AHIP - 2026 - Modules 1-5

You are doing a sales presentation for Mrs. Mayo. 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."

Mrs. Sharma 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. Sharma 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.

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

AB MA plan does not have to recoup Agent Higgins' compensation because she has moved away from its service area.

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

Mrs. Hamilton likes to handle most of her business matters through telephone calls. She is currently enrolled in Original Medicare Parts A and B but has heard about a Medicare Advantage plan offered by Senior Health from a neighbor. Mrs. Hamilton asks you whether she can enroll in Senior Health's MA plan over the telephone. What can you tell her? I. Enrollment requests can only be made in face-to-face interviews or by mail. II. Telephone enrollment request calls must be recorded. III. Telephonic enrollments must include all required elements necessary to complete an enrollment. IV. The signature element must be completed via certified mail.

II and III only

Mrs. Castro 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.

Mrs. Kelly 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. Kelly can do this.

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

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

Mr. Sutton 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.

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

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

Edward suffered from serious kidney disease. As a result, Edward became eligible for Medicare coverage due to end-stage renal disease (ESRD). A close relative donated their kidney and Edward successfully underwent transplant surgery 12 months ago. Edward is now age 50 and asks you if his Medicare coverage will continue, what should you say?

Individuals eligible for Medicare based on ESRD generally lose eligibility 36 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward may, however, remain enrolled in Part B but solely for coverage of immunosuppressive drugs if he has no other health care coverage that would cover the drugs.

Mr. 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.

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 compliant 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.

Ms. Kumar 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.

Mr. and Mrs. Cole both take a specialized multivitamin prescription each day. Mr. Cole takes a prescription to help 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 Coles are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Coles could look into that possibility.

Mrs. Willis has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drugs are 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.

Mrs. Foster 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. Foster'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.

Melina Giles recently suffered a stroke while visiting her daughter and grandchildren. As a result, Melina 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 Melina regarding her health plan coverage?

Melina may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan.

Mildred Savage enrolled in Allcare Medicare Advantage plan several years ago. Mildred recently learned that she is suffering from inoperable cancer and has just a few months to live. She would like to spend these final months in hospice care. Mildred's family asks you whether hospice benefits will be paid for under the Allcare Medicare Advantage plan. What should you say?

Mildred may remain enrolled in Allcare and make a hospice election. Hospice benefits will be paid for by Original Medicare under Part A and Allcare will continue to pay for any non-hospice services.

Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted concerning the marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise him concerning the type of scrutiny he will be under?

Organizations sponsoring Medicare health plans are responsible for the behavior of their contracted representatives and will be conducting monitoring activities to ensure compliance with all applicable federal law and guidance and plan policies. Furthermore, state agent licensure laws are not preempted and he must abide by their requirements.

Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-Service (FFS) Medicare. What could you tell him?

Part A, which covers hospital, skilled nursing facility, hospice, and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare.

Mrs. Ellis recently turned 66 and decided after many years of work to retire and begin receiving Social Security benefits. Shortly thereafter Mrs. Ellis received a letter informing her that she had been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Ellis?

Part B primarily covers physician services. She will be paying a monthly premium and, except for many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible.

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 step therapy.

Mr. Weitz 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. Weitz 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. Barrow 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. Barrow, and they provide prescription drug coverage that could be very helpful as well.

Mr. Dalton 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. Dalton 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.

Mrs. Pearson 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.

Mrs. Nguyen is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan?

She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution.

Mrs. Nelson likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her?

She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan.

Mrs. Thomas 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.

Ms. Ramos 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.

Mrs. Brown 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. Cook is an elderly retiree. Mrs. Cook has a low fixed income. What could you tell Mrs. Cook 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.

Steban Marsh is a newly appointed agent. Steban intends to conduct an educational session on Medicare at a senior citizens center near his home. He has advertised the session as an educational event. Steban asks you what is permissible at such an event. What should you say?

Steban may provide a meal as long as its value is $15 or less per attendee and he may make available business reply cards (BRCs).

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.

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.

Mrs. Esmeralda Avila is a Medicare beneficiary enrolled in a MA-PD plan you represent. Her neighbor recently suffered from a painful case of shingles. Mrs. Avila hopes to avoid such an illness through vaccination. She asks you whether the cost of the shingles vaccination will be covered under the plan you represent. What should you say?

Yes, there is no cost sharing for the shingles vaccine even in the deductible phase of her prescription drug plan because it is an adult vaccine recommended by the Advisory Committee on Immunization Practices (AICP).

Mrs. Russo 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. Russo must be entitled to Part A and/or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program.

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.

Mr. Bryant 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.

This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do?

