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1 AHIP Module 1 Answers
2 AHIP Nodule 2 Answers
3 AHIP Module 3 Answers
4 AHIP Module 4 Answers
5 AHIP Module 5 Answers
6 AHIP Final Exam Answers
AHIP Module 1 Answers
Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern?
Medicare is a program for people 65 or older and those under the age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig’s disease so she will be eligible for Medicare.
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.
Mr. Hernandez is concerned that if he signs up for a Medicare Advantage plan, the health plan may, at some time in the future, reduce his benefits below what is available in Original Medicare. What should you tell him about his concern?
Medicare Advantage plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs.
Mrs. Roberts has just received a new Medicare identity card in the mail. She is concerned that it is a forgery since it does not have her Social Security number on it. What should you tell her?
The card she received is valid, the change has been made to protect Medicare beneficiaries from identity theft, and she should now destroy her old card.
Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefit package of a Medicare Health Plan before she starts looking at specific plans. What could you tell her?
Medicare Health Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services.
Mr. Moy’s wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife’s needs. What could you tell Mr. Moy?
Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.
Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under Part A because she was not born in the US. What should you tell her?
Most individuals who are citizens and over age 65 are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums.
Bauer is 49 years old, but eighteen months ago he was declared disabled by the SSA 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.
Mr. Denton is 52 years old and has recently been diagnosed with end-stage renal disease and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him?
He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start.
Ms. Henderson believes that she will qualify for Medicare coverage when she turns 65, w/o paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her?
In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes.
Mr. Diaz continued working with his company and was insured under his employer’s group plan until he reached 68 years old. He has heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know how much he will have to pay.
Mr. Diaz will not pay any penalty because he had continuous coverage under his employer’s plan.
Mrs. Pena 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.
She may not enroll at any time while she is covered under her employer plan, but she will have a special eight month enrollment period that differs from the standard general enrollment period, during which she may enroll in Medicare Part B.
Mrs. Kelly, age 65, is entitles to Part A, but is not yet enrolled in Part B. She is considering enrollment in a Medicare health plan. What should you advise her to do before she will be able to enroll into a Medicare health plan?
In order to join a Medicare plan, she also must enroll in Part B.
Mrs. Park is an elderly retiree. She has a low, fixed income. What could you tell Mrs. Park that might be of assistance?
She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible.
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.
Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare?
Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare’s coverage of care in a skilled nursing facility?
Medicare will cover Mrs. Shields’ skilled nursing services provided during the first 20 days of her stay, after which she would have a coinsurance until she has been in the facility for 100 days
Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover?
Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime.
Mrs. Quinn has recently turned 66 and decided after many years of work to begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn and received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn?
Part B primarily covers physician services. She will be paying a monthly premium and, with the exception of many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible.
Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him?
Medicare covers periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered. Correct
Mrs. Turner is comparing her employer’s retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met? What could you tell her?
Original Medicare covers ambulance services
Mrs. Wolf wears glasses and dentures and has enjoyed considerable pain relief from arthritis through acupuncture. She is concerned about whether or not Medicare will cover these items and services. What should you tell her?
Medicare does not cover acupuncture, or, in general, glasses or dentures.
Mr. Singh would like drug coverage, but does not want to be enrolled into a health 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. Alonso receives some help paying for his two generic prescription drugs from his employer’s retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him?
He generally would pay a monthly premium, annual deductible, and per-prescription cost sharing.
Mrs. Geisler’s neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can’t remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her?
Part D covers prescription drugs and she should look at her premiums, formulary, and cost sharing among other factors to see if they have changed.
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her?
Mrs. Duarte should file and appeal of this initial determination within 120 days of the date she received the MSN in the mail.
Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern?
Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services.
Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has, but replace her existing Medigap plan with one that provides drug coverage. What should you tell her?
Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan.
Mr. Kelly has substantial financial means. He enrolled in Original Medicare and purchased a Medigap policy many years ago that offered prescription drug coverage. The prescription drug coverage has not been comparable to that offered by Medicare Part D for several years and despite notification, Mr. Kelly took no action. Which of the following statements best describes what will occur if Mr. Kelly now decides to enroll in Medicare Part D?
He will incur a late enrollment penalty
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.
What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have upon Medigap plans?
The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020.
AHIP Nodule 2 Answers
Mr. Lopez has heard that he can sign up for a product called “Medicare Advantage” but is not sure about what type of plan designs are available through this program. What should you tell him about the types of health plans that are available through the Medicare Advantage program?
c. They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Correct
Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be a correct description?
a. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Correct
Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?
b. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Correct
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him?
a. He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Correct
Mrs. Billings enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs. Billings have in regard to her MA plan during the next open enrollment season?
a. She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. Correct
Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him?
a. C-SNP Correct
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him?
d. In most Medicare Advantage HMOs, Mr. Kumar must obtain his services only from providers who have a contractual relationship with the plan (except in an emergency). Correct
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can go to for her health care. What should you tell her?
b. Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will have a higher cost-sharing amount if she sees a provider who/that is not part of the PPO network. Correct
Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him?
b. SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well. Correct
Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that plan. What should you tell him?
b. SNPs limit enrollment to certain sub-populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. Correct
Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network like his current HMO plan requires him to do. What should you tell him?
b. He may receive health care services from any doctor allowed to bill Medicare, as long as he shows the doctor the plan’s identification card and the doctor agrees to accept the PFFS plan’s payment terms and conditions, which could include balance billing. Correct
Mrs. Lee is discussing with you the possibility of enrolling in a Private Fee-for-Service (PFFS) plan. As part of that discussion, what should you be sure to tell her?
