharmacists, doctors, and other experts.

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

Eleanor takes several high-cost prescription drugs. She would like to enroll in a standalone Part D prescription drug plan that is available in her area. In what type of Medicare Health Plan can she enroll if she also wishes to enroll in the standalone Part D plan?

A Cost Plan that does not offer drug coverage or a Cost Plan that does offer drug coverage if she chooses not to enroll in it.

During a sales presentation in Ms. Sullivan's home, she tells you that she has heard about a type of Medicare health plan known as Private Fee-for-Service (PFFS). She wants to know if this would be available to her. What should you tell her about PFFS plans?

A PFFS plan is one of various types of Medicare Advantage plans offered by private entities and she may enroll in one if it is available in her area.

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 cannot be provided, but light snacks would be permitted.

You have come to Mrs. Midler's home for a sales presentation. At the beginning of the presentation, Mrs. Midler 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. What should you do?

Answer: You have come to Mrs. Midler's home for a sales presentation. At the beginning of the presentation, Mrs. Midler 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. What should you do?

Mr. Wong is a single individual. He has had a successful business career and is now able to retire with a comfortable income. Mr. Wong's taxable income is in excess of $100,000. Mr. Wong has health coverage through his employer but will sign-up Medicare Part A, Part B and Part D when he leaves the workforce. How would you advise him as he budgets for Medicare premiums?

Due to his participation in the workforce he will not have to pay premiums for Part A but he will pay higher premiums for Part B and Part D due to the amount of his income.

Mrs. Johnson calls 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 date of coverage.

Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him?

He is eligible for the Part D prescription drug benefit because he is entitled to Part A and he does not have to be enrolled in Part B.

Mr. Kelly has substantial financial means. He enrolled in Original Medicare and purchased a Medigap policy many years ago that offered prescription drug coverage. The prescription drug coverage has not been comparable to that offered by Medicare Part D for several years and despite notification, Mr. Kelly took no action. Which of the following statements best describes what will occur if Mr. Kelly now decides to enroll in Medicare Part D?

He will incur a late enrollment penalty.

Mr. James has end-stage renal disease (ESRD). He has been covered under Original Medicare but would like to know if he can enroll in a Medicare Advantage plan. What should you tell him?

He will not be able to enroll in a Medicare Advantage plan because he has endstage renal disease unless a special needs plan for beneficiaries with ESRD is available in his service area.

Mrs. Lenard is enrolled in a Medicare Cost plan. Recently the cost plan announced its intention to end its cost contract and transition to a Medicare Advantage (MA) Mrs. Lenard received a letter indicating that unless she chooses another plan or opts out she will be automatically enrolled in the new Medicare Advantage plan operated by an organization affiliated with her cost plan. What does this mean?

If Mrs. Lenard wants to enroll in a Medicare Advantage plan affiliated with her cost plan effective January 1, she should do nothing and she will be automatically enrolled. If she does not want to enroll in that MA plan, she should choose another plan or otherwise opt out of the automatic enrollment.

Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him?

It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare.

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

Market non-Medicare health-related products, such as dental insurance, to current members as permitted by HIPAA Privacy Rules.

Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through acupuncture. She is concerned about whether or not Medicare will cover these items and services. What should you tell her?

Medicare does not cover acupuncture, or, in general, glasses or dentures.

Mr. Hernandez is concerned that if he signs up for a Medicare Advantage plan, the health plan may, at some time in the future, reduce his benefits below what is available in Original Medicare. What should you tell him about his concern?

Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs.

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?

Medicare will cover Mrs. Shields' skilled nursing services provided during the first 20 days of her stay, after which she would have a coinsurance until she has been in the facility for 100 days.

Mr. Jackson just turned 65. He has been seeing the same general practitioner for annual check-ups for the past 15 years, likes these yearly visits, and would like to continue obtaining these services as a Medicare beneficiary. What should you tell him about annual check-ups?

Medicare will cover an annual wellness visit, even if he has no illnesses or injuries.

Mr. Singh would like drug coverage, but does not want to be enrolled into a health plan. What should you tell him?

Mr. Singh can enroll in a stand-alone prescription drug plan and continue to be covered for Part A and Part B services through Original Fee-for-Service Medicare.

Mrs. Valentino is currently enrolled in a Medicare Cost plan. This plan is no longer meeting her needs, but it is now mid-year and past the annual election period (AEP). What would you say to Mrs. Valentino regarding her options?

