2023 AHIP

Which Medicare programs are covered by ACA Section 1557?

Parts A, C, and D, but not B.

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.

ACA Section 1557 rules for disability concern

Policies and procedures, physical access, and communication.

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.

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 within the plan's network (except in an emergency or where care is unavailable within the network).

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

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.

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

Melissa Meadows is a marketing representative for Best Care which has recently introduced a Medicare Advantage plan offering comprehensive dental benefits for $15 per month. Best Care has not submitted any potential posts to CMS for approval. Melissa would like to use the power of social media to reach potential prospects. What advice would you give her?

As soon as CMS approves Best Care's social media posts, Agent Meadows could post a tweet stating that "Best Care offers an array of Medicare Advantage benefit packages. One might be right for you. Call me to find out more!"

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 Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong?

Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located.

Ways to report a compliance issue include: a.In-person reporting to the compliance department/supervisor b.Report on the Sponsor's website c.Telephone hotlines d.All of the above

All of the above

Ways to report potential fraud, waste, and abuse (FWA) include: a. Mail drops b. Special Investigative Units (SIUs) c. Tekephone hotlines d. All of the above e. In-person reporting to the compliance department/supervisor

All of the above

What are some of the consequences for non-compliance, fraudulent, or unethical behavior? a.Exclusion from participating kin all Federal health care programs b.Termination of employment c.Disciplinary action d.All of the above

All of the above

What are some of the penalties for violating fraud, waste, and abuse (FWA) laws? a.Civil Monetary Penalties b.Imprisonment c.All of the above d.Exclusion from participation in all Federal health care programs

All of the above

Which of these actions is most likely to be permitted in dealing with a person with limited English proficiency?

Allowing a child to interpret in an emergency.

You work for a Sponsor. Last month, while reviewing a Centers for Medicare & Medicaid Services (CMS) monthly report, you identified multiple individuals not enrolled in the plan but for whom the Sponsor is paid. You spoke to your supervisor who said don't worry about it. This month, you identify the same enrollees on the report again. What should you do?

Although you know about the Sponsor's non-retaliation policy, you are still nervous about reporting—to be safe, you submit a report through your compliance department's anonymous tip line to avoid identification

Mulcahy, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her?

An individual who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan.

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 can 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.

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.

Xi will soon turn age 65 and has come to you for advice as to what services are provided under Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to Medicare beneficiaries?

Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots.

Which of the following would be considered permissible under Section 1557 and the 2020 Final Rule?

Broker Mary Jones has recruited a diverse workforce. She encourages her agents to prospect through community-based marketing and within their community of influence.

A person drops off a prescription for a beneficiary who is a "regular" customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step?

Call the prescriber to verify the quantity

You are in charge of paying claims submitted by providers. You notice a certain diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize Doe Diagnostics' claims far exceed any other provider you reviewed. What should you do?

Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or other mechanism)

You discover an unattended email address or fax machine in your office receiving beneficiary appeals requests. You suspect no one is processing the appeals. What should you do?

Contact your compliance department (via compliance hotline or other mechanism)

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.

Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud, waste, and abuse (FWA)?

Deportation

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.

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.

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.

Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel?

During the MA-OEP, Miguel can have one-on-one meetings with beneficiaries who have requested such meetings.

Lopez, who is fairly well-off financially, 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.

Any person who knowingly submits false claims to the Government is liable for five times the Government's damages caused by the violator plus a penalty.

False

At a minimum, an effective compliance program includes four core requirements.

False

Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only.

False

Medicare Parts C and D sponsors are not required to have a compliance program.

False

Once a corrective action plan begins addressing non-compliance for fraud, waste, and abuse (FWA) committed by a Sponsor's employee or first-tier, downstream, or related entity's (FDR's) employee, ongoing monitoring of the corrective actions is not necessary.

False

Once a corrective action plan is started, the corrective action plan must be monitored annually to ensure they are effective.

False

Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA) include the Health Insurance Portability and Accountability Act (HIPAA), the False Claims Act the Anti-Kickback Statute, and the Health Care Fraud Statute.

False

Standards of Conduct are the same for every Medicare Parts C and D sponsor.

False

You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?

Follow your pharmacy's procedures

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.

Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him?

He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start.

Which of the following requires intent to obtain payment and the knowledge the actions are wrong?