c. PFFS plans may choose to offer Part D benefits but are not required to do so. Correct
Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know what makes them different from an HMO or a PPO. What should you tell him?
d. Enrollees in a PFFS plan can obtain care from any provider in the U.S. who accepts Original Medicare, as long as the provider has a reasonable opportunity to access the plan’s terms and conditions and agrees to accept them. Correct
Dr. Elizabeth Brennan does not contract with the PFFS plan but accepts the plan’s terms and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan charge?
b. Dr. Brennan can charge Mary Rogers no more than the cost sharing specified in the PFFS plan’s terms and condition of payment which may include balance billing up to 15 percent of the Medicare rate. Correct
Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA), but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan?
b. All MSAs cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling in a separate prescription drug plan. Correct
Which of the following statement is correct about Medicare Savings Account (MSA) Plans? I. MSAs may have not have a network or may have a full or partial network of providers. II. MSA plans must cover preventive services that have no cost sharing before the enrollee has met the deductible. III. An individual who is eligible for health care benefits through the Veteran’s Administration may enroll in an MSA. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full.
c. I, II, and IV only Correct
Mr. Davies is turning 65 next month. He would like to enroll in a Medicare health plan, but does not want to be limited in terms of where he obtains his care. What should you tell him about how a Medicare Cost Plan might fit his needs?
d. Cost plan enrollees can choose to receive Medicare covered services under the plan’s benefits by going to plan network providers and paying plan cost sharing, or may receive services from non-network providers and pay cost-sharing due under Original Medicare. Correct
For which of the following individuals would a Cost Plan be most appropriate?
c. Ms. Baker who is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan premiums. Correct
Which statement best describes PACE plans?
b. It includes comprehensive medical and social service delivery systems using an interdisciplinary team approach in an adult day health center, supplemented by in-home and referral services. Correct
Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan that includes drug coverage with nominal copays. He heard about a neighbor’s MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him?
c. Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep. Correct
Mrs. Walters is enrolled in her state’s Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Health Plan?
c. She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account (MSA) plan. Correct
Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her?
a. Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. Correct
Mr. Rivera has Qualified Medicare Beneficiary (QMB) eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) PPO plan. Later he sees an out-of-network doctor to receive a Medicare covered service. How much may the doctor collect from Mr. Rivera?
b. The doctor may only collect from Mr. Rivera the cost sharing allowable under the state’s Medicaid program. Correct
Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr. Lombardi’s area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell him about this situation?
b. He could enroll in one of the MA plans that include prescription drug coverage or a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. Correct
Mrs. Chou likes a 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?
a. She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. Correct
AHIP Module 3 Answers
Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him?
b. Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. Correct
Mrs. Mulcahy 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?
a. Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. Correct
Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost creditable coverage previously available through her husband’s employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her?
b. If a Part D benefit is offered through her plan she may choose in enroll in that plan or a standalone PDP. Correct
Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan.
b. I, II, and III only Correct
All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a beneficiary incur for prescription drugs in 2019 under the standard coverage?
c. Standard Part D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a portion of costs for both generics and brand-name drugs in the coverage gap, and co-pays or co-insurance after the coverage gap. Correct
Mrs. Andrews was preparing a budget for next year because she takes quite a few prescription drugs, she will reach the coverage gap, and wants to be sure she has enough money set aside for those months. She received assistance calculating her projected expenses from her daughter who is a pharmacist, but she doesn’t think the calculations are correct because her out-of-pocket expenses would be lower than last year. She calls to ask if you can help. What might you tell her?
a. It would not be unusual for her costs to be a bit less because the Bipartisan Budget Act of 2018 moved up the date for closing the so-called “donut hole” for brand name drugs to 2019. Correct
Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums and cost sharing. How can you explain this to him?
b. Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. Correct
Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of her prescriptions that she has lost. How would you advise her?
d. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Correct
What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?
b. Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization. Correct
Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her?
c. 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. Correct
Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them?
b. Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn’s could look into that possibility. Correct
Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year?
a. When a formulary change is in response to a drug’s removal from the market. Correct
Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of misusing or abusing frequently abused drugs? I. Identifying at risk individuals by using criteria that includes the number of opioid prescriptions the beneficiary has and the number of prescribers who have written those prescriptions. II. Locking an at-risk beneficiary into one pharmacy. III. Locking an at-risk beneficiary into one prescriber. IV. Increasing deductibles and copays for at-risk beneficiaries.
b. I, II and III only Correct
Mrs. Roswell is a new Medicare beneficiary and is interested in selecting a Medicare Part D prescription drug plan. She takes a number of 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?
a. 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. Correct
Mr. Zachow has a condition for which three drugs are available. He has tried two, but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan’s formulary. What could you tell him to do?
d. Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan’s website, fill it out, and submit it to his plan. Correct
Mrs. Quinn has just turned 65, is in excellent health, and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. What could you tell her about the implications of such a decision?
a. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, 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. Correct
Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him?
d. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Correct
Mr. Katz reached the Part D coverage gap in August last year. His prescriptions have not changed, he is keeping the same Part D plan and the benefits, cost-sharing, and coverage of his drugs are all the same as last year. He asked what to expect for this year about his out-of-pocket costs. What could you tell him?
a. Because he reached the coverage gap last year, he will probably reach it again this year close to the same time. Correct
Mrs. Grant uses several very expensive drugs and anticipates that she will enter catastrophic coverage at some point during the year. To help her determine when she is likely to qualify for catastrophic coverage, she asked which expenses count toward the out-of-pocket limit that qualifies her for catastrophic coverage. Which one of the following would count?