You may go ahead and call them.

Mrs. Lewis 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 concerning meals?

You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of the total value of the meal.

You are working with 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 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.

Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline, who has only worked part-time for the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her?

You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband's long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at more than the standard lowest rate but less than the highest rate due her substantial income.

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.

Mr. Anderson 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. Anderson if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area.

Which of the following statements about Medicare Part D is/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 an MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in an MA-PPO may obtain Part D benefits through a standalone PDP or through their plan.

I, II, and III only

Stephanie King becomes eligible for Medicare for the first time in July. With the help of Agent James Chan, she enrolls in FeelBetter Medicare Advantage plan with an effective date of July 1st. Which statement best describes how Agent Chan may be compensated under CMS rules?

FeelBetter will pay Agent Chan initial year compensation for July through December. The renewal amounts will be paid starting in January if Ms. King remains enrolled the following year.

Tariq is a Medicare beneficiary who is considering switching to a Medicare Advantage plan during this year's open enrollment season. He has read about prior authorization and the need for referrals in the newspapers and asks you what type of plans can require prior authorization. What do you say?

HMOs can require prior authorization for out-of-network services except for emergency services and certain other carved-out services. HMOs may also require referrals for in-network specialist services.

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

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

Mr. Trevino 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, if 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. Bean 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.

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

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

Ms. Lewis has aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her?

Medicare covers hospice services, and they will be available for her.

Mr. Abbott 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?

There are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.

Mrs. Sanchez cares for her frail elderly mother, Maria, who lives in North Carolina. She is worried that without additional support, her mother will need to go into a nursing home. Mrs. Sanchez asks you if there is any Medicare plan that might allow her mother to remain in the community rather than going into a nursing home. How should you advise Mrs. Sanchez?

There are Programs of All-Inclusive Care for the Elderly (PACE) for frail elderly beneficiaries certified as needing a nursing home level of care but are able to live safely in the community at the time of enrolment.

Ms. Moss 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 an MA plan. Ms. Moss comes to you for advice shortly after speaking to her neighbor. What should you tell her?

There is an MA Open Enrollment Period (OEP) that takes place between January 1 and March 31, but Ms. Moss cannot use it because eligibility to use the OEP is available only to MA enrollees.

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

To join a Medicare Advantage plan, she also must enroll in Part B.

Ms. 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.

Mrs. Silva is in her Medicare initial coverage election period (ICEP) and the date of her entitlement to Part A and B has already occurred. Mrs. Silva has 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.

Mr. Vasquez 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 because 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.

Mrs. McFarren 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.

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. 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 Lopez helps Ralph to enroll in Top Choice Medicare Advantage plan during the Annual Open Enrollment Period. Ralph's effective enrollment date is January 1st. Ralph disenrolls on February 12th because he discovers that the plan does not cover services furnished by several of his longtime providers. Which of the following statements best describes the impact of Ralph's action upon Agent Lopez's compensation?

Agent Lopez's entire compensation must be recouped because Ralph disenrolled within 3 months of enrollment.

Mrs. Wood, 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. Wood is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan.

Angel is new to the Medicare marketplace having previously been focused on life insurance and disability income protection products. He intends to conduct an educational seminar during the AEP at a local hotel and then invite those who attend to a subsequent marketing meeting to discuss the benefits of next year's plans. How would you advise Angel?

Angel should conduct the education seminar as an early morning meeting and the marketing meeting on the following day in the late afternoon so that there are at least 12 hours between the two meetings.

Anthony Boniface turned 65 in 2024. He was not receiving Social Security or Railroad Retirement Benefits on his 65th birthday. He was interested in obtaining Medicare coverage and is eligible for premium-free Part A. Before he could enroll in Medicare, his entire area was impacted by a hurricane causing massive flooding and severe wind damage. The Federal government declared this to be a natural disaster which has recently ended. During this period Anthony's initial enrollment period expired. Anthony asks you how he can now obtain Medicare coverage. What should you say?

Anthony is eligible for a special enrollment period (SEP) because he missed an enrollment period due to the impact of the Federally declared disaster. This SEP will allow Anthony to enroll in Part B up to six months after the end of the emergency declaration. Anthony may enroll in premium-free Part A at any time and his Part A coverage will be retroactive for up to 6 months.

Mr. Lu is selling his home to permanently move into a retirement facility near his daughter in a neighboring state before the Annual Election Period. 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.

Alice is a marketing representative employed by a health plan. Betty is a captive agent of a health plan who markets for multiple plans and sponsors. Carl is a captive agent who markets for only one plan/sponsor. Denise is an independent agent who markets to different types of groups. Edward is an independent agent who markets only to employer and union groups. CMS marketing representative compensation rules generally apply to:

Betty and Denise, but not Alice (the employee) or Carl or Edward (to whom exceptions apply).

