Medicare Certification

True or false: The Federal Government can impose rewards or incentives upon organizations or persons who fail to grant Medicare beneficiaries one of their guaranteed rights.

False, rewards or incentives would be desirable and not punitive

True or false: The Federal Government can impose taxes upon organizations or persons who fail to grant Medicare beneficiaries one of their guaranteed rights.

False, taxation is not a penalty.

True or false: The explanation of benefits ensures that Medicare beneficiaries who enroll in Medicare Advantage plans or prescription drug plans have access to services that should be covered.

False, the EOB gives an outline of covered services

True or false: Appeals are also called grievances

False, these are different.

True or false: It is not a guaranteed right of a Medicare beneficiary to file a complaint or a grievance about concerns or problems with the plan.

False, this is a vital part of the CMS oversight process

True or false: A plan has a vague time window in which to respond to an appeal

False, this process is highly structured, including the time allowed to respond to an appeal

True or false: Grievances can only be filed in writing.

False, writing is preferred for clarity, but verbal must be accepted and processed as a legal filing

True or false: The provider directory ensures that Medicare beneficiaries who enroll in Medicare Advantage plans or prescription drug plans have access to services that should be covered.

False. The provider directory is a roster of network providers.

True or false: If the MA organization denies the appeal, the appeal is ended and the member has no right to further due process

False. There is a fully structured six tier appeals process in place.

If the scope of appointment has been signed, and later in the meeting, the clients friend arrives and tells you that he or she wants to sit in and learn about the products, what should the agent do?

Fill out another scope of appointment, and indicate that the friend was a "walk in" to the meeting in progress.

There are three major requirements for a Medicare Advantage enrollment request form to be considered complete. What are they?

1. Permanant residence is determined to be in the service area. 2. The beneficiary must be in BOTH part A and part B of original Medicare, 3. The enrollment form must be entirely complete and signed by the Medicare Beneficiary or the legal representative. This requirement is waived for online enrollments.

A plan is not required to disenroll a member under CMS guidelines if the member.....

Fails to pay plan premium. In fact an MAO is never required to terminate a member on their own.

If the CMS terminates a part D member for failure to properly remit their part D Income related monthly adjustment amount, this triggers what?

Failure to pay the IRMAA triggers an involuntary disenrollment from their part D plan.

True or false: During the coverage gap, any pharmacy dispensing fees count toward the true out of pocket expense.

False

True or false: Expenses that were paid by the beneficiary towards the Initial Coverage Limit, excluding the deductible, and the beneficiary cost share for any medications purchased count towards the true out of pocket expense, but the plan's share of the cost for the medications do not count.

False

True or false: Expenses that were paid by the beneficiary towards the Initial Coverage Limit, including the deductible, and the beneficiary cost share for any medications purchased count towards the true out of pocket expense, as well as the plan's share of the cost for the medications.

False

True or false: Expenses that were paid by the beneficiary towards the Initial Coverage Limit, including the deductible, but excluding the beneficiary cost share for any medications purchased count towards the true out of pocket expense, but the plan's share of the cost for the medications do not count.

False

True or false: Occasionally, what the beneficiary pays for medications that are not covered may count toward the true out of pocket expense.

False

True or false: The Federal Government can impose interest upon organizations or persons who fail to grant Medicare beneficiaries one of their guaranteed rights.

False, interest would be a desirable thing.

True or false: Membership handbooks ensure that Medicare beneficiaries who enroll in Medicare Advantage plans or prescription drug plans have access to services that should be covered.

False, membership handbooks cover membership rules

True or false: It is a guaranteed right of a Medicare beneficiary to have any medical expenses that they incur to be paid for by the plan.

False, on two levels. First, not all medical services will be covered, and second, those that are must be medically necessary.

If the scope of appointment has been signed, and later in the meeting, the client expresses an interest in products that are not included in the scope of appointment, what should the agent do?

Fill out another scope of appointment.

For 2016, what is the Part B Deductible?

For 2017, the deductible is $183

A potential beneficiary asks for a sales meeting with an agent at a local coffee shop. Is it legally required that the agent check out the coffee shop to assure that there will be enough discretion for a private conversation in that coffee shop?

Its a good idea, but NO, it is not legally required.

If an MAO loses its contract with CMS, this triggers what?

Involuntary disenrollment of all members. Note that this circumstance creates an SEP for each member that has been disenrolled.

When would the OEPI be discontinued for an institutionalized person?

It ends two months after the month that the individual moves out of the institution.

What is an MAO?

It is a Medicare Advantage Organization, usually but not necessarily a private insurance company, which has contracted with the Federal government to administer Medicare parts A and B benefits.

What may cause a Medicare part C involuntary disenrollment?

It is a determination by the Part C Provder organization, or the CMS, that the requirements for enrollment are no longer being met by the member.

What is a Medicare part C involuntary disenrollment?

It is a disenrollment initiated by the Part C Provider organization, or the CMS.

What is the Initial Coverage Election Period?

It is a seven month time period that includes the three months before the clients birth month, the birth month, and the three month time period after the birth month of the year that the client becomes eligible for Medicare, usually their 65th birthday.