Fraud

You will be holding a sales event soon, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation?

Gift cards or gift certificates of $15 or less that can be readily converted to cash.

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 to 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.

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.

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 does not have to enroll in Part B but, must pay a penalty for his failure to do so when he first turned 65. After that, he can enroll in a Part D prescription drug plan.

Alonso receives some help paying for his two generic prescription drugs from his employer's retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard MedicarePart D prescription drug plan. What should you tell him?

He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing.

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.

Johannsen is entitled to Medicare Part A and Part B. He 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 election period and can enroll in or disenroll from a Part D plan once during that period.

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.

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.

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.

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 statements best describes the scope of operations subject to Section 1557 under the 2020 Final Rule?

Health insurers under the 2020 Final Rule are not considered to be principally engaged in delivering health care, and thus lines of business that do not receive federal funding or administered under Title I of the ACA, such as life insurance, do not fall under the scope of 1557.

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.

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.

Auxiliary aids and services must be provided to individuals with disabilities, such as those suffering from vision or hearing impairments, free of charge, and in a timely manner. Auxiliary aids and services include which of the following: I. large print materials II. qualified sign language interpreters III. braille materials and displays IV. screen reader software

I, II, III, and IV

Which of the following is/are most likely to be characterized as an involuntary disenrollment from a Medicare Advantage (MA) plan? I. The enrollee dies. II. An SNP enrollee loses special needs status due to substantially improved health. III. It is determined that the member is not lawfully present in the United States. IV. The member enrolls in another plan during the Annual Open Enrollment period.

I, II, and III only

Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan.

I, II, and III only

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

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.

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.

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.

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, and 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.

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 plan, Mrs. Berkowitz can do this.

Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him?

If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty.

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 certain MA plans 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 election period (SEP)

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 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 election period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area.

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.

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 or Part D prescription drug plan.

ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees' information to market non-health related products such as life insurance and annuities. Which statement best describes ABC's obligation to its enrollees regarding marketing such products?

It must obtain a HIPAA complaint authorization from an enrollee that indicates the plan or plan sponsor may use their information for marketing purposes.

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

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

Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of15 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.

For a health plan, what are the possible consequences of violations of ACA Section 1557?

Loss of federal business and compensatory damages.

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

Market non-health related items or services such as life insurance or annuities policies to current members as permitted following HIPAA Privacy Rules.

Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her?

Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided.

Agent Marvin Millner wants to reach out to his current clients for referrals. What advice would you give to Marvin?

Marvin should understand that under CMS guidelines he can no longer provide gifts, even of minimal value, in exchange for referrals. NOT SURE

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.

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.

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

Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him?

Medicare covers the periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered.

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

Medicare does not cover massage therapy, or, in general, glasses or dentures.

Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern?

Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's disease so she will be eligible for Medicare.

Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them?

Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn's could look into that possibility.

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.

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.

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.

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 age 65 or over 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.

Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him?

Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries.

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.

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 election 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.

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 within the last two weeks. 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.

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.

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 MS MSA plan and remain in her current standalone Part D prescription drug plan.

Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her?

Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail.

Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has but replace her existing Medigap plan with one that provides drug coverage. What should you tell her?

Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan.

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.

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

Ms. Davis who is entitled to Part A and has just enrolled in Part B.a sales presentation, your client asks you wh

Morris will turn 65 on June 10th. She has never previously qualified for Medicare. She is entitled to Medicare Part A and intends to enroll in Part B. She wants to know if she is eligible to enroll in a Medicare Advantage plan that includes prescription drug coverage. What do you tell her?

Ms. Morris can enroll in an MA-PD plan now since her initial election period (IEP) for Part D prescription drug coverage and initial coverage period are occurring together beginning March 1st and ending September 30th.

White has Medicare Parts A and B with a Part D plan. Last year, he received a notice that his plan sponsor identified him as a "potential at-risk" beneficiary. This month, he started receiving assistance from Medicaid. He wants to find a different Part D plan that's more suitable to his current prescription drug needs. He believes he's entitled to a SEP since he is now a dual eligible. Is he able to change to a different Part D plan during a SEP for dual eligible individuals?

No. Once he is identified by the plan sponsor as a "potential at-risk" beneficiary, he cannot use the dual eligible SEP to change plans while this designation is in place.

Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan's formulary he takes several other medications. These include a prescription drug not on his plan's formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say?

