AHIP 2022-2023 Test

You have set up an appointment for an in-home sales presentation with Mrs. Fernandez, who expressed interest in the Medicare plans you represent. In preparation for the sales presentation, what must you do?

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

Which of the following individuals has enrolled in a plan based on a fixed enrollment period?

Ben, who enrolls in a Medicare Advantage plan during the Medicare Advantage Open Enrollment Period (MA OEP).

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

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

Miles is a licensed agent who represents Colgate Health and its Medicare Advantage (MA) plans. Miles has several clients who have recently come to him for help. They are in their initial coverage periods) (ICEP) and are interested in enrolling in one of Colgate Health's MA plans. Adam will soon turn 68 and has decided to retire. Betty is about to turn 65 and has also decided to retire. Adam and Betty both currently have coverage through Colgate Health. Charles had health coverage through Colgate but dropped the coverage when he retired early to travel to Europe. Charles has just turned age 65 and is now back in the United States. Diedre, who will turn 65 next month, currently has coverage through Ditmas Health - a company that Miles also represents. Who qualifies for the opt-in simplified enrollment mechanism?

Adam and Betty because each of them will not have a break between their non-Medicare and Medicare coverage through Colgate Health Plan.

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

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

Mr. Liu turns 65 on June 19. He has never previously qualified for Medicare so his first Medicare eligibility date will be by June 1. Mr. Liu's ICEP and Part D IEP begin March 1 and end on September 30. He wants prescription drug coverage with his Part A and Part B benefits. What advice can you provide him?

He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to Part A.

Mr. Rodriguez is currently enrolled in a MA plan, but his plan doesn't sufficiently cover his prescription drug needs. He is interested in changing plans during the upcoming MA Open Enrollment Period. What are his options during the MA OEP?

He can switch to a MA-PD plan.

Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him?

He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means 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.

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.

Which of the following statement(s) 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. 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)

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.

Agent Harriet Walker has recently begun marketing Medicare Advantage and related products aimed at meeting the needs of senior citizens. Client Mildred Jones has expressed interest in a Medicare Advantage plan. It is now the beginning of September. If you were in Agent Walker's position, what would you do?

Inquire whether the client qualifies for a special enrollment period, and if not, solicit an enrollment application once the annual open enrollment election period begins on October 15th.

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

Marvin should consult with the health plans he represents to determine whether those plans impose requirements around beneficiary referrals.

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 only pay for these services if they are furnished by 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.

Mr. 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.

Mr. and Mrs. 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.

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

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

Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern?

Medigap plans help beneficiaries cover Original Medicare benefits, but they coordinate with Original Medicare coverage.

Mr. Landry is approaching his 65th birthday. He has signed up for Medicare Part A, but he did not enroll in Part B because he has employer-sponsored coverage and intends to keep working for several more years. But he is considering enrolling in Part D prescription drug coverage because he believes it is superior to his employer plan. How would you advise him?

Mr. Landry is eligible for Part D since he has Part A, and his initial enrollment period (IEP) for Part D will continue for three months after his 65th birthday.

Mr. Rice is 68, actively working and has coverage for medical services and medications through his employer's group health plan. He is entitled to premium free Part A and thinking of enrolling in Part B and switching to an MA-PD because he is paying a very large part of his group coverage premium and it does not provide coverage for a number of his medications. Which of the following is NOT a consideration when making the change?

Mr. Rice's retiree plan is required to take him back if, within 63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his Medicare Part D plan.

Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him?

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

Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-income subsidy. Where might he turn for help with his prescription drug costs?

Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program.

Mrs. 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 but if she wishes prescription drug coverage it must be a MSA-PD plan that includes drug coverage.

Mrs. 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.

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

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

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.

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 do nothing when a plan member does not pay their premiums or disenroll the member after a grace period and notice.

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.

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.

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. 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.

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%. -maybe

During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5-star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the best statement to say to her?

The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4-stars.

What impact, if any, have recent regulatory changes had upon Medigap plans?

The Part B deductible is no longer covered for individuals newly eligible for Medicare starting January 1, 2020.

One of your clients, Lauren Nichols, has heard about a Medicare concept from one of her neighbors called TrOOP. She asks you to explain it. What do you say?

TrOOP stands for true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances drug manufacturer discounts.

Winthrop Brokerage wishes to place an advertisement in the local newspaper that says: "We offer Medicare Advantage plans offered by AB Health and Top Choice Health. Contact us if you would like to learn more." Which of the following best describes the obligation(s) of Winthrop Brokerage regarding the advertisement?

Winthrop Brokerage does not need to submit the advertisement to CMS for prior approval because it does not include information about the plans' benefits structures, cost-sharing, or information about measures or ranking standards.

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

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

While making an appointment to discuss Medicare Advantage (MA) and Part D plans with a potential enrollee, you are asked to describe other types of insurance products that your client might wish to purchase. What additional types of insurance can you present during the MA and Part D marketing appointment?

You can present only health care related lines of business but must obtain the beneficiary's permission to do so before the presentation occurs and document that you have obtained that permission.

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

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

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

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

Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled nursing facility?

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

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.

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

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

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

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

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

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

You work for Caring Health, a Medicare Advantage (MA) plan sponsor. Recently, Mrs. Garcia has completed an enrollment application for a plan offered by Caring Health, which is waiting for a reply from CMS indicating whether or not Mrs. Garcia's enrollment has been accepted. Once CMS replies, how long does Caring Health have to notify Mrs. Garcia that her enrollment has been accepted and in what format?

The plan has 10 calendar days to notify Mrs. Garcia in writing.

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 and/or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program.