AHIP MODULES 1 5 MEDICARE CERTIFICATION
COMPLETE STUDY GUIDE WITH SOLVED
QUESTIONS
◉ 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 (MA) plan?
Answer: She cannot enroll in an MA Medical Savings Account (MSA)
plan.
◉ 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?
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.
◉ 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?
,Answer: She can enroll in the PPO, but she will not be able to
purchase a stand-alone Medicare Part D prescription drug plan.
◉ Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in
Part B. She is considering enrollment in a Medicare Advantage plan
(Part C). What should you advise her to do before she will be able to
enroll in a Medicare Advantage plan?
Answer: To join a Medicare Advantage plan, she also must enroll in
Part B.
◉ 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
only pay for these services if they are furnished by Medicaid
participating providers.
◉ 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
generally obtain his services only from providers within the plan's
network (except in an emergency or where care is unavailable
within the network).
,◉ Juan Perez, who is turning age 65 next month, intends to work for
several more years at Smallcap, Incorporated. Smallcap has a
workforce of 15 employees and offers employer-sponsored
healthcare coverage. Juan is a naturalized citizen and has
contributed to the Medicare system for over 20 years. Juan asks you
if he will be entitled to Medicare and if he enrolls how that will
impact his employer-sponsored healthcare coverage. How would
you respond?
Answer: Juan is likely to be eligible for Medicare once he turns age
65 and if he enrolls Medicare would become the primary payor of
his healthcare claims and Smallcap does not have to continue to
offer him coverage comparable to those under age 65 under its
employer-sponsored group health plan.
◉ Dr. Elizabeth Brennan does not contract with the ABC 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?
Answer: 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%of the Medicare rate.
◉ 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?
Answer: C-SNP
, ◉ 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 either in one of the MA plans that include
prescription drug coverage or Original Medicare with a Medigap
plan and standalone Part D prescription drug coverage, but he
cannot enroll in the MA-only PPO plan and a stand-alone
prescription drug plan.
◉ 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: He should compare the benefits in his employer-sponsored
retiree group health plan with the benefits in his neighbor's MA-PD
plan to determine which one will provide sufficient coverage for his
prescription needs.
◉ Mrs. Lyons is in good health, uses a single prescription, and lives
independently in her own home. She is attracted by the idea of
COMPLETE STUDY GUIDE WITH SOLVED
QUESTIONS
◉ 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 (MA) plan?
Answer: She cannot enroll in an MA Medical Savings Account (MSA)
plan.
◉ 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?
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.
◉ 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?
,Answer: She can enroll in the PPO, but she will not be able to
purchase a stand-alone Medicare Part D prescription drug plan.
◉ Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in
Part B. She is considering enrollment in a Medicare Advantage plan
(Part C). What should you advise her to do before she will be able to
enroll in a Medicare Advantage plan?
Answer: To join a Medicare Advantage plan, she also must enroll in
Part B.
◉ 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
only pay for these services if they are furnished by Medicaid
participating providers.
◉ 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
generally obtain his services only from providers within the plan's
network (except in an emergency or where care is unavailable
within the network).
,◉ Juan Perez, who is turning age 65 next month, intends to work for
several more years at Smallcap, Incorporated. Smallcap has a
workforce of 15 employees and offers employer-sponsored
healthcare coverage. Juan is a naturalized citizen and has
contributed to the Medicare system for over 20 years. Juan asks you
if he will be entitled to Medicare and if he enrolls how that will
impact his employer-sponsored healthcare coverage. How would
you respond?
Answer: Juan is likely to be eligible for Medicare once he turns age
65 and if he enrolls Medicare would become the primary payor of
his healthcare claims and Smallcap does not have to continue to
offer him coverage comparable to those under age 65 under its
employer-sponsored group health plan.
◉ Dr. Elizabeth Brennan does not contract with the ABC 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?
Answer: 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%of the Medicare rate.
◉ 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?
Answer: C-SNP
, ◉ 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 either in one of the MA plans that include
prescription drug coverage or Original Medicare with a Medigap
plan and standalone Part D prescription drug coverage, but he
cannot enroll in the MA-only PPO plan and a stand-alone
prescription drug plan.
◉ 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: He should compare the benefits in his employer-sponsored
retiree group health plan with the benefits in his neighbor's MA-PD
plan to determine which one will provide sufficient coverage for his
prescription needs.
◉ Mrs. Lyons is in good health, uses a single prescription, and lives
independently in her own home. She is attracted by the idea of