a. Prescription drugs she purchases when in the Part D coverage gap. Correct
Mr. Shapiro gets by on a very small fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him?
a. The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Correct
Mrs. Fields wants to know whether applying for the Part D low income subsidy will be worth the time to fill out the paperwork. What could you tell her?
a. The Part D low income subsidy could substantially lower her overall costs. She can apply by contacting her state Medicaid office, or calling the Social Security Administration. Correct
Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him?
b. He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. Correct
Mrs. Fiore was in the Army for 35 years and is now retired. She has drug coverage through the VA. What issues might she consider with regard to whether to enroll in a Medicare prescription drug plan?
c. She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the VA for the specific medications she needs and whether any additional benefits are worth the Part D premium costs. Correct
Mr. Hutchinson has drug coverage through his former employer’s retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him?
d. If the drug coverage he has is not expected to pay, on average, at least as much as Medicare’s standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Correct
Mr. Rice has coverage for medical services and medications through his employer’s retiree plan. He is considering switching to a Medicare prescription drug plan because his retiree plan does not cover two important medications. What should he consider before making a change?
d. If Mr. Rice drops his drug coverage through the retiree plan, he may not be able to get it back and he also may lose his medical health coverage. Correct
Mr. Shultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has lost his employer group coverage. How would you advise him?
a. Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty. Correct
Mrs. McIntire is enrolled in her state’s Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen with respect to her drug coverage?
b. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Correct
AHIP Module 4 Answers
Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services’ Marketing Guidelines to ensure he is compliant for which type of products?
c. Medicare Advantage (MA) and Prescription Drug (PDP) plans Correct
Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same requirements as the plans themselves. How should you respond to such a statement?
c. Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules. Correct
Wendy Park 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 the months July through December. Renewal amounts will be paid starting in January if Ms. Park remains enrolled the following year.
You work for a company that has marketed Medigap products for many years. The company has added Medicare Advantage and Part D plans and you will begin marketing those plans this fall. You are planning what materials to use to easily show the differences in benefits, premiums and cost sharing for each of the products. What do you need to do with your materials before using them for marketing purposes?
b. You must submit your materials to the plan you represent, so CMS can review and approve the materials to ensure they are accurate. Correct
Which of the following is a correct statement about state laws as they pertain to marketing representatives?
d. Medicare health plans must comply with requests for information from state insurance departments investigating complaints about a marketing representative. Correct
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?
a. You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score, although you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing. Correct
Your colleague works at a third party marketing organization (TMO) and she said she did not need to take the Medicare training for brokers and agents or pass a test to market Medicare plans since her contract is with the TMO, not the plans that have the products she sells. What could you say to her?
d. You could tell her she is wrong, and that only agents selling employer/union group plans are permitted an exemption from testing, but some employer/union group plans may require testing to promote agent compliance with CMS marketing requirements. Correct
Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong?
c. Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located. Correct
You are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs. What should you keep in mind?
d. You may request RSVPs, but you are not permitted to require contact information. Correct
Agent Antonio is preparing for a presentation on Medicare and Medicare Advantage before a local senior citizen civic group where he hopes to enroll some attendees. Which of the following steps should he take in order to be in compliance with Medicare marketing rules?
a. Antonio should include on the invitation a statement that a salesperson will be present with information and applications. Correct
You have set up an appointment for an in-home sales presentation with Mrs. Fernandez, who expressed interest in the Medicare plans you represent. In preparation for the sales presentation, what must you do?
c. Prior to conducting the presentation, obtain, and document having obtained her permission to visit, along with her interest in the specific products you will present. Correct
Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you October 15. During the appointment, what are you permitted to do?
c. You may provide her with the required enrollment materials and take her completed enrollment application. Correct
While making an appointment to discuss Medicare Advantage (MA) and Part D plans with a potential enrollee, you are asked to describe other types of insurance products that your client might wish to purchase. What additional types of insurance can you present during the MA and Part D marketing appointment?
c. You can present only health care related lines of business, but must obtain the beneficiary’s permission to do so before the presentation occurs and document that you have obtained that permission. Correct
A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do?
d. You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. Correct
You are meeting with Mrs. Hall in her home. On her scope of appointment form she asked to discuss Medicare Advantage plans. During the meeting, she asks to discuss a stand-alone prescription drug plan. She is leaving the next day to visit her family for a week in another state, so it is important to her to make a decision before she leaves. What must happen before that additional discussion can take place?
a. Since Mrs. Hall specifically asked that you discuss the stand-alone Part D plan, you may do so, as long as she signs a new scope of appointment form first, indicating that she wants to discuss the Part D plan. Correct
Which of the following statements best describes how business reply cards (BRCs) may be employed in the marketing of Medicare Advantage products?
b. A BRC may be used to document a beneficiary’s scope of appointment agreement provided it has been submitted to CMS for approval and includes a statement informing the beneficiary that a salesperson may call. Correct
Ordinarily, you obtain referrals from a third-party that initiates contact with potential clients and usually sets up appointments for you. How would the guidelines for marketing Medicare Advantage and Part D plans apply to this practice?
c. Third parties may not make unsolicited calls, visits, or emails to Medicare beneficiaries in order to set up such appointments, or for any other reason related to the marketing of Medicare Advantage or Part D plans. Correct
You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To be in compliance with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plans?
d. You will have to avoid calling any potential client, unless he or she initiates contact with you and specifically asks that you give him or her a call. Correct
Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her?
