AHIP questions with complete solutions

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 (W) 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. (W) 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 (W) 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 (W) 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.