What is the Election Period of the OEPI?

It is continuous, and never ends for as long as the individual qualifies.

If a disenrollment can take place, how is the effective date of disenrollment determined?

It is determined by the election period used to effect the disenrollment. In general, disenrollments are considered effective at the earliest possible date, which in most cases is the first of the month following the receipt of the disenrollment request. However, in the case of using an SEP to disenroll, the rules of the SEP used determine the effective date of disenrollment.

In a part D plan, what is the second phase of coverage?

It is known as the initial coverage phase, and it is the segment of coverage where the beneficiary pays a cost-share for the medications that are covered by the plan, plus the plan premium.

Are preventative dental care and dentures covered under Medicare?

No, dental care is not covered

Are hearing aids and exams for hearing aids covered under Medicare?

No, hearing aids are not covered

A potential beneficiary asks for a sales meeting with an agent at a local coffee shop. Is it legally required that the agent pre-order refreshments at the coffee shop for the meeting?

No, in fact that may be illegal.

Is a written permission to call open ended?

No, it expires after a reasonable amount of time. For example, indicating that your preferred method of contact is telephone on a postcard and then returning it may be considered permission to contact for the current AEP, but not next years AEP.

A potential beneficiary asks for a sales meeting with an agent at a local coffee shop. Is it legally required that the agent have the potential enrollee complete an appointment reservation form to assure that the length of the meeting will be mutually understood?

No, no appointment reservation is not required

Is it permitted to discuss plan specific premiums and/or benefits at educational events?

No, only general education

Is it permitted to provide meals to prospects at sales and marketing events or at individual sales presentations?

No, only light snacks are permitted

Can a Part D PDP be added to a part C PFFS MA-PD plan without cancelling the part C PFFS MA-PD plan?

No, since the plan already has drug coverage, this would duplicate the coverage

Do recipients of original Medicare need a primary care physician?

No, they can see whatever physician they choose, as long as that physician accepts Medicare

Can a Part D PDP be added to a part C plan with prescription drug coverage without cancelling the part C plan with prescription drug coverage?

No, this enrollment will result in the beneficiary being on original Medicare with a stand-alone PDP

Are travel vaccinations covered under Medicare?

No, travel vaccinations are not covered

The acronym "SEP" stands for what, and is used in discussions of what Medicare family of plans?

It stands for Special Election Period, and this applies to Medicare Advantage plans (Part C) and Medicare Prescription Drug plans. (Part D)

Is it permissible to conduct sales activities at a pharmacy counter where patients obtain medications?

No. CMS considers this a "captive audience" in that the people have business at the Pharmacy counter and usually must remain here

True or false: It is a guaranteed right of a Medicare beneficiary to have access to some form of Medicare approved drug coverage.

True. It is a guaranteed right to have drug coverage, but no plan covers all prescription drugs.

True or false: A plan has a specific time frame in which to respond to an grievance

True. The process of appeals is strictly regulated, including time allowed to respond to a grievance

Is it OK to accept referrals from existing members through names and addresses, and then follow up through direct mail?

Yes, direct mail is fine.

Are foot exams covered under Medicare?

Yes, for people with diabeties

Are medical nutritional services covered under Medicare?

Yes, for people with diabeties or kidney disease

Is there a late enrollment fee for Medicare part A?

Yes, if a beneficiary is eligible for part A and does not take it, then if they elect to take part A coverage any time in the future, they may be assesed a late enrollment penalty of 10% per year for every full 12 month period that the beneficiary did not have part A coverage.

Is there any assistance available for the Part B Premium?

Yes, if the beneficiary is low income, they may be eligible for premium assistance. Refer the client to the state medicaid system.

Can a Part D PDP be added to a Medical only part C plan without cancelling the Medical only part C plan?

Not unless the Medical only part C plan is a PFFS plan, an MSA plan or a 1876 cost plan

SEP stands for what?

Special Election Period

When does the AEP occur?

The Annual Election Period (AEP) occurs every year starting on October 15th and ending on December 7th. During this period, the lock-in ends and everyone can choose a new plan effective on Jan 1 of the following year.

How does an MAO make money?

The CMS pays the organization a monthly, per-member lump sum which is based on an estimate of what it would have paid for administering part A and B benefits under original Medicare.

True or false: It is a guaranteed right of a Medicare beneficiary who meets the plan requirements to join a Special Needs Plan if there is one that services their area

True, these plans have to qualify with Medicare, and there are specific qualifiers to become a member.

True or false: Appeals can be filed by members, their appointed representatives, or providers.

True. All of these entities can file an appeal

Can a Part D PDP be added to another Part D PDP without cancelling the original Part D PDP?

No, only one plan is allowed

What four materials at a minimum must always be present at a face to face meeting?

A paper enrollment form Plan star ratings information, Summary of benefits, A multi-language insert

True or false: Only certain members can file grievances

False, the process is open to anyone who participates in the program.

True or false: It is a guaranteed right of a Medicare beneficiary to join any Special Needs Plan

False, these plans have specific qualifiers to become a member.