c. Marketing representatives may initiate electronic contact through e-mail but the subject line must say “marketing” and an opt-out process must be provided. Correct
Winthrop Brokerage wishes to place an advertisement in the local newspaper that says: “We offer Medicare Advantage plans offered by AB Health and Top Choice Health. Contact us if you would like to learn more.” Which of the following best describes the obligation(s) of Winthrop Brokerage regarding the advertisement?
b. Winthrop Brokerage does not need to submit the advertisement to CMS for prior approval because it does not include information about the plans’ benefit structures, cost sharing, or information about measures or ranking standards. Correct
ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees’ protected health information to market non-health related products such as life insurance and annuities. To do so it must obtain authorization from the enrollees. Which statement best describes the authorization process?
b. The request for authorization may include a brief synopsis of non-health related content. Incorrect
During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5-star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the correct statement to say to her?
a. The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4-stars. Correct
Mr. Valesquez asked if the Private Fee-for-Service plan you have discussed is like Original Medicare or a Medigap supplement plan. What should you say about a Private Fee-for-Service (PFFS) plan to explain it to Mr. Valesquez?
d. It is not Original Medicare and it works differently than a Medicare supplement plan. Correct
Ajax Agency is targeting potential enrollees for MSA plans. Which of the following statements best describes the rules that apply to the MSA materials it distributes?
a. The materials must make clear that Medicare MSA plans do not cover prescription drugs and that beneficiaries can join a separate Part D prescription drug plan. Correct
During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her?
c. Tell her that the Medicare agency does not endorse or recommend any plan. Correct
By contacting plans available in your area, you have learned that the plan you represent has a significantly lower monthly premium than the others. Furthermore, you see that the plan you represent has a unique benefit package. What should you do to make sure your clients know about these pieces of information?
b. You may present comparative information that has been created and approved by the Medicare agency (CMS), such as a print-out from the Medicare plan comparison website. Correct
You have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respect to meals?
a. You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. Correct
Ordinarily, you provide clients who purchase various types of insurance products from you with a gift when they enroll and you let them know that they will receive it after their enrollment is complete. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?
b. You may not provide any gift or prize as an inducement to enroll. Correct
One of your colleagues argues that it is better to focus your time and energy exclusively in neighborhoods with single family homes. He further argues that their older owners are more likely to have higher incomes and purchase the Medicare Advantage products you represent compared to those living in apartment complexes. How should you respond?
a. This could be considered discriminatory activity and a prohibited practice. Correct
Agent Harriet Walker has recently begun marketing Medicare Advantage and related products aimed at meeting the needs of senior citizens. Client Mildred Jones has expressed interest in a Medicare Advantage plan. It is now the beginning of September. If you were in Agent Walker’s position, what would you do?
d. Inquire whether the client qualifies for a special enrollment period, and if not, solicit an enrollment application once the annual open enrollment election period begins on October 15th. Correct
Mr. Murphy is an agent. A neighbor invited him to discuss the Medicare Advantage (MA) and Part D plans he sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Mr. Murphy tell his neighbor about the kinds of food that can be provided to potential enrollees who attend the sales presentation?
d. The neighbors may not provide a meal, but light snacks would be permitted. Correct
Ordinarily, you provide clients who purchase various types of insurance products from you with a gift when they enroll and you let them know that they will receive it after their enrollment is complete. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?
d. You may not provide any gift or prize as an inducement to enroll. Correct
Mr. Edwards, a marketing representative of the ACME Insurance Company, scheduled a marketing event and expects about 40 people to attend. He has hired a magician at a cost of $200 to entertain attendees. Can he do this in a way that complies with guidance from the Medicare agency?
d. He can do this, because the estimated number of attendees is based on the venue size and response rate and the value of the gift does not exceed $15. Correct
You will be holding a sales event in the near future, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation?
a. Gift cards or gift certificates of $15 or less that can be readily converted to cash. Correct
You are scheduled to give a sales presentation at a local senior center. At the beginning of the presentation, which of the following must you do?
d. Clearly state that no obligation exists to enroll if a gift or prize is being offered. Correct
Ordinarily, you ask your clients for referrals to people they think would benefit from the products you offer. When selling Medicare Advantage or Part D products, how might you solicit referrals?
d. You may solicit referrals from current MA and Part D enrollees and offer one thank you gift per member per year of less than $15, based on retail purchase price for the item, although you may not inform enrollees of the availability of the gift in your letter soliciting referrals. Correct
When soliciting referrals from current members of an MA or Part D plan, what may you do?
a. You may request names and mailing addresses. Correct
Several agents you work with are planning sales events in your area. One plans on giving door prizes worth $5, refreshments valued at $8 per anticipated attendee, and coupon books with discounts worth $10. Since no gift or prize exceeds the $15 limit he believes his plan is acceptable. What should you tell them
d. He can give away more than one gift during a single event, but the aggregate retail value cannot exceed $15 Correct
You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns?
d. Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider’s facility. Correct
You would like to market an MA plan at a neighborhood pharmacy. What should you keep in mind to comply with the marketing requirements for MA plans?
c. You must set up your table, make marketing presentations, and accept enrollment applications only in common areas outside of where the patient waits for services from the pharmacist. Correct
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?
b. You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request. Correct
ABC is a long-term care facility provider. What steps may it take to inform residents of the Medicare options available to them?
b. ABC may provide residents that meet the I-SNP criteria an explanatory brochure, reply card, and phone number for additional information for each I-SNP with which it contracts. Correct
You have sought permission from a hospital to place brochures for your product in their gift shop and cafeteria. The hospital administration expresses some hesitation about allowing marketing in a health care facility. What should you tell them?
