AHIP 2019-2020 Module 5

Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan?

A Medicare Advantage Prescription Drug (MA-PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone prescription drug plan.

Mr. and Mrs. Nunez attended one of your sales presentations. They've asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do?

As long as she is able to do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time.

Mr. Fitzgerald is selling his home to permanently move into a retirement facility near his daughter in a neighboring state. He has a stand-alone prescription drug plan, and has learned it is not available where he is moving. He doesn't know what he should do. What can you tell him?

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

Mrs. Goodman enrolled in an MA-PD plan during the Annual Election Period. In mid-January of the following year, she wants to switch back to Original Medicare and enroll in a stand-alone prescription drug plan. What should you tell her?

During the MA Open Enrollment Period, from January 1- March 31, she may only disenroll form a MA or MA-PD plan into Original Medicare and also may add a stand-alone prescription drug plan

Mrs. Disraeli is enrolled in Original Medicare (Parts A and B) and a standalone Part D prescription drug plan. 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.

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. 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.

If Mr. Johannsen gains the Part D low-income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan?

He Qualifies for a Special Enrollment Period and can enroll in or dis-enroll from a Part D plan and the subsidy will apply to the plan he chooses.

If Mr. Johnson gains the Part D low-income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan?

He Qualifies for a Special Enrollment Period and can enroll in or dis-enroll from a Part D plan and the subsidy will apply to the plan he chooses.

Mr. Ford enrolled in an MA-only plan in mid November. On December 1, he calls you up and says that he has changed his mind and would like to enroll into 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. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D. What could you tell him?

He is currently in the Part D initial Enrollment Period (IEP) and, during this time, he may make one Part D enrollment choice, including enrollment in a Stand-alone Part D plan or an MA-PD plan.

Mr. Garrett has just entered his MA initial Coverage Election Period (ICEP). What action could you help him take during this time?

He will have one opportunity to enroll in a Medicare Advantage Plan.

Mr. Sanchez 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

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.

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.

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 and III only

Which of the following individuals are likely to qualify for a special enrollment period (SEP) for both MA and 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 providing him with new MA and Part D options.

II., III., IV only

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

Mr. Garcia was told he qualifies for a Special Election 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

Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard that there are certain MA plans that might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him?

If there is a special needs plan (SNP) in Mr. Wendt's area that specializes in caring for individuals with diabetes, he may enroll in the SNP at any time under a special enrollment period (SEP)

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.

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

Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard?

Implying that only seniors can enroll in a Medicare Advantage plan when meeting with Mr. Hernandez, who is 58 but qualifies for Medicare because he is disabled.

Mrs. Schmidt is moving and a friend told her she might qualify for a "Special Election Period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a Special Election 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 Election 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 in an MA-PD Part D prescription drug plan.

Ms. Claggett is sixty-six (66) years old. She has been covered under both Parts A and B of Original Medicare for the last six years due to her disability, has never been enrolled in a 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" 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?

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.

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 aslum and has worked in the US for many years.

Mr. Wilcox has been enrolled in Lexington PFFS Medicare Advantage Health Plan (Lexington) for several years. Recently, Mr. Wilcox decided to spend time with his children who live in another state that is not in Lexington's service area. In the future, he may relocate near his children permanently. How does this move to another service area impact his PFFS MA coverage?

Lexington Can allow for Mr. Wilcox's continued enrollment for up to 12 months whether or not he is in a visitor/traveler (V/T) program

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.

Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him?

Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment, but he should revaluate if he really wants to drop his employer coverage

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 that his employer is cutting back on prescription drug benefits, and as of June 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 on September 1- two months after the loss of creditable coverage.

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?

Mr. Tully 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. Reynolds just signed up for a Medicare Advantage plan on the second of the month. She is leaving for vacation in two weeks and wants to know if her new coverage will start before she leaves. What should you tell her?

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

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.

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.

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.

Mrs. Burton is in an MA-PD plan and was disappointed in 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 wouldn't continue to 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.

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.

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

She may enroll in an MA plan beginning in 3 months immediately before her first entitlement to both Medicare Part A and Part B.

Ms. O'Donnell learned about a new MA-PD plan that her neighbor suggested and that you represent. She plans to switch from her old MA HMO plan to the new MA-PD plan during the Annual Election Period. However, she wants to make sure she does not end up paying premiums for two plans. What can you tell her?

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

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.

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 15th to December 7th, during which she can select an MA plan.

Mr. Anderson is a very organized individual and has filled out and brought to you an enrollment form on October 10th 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 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.

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

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. 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. 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.

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.

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.

You are completing a PFFS plan sale to Mr. West who is new to Medicare and prefers to be contacted by telephone. As you are finishing up, what should you tell him about the next steps in the enrollment process?

You need to get Mr. West's phone number and include it on the enrollment form because the plan must call him after you leave to ensure that he understood the nature of the PFFS plan he selected and to verify his intent to enroll.

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.