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  1. Final Exam - Attempt 2 - one wrong answer - not sure which one - From Sally of Bangor - very trusted Question1 Marks: 1 Mr. Wilcox has been enrolled in Lexington PFFS Medicare Advantage Health Plan (Lexington) for several years. Recently, Mr. Wilcox decided to spend time with his children who live in another state that is not in Lexington's service area. In the future, he may relocate near his children permanently. How does this move to another service area impact his PFFS MA coverage? Choose one answer. a. Lexington can allow for Mr. Wilcox’s continued enrollment for up to 12 months whether or not he is in a visitor/traveler (V/T) program. Question2 Marks: 1 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? Choose one answer. 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. Question3 Marks: 1 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? Choose one answer. b. The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4-stars. Question4 Marks: 1 Mr. Lopez takes several high-cost prescription drugs. He would like to enroll in a standalone Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan can he enroll? Choose one answer. c. Private Fee-for-Service (PFFS) plan that does not include drug coverage. Question5 Marks: 1 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? Choose one answer. b. Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig’s disease so she will be eligible for Medicare. Question6 Marks: 1 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? Choose one answer. b. Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program. Question7 Marks: 1 Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him? Choose one answer. a. 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. Question8 Marks: 1 Mr. Chen has heard about a Medical Savings Account (MSA), but wants to know if it is just about saving money, or if he will get insurance coverage for his health care expenditures as well. What should you tell him? Choose one answer. c. Under the Medicare Advantage program, a MSA plan involves the combination of a high deductible health plan and a savings account for health expenses. Medicare will make contributions to this savings account to help him pay his health care expenses while in the deductible. Question9 Marks: 1 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? Choose one answer. c. Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime. Question10 Marks: 1 Able, Baker, and Charles are engaged in the marketing to and enrollment of beneficiaries into Medicare health plans. Mr. Able is an independent agent paid directly by a health plan. Ms. Baker is an independent agent paid through a field marketing organization (FMO). Mr. Charles is an independent agent paid for his work by a third-party marketing organization (TMO). How do the CMS compensation rules apply to these three agents? Choose one answer. c. All three are treated as independent agents under CMS compensation rules. Question11 Marks: 1 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? Choose one answer. b. 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. Question12 Marks: 1 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? Choose one answer. c. He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Question13 Marks: 1 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? Choose one answer. b. 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. Question14 Marks: 1 Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales presentation? Choose one answer. c. A meal cannot be provided, but light snacks would be permitted. Question15 Marks: 1 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? Choose one answer. 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. Question16 Marks: 1 Ms. Lopez is an independent agent under contract with MarketCo, a third-party marketing organization. MarketCo has a contract with BestCare health plan, a Medicare Advantage (MA) organization, to offer marketing services through its contracted agents and agencies. Ms. Lopez returns calls to individuals who contact MarketCo in response to its mailers promoting BestCare health plan. Which of the following best describes the responsibilities of Ms. Lopez? Choose one answer. b. Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. Question17 Marks: 1 If a beneficiary is enrolled in a stand-alone prescription drug plan and wants to keep that plan, what type of Medicare health plan could the individual also enroll in, without being automatically disenrolled from the stand-alone prescription drug plan? Choose one answer. d. The beneficiary could enroll in a private fee-for-service (PFFS) plan that does not include prescription drug coverage; an 1876 cost plan; or a Medicare Medical Savings Account (MSA) plan Question18 Marks: 1 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? Choose one answer. d. You may go ahead and call them. Question19 Marks: 1 Mr. Jenkins is interested in enrolling in a Medicare cost plan and has sought your advice. What would you tell him? Choose one answer. d. Cost plans are required to be open to enrollment at least 30 days per year, and many are open for enrollment all year. So open enrollment will be dependent on the plan he chooses. Question20 Marks: 1 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? Choose one answer. a. She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. Question21 Marks: 1 Mrs. Sanchez lives in a state located near Canada. She has recently become eligible for Medicare and is considering enrollment in Part D prescription drug coverage. One of her friends has told her that she needs to be aware of something called TrOOP. What should you tell her when she asks you about TrOOP? Choose one answer. c. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include the annual deductible(s) and costs for drugs on the plan's formulary purchased at a plan's participating pharmacy. In some instances, amounts not directly paid by the enrollee (like manufacturer discounts) count toward TrOOP. Question22 Marks: 1 Agent Willis had several clients who disenrolled from the plans he represents during the AEP to try new Medicare Advantage plans. Agent Willis believes that the choices they made are not ideal for them and would like to get their business back during the Medicare Advantage Open Enrollment Period (MA-OEP). What can agent Willis do? Choose one answer. c. He can wait until October and send them information about the plans he represents. Question23 Marks: 1 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? Choose one answer. d. Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. Question24 Marks: 1 Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him? Choose one answer. a. 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. Question25 Marks: 1 Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him? Choose one answer. c. He is eligible for the Part D prescription drug benefit because he is entitled to Part A and he does not have to be enrolled in Part B. Question26 Marks: 1 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? Choose one answer. c. D-SNP Question27 Marks: 1 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? Choose one answer. d. You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if his doctor will accept the terms and conditions of payment of the PFFS plan Question28 Marks: 1 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? Choose one answer. c. The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. Question29 Marks: 1 Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband’s employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her? Choose one answer. d. If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. Question30 Marks: 1 This year you decide to focus your efforts on marketing to employer and union groups. Which of the following statements best describes what you can and cannot do in order to stay in compliance? Choose one answer. b. You are not required to submit communication and marketing materials specific only to those employer plans to CMS at the time of use, but CMS may request and review copies if employee complaints occur. Question31 Marks: 1 Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him? Choose one answer. b. Formularies must be developed with input from pharmacists, doctors, and other experts. Question32 Marks: 1 Ms. Hernandez has marketed several different types of insurance products in her home state and has typically sought approval of her materials from her State Department of Insurance. What would you advise her regarding seeking such approval for materials she uses to market Medicare Advantage plans? Choose one answer. a. Materials for marketing Medicare health plans to individuals are subject to Medicare’s uniform national requirements. They do not need to be reviewed by the state, but the company she represents must obtain approval from the Medicare agency (CMS) for any materials she uses. Question33 Marks: 1 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? Choose one answer. a. 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. Question34 Marks: 1 Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable income only sporadically. Her husband worked full-time throughout his long career. She has heard that to qualify for Medicare Part A she has to have worked and paid Medicare taxes for a sufficient time. What should you tell her? Choose one answer. a. Since her husband paid Medicare taxes during the entire time he was working, she will automatically qualify for Medicare Part A without having to pay any premiums. Question35 Marks: 1 Ms. Gardner is currently enrolled in an MA-PD plan. However, she wants to disenroll from the MA-PD plan and instead enroll in a Part D only plan and go back to Original Medicare. According to Medicare's enrollment guidelines, when could she do this? Choose one answer. c. She may make such a change during the Annual Election Period that runs from Oct. 15 to December 7, or during the MA Open Enrollment Period which takes place from January 1- March 31 of each year (beginning in 2019). Question36 Marks: 1 Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a meeting so that she can learn about Medicare and the products you represent. How should you respond? Choose one answer. d. Tell Julia that you will meet with her to explain Medicare and should she be interested you can accept and submit an enrollment request, since this is an initial enrollment qualifying her for a special enrollment period. Question37 Marks: 1 Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage (MA) health plans. This year she has decided to focus on non-MA products. What advice would you give Melanie if she wishes to continue to receive renewal fees? Choose one answer. c. Melanie must remain trained, tested, licensed, and appointed, regardless of whether she is actively selling MA products. Question38 Marks: 1 Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her area. Ms. Levi often travels to visit relatives and is concerned that she may need emergency care outside of her plan’s service area. What should you tell her about coverage of emergency care? Choose one answer. d. Plans are required to cover out-of-network emergency care. Question39 Marks: 1 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? Choose one answer. a. The neighbors may not provide a meal, but light snacks would be permitted. Question40 Marks: 1 Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to you for advice as to what options, if any, she has. What should you say regarding special enrollment periods (SEPs)? Choose one answer. d. Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the five-star plan. Question41 Marks: 1 Mr. Decaro has looked at Medicare prescription drug plans available in his area and noted a wide range in premiums. He thought that all the drug plans were required to offer the same standard benefits and would like you to explain why there is such a range in premiums. What should you tell him? Choose one answer. d. Some prescription drug plans may have higher operating costs and/or may offer enhanced coverage in return for an additional premium amount. He could look at plan designs to see if one of the enhanced plans would serve his needs better than a plan based on the standard design. Question42 Marks: 1 Mr. James has end-stage renal disease (ESRD). He has been covered under Original Medicare but would like to know if he can enroll in a Medicare Advantage plan. What should you tell him? Choose one answer. d. He will not be able to enroll in a Medicare Advantage plan because he has end-stage renal disease unless a special needs plan for beneficiaries with ESRD is available in his service area. Question43 Marks: 1 You are doing a sales presentation for Ms. Duarte and her son. Ms. Duarte has some cognitive impairment and her son informs you that he has power of attorney to make financial decisions for her. Can he execute the enrollment for her? Choose one answer. c. No, he cannot execute the enrollment for her. He must have a legal authorization, under state law that explicitly allows him to make health care decisions for his mother. Question44 Marks: 1 Mr. Landry is approaching his 65th birthday. He has signed up for Medicare Part A, but he did not enroll in Part B because he has employer-sponsored coverage and intends to keep working for several more years. But he is considering enrolling in Part D prescription drug coverage because he believes it is superior to his employer plan. How would you advise him? Choose one answer. a. Mr. Landry is eligible for Part D since he has Part A, and his initial enrollment period (IEP) for Part D will continue for three months after his 65th birthday. Question45 Marks: 1 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 and she is considered a dual eligible. Will gaining eligibility for this program affect her ability to enroll in a Medicare Advantage or Medicare Prescription Drug plan? Choose one answer. a. Yes. Qualifying for this state program gives Mrs. Schneider access to a Special Enrollment Period that allows her to make changes to her MA and/or Part D enrollment during the first 9 months of each calendar year beginning in 2019. Question46 Marks: 1 Mr. Wong is a single individual. He has had a successful business career and is now able to retire with a comfortable income. Mr. Wong's taxable income is in excess of $100,000. Mr. Wong has health coverage through his employer but will sign-up Medicare Part A, Part B and Part D when he leaves the workforce. How would you advise him as he budgets for Medicare premiums? Choose one answer. b. Due to his participation in the workforce he will not have to pay premiums for Part A but he will pay higher premiums for Part B and Part D due to the amount of his income. Question47 Marks: 1 Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is interested in that product. She wants to be sure she also has coverage for prescription drugs. Would she be able to obtain drug coverage if she enrolled in the SNP? Choose one answer. b. Yes. All SNPs are required to provide Part D coverage for prescription drugs. Question48 Marks: 1 Who is most likely to be eligible to enroll in a Part D prescription drug plan? Choose one answer. b. Ms. Davis who recently turned age 65 and is eligible for Part A and has just enrolled in Part B. . Question49 Marks: 1 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? Choose one answer. b. You may correct this information as long as you add your initials and date next to the correction . Question50 Marks: 1 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? Choose one answer. c. 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.
  2. at the top right of www.naaip.org it states Login.. as well at the bottom of your site.. in very small it has button member login
  3. We do have that 6 day per week conference call. If you are so busy to set up your business - will you be too busy to do your business.We can talk. Conference Call: Weekdays Noon & Sundays 2pm ET Dial (888)532-9320 - No Pin needed
  4. Hello Agent, For the longest time I have been shouting from the rooftop that agents should: 1. Seek out the highest possible commissions. 2. Figure out a lead system that works and then cut out the middleman/vendor. Let's talk leads. Here, I created a page that could be considered the Wikipedia of insurance agent lead generation. I am constantly adding more information and links. Join our daily conference call for an in-depth discussion on this topic. I have learned the following vis-à-vis insurance agent leads. 1. Direct mail postcards and now Facebook leads are the primary lead source for a very high percentage of agents. 2. The postcard companies will sell you 1,000 postcards for $450-$500. Obviously, if postcards are a major part of your business you should print them yourself and send from the local post office. 3. Facebook leads are much more complicated to set up for many agents. Facebook lead vendors are selling each FB lead from $20 to $25. Doing it yourself will have Facebook leads be between $4 and $8. This is a huge savings. 4. To drum up business for our favorite FEX and Annuity Carrier which is Oxford Life - I will personally set up your Facebook account for you with your credit card. At a certain point, I will hand over the account back to you with instructions to press On to Activate the leads and Off and Deactivate. Very simple. In order for me to be intimately involved in your business, I need you to sell Oxford Life. Last month's newsletter explained why Oxford Life is my favorite carrier, notwithstanding super-high compensation. I expect to be overloaded with work setting up Facebook advertising accounts for NAAIP/Oxford Life agents. Join our daily conference call for detailed discussion and sell lots of Oxford Life policies so I can put you at the top of the list. It should be noted that I put back the 5 links of iPipeline at the footer of NAAIP.org and this email. Many of the other 75 carriers that we contract agents for at the absolute highest commission are accessible via those 5 iPipeline links. Please register and be familiar with iPipeline.
  5. First set up your own websites well. Join our daily conference call if you need help. You can use your proficiency in setting things up to recruit other agents. NAAIP will protect you and your downline.