True or false: Appeals can be filed by members, but not their appointed representatives, or providers.

False. All of these entities can file an appeal

True or false: It is a guaranteed right of a Medicare beneficiary to get any prescription drug

False. It is a guaranteed right to have drug coverage, but no plan covers all prescription drugs.

Thue or false: It is a guaranteed right of a Medicare beneficiary to have no premium if they cannot afford one

False. It sometimes happens but it is not a right.

True or false: A plan has a vague time window in which to respond to an grievance

False. The process of appeals is strictly regulated, including time allowed to respond to a grievance

Are Section 1876 Cost plans also Medicare Advantage plans?

No, they are authorized under a different part of the Social Security Act, but they do present a health care option for a small number of Medicare beneficiaries.

What is a grievance?

A complaint or a dispute that a member may have with a MA plan organization that does not involve a coverage or a payment decision made by the plan

In order to be considered legally binding, the beneficiary must completely understand and agree to five things during the enrollment process. What are they?

1. They must agree to the disclosure and exchange of personal and medical information. They must understand that they have to keep Original Medicare both parts A and B. In the case of a stand-alone PDP, its either A or B, 3. They must understand that they can only enroll in one part C plan at a time, and that enrollment in another Part C plan will automatically disenroll them from whatever part C plan that they currently have. 4. They must agree to abide by the rules of the organization providing the plan. 5. They must understand their right to appeal service and payment denials made by their provider organization.

The plan must call the beneficiary and confirm the enrollment choice and the beneficiaries understanding of the plan they chose within how long?

15 calendar days.

What four materials at a minimum must always be available to the client at an online enrollment?

A link to an electronic enrollment form, A downloadable plan star ratings document, A downloadable summary of benefits, A downloadable multi-language insert

What are the two types of PPO?

A local PPO, which serves an area that the PPO plan designates. A regional PPO which services an area which may extend into other states, as determined by CMS.

What is a PPO and how does it work?

A Paid Provider Organization, or PPO has a network of providers that have agreed to provide services to plan beneficiaries for an agreed price. A PPO provides reimbursement for all covered services without regard to the service being provided by a network provider. A PPO may charge more for services covered outside of the network.

What is a PFFS?

A Private Fee For Service organization is based on, but is somewhat different from Original Medicare A and B. Members can see any physician or provider they want, as long as the physician or provider agrees to accept what the plan offers to pay for services.

What is a SNP?

A Special Needs Plan is a specalized plan developed for one of three possible special needs groups.

What is a Non-Network Pharmacy?

A pharmacy that is not under contract with the plan. These pharmacies will provide medications at normal retail prices and the plan will not share the cost of the medications.

What is a Non-Preferred Network Pharmacy?

A pharmacy that is under contract with a plan to provide negotiated prices which are higher then a Preferred Network Pharmacy, and with which the plan offers a somewhat less favorable cost share to its beneficiaries.

What is a Preferred Network Pharmacy?

A pharmacy that is under contract with a plan to provide negotiated prices which are lower then a Non-Preferred Network Pharmacy, and with which the plan offers the most favorable cost share to its beneficiaries.

What is a Medicare Advantage HMO?

A plan where the MAO contracts in an exclusive way with a group of doctors, hospitals and providers known as a network. An HMO will require its members to get care only from doctors, hospitals and providers only in that MAOs HMO network. Any other care is obtained entirely at the members expense. Usually in an HMO, members will need to select a primary care physician and obtain referrals to see any other physician, specialist, hospital or provider.

What is included in part A inpatient care?

A semi-private room, general nursing, meals, treatment drugs, other hospital services and supplies

What is considered a forgery by the CMS?

A signature on an enrollment form which was not originated by the enrollee or the enrollees legal representative. Back dating enrollment forms.

True or false: Under some circumstances, the plan premium may count toward the true out of pocket expense.

False

True or false: It is not a guaranteed right of a Medicare beneficiary to have the privacy of their personal health information protected.

False, a patients privacy must be protected

In order to qualify for Medicare, an individual must be 65 years old, lawfully present in the United States, and meet one more CMS enrollment criteria. What is that?

Be eligible to recieve Social Security

What is the one thing that all marketing material must have in common?

CMS approval before distribution or use.

True or false: The second level of the grievance process is called the appeal

False, appeals and grievances are not a part of the process, these words describe the process.

True or false: A Medicare beneficiary is not protected from discrimination in every possible case

False, discrimination based on multiple characteristics is illegal in many areas, including Medicare.

True or false: Emergency care is not a guaranteed right of a Medicare beneficiary

False, emergency care is a guaranteed right

What are the fees for a hospital stay under Part A coverage in 2016

Days 1-60 are covered by the deductible of $1288, Days 61-90 are covered at $322 per day, Days 91-150 are lifetime reserve days and are $644 per day.

If a Medicare Advantage member dies, this triggers what?

Death triggers an involuntary disenrollment from their part C plan.

If an individual wants Parts A and B original Medicare, what are the next two choices to be made?

Decide if they want Part D perscription Drug coverage, and decide if they want supplemental coverage.