a. Marketing in health care facilities is an acceptable practice, as long as it takes place in common areas where patients are not receiving or waiting to receive health care and as long as the hospital displays materials for all plans that provide them to the hospital. Correct
Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members?
c. Market non-Medicare health-related products, such as dental insurance, to current members as permitted by HIPAA Privacy Rules. Correct
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?
a. You may go ahead and call them. Correct
Next week you will be participating in your first “educational event” for prospective enrollees. In order to be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage?
a. You should plan to ensure that the educational event is a social event, and must not conduct a sales presentation or distribute or accept enrollment forms at the event. Correct
If you are to be in compliance with Medicare’s guidance regarding educational events, which of the following would be acceptable activities?
b. You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent. Correct
You are working with a number of plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do?
c. You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. Correct
You plan to participate in an educational event sponsored by a large regional health care system. One of your colleagues suggests that you do a presentation on one of the Medicare Health plans you market, and modify it to include information about preventive screening tests showcased at the event. How should you respond to your colleague’s suggestion?
c. You should tell your colleague no because participation in an educational event may not include a sales presentation. Correct
Agent Mary Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational in nature. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational?
c. Yes. When an event has been advertised as “educational,” discussing plan-specific premiums is impermissible. Correct
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?
d. The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. Correct
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?
b. Cooperate with the state and supply requested information. Correct
Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted with regard to 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?
d. 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. Correct
Medicare health plans establish provisions in marketing representative contracts to ensure compliance with applicable laws and policies. If non-compliance occurs, CMS can penalize a plan in which of the following ways?
d. CMS requires plan sponsors to create and complete a corrective action plan and may terminate a sponsor’s contract. Correct
Monica is an agent focused on serving seniors eligible for Medicare. As she reviews her records, she is trying to determine which of the following items are considered compensation. What do you tell her? I. Commissions II. Bonuses III. Mileage reimbursement IV. Referral fees
b. I, II, and IV only Correct
Alice is a marketing representative employed by a health plan. Betty is a captive agent of a health plan who markets to multiple plans and sponsors. Carl is a captive agent who markets to 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:
d. Betty and Denise, but not Alice (the employee) or Carl or Edward (to whom exceptions apply). Correct
Wendy Park 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?
b. FeelBetter will pay Agent Chan initial year compensation for the months July through December. Renewal amounts will be paid starting in January if Ms. Park remains enrolled the following year. Correct
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 did not understand that the plan did 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?
b. Agent Lopez’s entire compensation must be recouped because Ralph disenrolled within 3 months of enrollment. Correct
Agent Higgins helps Mrs. O’Malley to 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?
a. AB MA plan does not have to recoup Agent Higgins’ compensation because she has moved away from its service area. Correct
AHIP Module 5 Answers
Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to?
c. Yes. Mrs. Walters must be entitled to Part A or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program. Correct
Mr. Sanchez is entitled to Part A, but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do?
c. He will have to enroll in Part B. Correct
Mr. Kelly wants to know whether he is eligible to sign up for a Private fee-for-service (PFFS) plan. What questions would you need to ask to determine his eligibility?
a. You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if he lives in the PFFS plan’s service area. Correct
Mr. Gonzalez is entitled to Part A, but has not yet enrolled in Part B. If he wants to enroll in a Private Fee-for-Service (PFFS) plan, what will he have to do?
d. He will have to enroll in Part B prior to enrolling in the PFFS plan. Correct
Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this?
c. If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account, Mrs. Berkowitz can do this. Correct
Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan?
d. 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. Correct
Which of the following individuals is most likely to be eligible to enroll in a Medicare Advantage or Part D Plan?
d. Jose, a grandfather who was granted asylum and has worked in the United States for many years. Correct
Mr. and Mrs. Nunez attended one of your sales presentations. They’ve asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do?
d. As long as she is able to do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time. Correct
You are visiting with Mr. Tully and his daughter at her request. He has advanced Alzheimer’s and is incapable of understanding the implications of choosing a Medicare Advantage or prescription drug plan. Can his daughter fill out the enrollment form and sign it for him?
c. Mr. Tully’s daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions. Correct
You are meeting with Ms. Berlin and she has completed an enrollment form for a MA-PD plan you represent. You notice that her handwriting is illegible and as a result, the spelling of her street looks incorrect. She asks you to fill in the corrected street name. What should you do?
c. You may correct this information as long as you add your initials and date next to the correction Correct
Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare’s efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment site, which of the following must Phiona consider? I. If a legal representative is completing an electronic enrollment request, he or she must first upload proof of his or her authority. II. All data elements required to complete an enrollment request must be captured. III. The process must include a clear and distinct step that requires the applicant to activate an “Enroll Now” or “I Agree” type of button or tool. IV. The mechanism must capture an accurate time and date stamp at the time the applicant enters the online site.
b. II and III only Correct
Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He found a stand-alone Medicare prescription drug plan in his area that offers better coverage than that available through his MA-PD plan and in addition has a low premium. It won’t cost him much more and, because he has the means to do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan. What should you tell him?
c. If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. Correct
You are doing a sales presentation for Mrs. Pearson. You know that the Medicare marketing guidelines prohibit certain types of statements. Apply those guidelines to the following statements and identify which would be prohibited.
d. “If you’re not in very good health, you will probably do better with a different product.” Correct
You have come to Mrs. Midler’s home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical record available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan. What should you do?
b. You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has end stage renal disease or one of the conditions that would qualify her for a special needs plan. Correct
Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard?
a. Implying that only seniors can enroll in a Medicare Advantage plan when meeting with Mr. Hernandez, who is 58 but qualifies for Medicare because she is disabled. Correct
Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time?