Mrs. Valentino can submit a written request to Medicare to be disenrolled from the Cost plan and enroll in Original Medicare.

Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to you for advice as to what options, if any, she has. What should you say regarding special enrollment periods (SEPs)?

Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the five-star plan.

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 the way for consumers to judge plan performance, what else would you say?

New plans and Part D sponsors that do not have any Star Rating are not required to provide Star Rating information until the next contract year.

Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted with regard to the marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise him concerning the type of scrutiny he will be under?

Organizations sponsoring Medicare health plans are responsible for the behavior of their contracted representatives and will be conducting monitoring activities to ensure compliance with all applicable Federal law and guidance and plan policies. Furthermore, state agent licensure laws are not preempted and he must abide by their requirements.

Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him?

SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well.

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.

Alice is enrolled in a MA-PD plan. She makes a permanent move across the country and wonders what her options are for continuing MA-PD coverage. What would you say to her in regard to a special enrollment period (SEP)?

She is likely to qualify for a SEP. She can choose an effective date of up to three months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than the date of her permanent move.

Ms. Lewis understands that Medicare prescription drug plans may use various methods to control the use of specific drugs. She has heard about a technique called "step therapy" and is wondering if you can explain what that is. What should you tell her?

Step therapy involves using one or more lower priced drugs before trying a more expensive drug when all are used to treat the same condition.

If a beneficiary is enrolled in a stand-alone prescription drug plan and wants to keep that plan, what type of Medicare health plan could the individual also enroll in, without being automatically disenrolled from the standalone prescription drug plan?

The beneficiary could enroll in a private fee-for-service (PFFS) plan that does not include prescription drug coverage; an 1876 cost plan; or a Medicare Medical Savings Account (MSA) plan

Mr. Rivera has Qualified Medicare Beneficiary (QMB) eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) PPO plan. Later he sees an out-of-network doctor to receive a Medicare covered service. How much may the doctor collect from Mr. Rivera?

The doctor may only collect from Mr. Rivera the cost sharing allowable under the state's Medicaid program.

Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation rules apply to this situation?

This situation is considered a "dual enrollment," and CMS compensation rules are applied to the two plans at once and independently of each other.

Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare?

Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a perday coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs

Mr. Chen has heard about a Medical Savings Account (MSA), but wants to know if it is just about saving money, or if he will get insurance coverage for his health care expenditures as well. What should you tell him?

Under the Medicare Advantage program, a MSA plan involves the combination of a high deductible health plan and a savings account for health expenses. Medicare will make contributions to this savings account to help him pay his health care expenses while in the deductible.

Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year?

When a formulary change is in response to a drug's removal from the market.

Mr. Barker had surgery recently and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included a number of services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him?

You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.

If you are to be in compliance with Medicare's guidance regarding educational events, which of the following would be acceptable activities?

You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent.

Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you October 15. During the appointment, what are you permitted to do?

You may provide her with the required enrollment materials and take her completed enrollment application.

You are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs. What should you keep in mind?

You may request RSVPs, but you are not permitted to require contact information.

You are working with a number of plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do?

You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event.

Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know what makes them different from an HMO or a PPO. What should you tell him?

Enrollees in a PFFS plan can obtain care from any provider in the U.S. who accepts Original Medicare, as long as the provider has a reasonable opportunity to access the plan's terms and conditions and agrees to accept them.

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?

Enrollees should pay using automatic withdrawal from a bank account or credit or debit card, direct monthly billing from the plan, or deductions from their Social Security check.

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.

Mrs. Roswell is a new Medicare beneficiary and is interested in selecting a Medicare Part D prescription drug plan. She takes a number of medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her?

Every Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90 day transition period.

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 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.

Mrs. Kumar would like her daughter, who lives in another state, to meet with you during the Annual Election Period to help her complete her enrollment in a Part D plan. She asked you when she should have her daughter plan to visit. What could you tell her?

Her daughter should come in November

Mr. Roberts is enrolled in an MA plan. He recently suffered complications following hip replacement surgery. As a result, he has spent the last three months in Resthaven, a skilled nursing facility. Mr. Roberts is about to be discharged. What advice would you give him regarding his health coverage options?

His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility.

Monica is an agent focused on serving seniors eligible for Medicare. As she reviews her records, she is trying to determine which of the following items are considered compensation. What do you tell her? I. Commissions II. Bonuses III. Mileage reimbursement IV. Referral fees

I, II, and IV only

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, 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.