  6. Let's keep this simple. 1. I need you to know and sell www.naaip.org/oxford-life Oxford has three products that are superior to anything in the market-place. a. Final Expense - Super low rates - Point of Sale acceptance - simple application and then Point of Sale (POS) w/ InstaWrite - You will input the name, social security and dob (over phone or online) and get a Accept/Decline in 7 Seconds. Wow! Know this product - Oxford Life is our Flagship Product - Super High Compensation! b. Annuities - Among best payouts in industry on Fixed annuities (MYGA). Lifetime income, Indexed Annuities are superb. We offer recruiter level compensation to you. We want you to sell Oxford. c. Single Premium Whole Life (SPWL). Point of Sale (POS) w/ InstaWrite - Accept/Decline in 7 Seconds. 2. I need you to register for www.naaip.org/dental-plans (also offering discount health plans), and then place on your enrollment link on your NAAIP website. When you first signed up, this was the one product that we placed at the bottom of your site. Many of you hid via banners & hyperlinks. Others took our advice and are earning beau-coup bucks since this is virtually the only product I have seen that sells itself. Visitors will buy while you sleep. I created a Youtube video showing you the steps you need to do to make this work. https://youtu.be/ZhVXikKm_Iw 3. I see that you not properly hosting your domain name with NAAIP. It looks like you attempted to do so at the bottom of Profile Settings in your back office. - I see here - and here - As you know we placed advertisements after 50 hits, to hide the ads you can sell either oxford-life or dental-plans, or refer others to do so. The alternative is to input your credit card/paypal for 99 cents first month and 9.99 afterwards. Go to this page for instructions to properly host Scroll down and you will see step one and two and a 3 minute video. Watch it. If you still cannot figure out just send me your user name and pw from godaddy. Website News 1. We placed your office map at the bottom of every NAAIP site and on your contact page. If you see that it does not look good/showing world map please go into your back office and edit your address / hide the map. Map settings is the 19th button down on the left side. 2. Those that are using our i-frame Stand-alone Med Sup & Term Life Quoters should slightly change the code. Remove the .php - your site will upload faster. 3. We now have a i-frame Stand-alone Auto Insurance Quoter - See the code in NAAIP back office. 4. Within a week we will have a data-capture forms and stand-alone iframe for additional insurances such as homeowners, motorcycle, rental, health, business, etc. 5. We have pretty-much solved the spam issue from your contact form. Lots of brain power went into this issue. 6. Within six weeks we will have a Living Will / Last Will & Testament on every NAAIP site. It is a huge project that will make your site more valuable. 7. We are in the process of being a more traditional IMO/FMO - So I had to hide the commission grid from the online. The compensation grid will now be accessible from your NAAIP back office. Thank you for giving me the opportunity to help you earn more money.
  7. Aetna Supplemental does not require e and o. Silverscript agents are required to complete an Aetna MAPD contract now and they do not need to submit E&O through the new Aetna callidus system either.
  8. Test 2 and 3 are 100% accurate. I do know that all three are guided by CMS compensation rules in the same manner..
  9. Edward, Test 2 is 100% accurate while Test 1 has one wrong answer and one that I am not sure about. I assume test 2 answer is right. As well, test 3 has one wrong answer. Please comment.. before I make the changes by editing the results. You found the one wrong answer on TEST 3. Congratulations. I will edit the test and now write the that Test 3 is 100% accurate. Can you review test 1 and answer that one debatable question and find the other wrong answer.
  10. AHIP TEST 3 2020 Judy from Nevada was kind enough to give us her 50 questions on her AHIP Test. Judy got one answer out of 50. Let’s find that one wrong answer for her. Hi David, Attached is my Ahip test for you to review and shared in the forum, i got only 98%, don't know which is the wrong answer. Best wishes, Judy We found the one wrong answer - It was question 46. I edited your answer and now the answers showing are 100% correct. David Question 1. Richard is a licensed agent who represents Spartan Health Plan and its Medicare Advantage (MA) plans. Richard has several clients who have recently come to him for help who are in their initial coverage election period (ICEP) and are interested in enrolling in one of Spartan Health Plan's MA plans. Alice will soon turn 65 and retire. Alice has coverage through Spartan Health Plan offered by her employer. Bob had health coverage through Spartan but dropped the coverage when he retired early to travel overseas. Bob, who has just turned age 65, is now back in the United States. Charlotte, who will turn 65 next month, has coverage through Athena Health plan – a company Richard also represents. Who qualifies for the opt-in simplified enrollment mechanism? a. Alice, Bob, and Charlotte because electronic health record interoperability will allow Richard to access any needed information for their applications. b. Alice and Bob because each of them has had coverage through Spartan Health Plan. c. Alice because she will not have a break between her non-Medicare and Medicare coverage through Spartan Health Plan. d. Alice and Charlotte because each of them currently have health coverage and is in their initial coverage election period (ICEP). Answer: C. Alice because she will not have a break between her non-Medicare and Medicare coverage through Spartan Health Plan. Question 2. Ms. Bushman has two homes in different states and is concerned about restrictions on where she can get her medications. What should you tell her? a. Part D prescription drug plans are restricted to local service areas. She will have to use mail order to fill all of her prescriptions. b. Part D prescription drug plans use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states. c. Part D prescription drug plans generally contract with every pharmacy in the country, so she should be able to obtain her drugs in both states with no problem. Answer: B. Part D prescription drug plans use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states. Question 3. 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 30 days after she submits the application form, so she should not expect the coverage to begin until after she leaves. b. Coverage always begins on the first of July, or the first of January after a beneficiary enrolls, whichever comes first. c. Typically, coverage is effective on the date that the beneficiary completes the application form, so her coverage will be in place before she leaves. d. 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. Answer: d. 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. Question 4: 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? a. 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. b. SNPs offer care from any doctor or hospital Mr. Sinclair would like to use and his costs will always be lower than in Original Medicare. c. Since SNPs don’t cover prescription drugs Mr. Sinclair should consider a different option. d. SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. Answer: a. 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 Question 5. 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? a. Winthrop Brokerage does not need to submit the advertisement to CMS for prior approval and may also include in the advertisement information about the plans’ benefit structures and star rankings. 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. c. Winthrop Brokerage must submit the advertisement to CMS for prior approval because it is considered general audience marketing. d. Winthrop Brokerage must submit the advertisement to CMS for prior approval because it meets the definition of marketing material. Answer: 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. Question 6. Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to you for advice as to what options, if any, she has. What should you say regarding special enrollment periods (SEPs)? a. Mrs. Wellington must first enroll in a standalone PDP before she is eligible for a SEP to enroll in the MA five-star plan. b. Mrs. Wellington can enroll in the five-star plan in the following October, when the next annual enrollment period (AEP) begins – not before. c. Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the five-star plan. d. Mrs. Wellington is eligible for a two- month SEP that began on January 1, so she should act quickly if she wishes to enroll in the MA five-star plan. Answer: c. Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the five-star plan. Question 7. 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? a. Step therapy refers to incentives plans can provide to enrollees to engage in regular walking in order to reduce their need for medications treating heart and cholesterol problems. b. 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. c. Step therapy involves slow changes in the dosages of a given drug in order to discover the correct amount. d. Step therapy involves taking somewhat larger doses but skipping every other day, resulting in lower overall consumption of the drug. Answer: b. 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. Question 8. 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? a. PFFS plans are the same as Medicare supplement plans and he may obtain care from any provider in the U.S. b. If offered, beneficiaries can select a stand-alone Part D prescription drug plan (PDP) with an HMO or a PPO, but not with a PFFS plan. c. If a PFFS enrollee shows his/her card when obtaining services from a provider who participates in Original Medicare, then that provider is required to accept the plan’s terms and conditions. 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. Answer: 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. Question 9. 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 a MA-PD plan. What enrollment rules would apply in this case? a. He should wait for at least six months into the plan year to be sure that he really wants to make the change. If he still wants to do so, he can make any sort of change he likes at that point. b. He can return to Original Medicare, but must then enroll in a Medicare Part D plan. c. 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. d. He can only make a single enrollment change during the Annual Election Period, so he will not be able to change his enrollment. Answer: c. 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. Question 10. This year you decide to focus your efforts on marketing to employer and union groups. Which of the following statements best describes what you can and cannot do in order to stay in compliance? a. You do not need to take an annual test, but you must not provide potential enrollees with more than light snacks at presentations b. You do not need to complete a scope of appointment, but CMS can ask you to reconstruct one if there is a subsequent employee complaint. C. You can make unsolicited contacts but you cannot cross-sell other products. d. You are not required to submit communication and marketing materials specific only to those employer plans to CMS at the time of use, but CMS may request and review copies if employee complaints occur. Answer: d. You are not required to submit communication and marketing materials specific only to those employer plans to CMS at the time of use, but CMS may request and review copies if employee complaints occur. Question 11. 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. As long as the meal is paid for by another person or entity, you are permitted to invite your clients and their friends to partake of the meal at your sales presentation. b. You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. c. You may offer meals to existing enrollees of the plan(s) you represent, but potential enrollees may not have a meal. d. There is no limitation on meals. You may continue to provide your Thanksgiving style meal, to any individual, in any manner you see fit. Answer: b. You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. Question 12. Mr. Chen has heard about a Medical Savings Account (MSA), but wants to know if it is just about saving money, or if he will get insurance coverage for his health care expenditures as well. What should you tell him? a. Under the Medicare Advantage program, the MSA is funded by money he sets aside each year. If he does not use it all on IRS allowable health care expenditures then he will lose the money the following year. b. Under the Medicare Advantage program, the MSA plan is a form of prescription drug coverage. c. Under the Medicare Advantage program, the MSA is only an account to help him pay for IRS-allowed health expenditures he may have. It does not involve health insurance of any kind. d. Under the Medicare Advantage program, a MSA plan involves the combination of a high deductible health plan and a savings account for health expenses. Medicare will make contributions to this savings account to help him pay his health care expenses while in the deductible. Answer: d. Under the Medicare Advantage program, a MSA plan involves the combination of a high deductible health plan and a savings account for health expenses. Medicare will make contributions to this savings account to help him pay his health care expenses while in the deductible. Question 13. Mr. Lopez takes several high-cost prescription drugs. He would like to enroll in a standalone Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan can he enroll? a. Medicare Advantage (MA) HMO-POS plan that does not include drug coverage. b. Medicare Advantage (MA) PPO that does not include drug coverage. c. Medicare Advantage (MA) HMO that does not include drug coverage. d. Private Fee-for-Service (PFFS) plan that does not include drug coverage. Answer: d. Private Fee-for-Service (PFFS) plan that does not include drug coverage Question 14. You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA) plans you represent. Before you conduct such sales presentations, what must you do? a. There is no special action that you must take. If they choose, you may go to an individual’s house to provide presentations and offer assistance with enrolling in a plan. b. You must first contact the Medicare agency to ensure that the individual is actually a Medicare beneficiary. c. A proper introduction at the door that includes a disclaimer regarding your relationship with the plan you represent is the only required action you must take, prior to entering the beneficiary’s home. d. You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in-home presentation. Answer: d. You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in-home presentation. Question 15. 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? a. 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. b. You could tell her she was right, but new rules will require her to take the training and pass the test at least every other year. c. You could tell her she is wrong and that only agents employed by the plans are exempt from training and testing requirements. d. You could tell her she is right and ask if you could get a contract with the TMO too. Answer: a. 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. Question 16. Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him? a. The extra help is available only to Medicare beneficiaries who are enrolled in Medicaid. He should apply for coverage under his state’s Medicaid program to access the extra help with his drug costs. b. He must apply for the extra help at the same time he applies for enrollment in a Part D plan. If he missed this opportunity, he will not be able to apply for the extra help again until the next annual enrollment period. c. The government pays a per-beneficiary dollar amount to the Medicare Part D prescription drug plans, to offset premiums for their low-income enrollees in accordance with the plan’s set criteria. Mr. Shapiro should check with his plan to see if he qualifies. d. The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Answer: d. The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Question 17. 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? a. All costs not covered by Medicare are covered by some Medigap plans. b. If Mrs. Paterson applies during the Medigap open enrollment period, she will have to undergo a medical review to determine if she has a pre-existing condition that would increase the premium for a Medigap policy. c. Medigap plans are not sold by private companies and are a government insurance product. d. Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. Answer d. Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. Question 18. Mr. James has end-stage renal disease (ESRD). He has been covered under Original Medicare but would like to know if he can enroll in a Medicare Advantage plan. What should you tell him? a. Individuals with end-stage renal disease may enroll in a Medicare Advantage plan, but only if they are willing to pay an extra premium to do so. b. Individuals with end-stage renal disease can only enroll in a Medicare Advantage plan after they have been on dialysis for 12 months. c. Individuals with end-stage renal disease can enroll in any Medicare Advantage plan that they choose without paying an extra premium. d. He will not be able to enroll in a Medicare Advantage plan because he has end-stage renal disease unless a special needs plan for beneficiaries with ESRD is available in his service area. Answer: d. He will not be able to enroll in a Medicare Advantage plan because he has end-stage renal disease unless a special needs plan for beneficiaries with ESRD is available in his service area. Question 19. Which of the following statements is correct about the appeal and grievance processes? I. Enrollees have a right to obtain a review (appeal) of certain decisions about prescription drug coverage. II. The grievance process is used for reviews of coverage decisions on plan benefits. III. Plans must provide a link to the Medicare.gov website where an enrollee can enter a complaint. IV. Enrollees have a right to file complaints (sometimes called grievances) about the quality of their care. Answer: will be b. I, III, and IV only Question 20. Ms. Jensen has heard about “Original Fee-for-Service Medicare” and “Private Fee-for-Service” plans. She wants to know what the difference is, if any. What should you tell her? a. PFFS plans primarily cover drugs that Original FFS Medicare does not cover. b. Original Medicare and PFFS plans are essentially the same thing. c. PFFS plans are a type of Medicare Advantage plan offered by private companies. d. PFFS is a form of supplemental coverage that fills in the gaps where Original Medicare leaves off. Answer: c. PFFS plans are a type of Medicare Advantage plan offered by private companies. Question 21. 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? a. The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval. b. The government bases its payments to Part D plans on the standard benefit model. For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries. c. The Part D standard model’s importance is that it is the only type of plan into which low-income beneficiaries can enroll and still receive any extra help for which they may qualify. d. 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. Answer: d. 