AHIP Testing 2018

Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern?

Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end stage renal disease or Lou Gehrig’s disease, so she will be eligible for Medicare

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

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

Mr. Hernandez is concerned that if he signs up for a Medicare Advantage plan, the health plan may, at some time in the future, reduce his benefits below what is available in Original Medicare. What should you tell him about his concern?

Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs.

Mrs. Raskin is a widow who will attain aged 65 and enroll in Medicare in just a few weeks. She concerned about having prescription drug coverage. Which of the following statements provides the best advice?

Prescription drug coverage can be obtained by enrolling in a Medicare Advantage plan that includes Part D coverage.

Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefit package of a Medicare Health Plan before she starts looking at specific plans. What could you tell her?

Medicare Health Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services.

Mr. Meoni’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.Meoni?

Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.

Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her?

Most individuals who are citizens and over age 65 are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums.

Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him?

After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.

Mr. Davis is 49 years old and has been receiving disability benefits from the Social Security Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescription Drug policy?

No, he cannot purchase a Medicare Advantage or Part D policy because he has not received Social Security or Railroad Retirement disability benefits for 24 months.

Ms. Henderson believes that she will qualify for Medicare coverage when she turns 65, without paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her?

In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes.

Mr. Diaz continued working with his company and was insured under his employer’s group plan until he reached 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?

Mr. Diaz will not pay any penalty because he had continuous coverage under his employer’s plan.

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?

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.

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?

In order to join a Medicare health plan, she also must enroll in Part B.

Mrs. Park has a low, fixed income. What could you tell her that might be of assistance?

She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible.

Mr. Yu has limited income and resources so you have encouraged him to see if he qualifies for some type of financial assistance. Mr. Yu is not sure it is worth the trouble to apply and wants to know what the assistance could do for him if he qualifies. What could you tell him?

He might qualify for help with Part D prescription drug costs and help paying Part A and/or Part B premiums, deductibles, and/or cost sharing.

Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare?

Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs

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

Medicare will cover Mrs. 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

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

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

Mrs. Quinn has just turned 65 and received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn?

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

Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him?

Medicare covers periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered.

Mrs. Turner is comparing her employer’s retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met? What could you tell her?

Original Medicare covers ambulance services.

Mrs. Wolf wears glasses and dentures and has enjoyed considerable pain relief from arthritis through acupuncture. She is concerned about whether or not Medicare will cover these items and services. What should you tell her?

Medicare does not cover acupuncture, or, in general, glasses or dentures.

Mr. Singh would like drug coverage, but does not want to be enrolled into a health plan. What should you tell him?

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

Mr. Alonso receives some help paying for his two generic prescription drugs from his employer’s retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him?

He generally would pay a monthly premium, annual deductible, and per-prescription cost sharing.

Mrs. Geisler’s neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can’t remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her?

Part D covers prescription drugs and she should look at her premiums, formulary, and cost sharing among other factors to see if they have changed.

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

Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services.

Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has, but replace her existing Medigap plan with one that provides drug coverage. What should you tell her?

Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan.

Mr. Kelly has substantial financial means. He enrolled in Original Medicare and purchased a Medigap policy many years ago that offered prescription drug coverage. The prescription drug coverage has not been comparable to that offered by Medicare Part D for several years and despite notification, Mr. Kelly took no action. Which of the following statements best describes what will occur if Mr. Kelly now decides to enroll in Medicare Part D?

He will incur a late enrollment penalty.

Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him?

It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare.

What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have upon Medigap plans?

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

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?

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

Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be a correct description?

Medicare Advantage is a way of covering all of the Original Medicare benefits through private health insurance companies.

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

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

Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?

Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.

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

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

Mrs. Billings enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs. Billings have in regard to her MA plan during the next open enrollment season?

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.

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

In most Medicare Advantage HMOs, Mr. Kumar must obtain his services only from providers who have a contractual relationship with the plan (except in an emergency).

Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can go to for her health care. What should you tell her?

Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will be charged a lower co-payment if she goes to one of the plan’s preferred providers.

Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him?

SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well.

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?

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.

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?

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.

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?

If she uses non-network providers, her doctors and hospital could decide whether to treat her on a visit-by-visit basis

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?

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.

If Dr. Elizabeth Brennan does not contract with the PFFS plan, but accepts the plan’s terms and conditions for payment, how will she be paid?

Generally, the PFFS plan will pay Dr. Brennan directly the same amount Original Medicare would pay her.

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?

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

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?

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.

Which statement best describes PACE plans?

It includes comprehensive medical and social service delivery systems using an interdisciplinary team approach in an adult day health center, supplemented by in-home and referral services.

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?

Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep.

Mrs. Walters is enrolled in her state’s Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Health Plan?

Medicaid will coordinate benefits only with Medicaid participating providers.

Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her?

Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers.

Mr. Rivera has QMB-Plus eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later in the year, Mr. Rivera needs dentures, a service only covered under Medicaid. What action would you recommend he take in order to have this cost covered?

He should go to a Medicaid provider or obtain the services through a Medicaid manage care plan if he is enrolled in one.

Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr. Lombardi’s area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell him about this situation?

He could enroll in one of the MA plans that include prescription drug coverage or a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan.

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?

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

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?

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.

Mrs. Mulcahy is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her?

Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan.

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?

If a Part D benefit is offered through her plan she may choose in enroll in that plan or a standalone PDP.

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 2018 under the standard coverage?

Standard Part D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a portion of costs for both generics and brand-name drugs in the coverage gap, and co-pays or co-insurance after the coverage gap.

Mrs. Andrews was preparing a budget for next year because she takes quite a few prescription drugs, she will reach the coverage gap, and wants to be sure she has enough money set aside for those months. She received assistance calculating her projected expenses from her daughter who is a pharmacist, but she doesn’t think the calculations are correct because her out-of-pocket expenses would be lower than last year. She calls to ask if you can help. What might you tell her?

It would not be unusual for her costs to be a bit less because each year until 2020, an enrollee’s share of the drug costs in the coverage gap are less.

Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums and cost sharing. How can you explain this to him?

Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government.

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?

She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy.

What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?

Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization.

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

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

Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them?

Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn’s could look into that possibility

Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug mid-way through the year?

When a new generic drug for the same condition becomes available or when the FDA or manufacturer withdraws the drug from the market, a brand name drug can be replaced.

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?

Every Part D drug plan is required to cover a 30 day supply of her existing medications sometime during a 90 day transition period.

Mr. Zachow has a condition for which three drugs are available. He has tried two, but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan’s formulary. What could you tell him to do?

Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan’s website, fill it out, and submit it to his plan.

Mr. Katz reached the Part D coverage gap in August last year. His prescriptions have not changed, he is keeping the same Part D plan and the benefits, cost-sharing, and coverage of his drugs are all the same as last year. He asked what to expect for this year about his out-of-pocket costs. What could you tell him?

Because he reached the coverage gap last year, he will probably reach it again this year close to the same time.

Mrs. Grant uses several very expensive drugs and anticipates that she will enter catastrophic coverage at some point during the year. To help her determine when she is likely to qualify for catastrophic coverage, she asked which expenses count toward the out-of-pocket limit that qualifies her for catastrophic coverage. Which one of the following would count?

Prescription drugs she purchases when in the Part D coverage gap.

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?

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

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?

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.

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

He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses.

Mrs. Quinn has just turned 65, is in excellent health, and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. What could you tell her about the implications of such a decision?

If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered.

Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him?

In general, he must select a single Part D premium payment mechanism that will be used throughout the year.

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?

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.

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?

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.

Mr. Jenkins 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?

If Mr. Jenkins 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.

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?

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.

Mrs. McIntire is enrolled in her state’s Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen with respect to her drug coverage?

Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.

Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services’ Marketing Guidelines to ensure he is compliant for which type of products?

Medicare Advantage (MA) and Prescription Drug (PDP) plans

Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same requirements as the plans themselves. How should you respond to such a statement?

Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules.

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?

You must submit your materials to the plan you represent, so CMS can review and approve the materials to ensure they are accurate.

Which of the following is a correct statement about state laws as they pertain to marketing representatives?

Medicare health plans must comply with requests for information from state insurance departments investigating complaints about a marketing representative.

You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation?

You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score, although you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing.

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?

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.

Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong?

Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located.

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?

You may request RSVPs, but you are not permitted to require contact information.

Agent Antonio is preparing for a presentation on Medicare and Medicare Advantage before a local senior citizen civic group where he hopes to enroll some attendees. Which of the following steps should he take in order to be in compliance with Medicare marketing rules?

Antonio should include on the invitation a statement that a salesperson will be present with information and applications.

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?

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.

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?

You may provide her with the required enrollment materials and take her completed enrollment application.

While marketing Medicare Advantage and Part D plans, you collected a large number of scope of appointment forms from your clients, wherein they indicated their interest in specific products and their wish for you to provide information on those products in their homes. What should you do with those forms?

The scope of appointment forms must be retained for a period of ten (10) years.

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?

You must have her sign a scope of appointment form, indicating which products she wishes to discuss, and note on the form that she is a "walk in." You may then proceed with the discussion.

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?

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.

Which of the following statements best describes how business reply cards (BRCs) may be employed in the marketing of Medicare Advantage products?

A BRC may be used to document a beneficiary’s scope of appointment agreement provided it has been submitted to CMS for approval and includes a statement informing the beneficiary that a salesperson may call.

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?

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.

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?

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.

You have received an advertisement from a vendor who says they can provide you with an extensive list of publicly available e-mail addresses for individuals who are Medicare beneficiaries. In addition, one of your Medicare Advantage clients offered to share her e-mail address book with you so you could contact her Medicare-eligible friends. In considering these sources of leads, what rules must you be sure to abide by?

You may send an e-mail to a beneficiary about Medicare Advantage plan information if the beneficiary provides his/her email address to the plan and agrees to receive e-mails from the plan.

Agent Mark Andrews would like to employ technology to facilitate the growth of his Medicare Advantage (MA) practice. What step(s) would you recommend that Mark take?

Purchase Internet pop-up ads providing plan-specific information that have been reviewed and approved by CMS.

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?

Authorization may be obtained by directing a beneficiary to a website to provide consent.

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?

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

Mr. Valesquez asked if the Private Fee-for-Service plan you have discussed is like Original Medicare or a Medigap supplement plan. What should you say about a Private Fee-for-Service (PFFS) plan to explain it to Mr. Valesquez?

It is not Original Medicare and it works differently than a Medicare supplement plan

Ajax Agency is targeting potential enrollees for MSA plans. Which of the following statements best describes the rules that apply to the MSA materials it distributes?

The materials must make clear that Medicare MSA plans do not cover prescription drugs and that beneficiaries can join a separate Part D prescription drug plan.

During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her?

Tell her that the Medicare agency does not endorse or recommend any plan

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?

You may present comparative information that has been created and approved by the Medicare agency (CMS), such as a print-out from the Medicare plan comparison website.

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?

You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal

Ordinarily, you provide clients who purchase various types of insurance products from you with a gift when they enroll and you let them know that they will receive it after their enrollment is complete. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?

You may not provide any gift or prize as an inducement to enroll.

One of your colleagues argues that face-to-face meetings with potential enrollees should be required because they cannot make an appropriate decision with the minimal information that can be provided over the phone or in small brochures. How should you respond to this argument?

This is incorrect. Brokers and agents cannot require face to face meetings in order to answer questions or enroll a Medicare beneficiary.

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

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

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?