c. He will have one opportunity to enroll in a Medicare Advantage plan Correct
Mrs. Kendrick is six months away from turning 65. She wants to know what she will have to do to enroll in a Medicare Advantage (MA) plan as soon as possible. What could you tell her?
c. She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B. Correct
Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D. What could you tell him?
a. He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may make one Part D enrollment choice, including enrollment in a stand-alone Part D plan or an MA-PD plan. Correct
Ms. Claggett is sixty-six (66) years old. She has been covered under both Parts A and B of Original Medicare for the last six years due to her disability, has never been enrolled in a Medicare Advantage or a Part D plan before. She wants to enroll in a Part D plan. She knows that there is such a thing as the “Part D Initial Enrollment Period” and has concluded that, since she has never enrolled in such a plan before, she should be eligible to enroll under this period. What should you tell her about how the Part D Initial Enrollment Period applies to her situation?
c. It occurs three months before and three months after the month when a beneficiary meets the eligibility requirements for Part B, so she will not be able to use it as a justification for enrolling in a Part D plan now. Correct
When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice would you give her?
d. She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA plan. Correct
Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period. On December 1, he calls you up and says that he has changed his mind and would like to enroll into an MA-PD plan. What enrollment rules would apply in this case?
d. He can make as many enrollment changes as he likes during the Annual Election Period and the last choice made prior to the end of the period will be the effective one as of January 1. Correct
Mrs. Kumar would like her daughter, who lives in another state, to meet with you during the Annual Election Period to help her complete her enrollment in a Part D plan. She asked you when she should have her daughter plan to visit. What could you tell her?
d. Her daughter should come in November. Correct
Mr. Anderson is a very organized individual and has filled out and brought to you an enrollment form on October 10 for a new plan available January 1 next year. He is currently enrolled in Original Medicare. What should you do?
a. Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins. Correct
A client wants to give you an enrollment application on October 1 prior to the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him?
c. 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. Correct
Mrs. Goodman enrolled in an MA-PD plan during the Annual Election Period. In mid-January of the following year, she wants to switch back to Original Medicare and enroll in a stand-alone prescription drug plan. What should you tell her?
a. During the MA Open Enrollment Period, from January 1 – March 31, she may disenroll from the MA-PD plan into Original Medicare and also may add a stand-alone prescription drug plan. Correct
Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application prior the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams?
b. This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form prior to the start of the AEP. Correct
Ms. Gonzales decided to remain in Original Medicare (Parts A and B) and Part D during the Annual Enrollment Period (AEP). At the beginning of January, her neighbor told her about the Medicare Advantage (MA) plan he selected. He also told her there was an open enrollment period that she might be able to use to enroll in a MA plan. Ms. Gonzales comes to you for advice shortly after speaking to her neighbor. What should you tell her?
d. There is a MA Open Enrollment Period (OEP) that takes place between January 1 and March 31, but Ms. Gonzales cannot use it because eligibility to use the OEP is available only to MA enrollees. Correct
Mrs. Schmidt is moving and a friend told her she might qualify for a “Special Election Period” to enroll in a new Medicare Advantage plan. She contacted you to ask what a Special Election Period is. What could you tell her?
a. It is a time period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically the Special Election Period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area. Correct
Mr. Garcia was told he qualifies for a Special Election Period (SEP), but he lost the paper that explains what he could do during the SEP. What can you tell him?
a. If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage. Correct
Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard that there are certain MA plans that might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him?
d. If there is a special needs plan (SNP) in Mr. Wendt’s area that specializes in caring for individuals with diabetes, he may enroll in the SNP at any time under a special enrollment period (SEP). Correct
Which of the following individuals are likely to qualify for a special enrollment period (SEP) for both MA and Part D due to a change of residence? I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan’s service area. II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan’s service area. III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area where no Part D plan was available. IV. Henry makes a permanent move providing him with new MA and Part D options.
c. II, III, and IV only Correct
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 enrollment periods (SEPs)?
d. Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends September 1 – two months after the loss of creditable coverage. Correct
Ms. Lee is enrolled in an MA-PD plan, but will be moving out of the plan’s service area next month. She is worried that she will not be able to enroll in another plan available in her new residence until the Annual Election Period. What should you tell her?
c. She is eligible for a Special Election Period that begins either the month before her permanent move, if the plan is notified in advance, or the month she provides notice of the move, and this period typically lasts an additional two months. Correct
Mr. Yoo’s employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a Special Election Period. Mr. Yoo contacted you to find out more about what this means. What can you tell him?
d. It means that he qualifies for a one-time opportunity to enroll into an MA-PD or Part D prescription drug plan. Correct
Mrs. Schneider has Original Medicare Parts A and B and has just qualified for her state’s Medicaid program, so the state is now paying her Part B premium. Will gaining eligibility for this program affect her ability to enroll in a Medicare Advantage or Medicare Prescription Drug plan?
a. Yes. Qualifying for this state program gives Mrs. Schneider access to a Special Election Period that allows her to make changes to her MA and/or Part D enrollment at any time. Correct
If Mr. Johannsen gains the Part D low-income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan?
a. He can enroll in or disenroll from a Part D plan at any time and the subsidy will apply to the plan he chooses. Correct
Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirements several years ago. Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the first time. Unfortunately, Mrs. Ridgeway has found that many of her providers are not in the MA plan’s network. She has come to you for advice? What should you tell her?