Mrs. Kelly, age 65, is entitled to Part A, but has not yet enrolled in Part B. She is considering enrollment in a Medicare health plan (Part C). What should you advise her to do before she will be able to enroll into a Medicare health plan?

In order to join a Medicare health plan, she also must enroll in Part B.

Mrs. Schmidt is moving and a friend told her she might qualify for a "Special Enrollment Period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a Special Enrollment Period is. What could you tell her?

It is a time period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically the Special Enrollment Period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area.

Mr. Yoo's employer has recently dropped comprehensive creditable prescription drug 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 Special Enrollment Period. Mr. Yoo contacted you to find out more about what this means. What can you tell him?

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

Which of the following individuals is most likely to be eligible to enroll in a Medicare Advantage or Part D Plan?

Jose, a grandfather who was granted asylum and has worked in the United States for many years

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.

Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her?

Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers.

Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services' communication and Marketing Guidelines to ensure he is compliant for which type of products?

Medicare Advantage (MA) and Prescription Drug (PDP) plans

Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be a correct description?

Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies.

Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums and cost sharing. How can you explain this to him?

Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government.

Mr. Meoni'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.Meoni?

Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing 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. 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. Zachow has a condition for which three drugs are available. He has tried two but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What could you tell him to do?

Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan.

Mrs. Tanner is enrolled in a Medicare Advantage HMO that offers a point of service option. This allows Mrs. Tanner to do which of the following?

Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval.

You meet with Mrs. Wilson to complete her enrollment in a Medicare Advantage plan. You tell her that there will be an enrollment verification process to confirm that she is enrolled in the plan that she requested and understands the plan features and rules. What should Mrs. Wilson expect regarding the verification process?

Mrs. Wilson will be contacted by the plan sponsor within 15 calendar days of receipt of the enrollment request.

Mrs. Quinn has recently turned 66 and decided after many years of work to begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn?

Part B primarily covers physician services. She will be paying a monthly premium and, with the exception of many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible.

Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her?

Part D covers prescription drugs and she should look at her premiums, formulary, and cost sharing among other factors to see if they have changed.

What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?

Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization.

Ms. Bushman has two homes in different states and is concerned about restrictions on where she can get her medications. What should you tell her?

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

Mr. Robinson was quite ill recently and forgot to pay his monthly premium for his MA-PD plan. He is worried that he will lose his coverage now when he needs it the most. He is certain his plan will disenroll him because that is what happened to a friend of his in a similar type of plan. What can you tell Mr. Robinson about his situation?

Plan sponsors have the option to disenroll members who do not pay their premiums, but they must first provide each member with a grace period of not less than 2 months.

Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her area. 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?

Plans are required to cover out-of-network emergency care.

Mrs. Grant uses several very expensive drugs and anticipates that she will enter catastrophic coverage at some point during the year. To help her determine when she is likely to qualify for catastrophic coverage, she asked which expenses count toward the out-of-pocket limit that qualifies her for catastrophic coverage. Which one of the following would count?

Prescription drugs she purchases when in the Part D coverage gap.

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?

Prior to conducting the presentation, obtain, and document having obtained her permission to visit, along with her interest in the specific products you will present.

Mr. Lopez takes several high cost prescription drugs. He would like to enroll in a standalone Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan can he enroll?

Private Fee-for-Service (PFFS) plan that does not include drug coverage.

Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her?

She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy.

Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs. Davenport have in regard to her MA plan during the next open enrollment season?

She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area.

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?

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. Park is an elderly retiree. She 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.

During an appointment scheduled to discuss a Medicare Advantage Prescription Drug plan (MA-PD), Mr. Peters asked his agent to describe a stand-alone prescription drug plan (Part D plan) that his neighbor told him about. What should his agent do?

Since Mr. Peters requested a description of the Part D plan, his agent must have Mr. Peters sign a new scope of appointment form that includes Part D, and then the agent may discuss the Part D plan so Mr. Peters can compare plans and make an informed enrollment choice during the appointment.

Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable income only sporadically. Her husband worked full-time throughout his long career. She has heard that to qualify for Medicare Part A she has to have worked and paid Medicare taxes for a sufficient time. What should you tell her?

Since her husband paid Medicare taxes during the entire time he was working, she will automatically qualify for Medicare Part A without having to pay any premiums.

All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a beneficiary incur for prescription drugs in 2019 under the standard coverage?