The neighbors may not provide a meal, but light snacks would be permitted

Ordinarily, you provide clients who purchase various types of insurance products from you with a gift when they enroll and you let them know that they will receive it after their enrollment is complete. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?

You may not provide any gift or prize as an inducement to enroll.

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?

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.

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?

Gift cards or gift certificates of $15 or less that can be readily converted to cash.

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?

Clearly state that no obligation exists to enroll if a gift or prize is being offered.

Ordinarily, you ask your clients for referrals to people they think would benefit from the products you offer. When selling Medicare Advantage or Part D products, how might you solicit referrals?

You may solicit referrals from current MA and Part D enrollees and offer one thank you gift per member per year of less than $15, based on retail purchase price for the item, although you may not inform enrollees of the availability of the gift in your letter soliciting referrals.

When soliciting referrals from current members of an MA or Part D plan, what may you do?

You may request names and mailing addresses.

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

He can give away more than one gift during a single event, but the aggregate retail value cannot exceed $15

You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns?

Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider’s facility.

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?

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.

Your friend’s mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him?

You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request.

ABC is a long-term care facility provider. What steps may it take to inform residents of the Medicare options available to them?

ABC may provide residents that meet the I-SNP criteria an explanatory brochure, reply card, and phone number for additional information for each I-SNP with which it contracts.

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?

Marketing in health care facilities is an acceptable practice, as long as it takes place in common areas where patients are not receiving or waiting to receive health care and as long as the hospital displays materials for all plans that provide them to the hospital.

Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members?

Market non-Medicare health-related products, such a dental insurance, to current members as permitted by HIPAA Privacy Rules.

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

You may go ahead and call them.

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?

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

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

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

You 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?

You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event.

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?

You should tell your colleague no because participation in an educational event may not include a sales presentation.

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?

Yes. When an event has been advertised as "educational," discussing plan-specific premiums is impermissible.

Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual?

The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract.

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

Cooperate with the state and supply requested information.

ABC Health Plan has just learned that several individuals marketing their Medicare Advantage plans in a state are unlicensed. What actions must ABC take in response?

Among other steps, ABC must terminate these individuals and report to both the state and CMS incidences of submission of applications by unlicensed agents and or brokers.

Roberta is a retiree who has just learned that she has purchased a Medicare Advantage (MA) plan from an unlicensed individual representing BestCare Health Plan. What are Roberta’s options, if any?

Roberta may request to change plans upon receiving notification of the agent’s unlicensed status.

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?

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.

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?

CMS requires plan sponsors to create and complete a corrective action plan and may terminate a sponsor’s contract.

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

I, II, and IV only

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:

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

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. How will Agent Chan be compensated under CMS rules?

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

Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to?

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

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?

He will have to enroll in Part B.

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?

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

Mr. Gonzalez is entitled to Part A, but has not yet enrolled in Part B. If he wants to enroll in a Private Fee-for-Service (PFFS) plan, what will he have to do?

He will have to enroll in Part B prior to enrolling in the PFFS plan.

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?

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.

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?

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.

Mr. and Mrs. Nunez attended one of your sales presentations. They’ve asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do?

As long as she is able to do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time.

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?

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.

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?

You may correct this information as long as you add your initials and date next to the correction

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.

II and III only

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?

If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan.

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.

"If you’re not in very good health, you will probably do better with a different product."

You have come to Mrs. Midler’s home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical record available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan. What should you do?

You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has end stage renal disease or one of the conditions that would qualify her for a special needs plan.

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

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

Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time?

He will have one opportunity to enroll in a Medicare Advantage plan

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?

She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B.

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?

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.

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?

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.

When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice would you give her?

She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA plan

Mr. 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?

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.

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?

Her daughter should come in November.

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?

Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins.

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?

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.

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?

During the MA Disenrollment Period, from January 1 – February 14, she may disenroll from the MA-PD plan into Original Medicare and also may add a stand-alone prescription drug plan.

Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application prior the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams?

This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form prior to the start of the AEP.

Mrs. Schmidt is moving and a friend told her she might qualify for a "Special Election Period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a Special Election Period is. What could you tell her?

It is a time period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically the Special Election Period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area.

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?

If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage.

Mrs. Gunner thought she was enrolling in a stand-alone PDP, but when she received her plan materials, she found out she was enrolled in a Private Fee-for-Service (PFFS) plan with drug coverage. She called her marketing representative for help. What should the marketing representative tell her?

If she believes she received misleading information, she must contact Medicare and, if she qualifies for a Special Enrollment Period, she can select a new option, which could include a different MA plan, a PDP, or Original Medicare.

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 no Part D plan available.
IV. Henry makes a permanent move providing him with new MA and Part D options.

II and IV only

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 that his employer is cutting back on prescription drug benefits, and as of June his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special enrollment periods (SEPs)?

Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends two months later.

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?

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.

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?

It means that he qualifies for a one-time opportunity to enroll into an MA-PD or Part D prescription drug plan.

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?

Yes. Qualifying for this state program gives Mrs. Schneider access to a Special Election Period that allows her to make changes to her MA and/or Part D enrollment at any time.

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?

He can enroll in or disenroll from a Part D plan at any time and the subsidy will apply to the plan he chooses

Mr. Carter, who is enrolled in a stand-alone Part D plan, receives the Part D low-income subsidy and just received a letter from the Social Security Administration informing him that he will no longer qualify for the subsidy? He is wondering if he can switch to a lower cost Part D plan. What should you tell him?

He qualifies for a Special Election Period which begins the month he was notified of his loss and continues for two more months. This SEP allows him one opportunity to enroll into another PDP or an MA-PD.

Mr. Chen is enrolled in his employer’s group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him?

Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment, but he should revaluate if he really wants to drop his employer coverage

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?

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

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?

His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility

Mrs. Lenard is enrolled in a Medicare Cost plan. Recently the cost plan has transitioned to a Medicare Advantage (MA) contract, and Mrs. Lenard has been told that she has been subject to "deemed enrollment." What does this mean?

Mrs. Leonard will be automatically enrolled in an MA plan offered by the same organization as the cost plan, notified by CMS, and given the opportunity to choose another option.

You are completing a PFFS plan sale to Mr. West who is new to Medicare, and as you are finishing up, what should you tell him about next steps in the enrollment process?

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.

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?

Evidence of plan membership, information on how to obtain services, and the effective date of coverage.

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?

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.

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?

Mrs. Wilson will be contacted by the plan sponsor within 15 calendar days of receipt of the enrollment request.

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?

She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment.

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?

You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.

Ms. O’Donnell learned about a new MA-PD plan that her neighbor suggested and that you represent. She plans to switch from her old MA HMO plan to the new MA-PD plan during the Annual Election Period. However, she wants to make sure she does not end up paying premiums for two plans. What can you tell her?

She only needs to enroll in the new MA-PD plan and she will automatically be disenrolled from her old MA plan.

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?

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.

Mrs. Murdock has been very ill and has been in the hospital multiple times this year. She is concerned that her expenses have reached the maximum out-of-pocket costs and now her special needs plan (SNP) will disenroll her. What can you tell her?

There is no limit on the expenses a plan can incur on behalf of any one beneficiary and a plan sponsor may not end a member’s enrollment just because of high costs, so she should not be concerned.

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?

Mrs. Valentino can submit a written request to Medicare to be disenrolled from the Cost plan and enroll in Original Medicare.

Mr. Robinson was quite ill recently and forgot to pay his monthly premium for his MA-PD plan. He is worried that he will lose his coverage now when he needs it the most. He is certain his plan will disenroll him because that is what happened to a friend of his in a similar type of plan. What can you tell Mr. Robinson about his situation?

Plan sponsors have the option to 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.