What is the second step in finding appropriate Medicare coverage?

Decide whether to select original Medicare A & B or Medicare part C

What are the four stages of drug coverage under Part D?

Deductible phase, Initial coverage phase, Coverage gap, Catastrophic coverage

What is the first step in finding appropriate Medicare coverage?

The first step is to determine if the individual is elegible to be covered under employer group coverage.

Some HMOs offer a POS benefit. What is that?

This benefit will offer some limited coverage for services obtained outside of the network.

Is it permissible to conduct sales activities in community or recreation rooms?

Yes, recreation rooms are public areas

Agents who engage in misconduct in marketing practices are subject to one or more of five kinds of disciplinary actions. What are they?

Additional mandatory training and/or reporting, Suspension, Loss of employment or termination of contract, Loss of state license, Forfiture of future compensation

What happens after all hospital inpatient lifetime reserve days have been used?

After all lifetime reserve days have been used, all days of a hospital stay after day 90 which are in the same benefit period are not covered.

What is "Medicare Advantage Lock-In?"

After the effective date of enrollment, the member will remain in the plan and will not be permitted to disenroll or change plans. The member is "locked in" until an applicable election period arises, either the annual election period or a special election period.

What are the three rules concerning prohibited language?

Agents may not misrepresent themselves, their organization, or the benefits and services of the plan they are selling. Agents may not claim that the plan they are representing has been recommended or endorsed by CMS, Medicare, or the Department of Health and Human Services. Agents may not claim they are a Medicare Representative.

Is an MAO required to terminate a member if just cause arises?

An MAO is never required by CMS to involuntarily disenroll members for any reason, but if the MAO elects to do so, they are required to apply the same process consistently across all of its membership.

A Medicare Advantage Organization may terminate a member from their part C plan for three reasons. What are they?

An MAO may terminate a member for failure to pay premiums. An MAO may terminate a member if the member is engaging in behavior which is disruptive to the normal operations of the MAO. An MAO may terminate a member if it is found that the member provided false or fraudulent information as part of their enrollment process or has altered, misused or allowed misuse of their membership card.

What is an appeal?

An action that a medicare beneficiary can take if he or she disagrees with a coverage or a payment decision made by a plan

What is unique about a PFFS plan regarding the physicians who accept it?

An out of network physician or provider may decide on a case by case basis not to see or treat a particular beneficiary even if that physician or provider has seen the beneficiary before. This is true unless the beneficiary is experiencing an emergency situation.

AEP stands for what?

Annual Election Period

Mrs. Smith submits an enrollment request on November 11 and has no special election period. What regular election period may she use and what will her coverage effective date be?

Annual Election Period, Jan 1

What is the CMS definition of Marketing?

Any activity conducted by an agent intended to affect the beneficiaries choice of a Medicare plan.

What specifically would define any material as marketing material?

Anything that goes beyond mentioning the plan type (HMO, PDP, PFFS) that an agent sells. Anything with more information then that is considered marketing material.

What does the CMS regard as unsolicited contact?

Approaching prospective beneficiaries in public places, contacting prospective beneficiaries by phone, email or other electronic contact, such as texting, messaging, etc., and door-to-door solicitation, including door knocking, leaving flyers or leaflets on doorsteps, mail boxes, or on cars. However, if the agent had an appointment with the prospective beneficiary and they were not home, it is permissible to leave some information.

What is the CMS ruling regarding unsolicited contact?

Dont do it.

What are the three types of Medicare Beneficiaries that can change plans at any time, as long as their status does not change?

Dual-eligibles (those who have both Medicare and Medicaid) Institutionalized individuals LIS (Low income subsidy) eligible individuals In all of these cases, their plan choice will become effective the first of the month following their election.

As regards Medicare Advantage, the term Election means what?

Either enrollment in, or disenrollment from, a Medicare Advantage plan

There are four ways plans manage perscription drug costs. What are they?

Formularies-choosing which drugs will be covered. Quantity limits-limited dosages for a period of time. Step therapy-trying other medications first Prior authorization-the plan must approve before the drug will be covered

What is the cost involved with Original Medicare?

Generally a patient pays a premium for Part B, and after that is responsible for the deductibles, and co-insurances for the services they need or want.

What are the five types of organizations that an MAO can form to administer their care?

HMO Health maintenance organization plan, PPO Preferred provider organization plan, PFFS Paid fee for service plan, SNP Special needs plan MSA Medical savings account

Medicare part A is what?

Hospital insurance

There are three criteria, at least one of which must be met in order for a plan to release a members personal information. What are they?

If it relates to treatment, If it relates to payment, If it relates to the operations of the organization.

CMS Guidance states that an MA plan organization must provide all of its enrollees with all Part A and Part B services included in original Medicare under what conditions?

If the enrollee is entitled to part A and enrolled in part B.

There are three reasons that a plan might release a person's medical information. What are they?

If the enrollee or their designee request it. If the Department of Health and Human Services requests it. If the law requires it.