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. Question 22. Mr. Polanski likes the cost of an HMO plan available in his area, but would like to be able to visit one or two doctors who aren’t participating providers. He wants to know if the Point of Service (POS) option available with some HMOs will be of any help in this situation. What should you tell him? a. The POS option refers to a method of processing claims in real time so that Mr. Polanski will be able to finalize his bill at the point of service with the provider, rather than waiting for the plan to mail him statements several weeks later. It does not have anything to do with his ability to access out-of-network providers. b. The POS option might be a good solution for him as it will allow him to visit out-of-network providers, generally without prior approval. However, he should be aware that it is likely he will have to pay higher cost- sharing for services from out-of-network providers. c. The POS option is only to allow him to visit in-network specialists without a referral. He will have no coverage if he goes out-of-network. d. The POS option will allow him to visit out-of-network providers and generally the plan must provide the same level of cost sharing as if he went to in-network providers. Answer: b. The POS option might be a good solution for him as it will allow him to visit out-of-network providers, generally without prior approval. However, he should be aware that it is likely he will have to pay higher cost- sharing for services from out-of-network providers. Question 23. Mr.Chan is one of your clients and in excellent health. He is enrolled in a Medicare prescription drug plan that you represent. He recently heard about a Medication Therapy Management (MTM) program in which his friend is enrolled. What should you tell him? a. To be eligible for a MTM program, a Medicare beneficiary must suffer from at least one chronic disease, such as asthma, and be likely to incur considerable drug costs. b. A MTM program is an excellent choice for someone taking very few prescription drugs such as Mr. Chan. c. A MTM program is available to all Medicare Part D enrollees who seek help in selecting the prescription drugs most appropriate to their needs. d. To be eligible for a MTM program, a Medicare beneficiary must have multiple chronic diseases, be taking multiple Part D prescription drugs, and likely to incur considerable drug costs. Answer: d. To be eligible for a MTM program, a Medicare beneficiary must have multiple chronic diseases, be taking multiple Part D prescription drugs, and likely to incur considerable drug costs. Question 24. Ms. Lopez is an independent agent under contract with MarketCo, a third-party marketing organization. MarketCo has a contract with BestCare health plan, a Medicare Advantage (MA) organization, to offer marketing services through its contracted agents and agencies. Ms. Lopez returns calls to individuals who contact MarketCo in response to its mailers promoting BestCare health plan. Which of the following best describes the responsibilities of Ms. Lopez? a. Ms. Lopez needs to maintain state licensure, but because she is working for a third-party marketing organization she is exempt from CMS training requirements that apply to BestCare captive agents. b. Ms. Lopez no longer needs to be concerned about state licensure since she is marketing an MA product subject to federal rules. c. Ms. Lopez is considered a marketing representative of BestCare but is exempt from the marketing rules regarding approved call scripts because she works directly for MarketCo. d. Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. Answer: d. Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. Question 25. Mr. Landry is approaching his 65th birthday. He has signed up for Medicare Part A, but he did not enroll in Part B because he has employer- sponsored coverage and intends to keep working for several more years. But he is considering enrolling in Part D prescription drug coverage because he believes it is superior to his employer plan. How would you advise him? a. Mr. Landry must enroll in Part B to enroll in Part D, but his initial enrollment period for Part B lapsed when he enrolled in Part A. b. Mr. Landry must enroll in Part B to enroll in Part D, and he still has time to do so. c. Mr. Landry is eligible for Part D since he has Part A, and his initial enrollment period (IEP) for Part D will continue for three months after his 65th birthday. d. Mr. Landry must wait until the next annual open enrollment period because his initial enrollment period for Part D lapsed when he enrolled in Part A Answer: c. Mr. Landry is eligible for Part D since he has Part A, and his initial enrollment period (IEP) for Part D will continue for three months after his 65th birthday. Question 26. 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? a. 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. b. All individuals who are citizens and over age 65 will be covered under Part A. c. Most individuals who are citizens and over age 65 and are covered under Part A must pay a monthly premium for that coverage. d. Most individuals who are citizens and over age 65 and wish to be covered under Part A must enroll in a Medicare Health Plan. Answer: a. 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. Question 27. 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? A. He will not be able to enroll in Part D unless he decides to also enroll in a Medicare Advantage plan. B. He will incur a one-time financial penalty equal to 30 percent of the annual Part D premium. C. He will avoid any financial penalty or late enrollment fee under the grandfathering provisions of Medicare Part D. D. He will incur a late enrollment penalty. Answer: d. He will incur a late enrollment penalty. Question 28. Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard? a. Asking health questions to determine whether Mr. Ryan would be eligible to enroll in an SNP because he has a chronic condition. a. Discouraging Mrs. Johnson from enrolling in a Medicare Advantage plan that does not service her area. b. 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. c. Setting an appointment with Mrs. McLaughlin without first asking about her financial health to determine whether she can afford a plan offering Willard the best commission. Answer: c. 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. Question 29: 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? a. Medicaid will cover his cost-sharing, regardless of from which physician or hospital he receives his Medicare-covered services. b. He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers. c. Medicaid will no longer pay any cost sharing once he is eligible for Medicare, so he will need to rely only on Medicare providers. d. For Medicaid beneficiaries, Medicare reduces its cost-sharing amounts to match those charged by the state Medicaid program so there will be no change in his cost-sharing amounts. Answer: b. He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers. Question 30. Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales presentation? a. Nothing may be provided to eat or drink during the sales presentation. b. Any meal is allowed, as long as it is valued at less than $15. c. Any type of meal or food is allowed, as long as it is available to the general public and not just those who are eligible to enroll in the plans. d. A meal cannot be provided, but light snacks would be permitted. Answer: d. A meal cannot be provided, but light snacks would be permitted. Question 31. 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? a. 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. b. MSA enrollees may only receive covered health care services from a limited panel of network providers because otherwise some providers may charge more than Original Medicare rates. c. All beneficiaries enrolled in an MSA pay a plan premium in addition to their Part B premium. d. For enrollees in an MSA, after the annual deductible is met, the MSA plan generally pays 75% of covered services. Answer: a. 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. Question 32. 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. D-SNP b. I-SNP c. C-SNP d. FIDE-SNP Answer: c. C-SNP Question 33. Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation rules apply to this situation? a. When an MSA Medicare health plan is combined with a PDP, initial and renewal year(s) compensation is paid only for the MSA enrollment in order to recompense CMS for contributions made to the enrollee’s MSA account. b. Regular CMS and renewal compensation rules apply to the PDP enrollment, but compensation is limited to $100 for the MSA health plan enrollment in order to recompense CMS for contributions made to the enrollee’s MSA account. c. This situation is considered a “dual enrollment,” and CMS compensation rules are applied to the two plans at once and independently of each other. d. MSA Medicare health plans are subject to special rules limiting initial year compensation to 50 percent of the fair market value (FMV) published annually by CMS. Regular initial year enrollment rules apply to the PDP. Answer: c. This situation is considered a “dual enrollment,” and CMS compensation rules are applied to the two plans at once and independently of each other. Question 34. 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? a. Agent Lopez’s compensation is not impacted because Ralph’s disenrollment occurred more than 30 days after the effective date of coverage. b. Agent Lopez is entitled to a pro rata amount of the compensation earned including the full amount for the month of February. c. Agent Lopez’s entire compensation must be recouped because Ralph disenrolled within 3 months of enrollment. d. Agent Lopez’s compensation is not impacted because Ralph’s disenrollment occurred after the Annual Open Enrollment Period. Answer: c. Agent Lopez’s entire compensation must be recouped because Ralph disenrolled within 3 months of enrollment. Question 35. 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. She currently does not have creditable coverage. What could you tell her about the implications of such a decision? a. a. If she does not sign up for a Medicare prescription drug plan, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications. b. 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, she will have to pay a one-time penalty equal to 10% of the annual premium amount. c. 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, she will be required to pay a higher premium during the first year that she is enrolled in the Medicare prescription drug program. After that point, her premium will return to the normal amount. d. 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. Answer: d. 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. Question 36. 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? a. The card is indeed a forgery since all identity cards are being phased out in favor of a new electronic identity system developed by the Social Security Administration. b. The card she received is valid but she should keep her old card for at least two years and present it whenever she receives health care. c. The card is indeed a forgery since newly issued Medicare cards will have both a beneficiary’s Social Security number and date of birth imprinted on them. d. 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. Answer d. 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. Question 37. 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? a. 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. b. Mrs. Disraeli would have substantial restrictions on obtaining emergency care and must use network facilities or be responsible for most emergency care costs. c. The SNP would select her primary care provider (PCP) but she could file a grievance within 90 days if the PCP proved incapable. d. Enrollees, while able to select their primary care provider (PCP), do have substantial restrictions and financial responsibilities regarding emergency care whether obtained at in-network or out-of-network facilities. Answer: a. 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. Question 38. Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable income only sporadically. Her husband worked full-time throughout his long career. She has heard that to qualify for Medicare Part A she has to have worked and paid Medicare taxes for a sufficient time. What should you tell her? a. Since her husband paid Medicare taxes during the entire time he was working, she will automatically qualify for Medicare Part A without having to pay any premiums. b. She will have to pay the monthly Part A premium in order to obtain the coverage. c. Because her husband paid Medicare taxes, and she rarely did, she will have to pay Part A premiums but will do so at a reduced rate. d. She will have to obtain a job and work enough years to qualify for Medicare Part A. Answer: a. Since her husband paid Medicare taxes during the entire time he was working, she will automatically qualify for Medicare Part A without having to pay any premiums. Question 39. 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? a. The state sets most requirements for marketing Medicare health plans, but each plan has different policies that he must adhere to. b. The Medicare agency conducts only complaint-based oversight and he can market the products he represents as he sees fit, as long as he does so in a manner that would be considered ethical by a reasonable lay person. c. Organizations sponsoring Medicare health plans are not responsible for enforcing compliance with applicable law and guidance. This job belongs solely to the Medicare agency. 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. Answer: 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. Question 40. 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)? a. She is unlikely to qualify for a SEP but will be automatically covered by Original Medicare and a standalone Part D prescription drug plan. b. She is unlikely to qualify for a SEP and should remain on her current plan, relying on her current plan’s out-of-network benefits. c. She is likely to qualify for a SEP. She can choose an effective date of up to six months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than 30 days prior to the date of her move. d. 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. Answer: d. 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. Question 41. 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 the next steps in the enrollment process? a. You need to get Mr. West’s phone number and include it on the enrollment form because the PFFS plan will contact him once the organization receives the enrollment form and will ask about the quality of your service. You should not discuss the phone call with Mr. West to avoid influencing his answers. b. You should not include Mr. West’s phone number on the enrollment form in case he is on the “Do Not Call” registry. c. You need to ask Mr. West a few final questions to ensure he understands the nature of the plan and really wants to enroll. You also should tell Mr. Schmidt that after you leave, he should not answer any questions about his enrollment in the plan because it could result in a disenrollment. d. 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. Answer: d. 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. Question 42. Mr. Albert has heard about something called the Star Rating system for Medicare Advantage plans. He asks you to explain it to him since he is interested in enrolling in a plan that is newly available in his area. After you explain that it is the way for consumers to judge plan performance, what else would you say? a. New plans and Part D sponsors that do not have any Star Rating are not required to provide Star Rating information until the next contract year. b. New plans and part D sponsors must provide a projection of the Star Rating they will receive until they have been officially awarded an overall Star Rating by CMS. c. CMS generally issues plan ratings in January of each year, and plan sponsors must update the rating information available to enrollees within 30 days. d. Plans must provide Star Rating information as part of the Summary of Benefits package, but they may optionally choose to provide Star Rating information on their websites. Answer: a. New plans and Part D sponsors that do not have any Star Rating are not required to provide Star Rating information until the next contract year. Question 43. 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? a. The doctor may only collect from Mr. Rivera the cost sharing allowable under the state’s Medicaid program. b. The doctor may only collect the amount allowable under Medicare plus 25 percent balance billing. c. The doctor may only collect the amount allowable under Medicare plus 15 percent balance billing. d. The doctor may only collect the amount allowable under Medicare Advantage (MA) PPO plan cost sharing for non-QMB enrollees. Answer: a. The doctor may only collect from Mr. Rivera the cost sharing allowable under the state’s Medicaid program. Question 44. 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? a. Medicare covers 50% of the cost of these three services. b. Medicare covers glasses, but not dentures or acupuncture. c. Medicare does not cover acupuncture, or, in general, glasses or dentures. d. Medicare covers 80% of the cost of these three services. Answer: c. Medicare does not cover acupuncture, or, in general, glasses or dentures. Question 45. 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? a. As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding should begin, he can change his method of Part D premium payment and withholding will begin the month after his savings account is exhausted. b. During 2017, many people experienced significant problems with deductions from their Social Security check for their Part D premium. As a result, this method of payment is no longer an option for Part D premium payments c. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. d. In general, to pay his Part D premium, he only can have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals. Answer: c. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Question 46. Mrs. Tanner is enrolled in a Medicare Advantage HMO that offers a point of service option. This allows Mrs. Tanner to do which of the following? a. Mrs. Tanner can go to non-plan doctors knowing that cost sharing will generally be the same as with network providers. b. Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval. c. Mrs. Tanner can go to non-plan doctors without receiving prior approval for all services. d. Mr. Tanner can go to non-network doctors without worrying about a cap on the amount of out-of-network services she may receive. Answer: b. Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval. Question 47. 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? a. Mr. Zachow could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him. b. 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. c. Mr. Zachow will have to wait until the Annual Election Period when he can switch Part D plans. In the meantime, he will have to pay for his drug out of pocket. d. Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication. Answer: b. 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. Question 48. Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage (MA) health plans. This year she has decided to focus on non-MA products. What advice would you give Melanie if she wishes to continue to receive renewal fees? a. Melanie must remain trained, tested, licensed, and appointed, regardless of whether she is actively selling MA products. b. Melanie will need to do nothing to continue receiving renewal fees since the initial sale was made when she met all requirements. c. All that she needs to do is meet state licensure requirements moving forward. d. All that she needs to do is avoid being terminated for cause. Answer: a. Melanie must remain trained, tested, licensed, and appointed, regardless of whether she is actively selling MA products. Question 49: Mr. Jenkins is interested in enrolling in a Medicare cost plan and has sought your advice. What would you tell him? a. Costs plans are required to be open to enrollment year-round, so he should select a date when he would like coverage to begin. b. Cost plans are required to be open to enrollment at least 30 days per year, and many are open for enrollment all year. So open enrollment will be dependent on the plan he chooses. c. Cost plans that offer an optional supplemental Part D benefit are required to be open to enrollment at least 90 days per year in addition to accepting Part D enrollments during the annual enrollment period. d. All cost plans (like other types of MA plans) are required to be open for enrollment during the MA annual election period. Answer: b. Cost plans are required to be open to enrollment at least 30 days per year, and many are open for enrollment all year. So open enrollment will be dependent on the plan he chooses. Question 50. You are doing a sales presentation for Ms. Duarte and her son. Ms. Duarte has some cognitive impairment and her son informs you that he has power of attorney to make financial decisions for her. Can he execute the enrollment for her? a. No, he cannot execute the enrollment for her. He must have a legal authorization, under state law that explicitly allows him to make health care decisions for his mother. b. Yes, he can execute the enrollment for her. He can do so because he is an immediate family member. No power of attorney is necessary. c. No, he cannot execute the enrollment for her. Only Ms. Duarte can sign the form, regardless of her mental capacities. d. Yes, he can execute the enrollment for her. A financial power of attorney is sufficient. Answer: a. No, he cannot execute the enrollment for her. He must have a legal authorization, under state law that explicitly allows him to make health care decisions for his mother.