Standard Part D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a portion of costs for both generics and brandname drugs in the coverage gap, and co-pays or co-insurance after the coverage gap.

Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her?

The letter is to inform her that the drug coverage offered through her Medigap plan does not offer drug coverage that is at least comparable to that provided under the Medicare Part D prescription drug program. If she does not have such creditable coverage during periods when she is eligible for the Part D program, she will face a premium penalty if she enrolls in a Part D plan at a later date.

Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen with respect to her drug coverage?

Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.

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. 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.

Mr.Chan is one of your clients and in excellent health. He is enrolled in a Medicare prescription drug plan that you represent. He recently heard about a Medication Therapy Management (MTM) program in which his friend is enrolled. What should you tell him?

To be eligible for a MTM program, a Medicare beneficiary must have multiple chronic diseases, be taking multiple Part D prescription drugs, and likely to incur considerable drug costs.

Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is interested in that product. She wants to be sure she also has coverage for prescription drugs. Would she be able to obtain drug coverage if she enrolled in the SNP?

Yes. All SNPs are required to provide Part D coverage for prescription drugs.

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?

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 beginning in 2019.

Agent Mary Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational in nature. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational?

Yes. When an event has been advertised as "educational," discussing plan-specific premiums is impermissible.

This year you decide to focus your efforts on marketing to employer and union groups. Which of the following statements best describes what you can and cannot do in order to stay in compliance?

You are not required to submit communication and marketing materials specific only to those employer plans to CMS at the time of use, but CMS may request and review copies if employee complaints occur.

If you are to be in compliance with Medicare's guidance regarding educational events, which of the following would be acceptable activities?

You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent.

When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?

You may provide gifts or prizes to all potential enrollees during an event that do not exceed $15 in retail value.

You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA) plans you represent. Before you conduct such sales presentations, what must you do?

You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in-home presentation.

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?

You must submit your materials to the plan you represent, so CMS can review and approve the materials to ensure they are accurate.

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 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.

Agent Lopez helps Ralph to enroll in Top Choice Medicare Advantage plan during the Annual Open Enrollment Period. Ralph's effective enrollment date is January 1st. Ralph disenrolls on February 12th because he did not understand that the plan did not cover services furnished by several of his longtime providers. Which of the following statements best describes the impact of Ralph's action upon Agent Lopez's compensation?

Answer: Agent Lopez's entire compensation must be recouped because Ralph disenrolled within 3 months of enrollment.

Ms. Gardner is currently enrolled in an MA-PD plan. However, she wants to disenroll from the MAPD 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?

Answer: She may make such a change during the Annual Election Period that runs from Oct. 15 to December 7, or during the MA Open Enrollment Period which takes place from January 1- March 31 of each year (beginning in 2019).

Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him?

Formularies must be developed with input from pharmacists, doctors, and other experts.

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.

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?

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

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.

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 cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.

Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her?

Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs.

Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage (MA) health plans. This year she has decided to focus on non-MA products. What advice would you give Melanie if she wishes to continue to receive renewal fees?

Melanie must remain trained, tested, licensed, and appointed, regardless of whether she is actively selling MA products.

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. 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. 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 sub-populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP.

Mrs. Fiore was in the Army for 35 years and is now retired. She has drug coverage through the VA. What issues might she consider with regard to whether to enroll in a Medicare prescription drug plan?

She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the VA for the specific medications she needs and

Mrs. Chou likes a 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. 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.

Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a meeting so that she can learn about Medicare and the products you represent. How should you respond?

Tell Julia that you will meet with her to explain Medicare and should she be interested you can accept and submit an enrollment request, since this is an initial enrollment qualifying her for a special enrollment period.

Mr. Shapiro gets by on a very small fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him?

The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government.

Mr. Olsen is concerned that a Medicare Advantage plan will not cover the same range of services that would be covered under Original fee-for-service Medicare. What should you tell him?

Though their cost-sharing may differ from Original Medicare's, Medicare Advantage plans are required to cover all services covered by original Medicare.

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.

A client wants to give you an enrollment application on October 1 prior to 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.

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?

You should plan to ensure that the educational event is a social event, and must not conduct a sales presentation or distribute or accept enrollment forms at the event.

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 market many different types of insurance and ordinarily you spend time each evening calling potential clients. To be in compliance with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plans?

You will have to avoid calling any potential client, unless he or she initiates contact with you and specifically asks that you give him or her a call.