What are the fees under part A for a stay in a mental health facility

In 2016, Days 1-60 are covered by the deductible of $1288, Days 61-90 are covered at $322 per day, Days 91-190 are lifetime reserve days and are $644 per day.

In a part D plan, what is catastrophic coverage?

In 2019, Catastrophic coverage begins when the TROOP for the beneficiary reaches $5100. After that point, the cost to the beneficiary becomes very low.

How does a beneficiary enroll in part B?

In general, part B enrollment is automatic, and occurs at the same time part A enrollment takes place. If a beneficiary wants to delay their part B enrollment, they must notify Social Security.

Who must sign a Medicare enrollment form?

In general, the person enrolling in the plan and the enrolling agent must sign the enrollment form

Does a PPO require a beneficiary to name a Primary Care Physician?

In most cases a PPO does not.

Does a PPO require a beneficiary to obtain a referral to see a specialist?

In most cases a PPO does not.

Are eye glasses covered under Medicare?

In most cases eyeglasses are not

If a Medicare Advantage member becomes incarcerated, this triggers what?

Incarceration triggers an involuntary disenrollment from their part C plan.

ICEP stands for what?

Initial Coverage Election Period

IEP for part D stands for what?

Initial Election Period for Part D

If a Medicare Advantage member loses entitlement to Medicare part A, or is no longer enrolled in Medicare part B, this triggers what?

Losing either part A or part B triggers an involuntary disenrollment from any part C plan, because you must have both A and B. This will treigger an SEP. Losing either Part A or Part B, would also entitle the member to enroll in a stand-alone part D plan if the involuntary loss of coverage or any other SEP can be applied, because you only need either A or B.

AEP applies to what Medicare Advantage family of plans?

MA Only, MA-PD, and PDP Stand-Alone plans

Medicare Part C plans fall under three broad categories. What are they?

MA Only, MA-PD, and PDP Stand-Alone plans

ICEP applies to what two types of Medicare Advantage plans?

MA Only, and MA-PD plans

OEIP applies to what Medicare Advantage family of plans?

MA Only, and MA-PD plans

IEP for part D applies to what Medicare Advantage family of plans?

MA-PD and PDP Stand-Alone plans

Is there a requirement for benefit offerings that an MAO must meet?

MAO's must submit their plans to CMS for approval, and they are carefully checked so that their plans provide coverage that is at least as good as Original Medicare, and include at a minimum every service that a beneficiary might get under Original Medicare, with the exception of hospice benefits. MAOs are permitted and encouraged to offer services above and beyond what Original Medicare provides, and most do. Since plans are formulated independantly of the government or any other plan offering, prices, coverages, and rules vary by plan.

Since MSAs are so similar to original Medicare, what special requirements does CMS put on MAOs who market this plan in order to protect consumers?

MAOs are required to provide transparent, understandable MSA plan designs in order to ensure that beneficiaries understand and can predict out of pocket expenses. All plans must adhere to an annual Maximum Out Of Pocket limit which is set by CMS.

MAOs have MOOP limits imposed on them by CMS that come in two types. What are the types and what is the difference between them?

Mandatory MOOP, maximum allowed, as set by CMS, Voluntary MOOP, a lower amount encouraged by the CMS in return for greater flexibility in establishing cost sharing amounts.

What is a MSA plan?

Medical Savings Account plans are a combination of a savings account and original Medicare. The plan deposits money into the beneficiaries MSA and the beneficiary uses the money to pay the deductibles and the 20% coinsurance of original Medicare.

As a general rule, all services and supplies that are covered under part B must be what?

Medically necessary

MADP stands for what?

Medicare Advantage Disenrollment Period

If a beneficiary has multiple chronic conditions, is taking multiple Part D medications, and has a large expenditure in Part D, what should you explore for this beneficiary?

Medication Therapy Management

What are the three special needs groups served by a Special Needs Plan?

Members with severe or disabling chronic conditions (C-SNP) Members who are eligible for both Medicare and Medicaid, dual eligibles. (D-SNP) Members who are institutionalized (I-SNP)

What costs are a Medicare Part D plan member responsible for?

Monthly premium, Plan deductible, if any, Cost share amount Costs in the coverage gap A small co-pay in the catastrophic phase.

If a Medicare Advantage member moves permannatly outside the Medicare Part C service area, this triggers what?

Moving out of a plans area causes an involuntary disenrollment from their part C plan.

What are the three requirements a client must meet in order to enroll in a MA-only or an MA-PD plan?

Must have Medicare A and B, Must be a permanent resident in the plans coverage area, Must not have end stage renal disease

There are five categories of beneficiary that are protected by a transitional policy in Part D coverage. Who are they?

New enrollees who have joined during AEP. New enrollees who have joined during their ICEP. Enrollees who have just switched drug coverage due to a SEP. Enrollees who reside in LTC facilities. Enrollees who subscribe to a formulary which has changed while they were on it.

Do recipients of original Medicare need a referral to see a specialist?

No

Does the prohibition on unsolicited contact also apply to direct mail?

No direct mail is permissable.

Is the fact that a prospective beneficiary attended an event considered permission to contact?