d. She qualifies for a special enrollment period (SEP) that will allow her to make a one-time election to return to Original Medicare and she also has a guaranteed eligibility period to rejoin her Medigap plan. Correct
Mr. Chen is enrolled in his employer’s group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him?
d. Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment, but he should revaluate if he really wants to drop his employer coverage. Correct
Mary Samuels recently suffered a stroke while visiting her daughter and grandchildren. As a result, Mary has been admitted to a rehabilitation hospital where she is expected to reside for several months. The rehabilitation hospital is located outside the geographic area served by her current Medicare Advantage (MA) plan. What options are available to Mary regarding her health plan coverage?
a. Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan. Correct
Mr. Roberts is enrolled in an MA plan. He recently suffered complications following hip replacement surgery. As a result, he has spent the last three months in Resthaven, a skilled nursing facility. Mr. Roberts is about to be discharged. What advice would you give him regarding his health coverage options?
b. His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility. Correct
Mrs. Lenard is enrolled in a Medicare Cost plan. Recently the cost plan announced its intention to end its cost contract and transition to a Medicare Advantage (MA) Mrs. Lenard received a letter indicating that unless she chooses another plan or opts out she will be automatically enrolled in the new Medicare Advantage plan operated by an organization affiliated with her cost plan. What does this mean?
d. If Mrs. Lenard wants to enroll in a Medicare Advantage plan affiliated with her cost plan effective January 1, she should do nothing and she will be automatically enrolled. If she does not want to enroll in that MA plan, she should choose another plan or otherwise opt out of the automatic enrollment. Correct
You are completing a PFFS plan sale to Mr. West who is new to Medicare and prefers to be contacted by telephone. As you are finishing up, what should you tell him about next steps in the enrollment process?
c. You need to get Mr. West’s phone number and include it on the enrollment form because the plan must call him after you leave to ensure that he understood the nature of the PFFS plan he selected and to verify his intent to enroll. Correct
Mrs. Johnson calls to tell you she has not received her new plan ID card yet, but she needs to see a doctor. What can she expect to receive from the plan after the plan has received her enrollment form?
b. Evidence of plan membership, information on how to obtain services, and the effective date of coverage. Correct
Mrs. Reynolds just signed up for a Medicare Advantage plan on the second of the month. She is leaving for vacation in two weeks and wants to know if her new coverage will start before she leaves. What should you tell her?
a. 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. Correct
You meet with Mrs. Wilson to complete her enrollment in a Medicare Advantage plan. You tell her that there will be an enrollment verification process to confirm that she is enrolled in the plan that she requested and understands the plan features and rules. What should Mrs. Wilson expect regarding the verification process?
c. Mrs. Wilson will be contacted by the plan sponsor within 15 calendar days of receipt of the enrollment request. Correct
Mrs. Burton is in an MA-PD plan and was disappointed in the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she wouldn’t continue to have to put up with such poor access to care. What could you tell her?
a. She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Correct
Mr. Barker had surgery recently and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included a number of services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him?
d. You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Correct
Mrs. Disraeli is enrolled in Original Medicare (Parts A and B) and a standalone Part D prescription drug plan. She has recently developed diabetes and has suffered from heart disease for several years. She has also recently learned that her area is served by a SNP for individuals suffering from such a combination of chronic diseases (C-SNP). Mrs. Disraeli is concerned however, that she will have few rights or protections if she enrolls in a C-SNP. How would you respond?
d. Enrollees in SNPs must have access to provider networks that include enough doctors, specialists, and hospitals to provide all covered services necessary to meet enrollee needs within reasonable travel time. Correct
Ms. O’Donnell learned about a new MA-PD plan that her neighbor suggested and that you represent. She plans to switch from her old MA HMO plan to the new MA-PD plan during the Annual Election Period. However, she wants to make sure she does not end up paying premiums for two plans. What can you tell her?
d. She only needs to enroll in the new MA-PD plan and she will automatically be disenrolled from her old MA plan. Correct
Mr. Fitzgerald is selling his home to permanently move into a retirement facility near his daughter in a neighboring state. He has a stand-alone prescription drug plan, and has learned it is not available where he is moving. He doesn’t know what he should do. What can you tell him?
a. 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. Correct
Mr. Robinson was quite ill recently and forgot to pay his monthly premium for his MA-PD plan. He is worried that he will lose his coverage now when he needs it the most. He is certain his plan will disenroll him because that is what happened to a friend of his in a similar type of plan. What can you tell Mr. Robinson about his situation?
b. Plan sponsors have the option to disenroll members who do not pay their premiums, but they must first provide each member with a grace period of not less than 2 months. Correct
Mrs. Valentino is currently enrolled in a Medicare Cost plan. This plan is no longer meeting her needs, but it is now mid-year and past the annual election period (AEP). What would you say to Mrs. Valentino regarding her options?
b. Mrs. Valentino can submit a written request to Medicare to be disenrolled from the Cost plan and enroll in Original Medicare. Correct
If Mr. Johannsen gains the Part D low-income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan?
b. He qualifies for a special enrollment period and can enroll in or disenroll from a Part D plan and the subsidy will apply to the plan he chooses. Correct
AHIP Final Exam Answers
Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums and cost sharing. How can you explain this to him?
Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through acupuncture. She is concerned about whether or not Medicare will cover these items and services. What should you tell her?
Medicare does not cover acupuncture, or, in general, glasses or dentures.
Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him?
He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses.
Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has received a letter from her Medigap carrier informing her that her drug coverage is not “creditable.” She wants to know what this means. What should you tell her?