  11. Question: 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 Medicare covered services. How much may the doctor collect from Mr. Rivera? Answer: The doctor may only collect from Mr. Rivera the cost sharing allowable under the state's Medicaid program. this is from the modules as well. this answer is C correct c. The doctor may only collect from Mr. Rivera the cost sharing allowable under the state’s Medicaid program.
  12. the 2nd test is now 100% correct - The first test we still have 1 question we are not sure of and a second question that I cannot find.. Please email me your test in pdf format or any format so I can format and post online. My email is david@naaip.org
  13. Agent Gary from Florida - TEST 2 sent me his AHIP 2020 Test Questions and Answers. Attached is my AHIP Final Exam – I got a 98% on it the first time. Realize that I have been doing these AHIP exams since 2010 and Medicare is my primary business. I am surprised I got any wrong. Not sure which answer is incorrect. Sincerely, Agent Gary (I believe that I found the wrong answer - please comment) - Patty and Susan found the wrong answer - all 50 questions are now answered correctly. Question 1. Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug coverage. What should you tell her about obtaining drug coverage? a. She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. b. She can enroll in the PPO and purchase drug coverage through a stand-alone Medicare Part D prescription drug plan. c. She can enroll in the PPO and purchase drug coverage through a Medigap plan. d. She can enroll in the PPO and if she decides that she wants drug coverage, she will be able to drop her PPO at any time in favor of a Medicare Advantage plan that includes such drug coverage. Answer: a. She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. Question 2. 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? a. Medicaid will cover his cost-sharing, regardless of from which physician or hospital he receives his Medicare-covered services. b. He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers. c. For Medicaid beneficiaries, Medicare reduces its cost-sharing amounts to match those charged by the state Medicaid program so there will be no change in his cost-sharing amounts. d. Medicaid will no longer pay any cost sharing once he is eligible for Medicare, so he will need to rely only on Medicare providers Answer: b. He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers. Question 3. You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA) plans you represent. Before you conduct such sales presentations, what must you do? a. You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in-home presentation. b. There is no special action that you must take. If they choose, you may go to an individual’s house to provide presentations and offer assistance with enrolling in a plan. c. You must first contact the Medicare agency to ensure that the individual is actually a Medicare beneficiary. d. A proper introduction at the door that includes a disclaimer regarding your relationship with the plan you represent is the only required action you must take, prior to entering the beneficiary’s home. Answer: a. You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in-home presentation. Question 4. 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? a. The doctor may only collect the amount allowable under Medicare plus 25 percent balance billing. b. The doctor may only collect the amount allowable under Medicare Advantage (MA) PPO plan cost sharing for non-QMB enrollees. c. The doctor may only collect the amount allowable under Medicare plus 15 percent balance billing. d. The doctor may only collect from Mr. Rivera the cost sharing allowable under the state’s Medicaid program. Answer d. The doctor may only collect from Mr. Rivera the cost sharing allowable under the state’s Medicaid program. B 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? a. Once she has expended her liquid assets, Medicare will cover 80% of Mrs. Shields' long-term care costs. b. Medicare will cover an unlimited number of days in a skilled-nursing facility, as long as a physician certifies that such care is needed. c. Mrs. Shields will have to apply for Medicaid to have her skilled nursing services covered because Medicare does not provide such a benefit. d. 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 Answer d. 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. Question 6. 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? a. You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. b. Plans may not participate in advertising such an event. All advertising must be done by community organizations. c. You must state in the advertisement that it will be an educational event and that the education will consist of specific information about the participating plans. d. You must only ensure that the advertisement is factually accurate. Answer: a. You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. Question 7. 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? a. A signature is not necessary since Mr. Tully is not physically or mentally capable of filling out and signing the form. b. Mr. Tully’s daughter can do so because she is an immediate family member who has taken responsibility for her father’s care. c. Mr. Tully’s daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has a durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions. d. If the enrollment form is countersigned by one of Mr. Tully’s treating physicians, she can sign it for him. Answer: c. a. Mr. Tully’s daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has a durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions. Question 8. 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? a. All individuals who are citizens and over age 65 will be covered under Part A. b. Most individuals who are citizens and over age 65 and are covered under Part A must pay a monthly premium for that coverage. c. Most individuals who are citizens and over age 65 and wish to be covered under Part A must enroll in a Medicare Health Plan. d. 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. Answer: d. 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. Question 9. 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? a. He will need to mail in his payment with his enrollment form. b. You can take his first payment, but after that, he will need to make arrangements to send his monthly premium payment to the plan. c. This is perfectly acceptable. You will be happy to forward his payment to the plan. d. 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. Answer: d. 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 Question 10. Mrs. Patterson is a new enrollee in the HealthBest Medicare Advantage (MA-PD) plan. She is new to this type of coverage and asks you what materials, if any, she should expect to receive. How would you reply? a. She should expect to receive Evidence of Coverage (EOC) within 21 days of confirmation of enrollment. b. She should expect to receive hard copies of both the provider and pharmacy directories automatically within 30 days of confirmation of enrollment. c. She should expect to receive a hard copy of the provider directory in and a separate notice describing where she can find monthly periodic updates online and how to request hardcopies. d. She should expect either the pharmacy directory in hard copy or a distinct and separate notice (in hard copy) describing where she can find the pharmacy directory online and how to request a hard copy. Answer: d. She should expect either the pharmacy directory in hard copy or a distinct and separate notice (in hard copy) describing where she can find the pharmacy directory online and how to request a hard copy. Question 11. During a sales presentation in Ms. Sullivan’s home, she tells you that she has heard about a type of Medicare health plan known as Private Fee-for-Service (PFFS). She wants to know if this would be available to her. What should you tell her about PFFS plans? a. PFFS plans are designed to cover only prescription drugs and if that is the type of coverage she wants, she may enroll in one if it is available in her area. b. A PFFS plan is one of the various types of Medicare Advantage plans offered by private entities and she may enroll in one if it is available in her area. c. A PFFS plan is a type of Medicare Supplement plan and she may enroll in one if it is available in her area. d. A PFFS plan is exactly the same as Original Medicare, only offered by a private entity and she may enroll in one if it is available in her area. Answer: b. a. A PFFS plan is one of the various types of Medicare Advantage plans offered by private entities and she may enroll in one if it is available in her area. Question 12. 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? a. Original Medicare covers ambulance services. b. Original Medicare covers orthopedic shoes. c. Original Medicare covers cosmetic surgery. d. Original Medicare covers routine foot care. Answer: a. Original Medicare covers ambulance services. Question 13. Ms. Lopez is an independent agent under contract with MarketCo, a third-party marketing organization. MarketCo has a contract with BestCare health plan, a Medicare Advantage (MA) organization, to offer marketing services through its contracted agents and agencies. Ms. Lopez returns calls to individuals who contact MarketCo in response to its mailers promoting BestCare health plan. Which of the following best describes the responsibilities of Ms. Lopez? a. Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. b. Ms. Lopez is considered a marketing representative of BestCare but is exempt from the marketing rules regarding approved call scripts because she works directly for MarketCo. c. Ms. Lopez no longer needs to be concerned about state licensure since she is marketing an MA product subject to federal rules. d. Ms. Lopez needs to maintain state licensure, but because she is working for a third-party marketing organization she is exempt from CMS training requirements that apply to BestCare captive agents. Answer: a. Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. Question 14. Mrs. Walters is enrolled in her state’s Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Advantage plan? a. She can submit any bills she has for co-payments under Medicare to the state’s Medicaid program and they will always be fully covered. b. If a provider accepts her Medicare Advantage plan coverage, that provider is legally obligated to also accept her Medicaid coverage, so she does not need to worry about finding providers who participate in both Medicare and Medicaid. c. State Medicaid programs do not coordinate any of their coverage with Medicare Advantage plans. d. She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account (MSA) plan. Answer: d. She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account (MSA) plan. Question 15 explained by Susan Question 15. Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a meeting so that she can learn about Medicare and the products you represent. How should you respond? a. Tell Julia that you are happy to meet with her once this year’s open enrollment begins on October 15th. b. Tell Julia that you will meet with her at a time of her convenience within the next week, when you can accept a completed enrollment application to be submitted after October 15th. c. Tell Julia that you will meet with her to explain Medicare and should she be interested you can accept and submit an enrollment request, since this is an initial enrollment qualifying her for a special enrollment period. d. Tell Julia that she must first complete a questionnaire providing her health history so that you can recommend an appropriate product before submitting an enrollment application, since she qualifies for a special enrollment period. Answer: a. Tell Julia that you are happy to meet with her once this year’s open enrollment begins on October 15th. Question 16. 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 Answer: d. I, II, and IV only Question 17. 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 2020 under the standard coverage? a. Standard Part D coverage would require payment of an annual deductible of $435, 25% cost-sharing between $435 and $4,020, and once through the catastrophic coverage threshold the beneficiary pays either co-pays for generic and brand name drugs or coinsurance of 5%, whichever is greater. b. Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap. c. Standard Part D coverage would require payment of only fixed per-prescription co-payments. d. Standard Part D coverage would require payment of an annual deductible, fixed per-prescription co-payments, 35% of the costs in the coverage gap, and once catastrophic coverage begins, the plan covers 100% of all costs. Answer: d. Standard Part D coverage would require payment of an annual deductible, fixed per-prescription co-payments, 35% of the costs in the coverage gap, and once catastrophic coverage begins, the plan covers 100% of all costs. Question 18. 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? a. Yes. Whether or not an event has been advertised as “educational” or a “sales presentation,” discussing plan-specific information is impermissible. b. No. This action is permissible. Handing out enrollment forms, on the other hand, would not be permissible. c. Yes. When an event has been advertised as “educational,” discussing plan-specific premiums is impermissible. d. No. Attendees expect some “puffery” at any event on a product in which they may be potentially interested. Answer: c. Yes. When an event has been advertised as “educational,” discussing plan-specific premiums is impermissible. Question 19: Agent Chan is conducting a sales presentation on senior issues where he hopes to enroll some attendees in the Medicare Advantage (MA) plans he represents. What action(s) may Agent Chan take during the event? Answer: the agent did not give me this answer. We don't have the 4 answer options here. Potential answers from Susan: He can provide snacks and gifts totaling less than $15 per person. He can provide reply cards so that potential enrollees can provide authorization for the agent to contact them. He can provide information as to star ratings, as long as he isn't misleading in his star rating statements. Question 20. Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him? a. If he enrolls in the PFFS plan and shows his card to a doctor who participates in Original Medicare, then that doctor is required to accept the plan’s terms and conditions, which could include balance billing. 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. c. He may receive services from any physician, regardless of whether or not that physician participates in the plan or Original Medicare. d. If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor accepts Original Medicare. Answer: 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. Question 21. Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him? a. Formularies must be developed with input from pharmacists, doctors, and other experts. b. Formularies are developed by a consortium of health plans. c. Plans must use a single, standard formulary developed by the Federal government to keep costs down and quality high for beneficiaries. d. Formularies are developed purely on the basis of drug costs and include the least expensive drugs to keep costs down for beneficiaries and the Medicare program. Answer: a. Formularies must be developed with input from pharmacists, doctors, and other experts. Question 22. Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales presentation? a. A meal cannot be provided, but light snacks would be permitted. b. Any type of meal or food is allowed, as long as it is available to the general public and not just those who are eligible to enroll in the plans. c. Nothing may be provided to eat or drink during the sales presentation. d. Any meal is allowed, as long as it is valued at less than $15. Answer: a. A meal cannot be provided, but light snacks would be permitted. Question 23. 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? a. 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. b. Mr. Carlini can keep Original Medicare, but if he does not sign up for an MA plan that includes prescription drug coverage, he will only be able to obtain prescription drug coverage through a Medigap plan. c. In order to obtain prescription drug coverage, Mr. Carlini must enroll in an MA plan. The plan will cover his Part A and Part B services, as well as provide him with the desired prescription drug coverage. d. Mr. Carlini can obtain drug coverage through the Federal government’s fallback plans, which are designed to provide an alternative to privately sponsored Medicare Advantage plans. Answer: a. 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. Question 24. Ms. Hernandez has marketed several different types of insurance products in her home state and has typically sought approval of her materials from her State Department of Insurance. What would you advise her regarding seeking such approval for materials she uses to market Medicare Advantage plans? a. Materials need only be reviewed and approved by the company(s) she represents. b. States often volunteer to review marketing materials on behalf of the Medicare agency. She should check with her Department of Insurance to see if such a review is available and would satisfy CMS requirements. c. Materials for marketing Medicare health plans to individuals are subject to Medicare’s uniform national requirements. They do not need to be reviewed by the state, but the company she represents must obtain approval from the Medicare agency (CMS) for any materials she uses. d. Obtaining approval of her materials from the State Department of Insurance is a good practice and she should continue it with materials for the Medicare health plans she represents. Answer: c. Materials for marketing Medicare health plans to individuals are subject to Medicare’s uniform national requirements. They do not need to be reviewed by the state, but the company she represents must obtain approval from the Medicare agency (CMS) for any materials she uses. Question 25. Mr. Wilcox has been enrolled in Lexington PFFS Medicare Advantage Health Plan (Lexington) for several years. Recently, Mr. Wilcox decided to spend time with his children who live in another state that is not in Lexington's service area. In the future, he may relocate near his children permanently. How does this move to another service area impact his PFFS MA coverage? a. Lexington must disenroll Mr. Wilcox after 12 weeks unless he can provide proof that he is simply visiting on a temporary basis. b. Lexington can offer an extended visitor/traveler (V/T) benefit to Mr. Wilcox for up to 15 months. c. Lexington can allow for Mr. Wilcox’s continued enrollment for up to 12 months whether or not he is in a visitor/traveler (V/T) program. d. Lexington must disenroll Mr. Wilcox after 6 months unless he can provide proof that he is simply visiting on a temporary basis Answer: c. Lexington can allow for Mr. Wilcox’s continued enrollment for up to 12 months whether or not he is in a visitor/traveler (V/T) program. Question 26: 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? a. Mrs. Wilson will be contacted by you within one week for a follow-up appointment to handle the verification process. b. Your assistant will contact Mrs. Wilson within seven calendar days to set up a joint call with the plan’s home office to verify that she has enrolled in a plan of her choice and understands its features and rules. c. You will contact Mrs. Wilson within 10 calendar days to set up a joint call with the plan’s home office to verify that she has enrolled in a plan of her choice and understands its features and rules. d. Mrs. Wilson will be contacted by the plan sponsor within 15 calendar days of receipt of the enrollment request. Answer: d. Mrs. Wilson will be contacted by the plan sponsor within 15 calendar days of receipt of the enrollment request. Question 27. Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him? a. He need not be entitled to Part A or enrolled in Part B to be eligible for the Part D prescription drug benefit. He must only be aged 65 to qualify for enrollment in Part D, so he can go ahead and enroll in a Part D prescription drug plan. b. He will have to enroll in Part B before he can enroll in a Part D prescription drug plan. c. He does not have to enroll in Part B but, must pay a penalty for his failure to do so when he first turned 65. After that, he can enroll in a Part D prescription drug plan. d. He is eligible for the Part D prescription drug benefit because he is entitled to Part A and he does not have to be enrolled in Part B. Answer: d. He is eligible for the Part D prescription drug benefit because he is entitled to Part A and he does not have to be enrolled in Part B. Question 28. 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? a. No. Mrs. Walters will have to enroll in Part B in order to qualify for enrollment into the Medicare prescription drug program. b. Yes, but Mrs. Walters must drop the employer coverage prior to enrolling in a Medicare prescription drug plan. c. No. As long as her employer offers coverage that is equivalent to that available through Medicare, Mrs. Walters cannot enroll in a Medicare prescription drug plan. d. 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. d. 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. Question 29. If you are to be in compliance with Medicare’s guidance regarding educational events, which of the following would be acceptable activities? a. You may discuss plan specific premiums and benefits. b. You may have a stack of enrollment forms on the table in your booth but may only pass them out to individuals who request one. c. You may ask passers-by to provide you with their names, addresses and phone numbers so that you could contact them later with information about the plan(s) you represent. d. You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent. Answer: d. You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent. Question 30. 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? a. Dr. Brennan can charge the beneficiary the same costsharing as Original Medicare as long as she sends the claim to Medicare and not the plan. b. Dr. Brennan can charge Mary Rodgers more than the cost sharing specified in the PFFS plan’s terms and conditions as long as she treats all beneficiaries the same. c. 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. d. Dr. Brennan can charge Mary no more than the cost sharing specified in the PFFS plan’s terms and conditions of payment which may include balance billing up to 25 percent of the Medicare rate. Answer: c. 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. Question 31. Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services’ communication and Marketing Guidelines to ensure he is compliant for which type of products? a. Medicare Advantage (MA) and Prescription Drug (PDP) plans b. Private long-term care policies for Medicare beneficiaries c. Section 1332 waiver plans d. Medigap plans. Answer: a. Medicare Advantage (MA) and Prescription Drug (PDP) plans Question 32. Ms. Brooks has an aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her? a. Medicare covers hospice services and they will be available for her. b. Hospice services are currently only offered under a limited demonstration project. Whether they will eventually become available nationally depends on the outcomes of the demonstration. c. Medicare does not cover hospice services. Hospice services are only available through state Medicaid programs, if the state offers such coverage. d. The Federal government facilitates competition between hospice programs to lower the price of their services for Medicare beneficiaries, but does not offer coverage for hospice services through the Medicare program. Answer: a. Medicare covers hospice services and they will be available for her. Question 33. Mr. Jackson just turned 65. He has been seeing the same general practitioner for annual check-ups for the past 15 years, likes these yearly visits, and would like to continue obtaining these services as a Medicare beneficiary. What should you tell him about annual check-ups? a. Medicare will cover only a one-time “Welcome to Medicare” wellness visit. b. Medicare will cover an annual wellness visit, even if he has no illnesses or injuries. c. He can have as many preventive physical exams as he feels that he needs. They will all be covered by Medicare. d. Physical exams, in the absence of readily observable illness or injury, are never covered under any circumstances. Answer: b. Medicare will cover an annual wellness visit, even if he has no illnesses or injuries. Question 34. Mr. Lopez takes several high-cost prescription drugs. He would like to enroll in a standalone Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan can he enroll? a. Medicare Advantage (MA) HMO-POS plan that does not include drug coverage. b. Medicare Advantage (MA) HMO that does not include drug coverage. c. Private Fee-for-Service (PFFS) plan that does not include drug coverage. d. Medicare Advantage (MA) PPO that does not include drug coverage. Answer: c. Private Fee-for-Service (PFFS) plan that does not include drug coverage. Question 35. Mr. Albert has heard about something called the Star Rating system for Medicare Advantage plans. He asks you to explain it to him since he is interested in enrolling in a plan that is newly available in his area. After you explain that it is the way for consumers to judge plan performance, what else would you say? a. New plans and Part D sponsors that do not have any Star Rating are not required to provide Star Rating information until the next contract year. b. Plans must provide Star Rating information as part of the Summary of Benefits package, but they may optionally choose to provide Star Rating information on their websites. c. CMS generally issues plan ratings in January of each year, and plan sponsors must update the rating information available to enrollees within 30 days. d. New plans and part D sponsors must provide a projection of the Star Rating they will receive until they have been officially awarded an overall Star Rating by CMS. Answer: a. New plans and Part D sponsors that do not have any Star Rating are not required to provide Star Rating information until the next contract year. Question 36. Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to you for advice as to what options, if any, she has. What should you say regarding special enrollment periods (SEPs)? a. Mrs. Wellington is eligible for a two- month SEP that began on January 1, so she should act quickly if she wishes to enroll in the MA five-star plan. b. Mrs. Wellington must first enroll in a standalone PDP before she is eligible for a SEP to enroll in the MA five-star plan. c. Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the five-star plan. d. Mrs. Wellington can enroll in the five-star plan in the following October, when the next annual enrollment period (AEP) begins – not before. Answer: c. Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the five-star plan. Question 37. Mr. Gonzalez is entitled to Part A, but has not yet enrolled in Part B. If he wants to enroll in a Medicare Advantage (MA) plan, what will he have to do? a. He will have to drop Part A and then will be eligible to enroll in a MA plan. b. He will have to enroll in a Medicare prescription drug plan prior to enrolling in a MA plan. c. He will need to do nothing. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan. d. He will have to enroll in Part B prior to enrolling in a MA plan. Answer: d. He will have to enroll in Part B prior to enrolling in a MA plan. Question 38. Ms. Bushman has two homes in different states and is concerned about restrictions on where she can get her medications. What should you tell her? a. Part D prescription drug plans generally contract with every pharmacy in the country, so she should be able to obtain her drugs in both states with no problem. b. Part D prescription drug plans focus almost entirely on mail order with fairly limited access to retail pharmacies, so as long as she orders all of her medications through the mail, she will be fine. c. Part D prescription drug plans use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states. d. Part D prescription drug plans are restricted to local service areas. She will have to use mail order to fill all of her prescriptions. Answer: c. Part D prescription drug plans use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states. Question 39. 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 otheroption he has for obtaining help with his considerable drug costs. What should you tell him? a. The only option available is to reduce his income so that he can qualify for the Part D extra help or wait until next year to see if the annual limits change. b. He should look into the possibility of purchasing his medications through the internet from off-shore pharmacies. c. He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. d. He should contact his neighbors and family members and let them know that any contributions they make toward his drug expenses will be tax deductible. Answer: c. He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. Question 40. Ms. Gardner is currently enrolled in an MA-PD plan. However, she wants to disenroll from the MA-PD plan and instead enroll in a Part D only plan and go back to Original Medicare. According to Medicare's enrollment guidelines, when could she do this? a. She may only make such a change during her “initial coverage election period,” which occurred when she first became entitled to Medicare. b. She may do it only during the MA Disenrollment Period, which runs from January 1 to February 14 of each year. c. Any time that she is dissatisfied with the plan’s network coverage or customer service she may make such a change. d. She may make such a change during the Annual Election Period that runs from Oct. 15 to December 7, or during the MA Open Enrollment Period which takes place from January 1- March 31 of each year (beginning in 2019). Answer: d. She may make such a change during the Annual Election Period that runs from Oct. 15 to December 7, or during the MA Open Enrollment Period which takes place from January 1- March 31 of each year (beginning in 2019). This question below was corrected by Susan and Patty- The correct answer is A and all 50 questions on this test are now correct. Question 41. Mrs. Quinn has recently turned 66 and decided after many years of work to begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn 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? a. 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. b. She will need to pay no premiums for Part B as she qualifies for premium-free coverage due to the number of quarters she has worked. c. Part B will cover her dental and vision needs. d. She should disenroll if she does not want to pay the monthly premiums. There is no disadvantage in doing so. Answer: a. 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. Question 42: 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? a. The VA will not offer drug coverage to Mrs. Fiore once she qualifies for the Medicare Part D program. b. The VA does not offer creditable coverage and Mrs. Fiore may incur a Part D premium penalty if she enrolls in a Medicare prescription drug plan at some point after her initial eligibility date. c. Costs under the VA are significantly higher than those under a Medicare Part D plan. d. 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. Answer: d. 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. Question 43. 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? a. If a PFFS enrollee shows his/her card when obtaining services from a provider who participates in Original Medicare, then that provider is required to accept the plan’s terms and conditions. b. If offered, beneficiaries can select a stand-alone Part D prescription drug plan (PDP) with an HMO or a PPO, but not with a PFFS plan. c. 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. d. PFFS plans are the same as Medicare supplement plans and he may obtain care from any provider in the U.S. Answer: c. 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. Question 44. Mr. Jenkins is interested in enrolling in a Medicare cost plan and has sought your advice. What would you tell him? a. All cost plans (like other types of MA plans) are required to be open for enrollment during the MA annual election period. b. Costs plans are required to be open to enrollment year-round, so he should select a date when he would like coverage to begin. c. Cost plans that offer an optional supplemental Part D benefit are required to be open to enrollment at least 90 days per year in addition to accepting Part D enrollments during the annual enrollment period. d. Cost plans are required to be open to enrollment at least 30 days per year, and many are open for enrollment all year. So open enrollment will be dependent on the plan he chooses. Answer: d. Cost plans are required to be open to enrollment at least 30 days per year, and many are open for enrollment all year. So open enrollment will be dependent on the plan he chooses. Question 45. Mrs. Tanner is enrolled in a Medicare Advantage HMO that offers a point of service option. This allows Mrs. Tanner to do which of the following? a. Mrs. Tanner can go to non-plan doctors knowing that cost sharing will generally be the same as with network providers. b. Mrs. Tanner can go to non-plan doctors without receiving prior approval for all services. c. Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval. d. Mr. Tanner can go to non-network doctors without worrying about a cap on the amount of out-of-network services she may receive. Answer: c. Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval. Question 46. Who is most likely to be eligible to enroll in a Part D prescription drug plan? a. Mr. Charles, an undocumented immigrant, entered the country illegally. b. Ms. Davis who recently turned age 65 and is eligible for Part A and has just enrolled in Part B. c. Ms. Bradley is currently living abroad for a multi-year job assignment. d. Ms. Adams, a healthy early retiree who has just begun to collect Social Security at age 62. Answer: b. Ms. Davis who recently turned age 65 and is eligible for Part A and has just enrolled in Part B. Question 47. Mrs. Peňa is 66 years old, has coverage under an employer plan and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure nogap in coverage. What can you tell her? a. She may not enroll in Part B while covered under an employer group health plan and must wait until the standard general enrollment period after she retires. b. She may only enroll in Part B during the general enrollment period whether she is retired or not. c. She may 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. d. She must wait at least 30 days after her employment terminates before she may enroll in Medicare Part B Answer: c. She may 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. Question 48. Mrs. Sanchez lives in a state located near Canada. She has recently become eligible for Medicare and is considering enrollment in Part D prescription drug coverage. One of her friends has told her that she needs to be aware of something called TrOOP. What should you tell her when she asks you about TrOOP? a. TrOOP is calculated on an annual basis and consists of an enrollee's out-of-pocket deductible plus any amounts paid on behalf of an enrollee by Medicaid. b. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include, in addition to the annual deductible, costs for drugs not on the Part D plan's formulary and drugs purchased outside the United States. c. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include the annual deductible(s) and costs for drugs on the plan's formulary purchased at a plan's participating pharmacy. In some instances, amounts not directly paid by the enrollee (like manufacturer discounts) count toward TrOOP. d. TrOOP is calculated on a cumulative basis and consists of the sum of an enrollee's out-of-pocket deductibles from the date of his or her enrollment in Part D plus outlays for over-the-counter drugs Answer: c. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include the annual deductible(s) and costs for drugs on the plan's formulary purchased at a plan's participating pharmacy. In some instances, amounts not directly paid by the enrollee (like manufacturer discounts) count toward TrOOP. Question 49. Ms. Jensen has heard about “Original Fee-for-Service Medicare” and “Private Fee-for-Service” plans. She wants to know what the difference is, if any. What should you tell her? a. PFFS is a form of supplemental coverage that fills in the gaps where Original Medicare leaves off. b. PFFS plans primarily cover drugs that Original FFS Medicare does not cover. c. Original Medicare and PFFS plans are essentially the same thing. d. PFFS plans are a type of Medicare Advantage plan offered by private companies. Answer: d. PFFS plans are a type of Medicare Advantage plan offered by private companies. Question 50. 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)? a. She is likely to qualify for a SEP. She can choose an effective date of up to six months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than 30 days prior to the date of her move. b. She is unlikely to qualify for a SEP and should remain on her current plan, relying on her current plan’s out-of-network benefits. c. 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. d. She is unlikely to qualify for a SEP but will be automatically covered by Original Medicare and a standalone Part D prescription drug plan. Answer: c. 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.