No it is not

If an agent has a Facebook or other social media page, and a visitor "likes" the page, is this considered permission to contact through social media?

No it is not permission to contact

Is calling someone that an existing client asks you to call because they are interested legal?

No it is not, but you can have them call you.

Is there a network involved in Original Medicare?

No, Beneficiaries of Original Medicare can see any doctor they choose, as long as they are accepting new patients and accept Medicare assignment as payment for service. These Medicare-accepting doctors are not considered a network because no contracting is involved.

Is Long Term Care covered under Medicare?

No, LTC is not covered, although many people think that it is.

Is accupuncture covered under Medicare?

No, Medicare does not cover accupuncture

Is it permitted to ask a beneficiary for referrals during personal/individual marketing appointments?

No, and if they are offered, you must advise to have the referral call you.

Is routine foot care covered under Medicare?

No, but diabetics enjoy limited foot benefits

Is cosmetic surgery covered under Medicare?

No, cosmetic surgery is not covered

Are business cards considered marketing materials by the CMS?

Not unless they include plan-specific benefits. If they do, they are considered marketing materials.

What is the main difference in a client qualifying for Medicaid while not on Medicare verses qualifying for Medicaid after being enrolled in Medicare?

Once a Medicaid beneficiary becomes enrolled in Medicare, there is an asset test added to the income level test. The net worth is what counts, and a significant amount of assets are added to the qualification number, which excludes many Medicare recipients from Medicaid.

If a part C disenrollment is allowed and effected, what coverage takes effect and how long does the beneficiary have to select a new Part C plan?

Once disenrolled, the beneficiary is then covered by Original Medicare, and if they are allowed to, they usually have 63 days to make another selection. Note that if a selection is made and becomes effective, a new lock in period takes effect, even if the selection is made and becomes effective with some of the 63 days remaining.

How many ICEPs does an individual have?

One. Once it is used or elapses, it is irretrievable and lost forever.

OEIP stands for what?

Open enrollment for institutionalized persons

What does part A cover?

Part A covers hospital stays, including Mental hospitals, skilled Nursing Facility care, if such care is indicated after at least three days in the hospital, hospice care, (end of life hospital, but home hospice is included), some home health care (Extension of hospital care in a cheaper form), blood, religious non-medical care, because some people will not go into the hospital for religious reasons.

What is Medicare part B?

Part B is called Medical insurance, and covers providers that are oriented towards out-patient care.

What are the five conditions under which an individual would be eligible to enroll in Medicare?

People who are 65 or older, people under 65 who have been on disability for 24 months, people with end stage renal disease, people with amyotrophic lateral sclerosis (AKA Lou Gerigs disease), and certain individuals with Railroad Board Retirment Benefits

Can gifts be given in return for referrals?

Yes, but referrals cannot be solicited through the offer of a gift, and if a gift is given for a referral, then all referral providers must recieve gifts.

In order to call or email a beneficiary, the organization must have and retain what?

Some form of written consent to be called.

In a part D plan, what is the coverage gap?

Sometimes referred to as the donut hole, in 2019 this segment of coverage begins when the ICL expenses reach $3820, and will continue until the TROOP cost for the beneficiary reaches $5100.

If the person enrolling in a Part C plan is unable to sign the enrollment form, who may sign it?

State law would determine what other individuals may sign a Medicare enrollment form for the enrollee, but that person must attest to having the authority required by state law, and be prepared to present proof of that authority to CMS upon request. That person must also provide valid contact information in order for CMS to reach them should such proof be required. The attestation and contact information must be retained by the enrolling organization as a part of the record of the enrollment request.

What expenses count toward the ICL, or initial coverage limit?

The ICL expenses include the cost share that the beneficiary pays for the medications, as well as the plan benefits paid by the insurance company. The ICL expenses include the deductible paid by the beneficiary. Expenses that were paid by the beneficiary towards the ICL, including the deductible, and the beneficiary cost share all count towards the true out of pocket expense, but the money the plan paid for the medications does not count.

When does the IEP for part D take place?

The Initial Election Period (IEP) for part D begins three months before they become entitled to Part A OR enroll in Part B, includes the month they become entitled to Part A OR enroll in Part B, and continues for three months after they become entitled to Part A OR have enrolled in Part B.

What is the election period of the MADP?

The Medicare Advantage Disenrollment Period starts on Jan 1 and ends Feb 14th each year.

What government agency is responsible for enrolling people in Medicare?

The Social Secuity Administration

What is an "enrollment request mechanism?"

The method of enrollment

What are the costs that the client is responsible for with original Medicare?

The part A and Part B deductibles, The monthly part B premium, Usually 20 percent of the Medicare approved amount for the Medicare approved services, 100 Percent of the cost for services that Medicare does not cover.

What are the fees under part A for a stay in a skilled nursing facility?

The patient must stay 3 days in-hospital, and be certified by a physician to be admitted to a SNF, which means that in 2016 the patient will owe the Part A deductible of $1288 for days 1-20. There are no other charges for days 1-20. Days 21-100 are covered at $161 per day. All days after 100 in the same benefit period are not covered.

