2018 AHIP

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.

Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met? What could you tell her?

Original Medicare covers ambulance services.

During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her?

Tell her that the Medicare agency does not endorse or recommend any plan.

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 only if it does not offer drug coverage.

Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him?

After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.

Agent Higgins helps Mrs. O'Malley to enroll in AB Medicare Advantage (MA) plan during the Annual Open Enrollment Period. Mrs. O'Malley's effective enrollment date is January 1st. Subsequently, Mrs. O'Malley disenrolls on February 12th following a move outside the plan's service area. What impact will this have on Agent Higgins compensation?

Agent Higgins entire compensation must be recouped because Mrs. O'Malley has disenrolled within 3 months of enrollment.

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.

Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him?

C-SNP

Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period. On December 1, he calls you up and says that he has changed his mind and would like to enroll into an MA-PD plan. What enrollment rules would apply in this case?

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.

Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for Medicare as well. He is concerned about changes in his cost-sharing. What should you tell him?

He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers.

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?

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

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.

Which of the following statements is correct about the appeal and grievance processes? I. Enrollees have a right to obtain a review (appeal) of certain decisions about prescription drug coverage. II. The grievance process is used for reviews of coverage decisions on plan benefits. III. Plans must provide a link to the Medicare.gov website where an enrollee can enter a complaint. IV. Enrollees have a right to file complaints (sometimes called grievances) about the quality of their care.

I. Enrollees have a right to obtain a review (appeal) of certain decisions about prescription drug coverage. III. Plans must provide a link to the Medicare.gov website where an enrollee can enter a complaint. IV. Enrollees have a right to file complaints (sometimes called grievances) about the quality of their care.

Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of misusing or abusing frequently abused drugs?

I. Identifying at risk individuals by using criteria that includes the number of opioid prescriptions the beneficiary has and the number of prescribers who have written those prescriptions. II. Locking an at-risk beneficiary into one pharmacy. III. Locking an at-risk beneficiary into one prescriber.

Mrs. Lopez is enrolled in a Medicare Advantage cost plan. 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 must enroll in this plan.

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 process must include a clear and distinct step that requires the applicant to activate an "Enroll Now" or "I Agree" type of button or tool. IV. The mechanism must capture an accurate time and date stamp at the time the applicant enters the online site.

II. All data elements required to complete an enrollment request must be captured. III. The process must include a clear and distinct step that requires the applicant to activate an "Enroll Now" or "I Agree" type of button or tool.

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 prescription drug plan, he will be disenrolled from the Medicare Advantage plan.

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?

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

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.

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.

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.

Mrs. Wolf 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.

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

Medicare health plans must comply with requests for information from state insurance departments investigating complaints about a marketing representative.

Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover?

Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime.

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.

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. Shultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has lost his employer group coverage. How would you advise him?

Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty.

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.

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.

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.

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.

For which of the following individuals would a Cost Plan be most appropriate?

Ms. Baker who is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan premiums.

Ms. Jensen has heard about "Original Fee-for-Service Medicare" and "Private Fee-for-Service" plans. She wants to know what the difference is, if any. What should you tell her?

PFFS plans are a type of Medicare Advantage plan offered by private companies.

Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-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. 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.

You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns?

Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facility.

Ms. Goldstein is required by the plan she represents to obtain enrollment forms that have carbon copies in the back. She gives one to the beneficiary, sends another to the plan and retains the third. What should she do with her copies of the enrollment forms?

She should make every effort to safeguard the beneficiary information on those enrollment forms.

You are meeting with Mrs. Hall in her home. On her scope of appointment form she asked to discuss Medicare Advantage plans. During the meeting, she asks to discuss a stand-alone prescription drug plan. She is leaving the next day to visit her family for a week in another state, so it is important to her to make a decision before she leaves. What must happen before that additional discussion can take place?

Since Mrs. Hall specifically asked that you discuss the stand-alone Part D plan, you may do so, as long as she signs a new scope of appointment form first, indicating that she wants to discuss the Part D plan.

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 brand-name drugs in the coverage gap, and co-pays or co-insurance after the coverage gap.

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 stand-alone 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. 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.

Ajax Agency is targeting potential enrollees for MSA plans. Which of the following statements best describes the rules that apply to the MSA materials it distributes?

The materials must make clear that Medicare MSA plans do not cover prescription drugs and that beneficiaries can join a separate Part D prescription drug plan.

Mr. Murphy is an agent. A neighbor invited him to discuss the Medicare Advantage (MA) and Part D plans he sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Mr. Murphy tell his neighbor about the kinds of food that can be provided to potential enrollees who attend the sales presentation?

The neighbors may not provide a meal, but light snacks would be permitted.

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.

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.

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?

You can only ask Mrs. Midler 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.

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

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.

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 enrolled in Part A and Part B and if he lives in the PFFS plan's service area.

Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same 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.