  14. Susan M, Thank you - I edited the answers on my test to take into account your corrections. One question you are not sure and I am not sure as well. While another question is identified. Of the 50 questions here - 48 are definitely correct. Another agent sent me his test with answers - He claims to only have gotten one wrong - I will post shortly - please review that test.
  15. 43 looks good. They are married and told the government they are married. joint returns or joint filing separately. She is good. No need for pay for part A.
  16. United Healthcare is the only one that accept’s it on the 4th 5th or 6th attempts. But instead of paying it twice they could just take the UHC cert instead of taking AHIP.
  17. I don't know. That is why I am asking you. Follow up by Guest Susan M below - She is smart girl and found 4 of 6 wrong answers. One question she is not sure, and I am not sure as well.
  18. I will research further - Eugene 1:36 PM (53 minutes ago) Yes the 6 you answered incorrectly Kay says Question 45 is A Baker and Charles are subject to CMS If you find the other questions you missed, please let me know ====================================== JEFFREY to me The tests are different each time. There are 400 questions and one never knows which 50’will pop up. David Gordon: I did the research and I answered 6 correctly.
  19. AHIP 2020 Questions and Answers TEST 1 - 6 Wrong Answers were Here - So This was a 88% - Not a Passing Grade - 2 more attempts to pass and UHC gives me 5 more times. 90% would be passing. I wrote correct next to my answers - but I got 6 wrong - Oooops. Susan M correctly identified and answered 4 of the 6 wrong answers (I changed the answers). One question Susan is not sure, Now only one of the 50 questions is wrong while another one I am not 100% certain. Question 1 Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him? Choose one answer. a. He need not be entitled to Part A or enrolled in Part B to be eligible for the Part D prescription drug benefit. He must only be aged 65 to qualify for enrollment in Part D, so he can go ahead and enroll in a Part D prescription drug plan. correct b. He is eligible for the Part D prescription drug benefit because he is entitled to Part A and he does not have to be enrolled in Part B. c. He will have to enroll in Part B before he can enroll in a Part D prescription drug plan. d. He does not have to enroll in Part B but, must pay a penalty for his failure to do so when he first turned 65. After that, he can enroll in a Part D prescription drug plan. Question 2 Mr. Diaz continued working with his company and was insured under his employer’s group plan until he reached age 68. 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. What should you tell him? Choose one answer. a. During the first year, he is covered under Part B, his premiums will be 10% higher than they otherwise would be, after which point they will return to normal. correct b. Mr. Diaz will not pay any penalty because he had continuous coverage under his employer’s plan. c. Mr. Diaz will pay a penalty, which will be a flat amount each year, paid during the first month of coverage. d. The penalty will be a permanent 10% increase in his Part B premium for every 12 month period that passed during which he could have enrolled and did not. Question 3 Mr. Jackson just turned 65. He has been seeing the same general practitioner for annual check-ups for the past 15 years, likes these yearly visits, and would like to continue obtaining these services as a Medicare beneficiary. What should you tell him about annual check-ups? Choose one answer. a. Physical exams, in the absence of readily observable illness or injury, are never covered under any circumstances. b. He can have as many preventive physical exams as he feels that he needs. They will all be covered by Medicare. correct c. Medicare will cover an annual wellness visit, even if he has no illnesses or injuries. d. Medicare will cover only a one-time “Welcome to Medicare” wellness visit. Question 4 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? Choose one answer. a. Typically her coverage would begin 30 days after she submits the application form, so she should not expect the coverage to begin until after she leaves. correct b. 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. c. Coverage always begins on the first of July, or the first of January after a beneficiary enrolls, whichever comes first. d. Typically, coverage is effective on the date that the beneficiary completes the application form, so her coverage will be in place before she leaves. Question 5 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? Choose one answer. a. He may not sign-up for Medicare until he reaches age 62, the date he first becomes eligible for Social Security benefits. b. He may sign-up for Medicare at any time however coverage usually begins on the sixth month after dialysis treatments start. c. He may sign-up for Medicare at any time and coverage usually begins immediately. correct d. He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Question 6 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? Choose one answer.This maybe wrong correct a. 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. b. You could tell her she is wrong and that only agents employed by the plans are exempt from training and testing requirements. c. You could tell her she was right, but new rules will require her to take the training and pass the test at least every other year. d. You could tell her she is right and ask if you could get a contract with the TMO too. Question 7 You are doing a sales presentation for Ms. Duarte and her son. Ms. Duarte has some cognitive impairment and her son informs you that he has power of attorney to make financial decisions for her. Can he execute the enrollment for her? Choose one answer. a. Yes, he can execute the enrollment for her. He can do so because he is an immediate family member. No power of attorney is necessary. b. No, he cannot execute the enrollment for her. Only Ms. Duarte can sign the form, regardless of her mental capacities. c. Yes, he can execute the enrollment for her. A financial power of attorney is sufficient. Correct by Susan M d. No, he cannot execute the enrollment for her. He must have a legal authorization, under state law that explicitly allows him to make health care decisions for his mother. Question 8 Ms. Bushman has two homes in different states and is concerned about restrictions on where she can get her medications. What should you tell her? Choose one answer. a. Part D prescription drug plans generally contract with every pharmacy in the country, so she should be able to obtain her drugs in both states with no problem. b. Part D prescription drug plans are restricted to local service areas. She will have to use mail order to fill all of her prescriptions. c. Part D prescription drug plans focus almost entirely on mail order with fairly limited access to retail pharmacies, so as long as she orders all of her medications through the mail, she will be fine. correct d. Part D prescription drug plans use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states. Question 9 Eleanor takes several high-cost prescription drugs. She would like to enroll in a standalone Part D prescription drug plan that is available in her area. In what type of Medicare Health Plan can she enroll if she also wishes to enroll in the standalone Part D plan? Choose one answer. a. A MA PPO plan only if it does not offer drug coverage. b. A MA PPO plan that offers drug coverage if she chooses not to enroll in it. c. A Cost Plan only if it does not offer drug coverage. correct d. A Cost Plan that does not offer drug coverage or a Cost Plan that does offer drug coverage if she chooses not to enroll in it. Question 10 Marks: 1 Agent Willis had several clients who disenrolled from the plans he represents during the AEP to try new Medicare Advantage plans. Agent Willis believes that the choices they made are not ideal for them and would like to get their business back during the Medicare Advantage Open Enrollment Period (MA-OEP). What can agent Willis do? Choose one answer. Susan M says B, but she is not sure and I am not sure - I chose D a. He can e-mail them in January and ask them to let him know if they are not happy with their new plans. correct? b. He can send them information about the MA-OEP along with a flyer on the plans he represents. c. He can call them to let them know that if they do not like their new plans, they can change back during the MA-OEP. correct? d. He can wait until October and send them information about the plans he represents. Question 11 Marks: 1 Which of the following statements is correct about the appeal and grievance processes? I. Enrollees have a right to obtain a review (appeal) of certain decisions about prescription drug coverage. II. The grievance process is used for reviews of coverage decisions on plan benefits. III. Plans must provide a link to the Medicare.gov website where an enrollee can enter a complaint. IV. Enrollees have a right to file complaints (sometimes called grievances) about the quality of their care. Choose one answer. a. I and III only correct b. I, III, and IV only c. I and II only d. II and IV only Question 12 Marks: 1 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 the prescriptions that she has lost. How would you advise her? Choose one answer. a. She may fill one prescription out-of-network per year and it will be fully covered. Her second prescription will require her to pay the full cost out-of-pocket. b. She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. c. She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan’s network. correct 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. Question 13 Marks: 1 Mrs. Tanner is enrolled in a Medicare Advantage HMO that offers a point of service option. This allows Mrs. Tanner to do which of the following? Choose one answer. a. Mr. Tanner can go to non-network doctors without worrying about a cap on the amount of out-of-network services she may receive. b. Mrs. Tanner can go to non-plan doctors knowing that cost sharing will generally be the same as with network providers. c. Mrs. Tanner can go to non-plan doctors without receiving prior approval for all services. correct d. Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval. Question 14 Marks: 1 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? Choose one answer. a. The doctor may only collect the amount allowable under Medicare plus 25 percent balance billing. b. The doctor may only collect the amount allowable under Medicare plus 15 percent balance billing. correct c. The doctor may only collect from Mr. Rivera the cost sharing allowable under the state’s Medicaid program. d. The doctor may only collect the amount allowable under Medicare Advantage (MA) PPO plan cost sharing for non-QMB enrollees. Question 15 Marks: 1 Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her? Choose one answer. a. The letter is to inform her that her Medigap plan’s coverage has been determined by the Federal government to be inadequate and the plan must therefore discontinue offering such coverage. Ms. Eisenberg will have to select a different Medigap plan if she wants drug coverage. b. The letter is to inform her that her Medigap drug coverage must be supplemented by purchasing coverage under a Part D plan. If she does not do so within 63 days, she will not be able to obtain Part D coverage at a later date. c. The letter is to inform her that Medicare Part D prescription drug coverage is available, but there is no need for her to change her drug coverage since it is just as good as Part D. She may keep her current coverage through the Medigap plan. correct d. The letter is to inform her that the drug coverage offered through her Medigap plan does not offer drug coverage that is at least comparable to that provided under the Medicare Part D prescription drug program. If she does not have such creditable coverage during periods when she is first eligible for the Part D program, she will face a premium penalty if she enrolls in a Part D plan at a later date. Question 16 Marks: 1 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? Choose one answer. a. D-SNP b. I-SNP correct c. C-SNP d. FIDE-SNP Question 17 Marks: 1 Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband’s employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her? Choose one answer. a. Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage. b. Mrs. Lopez must first seek COBRA benefits under her husband’s plan before she can apply for Part D coverage. correct c. If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. d. If a Part D benefit is offered through her plan she must enroll in this plan. Question 18 Marks: 1 Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to you for advice as to what options, if any, she has. What should you say regarding special enrollment periods (SEPs)? Choose one answer. a. Mrs. Wellington is eligible for a two- month SEP that began on January 1, so she should act quickly if she wishes to enroll in the MA five-star plan. b. Mrs. Wellington must first enroll in a standalone PDP before she is eligible for a SEP to enroll in the MA five-star plan. correct c. Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the five-star plan. d. Mrs. Wellington can enroll in the five-star plan in the following October, when the next annual enrollment period (AEP) begins – not before. Question 19 Marks: 1 When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan? Choose one answer. a. You may provide cash promotions or giveaways as long they are offered to everyone, whether they are a Medicare beneficiary or the general public. b. You may give enrollees post-enrollment gifts to compensate them for their time. corect c. You may provide gifts or prizes to all potential enrollees during an event that do not exceed $15 in retail value. d. You may provide any gift to induce enrollment, as long as its retail value does not exceed $25 in value. Question 20 Marks: 1 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? Choose one answer. a. It is illegal for a marketing representative to sell her an MA-PD plan before she completes a voluntary disenrollment form and you can offer to help her do so before you assist with the new enrollment, but these must be during two separate appointments. correct b. She only needs to enroll in the new MA-PD plan and she will automatically be disenrolled from her old MA plan. c. She must wait until the MA Disenrollment Period and then she will be able to disenroll from the MA-HMO and select the MA-PD plan d. She will need to complete a disenrollment form the month before she wants to submit her application for the new plan to ensure she does not end up with two plans. Question 21 Marks: 1 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? Choose one answer. correct a. 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. b. Medicare Supplemental Insurance would cover all of his IRS approved health care expenditures not covered under Original Fee-for-Service (FFS) Medicare. c. Medicare Supplemental Insurance would cover his long-term care services. d. Medicare Supplemental Insurance would cover his dental, vision and hearing services only. Question 22 Marks: 1 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? Choose one answer. a. MA plans are only available to those who have been enrolled in a Medigap plan for at least six months. Therefore, before enrolling in an MA plan, she must first use a Medigap plan to supplement her Original Medicare coverage. b. She must first enroll in a Medicare Part D plan, before enrolling in a Medicare Advantage plan. correct c. She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B. d. She must have previously been enrolled in Original Fee-for-Service Medicare for at least one year before she may enroll in an MA plan. Question 23 Marks: 1 During a sales presentation in Ms. Sullivan’s home, she tells you that she has heard about a type of Medicare health plan known as Private Fee-for-Service (PFFS). She wants to know if this would be available to her. What should you tell her about PFFS plans? Choose one answer. a. PFFS plans are designed to cover only prescription drugs and if that is the type of coverage she wants, she may enroll in one if it is available in her area. b. A PFFS plan is a type of Medicare Supplement plan and she may enroll in one if it is available in her area. correct c. A PFFS plan is one of the various types of Medicare Advantage plans offered by private entities and she may enroll in one if it is available in her area. d. A PFFS plan is exactly the same as Original Medicare, only offered by a private entity and she may enroll in one if it is available in her area. Question 24 Marks: 1 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? Choose one answer. a. The Medicare Advantage plan received the best star rating in customer service and care coordination. b. The Medicare Advantage plan is a top rated plan. c. This Medicare Advantage plan is a 5-star rated plan due to its high rating in customer service. correct d. The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4-stars. Question 25 Marks: 1 Ms. Gardner is currently enrolled in an MA-PD plan. However, she wants to disenroll from the MA-PD plan and instead enroll in a Part D only plan and go back to Original Medicare. According to Medicare's enrollment guidelines, when could she do this? Choose one answer. a. Any time that she is dissatisfied with the plan’s network coverage or customer service she may make such a change. b. She may only make such a change during her “initial coverage election period,” which occurred when she first became entitled to Medicare. correct c. She may make such a change during the Annual Election Period that runs from Oct. 15 to December 7, or during the MA Open Enrollment Period which takes place from January 1- March 31 of each year (beginning in 2019). d. She may do it only during the MA Disenrollment Period, which runs from January 1 to February 14 of each year. Question 26 Marks: 1 Mr. Chen has heard about a Medical Savings Account (MSA), but wants to know if it is just about saving money, or if he will get insurance coverage for his health care expenditures as well. What should you tell him? Choose one answer. correct a. Under the Medicare Advantage program, a MSA plan involves the combination of a high deductible health plan and a savings account for health expenses. Medicare will make contributions to this savings account to help him pay his health care expenses while in the deductible. b. Under the Medicare Advantage program, the MSA plan is a form of prescription drug coverage. c. Under the Medicare Advantage program, the MSA is funded by money he sets aside each year. If he does not use it all on IRS allowable health care expenditures then he will lose the money the following year. d. Under the Medicare Advantage program, the MSA is only an account to help him pay for IRS-allowed health expenditures he may have. It does not involve health insurance of any kind. Question 27 Marks: 1 Mrs. Walters is enrolled in her state’s Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Advantage plan? Choose one answer. Susan M correctly fixed the answer - It is D a. She can submit any bills she has for co-payments under Medicare to the state’s Medicaid program and they will always be fully covered. b. If a provider accepts her Medicare Advantage plan coverage, that provider is legally obligated to also accept her Medicaid coverage, so she does not need to worry about finding providers who participate in both Medicare and Medicaid. c. State Medicaid programs do not coordinate any of their coverage with Medicare Advantage plans. correct d. She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account (MSA) plan. Question 28 Marks: 1 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)? Choose one answer. Susan M correctly fixed the answer - It is C a. She is unlikely to qualify for a SEP and should remain on her current plan, relying on her current plan’s out-of-network benefits. b. She is unlikely to qualify for a SEP but will be automatically covered by Original Medicare and a standalone Part D prescription drug plan. correct c. 