Who determines the effective date of a part C plan and when must the effective date be understood by all parties to the agreement?

The provider organization determines the effective date of a plan, but the beneficiary must also be clear as to their effective date before it passes.

In a part D plan, what is the deductible phase?

The segment of coverage where the beneficiary pays 100% of the cost of the drugs, plus the plan premium, until the deductible is reached. Note that some plans do not have a deductible.

If an individual delays enrollment in Medicare Part B, when do their ICEP and IEP for Part D occur?

The seven month IEP for Part D is centered around the automatic enrollment in Medicare part A, usually the 65th birthday. The seven month ICEP for a Medicare Advantage plan is centered around the enrollment in Medicare part B, which is usually when group coverage ends for that individual.

As regards Medicare Advantage, the term Election Period means what?

The specific dates between which an individual can elect to enroll in, or disenroll from a Medicare Advantage Plan

What is a benefit period?

The time period which is triggered the first day a beneficiary enters the hospital and becomes responsible for the part A deductible, is measured starting the day of discharge and ends when they have not received hospital care, or Medicare-covered skilled care in a skilled nursing facility for 60 days in a row from the date of discharge..

True or false: If the MA organization denies the appeal, the member has the right to further due process

There is a fully structured six tier appeals process in place. True

Are clinical laboratory services covered under Medicare?

Yes, clinical lab services are covered

In general, a Part C beneficiary is locked into a plan once the effective date has passed. What are the three time periods that a beneficiary can change their part C plan?

They can change plans during Open Enrollment, They can disenroll during the Medicare Advantage disenrollment period, but they can only take original Medicare, but not change plans, They can change plans if an SEP might qualify them to change their plan.

What is required that every Medicare Advantage Organization do every year with regard to their representatives who will be promoting its plans?

They must make sure they are Medicare-certified, which means trained and tested annually on Medicare rules and regulations, and on details specific to the plans they intend to offer.

If the agent does not fluently speak the language that the prospective beneficiary chooses to use, what must they do?

They must obtain the services of a translator, or they must refer the prospect to an agent who does speak the language.

If an individual chooses Medicare Part C, what is the next important choice?

To decide if they want medical benefits only or Part C with drug coverage.

True or false: During the coverage gap, any pharmacy dispensing fees do not count toward the true out of pocket expense.

True

True or false: Expenses that were paid by the beneficiary towards the Initial Coverage Limit, including the deductible, and the beneficiary cost share for any medications purchased count towards the true out of pocket expense, but the plan's share of the cost for the medications do not count.

True

True or false: The plan premium does not ever count toward the true out of pocket expense.

True

True or false: Whatever the beneficiary pays for medications that are not covered will never count toward the true out of pocket expense at any time.

True

True or false: Grevience and appeal rights ensure that Medicare beneficiaries who enroll in Medicare Advantage plans or prescription drug plans have access to services that should be covered.

True these are consumer protections

True or false: It is a guaranteed right of a Medicare benificiary to have the privacy of their personal health information protected.

True, a patients privacy must be protected

True or false: The Federal Government can impose civil or monetary penalties upon organizations or persons who fail to grant Medicare beneficiaries one of their guaranteed rights.

True, and they can be quite severe

True or false: It is a guaranteed right of a Medicare beneficiary to be protected from discrimination

True, discrimination based on multiple characteristics is illegal in many areas, including Medicare.

True or false: It is a guaranteed right of a Medicare beneficiary to get emergency care when needed

True, emergency care is a guaranteed right

True or false: Membership handbooks ensure that Medicare beneficiaries who enroll in Medicare Advantage plans or prescription drug plans have an understanding of how the plan itself works.

True, membership handbooks cover membership rules

True or false: It is not a guaranteed right of a Medicare beneficiary to have all medical services paid for by the plan, without regard to medical necessity.

True, not all medical services will be covered, and those that are must be medically necessary.

True or false: The explanation of benefits ensures that Medicare beneficiaries who enroll in Medicare Advantage plans or prescription drug plans have understanding of the services that should be covered.

True, the EOB gives an outline of covered services

True or false: All members can file grievances

True, the process is open to anyone who participates in the program.

True or false: Appeals and grievances are different types of complaints

True, these are different.

True or false: It is a guaranteed right of a Medicare beneficiary to file a complaint or a grievance about concerns or problems with the plan.

True, this is a vital part of the CMS oversight process

True or false: A plan has a specific time frame in which to respond to an appeal

True, this process is highly structured, including the time allowed to respond to an appeal

True or false: Grievances can be filed verbally or in writing.

True, writing is preferred for clarity, but verbal must be accepted and processed as a legal filing

True or false: It is a guaranteed right of a Medicare beneficiary to get appropriate help if they cannot afford Mediare.

True. Help is available.

True or false: The provider directory ensures that Medicare beneficiaries who enroll in Medicare Advantage plans or prescription drug plans have understanding of providers in the network.

True. The provider directory is a roster of network providers.

What are the three main questions that you must clarify completely about a clients situation before you can make an appropriate reccomendation for them?

What is their financial situation, What is their current coverage, What are their coverage needs?