The letter is to inform her that the drug coverage offered through her Medigap plan does not offer drug coverage that is at least comparable to that provided under the Medicare Part D prescription drug program. If she does not have such creditable coverage during periods when she is eligible for the Part D program, she will face a premium penalty if she enrolls in a Part D plan at a later date.
Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr. Lombardi’s area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell him about this situation?
He could enroll in one of the MA plans that include prescription drug coverage or a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan.
Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him?
In general, he must select a single Part D premium payment mechanism that will be used throughout the year.
Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational in nature. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational?
Yes. When an event has been advertised as “educational,” discussing plan-specific premiums is impermissible.
Mrs. Mulcahy 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?
Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan.
Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern?
Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end stage renal disease or Lou Gehrig’s disease, so she will be eligible for Medicare.
Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong?
Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located.
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.
You have come to Mrs. Midler’s home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical record available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan. What should you do?
You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has end stage renal disease or one of the conditions that would qualify her for a special needs plan.
You are 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, although you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing.
Mr. Chen is enrolled in his employer’s group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him?
Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment, but he should revaluate if he really wants to drop his employer coverage.
Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him?
He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start.
Mr. Johannsen is entitled to Medicare Part A and Part B. He gains the Part D low-income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan?
He qualifies for a special election period and can enroll in or disenroll from a Part D plan once during that period.
Mr. Lopez, who is fairly well-off financially, would like to enroll in a Medicare prescription drug plan you represent and simply give you a check to cover his premiums for the entire year. What should you tell him?
Enrollees should pay using automatic withdrawal from a bank account or credit or debit card, direct monthly billing from the plan, or deductions from their Social Security check.
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.
Mrs. Reeves is newly eligible to enroll in a Medicare Advantage plan and her MA Initial Coverage Election Period (ICEP) has just begun. Which of the following can she not do during the ICEP?
She can enroll in a Medigap plan to supplement the benefits of the MA plan that she’s also enrolling in.
Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi?
Mrs. Chi may enroll in a MS MSA plan and remain in her current standalone Part D prescription drug plan.
Alice is enrolled in a MA-PD plan. She makes a permanent move across the country and wonders what her options are for continuing MA-PD coverage. What would you say to her in regard to a special enrollment period (SEP)?
She is likely to qualify for a SEP. She can choose an effective date of up to three months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than the date of her permanent move.
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 enrollment periods (SEPs)?
Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends September 1 – two months after the loss of creditable coverage.
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.
When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice would you give her?
She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA plan.
Mr. Chen has heard about Medical Savings Account (MSA), but wants to know if it is just about saving money, or if he will get insurance coverage for his health care expenditures as well. What should you tell him?
Under the Medicare Advantage program. an MSA plan involves the combination of high deductible health plan and savings account for health expenses. Medicare will make contributions to this savings account to help him pay his health care expenses while in the deductible.
Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her?
Most individuals who are citizens and over age 65 are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums.
Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of her 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.
Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover?
Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime.
Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare?
Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day 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
Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover?
Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime.
Mr. and Mrs. Nunez attended one of your sales presentations. They’ve asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do?
As long as she is able to do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time.
Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for Medicare as well. He is concerned about changes in his cost-sharing. What should you tell him?
He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers.
Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included a number of services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him?
You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.
Mr. Zachow has a condition for which three drugs are available. He has tried two, but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan’s formulary. What could you tell him to do?
Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan’s website, fill it out, and submit it to his plan.
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her?
Mrs. Duarte should file and appeal of this initial determination within 120 days of the date she received the MSN in the mail
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.
Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her?
Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers.
Mrs. Schmidt is moving and a friend told her she might qualify for a “Special Election Period” to enroll in a new Medicare Advantage plan. She contacted you to ask what a Special Election Period is. What could you tell her?
It is a time period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically the Special Election Period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area.
Mrs. Quinn has just turned 65, is in excellent health, and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. 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, 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. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can go to for her health care. What should you tell her?
Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will have a higher cost-sharing amount if she sees a provider who/that is not part of the PPO network.
Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do?
He will have to enroll in Part B.
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 and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.
Mrs. McIntire is enrolled in her state’s Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen with respect 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.
Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application prior the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams?
This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form prior to the start of the AEP.
Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same requirements as the plans themselves. How should you respond to such a statement?
Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules.
Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her?
Marketing representatives may initiate electronic contact through e-mail but the subject line must say “marketing” and an opt-out process must be provided.
During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her?
Tell her that the Medicare agency does not endorse or recommend any plan.
Ms. Lewis understands that Medicare prescription drug plans may use various methods to control the use of specific drugs. She has heard about a technique called “step therapy” and is wondering if you can explain what that is. What should you tell her?
Step therapy involves using one or more lower priced drugs before trying a more expensive drug when all are used to treat the same condition.
Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?
Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him?
He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B.
You will be holding a sales event soon, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation?
Gift cards or gift certificates of $15 or less that can be readily converted to cash.
Juan Hernandez is turning 65 next month, Juan legally entered the United States over twenty years ago but is not a citizen. Since his entry into the country, Juan has worked at Smallcap Incorporated and contributed to the Medicare system. Juan 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?
Juan is eligible to enroll in a Medicare Advantage as long as he is entitled to Part A and enrolled in Part B. Juan 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. Morris will turn 65 on June 10th. She has never previously qualified for Medicare. She is entitled to Medicare Part A and intends to enroll in Part B. She wants to know if she is eligible to enroll in a Medicare Advantage plan that includes prescription drug coverage. What do you tell her?
Ms. Morris can enroll in an MA-PD plan now since her initial election period (IEP) for Part D prescription drug coverage and initial coverage period are occurring together beginning March 1st and ending September 30th.