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. d. She is likely to qualify for a SEP. She can choose an effective date of up to six months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than 30 days prior to the date of her move. Question 29 Marks: 1 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 2020 under the standard coverage? Choose one answer. correct a. Standard Part D coverage would require payment of an annual deductible of $435, 25% cost-sharing between $435 and $4,020, and once through the catastrophic coverage threshold the beneficiary pays either co-pays for generic and brand name drugs or co-insurance of 5%, whichever is greater. b. Standard Part D coverage would require payment of an annual deductible, fixed per-prescription co-payments, 35% of the costs in the coverage gap, and once catastrophic coverage begins, the plan covers 100% of all costs. c. Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap. d. Standard Part D coverage would require payment of only fixed per-prescription co-payments. Question 30 Marks: 1 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? Choose one answer. a. Agent Lopez is entitled to a pro rata amount of the compensation earned including the full amount for the month of February. b. Agent Lopez’s compensation is not impacted because Ralph’s disenrollment occurred more than 30 days after the effective date of coverage. c. Agent Lopez’s compensation is not impacted because Ralph’s disenrollment occurred after the Annual Open Enrollment Period. correct d. Agent Lopez’s entire compensation must be recouped because Ralph disenrolled within 3 months of enrollment. Question 31 Marks: 1 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? Choose one answer. a. You could suggest he call the doctor who performed the surgery to complain about the costs and ask for a discount on the charges. b. You could remind him that he cannot do anything until the next Annual Election Period when he will have an opportunity to change plans. correct c. You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. d. You could reassure him that such charges are typical, but if he needs assistance in paying, he should apply to the state. Question 32 Marks: 1 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? Choose one answer. a. If she uses non-network providers, her cost sharing would be the same under a PFFS plan as it would be under Original Medicare. b. If she uses non-network providers, she would not be permitted to obtain care outside of her plan’s service area. c. PFFS plans are not permitted to provide any benefits beyond what is covered under Original Medicare. correct d. PFFS plans may choose to offer Part D benefits but are not required to do so. Question 33 Marks: 1 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. She currently does not have creditable coverage. What could you tell her about the implications of such a decision? Choose one answer. a. If she does not sign up for a Medicare prescription drug plan, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications. correct b. 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. c. 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, she will have to pay a one-time penalty equal to 10% of the annual premium amount. d. 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, she will be required to pay a higher premium during the first year that she is enrolled in the Medicare prescription drug program. After that point, her premium will return to the normal amount. Question 34 Marks: 1 Mr. Olsen is concerned that a Medicare Advantage plan will not cover the same range of services that would be covered under Original fee-for-service Medicare. What should you tell him? Choose one answer. a. Medicare Advantage plans differ from Original Medicare in that they are required to cover any service ordered by a physician. b. Medicare Advantage plans are required to create a benefits package that results in roughly equivalent costs and may exclude coverage for some items and services that are covered under Part A and/or Part B of Original Medicare. correct c. Though their cost-sharing may differ from Original Medicare’s, Medicare Advantage plans are required to cover all services covered by original Medicare. d. Medicare Advantage plans are required to cover services mandated under health care reform and applicable state law, which may differ from the Original Medicare package of benefits. Question 35 Marks: 1 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? Choose one answer. a. Third parties may only make initial contact with a beneficiary if they first obtain certification from the Medicare agency as an approved marketing entity and are licensed under applicable state law. b. Third parties may make initial calls to a potential client, but they must then pass the name and phone number on to you and it will be your responsibility to set up the sales appointment and obtain a completed scope of appointment form. c. This is an acceptable practice, as long as the third party clearly states, during a call that it is calling on behalf of a Medicare Advantage or Part D plan, or the plan’s marketing representative. correct d. Third parties may not make unsolicited calls to potential Medicare enrollees in order to set up such appointments, or for any other reason related to the marketing of Medicare Advantage or Part D plans. Question 36 Marks: 1 Mr. Decaro has looked at Medicare prescription drug plans available in his area and noted a wide range in premiums. He thought that all the drug plans were required to offer the same standard benefits and would like you to explain why there is such a range in premiums. What should you tell him? Choose one answer. a. The premiums differ because some plans intend to market to sicker beneficiaries and have set their premiums to reflect expected greater costs. correct b. Some prescription drug plans may have higher operating costs and/or may offer enhanced coverage in return for an additional premium amount. He could look at plan designs to see if one of the enhanced plans would serve his needs better than a plan based on the standard design. c. All drug plans must offer exactly the same coverage model. The difference in premium is a result of the differing financial estimates of the companies offering the plans. d. Medicare permits plans that have the highest quality services to reduce their premiums below the standard amount in order to increase their market share. This accounts for the variation in premium amounts. Question 37 Marks: 1 Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? Choose one answer. a. Medicare Advantage is designed to pick up where Original Medicare leaves off, covering those health care services that would not normally be covered by Original Medicare. b. Medicare Advantage is a health insurance program operated jointly by the states with the Federal government. correct c. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. d. Medicare Advantage is a new name for the Original Medicare program. Question 38 Marks: 1 Mr. Jenkins is interested in enrolling in a Medicare cost plan and has sought your advice. What would you tell him? Choose one answer. Susan M correctly fixed to be D a. Cost plans that offer an optional supplemental Part D benefit are required to be open to enrollment at least 90 days per year in addition to accepting Part D enrollments during the annual enrollment period. b. All cost plans (like other types of MA plans) are required to be open for enrollment during the MA annual election period. c. Costs plans are required to be open to enrollment year-round, so he should select a date when he would like coverage to begin. correct d. Cost plans are required to be open to enrollment at least 30 days per year, and many are open for enrollment all year. So open enrollment will be dependent on the plan he chooses. Question 39 Marks: 1 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? Choose one answer. correct 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. b. He can keep his plan indefinitely because prescription drug plans must be available to all beneficiary’s regardless of where they live. c. Since he is moving before the Annual Election Period, he will need to continue using the prescription drug plan but should get his prescriptions filled through the plan’s mail order service. d. Since he is moving before the Annual Election Period, he should request an exception to continue using the plan for several more months until the AEP when he can enroll in a new plan. Question 40 Marks: 1 Ms. Lopez is an independent agent under contract with MarketCo, a third-party marketing organization. MarketCo has a contract with BestCare health plan, a Medicare Advantage (MA) organization, to offer marketing services through its contracted agents and agencies. Ms. Lopez returns calls to individuals who contact MarketCo in response to its mailers promoting BestCare health plan. Which of the following best describes the responsibilities of Ms. Lopez? Choose one answer. a. Ms. Lopez needs to maintain state licensure, but because she is working for a third-party marketing organization she is exempt from CMS training requirements that apply to BestCare captive agents. correct b. Ms. Lopez is considered a marketing representative of BestCare and thus is obligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. c. Ms. Lopez is considered a marketing representative of BestCare but is exempt from the marketing rules regarding approved call scripts because she works directly for MarketCo. d. Ms. Lopez no longer needs to be concerned about state licensure since she is marketing an MA product subject to federal rules. Question 41 Marks: 1 Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage (MA) health plans. This year she has decided to focus on non-MA products. What advice would you give Melanie if she wishes to continue to receive renewal fees? Choose one answer. correct a. Melanie must remain trained, tested, licensed, and appointed, regardless of whether she is actively selling MA products. b. All that she needs to do is avoid being terminated for cause. c. All that she needs to do is meet state licensure requirements moving forward. d. Melanie will need to do nothing to continue receiving renewal fees since the initial sale was made when she met all requirements. Question 42 Marks: 1 Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him? Choose one answer. correct a. Formularies must be developed with input from pharmacists, doctors, and other experts. b. Formularies are developed by a consortium of health plans. c. Plans must use a single, standard formulary developed by the Federal government to keep costs down and quality high for beneficiaries. d. Formularies are developed purely on the basis of drug costs and include the least expensive drugs to keep costs down for beneficiaries and the Medicare program. Question 43 Marks: 1 Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable income only sporadically. Her husband worked full-time throughout his long career. She has heard that to qualify for Medicare Part A she has to have worked and paid Medicare taxes for a sufficient time. What should you tell her? Choose one answer. a. She will have to obtain a job and work enough years to qualify for Medicare Part A. b. She will have to pay the monthly Part A premium in order to obtain the coverage. correct c. Since her husband paid Medicare taxes during the entire time he was working, she will automatically qualify for Medicare Part A without having to pay any premiums. d. Because her husband paid Medicare taxes, and she rarely did, she will have to pay Part A premiums but will do so at a reduced rate. Question 44 Marks: 1 Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year? Choose one answer. correct a. When a formulary change is in response to a drug’s removal from the market. b. Under no conditions can a Medicare Part D prescription drug plan reduce its coverage for a given drug at any point during the year. c. When the Part D plan can demonstrate to CMS that no enrollee has accessed the medication in the past six months, generally the plan can remove the drug from its formulary within the first 60 days of the year. d. If the Medicare prescription drug plan can show that reducing coverage early in the year will result in savings for the Part D plan and the Medicare program, generally the plan may make such a change. Question 45 Marks: 1 Able, Baker, and Charles are engaged in the marketing to and enrollment of beneficiaries into Medicare health plans. Mr. Able is an independent agent paid directly by a health plan. Ms. Baker is an independent agent paid through a field marketing organization (FMO). Mr. Charles is an independent agent paid for his work by a third-party marketing organization (TMO). How do the CMS compensation rules apply to these three agents? Choose one answer. This maybe wrong? a. Baker and Charles are subject to CMS compensation rules because they are paid by third parties. Able is not because he is paid directly by a health plan. correct b. All three are treated as independent agents under CMS compensation rules. c. Charles is subject to CMS compliance rules because he works for a TMO and CMS applies an extra layer of scrutiny to such organizations. Able and Baker are not. d. Able is subject to CMS compensation rules because he is paid directly by a health plan. Agents Baker and Charles are not because they are paid by third parties. Question 46 Marks: 1 Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a meeting so that she can learn about Medicare and the products you represent. How should you respond? Choose one answer. a. Tell Julia that she must first complete a questionnaire providing her health history so that you can recommend an appropriate product before submitting an enrollment application, since she qualifies for a special enrollment period. b. Tell Julia that you are happy to meet with her once this year’s open enrollment begins on October 15th. correct c. Tell Julia that you will meet with her to explain Medicare and should she be interested you can accept and submit an enrollment request, since this is an initial enrollment qualifying her for a special enrollment period. d. Tell Julia that you will meet with her at a time of her convenience within the next week, when you can accept a completed enrollment application to be submitted after October 15th. Question 47 Marks: 1 Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her area. Ms. Levi often travels to visit relatives and is concerned that she may need emergency care outside of her plan’s service area. What should you tell her about coverage of emergency care? Choose one answer. a. Plans are required to cover at least 20% of the cost of out-of-network emergency care. b. Plans are required to cover all charges for in-network emergency care, but coverage of out-of-network emergency care is not required. correct c. Plans are required to cover out-of-network emergency care. d. Plans are required to cover out-of-network emergency care only if she has the ambulance driver or ER doctor call her plan for approval prior to receiving emergency services. Question 48 Marks: 1 Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales presentation? Choose one answer. a. Any meal is allowed, as long as it is valued at less than $15. b. Any type of meal or food is allowed, as long as it is available to the general public and not just those who are eligible to enroll in the plans. correct c. A meal cannot be provided, but light snacks would be permitted. d. Nothing may be provided to eat or drink during the sales presentation. Question 49 Marks: 1 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? Choose one answer. correct a. Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig’s disease so she will be eligible for Medicare. b. Medicare is a program for people of all ages with specific mental health disabilities. Since she is in excellent health, she would not qualify, but should instead look into her state’s Medicaid program if she wants further coverage. c. Eligibility for Medicare is based on whether or not a person has ever been employed by the federal government. If she or her husband were ever employed by the federal government, she can enroll in Medicare. d. Medicare is a program for people who have incomes and assets below specific limits, so you will have to find out her exact financial situation before telling her whether she can obtain Medicare coverage. Question 50 Marks: 1 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? Choose one answer. a. He will incur a one-time financial penalty equal to 30 percent of the annual Part D premium. correct b. He will incur a late enrollment penalty. c. He will avoid any financial penalty or late enrollment fee under the grandfathering provisions of Medicare Part D. d. He will not be able to enroll in Part D unless he decides to also enroll in a Medicare Advantage plan.