When would the ICEP for MA and the IEP for part D coincide?

When the individual enrolls in both Medicare Part A and Medicare Part B when they are first eligible

Certian beneficiaries are protected by a transitional policy in Part D coverage. What is this protection?

Within the first 90 days of new coverage, plans are required to provide a one time 30 day suppy of non-formulary drugs at the request of the enrollee and their physician.

Is calling a prospective beneficiary to confirm an existing appointment which is covered by a scope of appointment legal?

Yes calling to confirm is legal

Are home health aide services covered under Medicare?

Yes home health aide services are covered on a limited basis

Are outpatient prescription drugs covered under Medicare?

Yes on a very limited basis, usually administered in the doctors office

Is calling an enrolled member to discuss new or expanded options legal?

Yes this call is permissible.

Is there a requirement for drug coverage that an MAO must meet?

Yes, MAOs are required to offer at least one plan with drug coverage.

Can a Part D PDP be added to a part C PFFS plan without cancelling the part C PFFS plan?

Yes, PFFS works with Stand-alone

Is it permissible to conduct sales activities in a hospital or nursing home cafeteria?

Yes, a cafeteria is a public area

Is it permissible to conduct sales activities in conference rooms?

Yes, a conference room is a public area

A potential beneficiary asks for a sales meeting with an agent at a local coffee shop. Is it legally required that the agent have the potential enrollee complete a scope of appointment form at least 48 hours in advance of the meeting to make sure there is a mutual understanding of the products that will be discussed?

Yes, a scope of appointment is legally required

Can a Part D PDP be added to a Med Sup plan without cancelling the Med Sup plan?

Yes, a stand alone works with Medigap

Can a Part D PDP be added to a part C MSA plan without cancelling the part C MSA plan?

Yes, an MSA plan will work with a stand alone PDP.

Can a Part D PDP be added to a 1876 cost plan without cancelling the 1876 cost plan?

Yes, because these plans are not Advantage plans

Are kidney dialysis services and supplies covered under Medicare?

Yes, dialysis is covered

If a client has end stage renal disease, is there any way that they can they still have a part C plan?

Yes, if the client has had a kidney transplant which has ended the need for regular dialysis, Yes, if they had a plan with a Medicare Provider Organization that lost or failed to renew their contract with CMS, Yes. if they "age in" to Medicare while a member of a plan with the same Medicare Provider Organization

Is it permitted to distribute or collect enrollment forms at an individual sales appointment?

Yes, in fact, that's the whole point.

Is there an income-related extra burden associated with the Part B Premium?

Yes, its called IRMAA which stands for Income Related Monthly Adjustment Amount. Basically, the higher the income, the higher the premium.

Are there open enrollment risks when a beneficiary has a Employer Group Plan?

Yes, members should check with their benefits administrator at work to avoid possibly losing coverage. Beneficiaries may still be able to use employer coverage with the plan that they join

Are Section 1876 Cost plans being discontinued?

Yes, new plans have not been created since 2010, and since 2012, Section 1876 Cost plans located in areas which have adaquate coverage by MA and MA-PD plans are not being renewed.

Is home health part time skilled nursing care covered under Medicare?

Yes, part time skilled nursing care is covered at 100% under the following conditions. It is recommended by a physician. It is provided by a Medicare authorized provider The patient is homebound. It includes skilled nursing, occupational therapy, language pathology, or physical therapy

Are second surgical opinions covered under Medicare?

Yes, second opinions are covered

Is there a restriction on the use of supurlatives to describe yourself, your organization or the plans you represent?

Yes, there is a restriction on using absolute supurlatives, such as "The best", "the highest rated", "the most liked", or even using qualified supurlatives such as "one of the best", "among the highest rated", "many agree that its the most liked", unless such descriptions can be substantiated with imperical data, and that imperical data and the accompanying discriptors, including specific supurlatives have been submitted to CMS as a part of the approval process

Can a Part D PDP be added to Original Medicare without cancelling Original Medicare?

Yes, these work together

Does any individual who makes use of the MADP have any sort of Special Election Period?

Yes, they may enroll in a stand alone PDP.

Are emergency room services covered under Medicare?

Yes, this is a right

Can an individual get part A if they have not worked 40 quarters in the United States?

Yes, those who have worked at least 30 qauarters can get Part A at a reduced out of pocket premium, which was $226/month in 2016. Those who have worked less then 30 quarters can get part A at full premium, which in 2016 was $411 per month.

Is there a late enrollment penalty for part B?

Yes. Although enrollment in part B is voluntary, the beneficiary is required to have some form of credible coverage, and if they cannot produce evidence of this credible coverage at the time of enrollment into part B, they may be assessed a late enrollment penalty of 10% of the premium per each 12 month time period in which they could have had part B and did not.

Is there a citizenship requirement for Medicare?

Yes. To enroll in Medicare, an individual must be a United States Citizen of have been a permanent legal resident of the United States for at least five continuous years.

If a Medicare Advantage member has and subsequently loses special needs status, this triggers what?

losing special needs status triggers an involuntary disenrollment from their part C plan.