None of the costs of Mr. Wingate's other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary.

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.

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.

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.

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. NOT SURE

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.

A sales agent, employed by the Sponsor's first-tier, downstream, or related entity (FDR), submitted an application for processing and requested two things: 1) to back-date the enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary. What should you do?

Process the application properly (without the requested revisions)—inform your supervisor and the compliance officer about the sales agent's request

What is the policy of non-retaliation?

Protects employees, who in good faith report suspected non-compliance

Correcting non-compliance________

Protects enrollees, avoids recurrence of same non-compliance, and promotes efficiency

Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this job, you use a process to verify the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain individuals. What should you do?

Report the incident to the compliance department (via compliance hotline or other mechanism)

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.

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.

Which of the following statements best describes Section 1557 of the Affordable Care Act (ACA)?

Section 1557 incorporates earlier civil rights protections in regard to race, color, national origin, disability, age and sex.

Reeves is newly eligible to enroll in a Medicare Advantage plan and her MA Initial Coverage Election Period (ICEP) has just begun. Which of the following can she not do during the ICEP?

She can enroll in a Medigap plan to supplement the benefits of the MA plan that she's also enrolling in.

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.

Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her?

She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period after the last month on her employer plan that differs from the standard general enrollment period, during which she may enroll in Medicare Part B.

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.

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

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.

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.

Park is an elderly retiree. Mrs. Park 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.

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. Which of the following statements best describes some of the costs a beneficiary would incur for prescription drugs under the standard coverage?

Standard Part D coverage would require payment of an annual deductible, and once past the catastrophic coverage threshold, the beneficiary pays whichever is greater of either the co-pays for generic and brand name drugs or coinsurance of 5%.

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.

Margolis contacts you in August because she will become eligible for Medicare for the first time in November. She would like to meet and discuss plan choices with you. What advice should you give her?

Tell her to wait until October to discuss plan choices with you so that you can share plan benefits for the current year as well as any changes for the following year that may impact her choice.

Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed?

Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage.

Which entity enforces Section 1557 for programs that receive funding from on are administered by HHS?

The Office of Civil Rights (OCR) of HHS.

Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently 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 first eligible for the Part D program, she will face a premium penalty if she enrolls in a Part D plan at a later date.

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; a cost plan; or a Medicare Medical Savings Account (MSA) plan.

Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual?

The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract.

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.

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.

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 before 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 before the start of the AEP.

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.

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.

Henderson believes that she will qualify for Medicare Coverage when she turns 65, without paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her?

To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes.

Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly or intentionally misrepresented facts to obtain payment.

True

Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which includes Medicare) constitute fraud by the person making as well as the person receiving them.

True

These are examples of issues that can be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA), potential health privacy violation, and unethical behavior/employee misconduct.

True

These are examples of issues that should be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA); potential health privacy violation, unethical behavior, and employee misconduct.

True

Waste includes any misuse of resources, such as the overuse of services or other practices that directly or indirectly result in unnecessary costs to the Medicare Program.

True

You can help prevent fraud, waste, and abuse (FWA) by doing all the following: Look for suspicious activity Conduct yourself in an ethical manner Ensure accurate and timely data and billing Ensure you coordinate with other payers Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance Verify all information provided to you

True

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 per-day 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.

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. NOT SURE

McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen 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.

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.

Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational. 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.

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.

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 some 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 records 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 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.

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 on 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 have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respect to meals?

You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal.

You are working several 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.

A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do?

You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion.

A client wants to give you an enrollment application on October 1 before 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. 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 an informative event and must not conduct a sales presentation or distribute or accept enrollment forms at the event.

You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation?

You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score. However, you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing.

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 marketing 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.

As a result of violations of ACA Section 1557 nondiscrimination rules,

a health plan may revoke an agent or broker's appointment with the health plan.

Section 1557 of the Affordable Care Act applies to

all health programs and activities administered by or receiving federal financial assistance from HHS

Under Section 1557, 2020 Final Rule issued during the Trump Administration sex was initially defined____________

as biologic sex only, meaning whether a person was determined to be male or female at birth.

Under ACA Section 1557, a health plan

cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge.

Under ACA Section 1557, a health plan premium sold through a state exchange may, based on an individual's age,

charge higher premiums.