  20. www.naaip.org/medicare-ahip-2020-part-5-enrollment-guidance-medicare-advantage-part-d-plans.pdf Question: 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? Answer: 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. Question: 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? Answer: He will have to enroll in Part B. Question: 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? Answer: 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. Question: Mr. Gonzalez is entitled to Part A, but has not yet enrolled in Part B. If he wants to enroll in a Medicare Advantage (MA) plan, what will he have to do? Answer: He will have to enroll in Part B prior to enrolling in a MA plan. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: Which of the following individuals is most likely to be eligible to enroll in Medicare Advantage of Part D Plan? Answer: Jose, a grandfather who was granted asylum and has worked in the United States for many years. Question: Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? Answer: He will have one opportunity to enroll in a Medicare Advantage plan. Question: 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? Answer: She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: 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 Question: Mr. Ford enrolled in an MA-only plan in mid November. 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? Answer: 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. Question: 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? Answer: Her daughter should come in November. Question: 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. What should you do? Answer: Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins. Question: 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? Answer: 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. Question: 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? Answer: During the MA Open enrollment Period, from January 1 - March 1, she may disenroll from the MA or MA-PD plan into Original Medicare and also may add a stand-alone prescription drug plan. Question: 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? Answer: This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form prior to the start of the AEP. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage. Question: 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? Answer: 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). Question: 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. Answer: II, III, and IV only Question: 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. Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: It means that he qualifies for a one-time opportunity to enroll into an MA-PD or Part D prescription drug plan. Question: 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? Answer: 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 during the first 9 months of each calendar year beginning in 2019. Question: 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? Answer: He can enroll in or disenroll from a Part D plan and the subsidy will apply to the plan he chooses. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan. Question: 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? Answer: His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility. Question: Mrs. Pierce would like to enroll in a Medicare Cost plan that offers Part D prescription drug coverage. She comes to you for advice about when she can enroll in a plan you have previously discussed. What should you tell her? Answer: Enrollment in Cost plans offering Part D coverage is available only during open enrollment periods under the Part D program, and Cost plans must accept enrollments during these periods. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: You may correct this information as long as you add your initials and date next to the correction. Question: 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. Answer: II and III only Question: 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? Answer: If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. Question: 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. Answer: "If you're not in very good health, you will probably do better with a different product." Question: 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? Answer: 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. Question: Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: Evidence of plan membership, information on how to obtain services, and the effective date of coverage. Question: 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? Answer: 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. Question: 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? Answer: Mrs. Wilson will be contacted by the plan sponsor within 15 calendar days of receipt of the enrollment request. Question: 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? Answer: She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Question: 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? Answer: You can offer to review the plans appeal process to help him ask the plan to review the coverage. Question: 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? Answer: 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. Question: 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? Answer: She only needs to enroll in the new MA-PD plan and she will automatically be disenrolled from her old MA plan. Question: 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? Answer: 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. Question: 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? Answer: 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. ] Question: 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? Answer: Mrs. Valentino can submit a written request to Medicare to be disenrolled from the Cost plan and enroll in Original Medicare. Question: Mr. Wilcox has been enrolled in Lexington PFFS Medicare Advantage Plan (Lexington) for several years. Recently, Mr. Wilcox decided to spend time with his children who live in another state that is not in Lexington's service area. In the future, he may relocate near his children permanently. How does this move to another service area impact his PFFS MA coverage? Answer: Lexington can allow for Mr. Wilcox's continued enrollment for up to 12 months whether or not he is in a visitor/traveler(V/T) program.
  21. www.naaip.org/medicare-ahip-part-4-marketing-advantage-part-d-plans.pdf Question: Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services' communication and Marketing Guidelines to ensure he is compliant for which type of products? Answer: Medicare Advantage (MA) and Prescription Drug (PDP) plans. Question: 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? Answer: 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. Question: 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? Answer: You must submit your materials to the plan you represent, so CMS can review and approve the materials to ensure they are accurate. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located. Question: Which of the following is a correct statement about state laws as they pertain to marketing representatives? Answer: Medicare health plans must comply with requests for information from state insurance departments investigating complaints about a marketing representative. Question: 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? Answer: You may request RSVPs, but you are not permitted to require contact information. Question: 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? Answer: 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. Question: If you are compliance with Medicare's guidance regarding education events, which of the following would be acceptable activities? Answer: You may distibute business cards to individuals who request information on how to contact for further details on the plan(s) you represent. Question: 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? Answer: You must ensure that the advertisements indicate it is an educational event, otherwise, it will be considered a marketing event. Question: 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? Answer: You should tell your colleague NO because participation in an educational event may NOT include a sales presentation. Question: 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? Answer: Yes. When an event has been advertised as "educational," discussing plan-specific premiums is impermissible. Question: 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? Answer: 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. Question: 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? Answer: 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 Question: 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? Answer: You may provide her with the required enrollment materials and take her completed enrollment application. Question: 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? Answer: 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. Question: 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? Answer: You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: Marketing representatives may initiate electronic contract through e-email but an opt-out process must be provided. Question: 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? Answer: 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. Question: 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? Answer: Authorization maybe obtained by directing the beneficiary to a website to provide consent as long as the website includes a mechanism for electronic signature that is valid under applicable law. Question: 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? Answer: The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4-stars. Question: 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? Answer: Tell her that the Medicare agency does not endorse or recommend any plan. Question: 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? Answer: You may make comparisons between the plans if you can support them by studies or statistical data and such comparisons are factually based. Question: 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? Answer: You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. Question: When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan. Answer: You may provide gifts or prizes to all potential enrolless during an event that do not exceed $15 retail value. Question: 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? Answer: This could be considered discriminatory activity and a prohibited practice. Question: 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? Answer: 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. Question: 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? Answer: The neighbors may not provide a meal, but light snacks would be permitted. Question: 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? Answer: 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. Question: 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? Answer: Gift cards or gift certificates of $15 or less that can be readily converted to cash. Question: 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? Answer: Clearly state that no obligation exists to enroll if a gift or prize is being offered. Question: 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? Answer: He can give away more than one gift during a single event, but the aggregate retail value cannot exceed $15. Question: You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns? Answer: Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facilityQu. Question: 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? Answer: 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. Question: 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? Answer: You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request. Question: 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? Answer: 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. Question: Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members? Answer: Market non-Medicare health-related products, such as dental insurance, to current members as permitted by HIPAA Privacy Rules. Question: 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? Answer: You may go ahead and call them. Question: 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? Answer: The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. Question: 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? Answer: Cooperate with the state and supply requested information. Question: 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? Answer: 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. Question: 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? Answer: CMS requires plan sponsors to create and complete a corrective action plan and may terminate a sponsor's contract. Question: 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 Answer: I, II, and IV only Correct Question: 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: Answer: Betty and Denise, but not Alice (the employee) or Carl or Edward (to whom exceptions apply). Question: 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? Answer: 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. Question: 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? Answer: Agent Lopez's entire compensation must be recouped because Ralph disenrolled within 3 months of enrollment. Question: 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? Answer: AB MA plan does not have to recoup Agent Higgins' compensation because she has moved away from its service area.
  22. www.naaip.org/medicare-ahip-2020-part-3-medicare-part-d-prescription-drug-coverage.pdf Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: If a Part D benefit is offered through her plan she may choose in enroll in that plan or a standalone PDP. Question: Which of the following statements about Medicare Part D is correct? 1. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. 2. Private fee-for-service (PFFS) plans are not required to usea pharmacy network but may choose to have one. 3. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. 4. Beneficiaries enrolled in a MA-PPO may obtain Part B benefits through a standalone PDP or through their plan. Answer: 1,2, and 3 only. Question: 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 2020 under the standard coverage? Answer: Standard Part D coverage would require payment of an annual deductible of $435, 25% cost-sharing between $435 and $4,020, and once through the catastrophic coverage threshold, the beneficiary pays either co-pays for generics and brand-name drugs or co-insurance of 5% whichever is greater. Question: 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? Answer: 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 Question: 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? Answer: 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. Question: 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 hat she has lost. How would you advise her? Answer: She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Question: What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medication? Answer: 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. Question: Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year? Answer: When a formulary change is in response to a drug's removal from the market. Question: 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. Answer: I, II and III only Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.
  23. www.naaip.org/medicare-AHIP-2020-part-2-program-medicare-health-plans.pdf Question: 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? Answer: They are Medicare health plans such as HMOs, PPOs, PFFS, SNPs, and MSAs. Question: Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be a correct description? Answer: Medicare Advantage is a way of covering all of the Original Medicare benefits through private health insurance companies. Question: Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? Answer: Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Question: Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? Answer: He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Question: Mrs. Davenport 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? Answer: 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. Question: Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problem functioning. What type of SNP is likely to be most appropriate for him? Answer: C-SNP Question: 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? Answer: 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. Question: 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? Answer: 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. Question: Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? Answer: 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 or care is unavailable within the network). Question: 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? Answer: Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will be charged a lower co-payment if she goes to one of the plan's preferred providers. Question: 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? Answer: 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. Question: 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? Answer: PFFS plans may choose to offer Part D benefits but are not entitled to do so. Question: 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? Answer: 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. Question: Dr. Elizabeth Brennan does not contract with the PFFS plan, but accepts the plan's terms and conditions for payment. Mary Rodger sees Dr. Brennan for treatment. How much may Dr. Brennan charge? Answer: Dr. Brennan can charge Mary Rogers no more than the cost sharing specified in the PFFS plan's terms and conditions of payment which may include balance billing up to 15 percent of the Medicare rate. Question: 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? Answer: 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. Question: Which of the following statementy is correct about Medicare Savings Account (MSA) Plans? 1. MSAs may hae either a partial network, full network, or no network of providers. 2. MSA plans cover Part D and Part B benefits but not Part D prescritpion drug benefits. 3. An individual who is enrolled in an MSA plan is responsible for minimal deductible of $500 indexed for inflation. 4. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. Answer: 1,2 and 4 only. Question: 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? Answer: 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. Question: For which of the following individuals would a Cost Plan be most appropriate? Answer: Mr. Baker who is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan premiums. Question: 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? Answer: 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. Question: Which statement best describes PACE plans? Answer: 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 service. Question: 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? Answer: Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep. Question: Mrs. Walters is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Advantage Plan?] Answer: She can enroll in any type of Medicare Advantage(MA) plan except an MA Medical Savings Account (MSA) plan. Question: 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? Answer: Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. Question: 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 Medicare covered services. How much may the doctor collect from Mr. Rivera? Answer: The doctor may only collect from Mr. Rivera the cost sharing allowable under the state's Medicaid program. Question: 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? Answer: 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. Question: Mrs. Chou likes a PFFS plan available in her area that does not offer drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her? Answer: She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan.
  24. The First 5 Posts will be the 5 Module Questions and Answers - The 6th Post will have AHIP 2020 Questions and 48 of 50 correct Answers - help me find the two incorect - A post further down on the first page from Agent Gary will have another set of 50 AHIP Questons and 50 correct Answers. On the 2nd page you see Judy from Nevada added another 50 questions and correct answers. We helped Judy find the one incorrect answer. How many questions are on the AHIP exam? 50 What score do you need to pass AHIP? 90% - no more than 5 wrong answers. How do you pass AHIP test? It is an open book test. It is useful to be skilled with the search feature (control + f) on the PC. You have three tries to pass with all carriers. If fail all three, you can try again next AEP. UHC allows 6 tries but it would be advantageous to you to do attempt 4, 5, and 6 from UHC's internal certification which is free and allows a lower passing score. How long does it take to complete AHIP? 2 Hours. How much does AHIP certification cost? $175 from AHIP but if you click from from a carrier back office it will be $125. This payment allows you three attempts to pass. As well, there is a link on our forum - Medicare All News - that has the $125 link without having to login to carrier back office. What does AHIP mean? America's Health Insurance Plans ================================================================================================================= www.naaip.org/medicare-AHIP-2020-part-1-program-basics.pdf Question: 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? Answer: Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's disease so she will be eligible for Medicare. Question: Mr. Schmidt would like to plan for retirement and asked you what is covered under Original Fee-for-Service (FFS) Medicare? What would you tell him? Answer: 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 by the Original Medicare. Question: 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? Answer: Medicare Advantage plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs. Question: Mrs. Roberts has just received a new Medicare identity card in the mail. She is concerned that is a forgery since it does not have her social security number on it. What should you tell her? Answer: 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. Question: Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Health Plan before she starts looking at specific plans. What should you tell her? Answer: Medicare Health Plans 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. Question: 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 would you tell Mr. Moy? Answer: 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. Question: Mrs. Chen will be 65 soon, has been a citizen for twelve year, has been employed full time, and paid taxed during that entire period. She is concerned that she not qualify for coverage under Part A because she was not born in the United States. What should you tell her. Answer: Most individuals what are citizens and over age 65 are covered under Part A by viture of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. Question: Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him? Answer: After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. Question: Mr. Denton 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? Answer: He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Question: Ms. Henderson believes that she will qualify for Medicare coverage when she turns 65, without paying any premiums, because she has been working 40 years and paying Medicare taxes. What should you tell her? Answer: In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. Question: Mr. Diaz continued working with his company and was insured under his employer's group plan until he reached age 68. 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. What should you tell him? Answer: Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. Question: Mrs. Peňa is 66 years old, has coverage under an employer plan and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her? Answer: She may 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. Question: Mrs. Kelly is entitled 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? Answer: In order to join a Medicare health plan, she also must enroll in Part B. Question: Mrs. Park is an elderly retiree. Mrs. Park has a low, fixed income. What could you tell her that might be of assistance? Answer: 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. Question: Mr. W is eligible for Medicare. He has limited financial resources but failed to qualify for Part D low-income subsidy. Where might he turn to for help with his prescription drug costs? Answer: Mr. Wu may still qualify for help in paying Part D costs through his State Pharmacuitical Assistance Program. Question: 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? Answer: 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. Question: 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? Answer: Medicare will cover Mrs. Schmidt's 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. Question: 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? Answer: Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. Question: Mrs. Quinn recently turned 65 and decided after many years of work to being receiving Social Security benefits. Shortly thereafter Mrs. Quinn 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? Answer: 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. Question: 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? Answer: 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. Question: 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? Answer: Original Medicare covers ambulance services. Question: 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? Answer: Medicare does not cover acupuncture, or, in general, glasses or dentures. Question: Mr. Singh would like drug coverage, but does not want to be enrolled into a health plan. What should you tell him? Answer: 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. Question: 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? Answer: He generally would pay a monthly premium, annual deductible, and per-prescription cost sharing. Question: 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? Answer: 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. Question: 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? Answer: Mrs. Duarte should file an appeal of this determination within 120 days of the date she received the MSN in the mail. Question: 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? Answer: Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. Question: 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? Answer: 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. Question: 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? Answer: He will incur a late enrollment penalty. Question: 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? Answer: 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. Question: What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have upon Medigap plans? Answer: The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020.
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