Mr. Solomon 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. Solomon 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.

Mrs. Duran is enrolled in a prescription drug plan. She has heard about something called True-Out-Pocket costs or "TrOOP" and asks you if any of the following count toward reaching the catastrophic coverage phase. What do you say? I. Her annual PDP deductible II. Supplemental coverage provided by an employer group waiver plan III. The off formulary drug her doctor prescribed but she pays for because the plan denied her exception request IV. Her over-the-counter (OTC) allergy medication.

I and II only

Raymond 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

Your client, Jaime Jones, calls you on December 4th about changing her Medicare Advantage plan during the annual election period which ends December 7th. What should you do?

Complete a scope of appointment (SOA) during the call and indicate that they will meet to discuss Medicare Advantage plans during an appointment the following day.

BestCare Health Plan has received a request from a state insurance department in connection with the investigation of several marketing representatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response?

Cooperate with the state and supply requested information.

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

Dr. Morgan 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.

Eva Huber is a new marketing representative. Eva asks you for advice as to what topics must be discussed with a Medicare beneficiary prior to enrollment in a Medicare Advantage (MA-PD) plan. What should you say?

Eva, there are many required questions and topics regarding beneficiary needs to be discussed prior to enrollment in an MA plan. These include information regarding primary care providers and specialists whether they are in the plan network, whether or not a beneficiary's current prescriptions are covered as well as premiums, benefits, and costs of health care services.

Mrs. Strickland is a new Medicare beneficiary who has just retired from retail work. She is interested in selecting a Medicare Part D prescription drug plan. She takes several medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her?

Every Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90-day transition period.

Mrs. Green 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.

Henrietta Ross is an elderly individual enrolled in a fully integrated dual-eligible (FIDE) special needs plan (SNP). Henrietta's daughter Gladys asks you to explain what a FIDE-SNP offers her mother. What do you say?

FIDE-SNPs provide individuals access to Medicare and Medicaid benefits under a single organization that has both a Medicare Advantage and Medicaid managed care contract with CMS.

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

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

Mr. White has been enrolled in the Lexington Private Fee-for-Service (PFFS) Medicare Advantage Health Plan (Lexington) for several years. Recently, Mr. White 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. White's continued enrollment for up to 12 months whether or not he is in a visitor/traveler (V/T) program since it is a PFFS plan.

Maria Valesquez is a marketing representative with RitzCo, a third-party marketing organization (TPMO). Maria meets with Henry Smythe, who has a website that provides information about different ways to get Medicare. The website allows beneficiaries to put in their name and contact information in order to receive additional information. Henry offers to sell Maria leads obtained through the website. What should Maria do?

Maria should pass on Henry's offer. Henry's website is a TPMO, and for a TPMO to provide contact information to another TPMO (including an agent/broker or FMO), it has to have prior express written consent that identifies each entity that will receive the information.

Agent Mendez 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.

Mr. Moy will soon turn age 65. He is slightly younger than his wife. Mr. 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 deductible and Part B coinsurance or copayments in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.

Mr. Chen 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. Chen has lost his employer group coverage within the last two weeks. How would you advise him?

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

John Cohen is a Medicare beneficiary who suffers from diabetes. Mr. Cohen is considering enrollment in an MA-PD plan that you represent. He asks you whether his insulin costs will be covered. What should you say?

Mr. Cohen's insulin costs for a one-month supply cannot be more than $35 in any coverage phase.

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 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.

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 (SPAP).

Mrs. Lester is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in an 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. Lester?

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

Mrs. Robles 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. Robles can obtain care from any provider who participates in Original Medicare, but generally will have a higher cost-sharing amount if she sees a provider who/that is not a part of the PPO network.

Mr. Trejo 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 for 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.

Mr. Aguilar 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. Aguilar'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.

Mr. Pham is a Qualified Medicare Beneficiary (QMB). He enrolls in a Medicare Advantage HMO. Shortly thereafter, Mr. Pham visits his primary care provider (PCP), Dr. Maria Sanchez. Mr. Pham complains of a bad cold and receives care - a Medicare-covered service. The normal copayment is $40. How much may Dr. Sanchez collects?

The minimal copayment that would apply under Medicaid, regardless of what the plan requires of other enrollees.

You work for Caring Health, a Medicare Advantage (MA) plan sponsor. Recently, Mrs. Gomez 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. Gomez's enrollment has been accepted. Once CMS replies, how long does Caring Health have to notify Mrs. Gomez that her enrollment has been accepted and in what format?

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

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.