AHIP - 2

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

Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan?

All MSAs cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling in a separate prescription drug plan.

Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the plan's terms and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan charge?

Dr. Brennan can charge Mary Rogers no more than the cost sharing specified in the PFFS plan's terms and condition of payment which may include balance billing up to 15%of the Medicare rate.

Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr. Lombardi's area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell him about this situation?

He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan.

Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him?

He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B.

Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him?

He may receive health care services from any doctor allowed to bill Medicare, as long as he shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing.

Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan that includes drug coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him?

He should compare the benefits in his employer-sponsored retiree group health plan with the benefits in his neighbor's MA-PD plan to determine which one will provide sufficient coverage for his prescription needs.

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. Sanchez has just turned 65 and 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 Medicare Advantage plan, what will he have to do?

He will have to enroll in Part B.

Which of the following statement is/are correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full.

I, II, and IV only

Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him?

In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network).

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

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

Juan Hernandez is turning 65 next month, Juan legally entered the United States over twenty years ago but is not a citizen. Since his entry into the country, Juan has worked at Smallcap Incorporated and contributed to the Medicare system. Juan suffers from diabetes. He will soon retire and asks you if he can enroll in a Medicare Advantage plan that you represent. How would you respond?

Juan is eligible to enroll in a Medicare Advantage as long as he is entitled to Part A and enrolled in Part B. Juan should go to the Social Security website to enroll in Medicare Part A and B if he has not done so already. Once he is enrolled, he can choose a Medicare Advantage plan.

Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of 15 employees and offers employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employer-sponsored healthcare coverage. How would you respond?

Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health 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.

Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could you tell her?

Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services.

Mrs. Wang wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could you tell her?

Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part A and Part B services.

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

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

Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi?

Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan.

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.

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. 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.

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

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.

Mrs. Walters is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Advantage (MA) plan?

She cannot enroll in an MA Medical Savings Account (MSA) plan.

Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease (ESRD). What options will Mrs. Davenport have regarding her MA plan during the next open enrollment season?

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

Mrs. Chou likes a Private Fee-for-Service (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.

Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was disappointed with the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she would not have to put up with such poor access to care. What could you tell her?

She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment.

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. Barker enjoys a comfortable retirement income. He recently had surgery 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.

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.