2022 AHIP UNIT 2

2022 AHIP UNIT 2 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? a. He could enroll in the MA-only PPO plan and a stand-alone Medicare prescription drug plan b. 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. c.He cannot enroll in a stand-alone prescription drug plan because you do not represent such a plan. d.He could enroll in the MA-only plan and purchase a Medigap plan with drug coverage. Source: Module 2, Slide - MA & Prescription Drugs. Question 2 Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? a.You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. 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. c.You could suggest he call the doctor who performed the surgery to complain about the costs and ask for a discount on the charges. d.You could reassure him that such charges are typical, but if he needs assistance in paying, he should apply to the state for Medicaid assistance. Source: Module 2, Slide - Enrollee Protections, Slide - Enrollee Protections: Complaints, Coverage Decisions, Appeals Question 3 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? a.They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. b.They are custodial long-term care plans for people with Medicare. c.They are Medigap Supplemental plans that fill in the gaps not covered by Medicare. d.They are major medical policies but are only for low-income beneficiaries with Medicare. Source: Module 2, Slide - Medicare Advantage Plans (Overview). Question 4 Mrs. Radford asks whether there are any special eligibility requirementsfor Medicare Advantage. What should you tell her? a.Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, before being accepted and enrolled. b.Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. c.Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States. d.Mrs. Radford must be enrolled in both Medigap and Part A to enroll in a Medicare Advantage plan. Source: Module 2, Slide - Medicare Advantage Eligibility Question 5 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.If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor accepts Original Medicare. c.He may receive servicesfrom any physician, regardless of whether or not that physician participates in the plan or Original Medicare. d.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. Source: Module 2, Slide - MA Plan Types Private Fee-for-Service (PFFS) Plans, MA Plan Types Private Feefor-Service Plans (2 of 3) and MA Plan Types Private Fee-for-Service Plans (3 of 3). Question 6 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 are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. b.Since SNPs don’t cover prescription drugs Mr. Sinclairshould consider a different option. c.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. d.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. Source: Module 2, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description (2 of 2). Question 7 Mr. Wellsistrying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? a.Medicare Advantage is a new name for the Original Medicare program. b.Medicare Advantage is a way of covering all the Original Medicare benefitsthrough private health insurance companies. c.Medicare Advantage is a health insurance program operated jointly by the states with the Federal government. d.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. Source: Module 2, Slide - Part C: Medicare Advantage Plans (Overview). Question 8 Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him? a.C-SNP b.I-SNP c.D-SNP d.FIDE-SNP Source: Module 2, Slide - Medicare Advantage Eligibility, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description (2 of 2). Question 9 Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the plan’s terms and conditionsfor payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan charge? a.Dr. Brennan can charge Mary Rodgers more than the costsharing specified in the PFFS plan’s terms and conditions as long as she treats all beneficiaries the same. Incorrect: Dr. Brennan cannot charge any PFFS plan enrollee more than the cost-sharing specified in that PFFS plan’s terms and conditions. b.Dr. Brennan can charge Mary Rogers no more than the costsharing specified in the PFFS plan’s terms and condition of payment which may include balance billing up to 15% of the Medicare rate. c.Dr. Brennan can charge the beneficiary the same cost-sharing as Original Medicare as long as she sends the claim to Medicare and not the plan. d.Dr. Brennan can charge Mary Rodgers no more than the cost sharing specified in the PFFS plan’sterms and conditions of payment which may include balance billing up to 25% of the Medicare rate. Source: Module 2, Slide - MA Plan Types: Private Fee-for-Service Plans (3 of 3). Question 10 Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctorrecently prescribed several expensive medications. Currently,she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? a.Mrs. Chi is ineligible for a MA MSA plan because she is ineligible for Medicaid due to her income level. b.Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage it must be a MSAPD plan that includes drug coverage. Incorrect. MA MSA plans are prohibited from offering prescription drug coverage. If an MSA member wants prescription drug coverage, the member must enroll in a standalone PDP. c.Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. d.Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage she must also enroll in a Medicare Supplement Plan (Medigap) F that covers the Medicare Part B deductible and includes both drug coverage. Source: Module 2, Slide - MA & Prescription Drugs, Slide - Medicare Advantage Eligibility: MSAs Question 11 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? a.Generally, employers prefer retireesto have both the retiree group plan and the MA-PD plan to fill in the gaps, but he would be better off with just the MA-PD plan. b.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. c.When possible, it is always the best option to have both the employer’s plan and the MA-PD, so he would have no out-of-pocket expenses. d.Generally, employers prefer retireesto enroll in a stand-alone PDP,so he should consider that instead of the MA-PD. Source: Module 2, Slide - Employer/Union Plans. Question 12 Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? a.He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. b.He can enroll in a Medicare Advantage plan if he has dropped Part B less than 90 days ago. c.He is not eligible to enroll in a Medicare Advantage as a naturalized citizen. d.He can enroll in a Medicare Advantage plan but it will pay only the benefits associated with Medicare Part A. Source: Module 2, Slide - Medicare Advantage Eligibility. See also, Slide - Eligibility for Part A and Part B Question 13 Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to servicessince she receives some assistance for her health care costs from the State. What should you tell her? a.Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. b.Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state’s Medicaid program. c.Medicaid will cover all of her PFFS out-of-pocket costs and Medicaid providers will accept amounts paid by the PFFS plan as payment in full. Incorrect: There are several types of Medicaid programs, called Medicare Savings Programs, that assist beneficiaries with premium and/or cost-sharing payments, but such programs do not guarantee Medicaid will cover all of a beneficiary’s out-of-pocket costs. d.If Mrs. Andrews joins a PFFS plan, the State will not cover any of her medical expenses because she will be using only Medicare providers. Source: Part 2, Slide -MA Plans and Dual Eligible Beneficiaries, continued and Slide - MA Plans and Dual Eligible Beneficiaries, continued Question 14 Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease (ESRD). What options will Mrs. Davenport have regarding her MA plan during the next open enrollment season? Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. b.She must remain enrolled in her ABC MA plan unless the plan terminates. c.She must immediately drop her ABC MA plan and enroll in Original Medicare. a.She may remain in her ABC MA plan, enroll in another MA plan in her service area, or enroll in a d.She must immediately drop her ABC MA plan and enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. Source: Module 2, Slide - Medicare Advantage Eligibility and Slide - Medicare Advantage Eligibility: SNPs Question 15 Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was disappointed with 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 would not have to put up with such poor access to care. What could you tell her? a.She should not expect to get in to see her doctor any more quickly since she is a Medicare patient. b.She must write to the plan and wait for a response and then, if she is still dissatisfied, she could file an appeal with her state Medicaid office requesting transfer to one of its managed care plans. c.She should call the doctor’s office to complain since the plan cannot do anything about the doctor’s schedule. d.She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Source: Module 2, Slide - Enrollee Protections, Slide - Enrollee Protections: Complaints, Coverage Decisions, Appeals and Slide - Enrollee Protections: Grievances. Question 16 Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? a.In Medicare Advantage HMO plans, services provided by primary care physicians are covered at 100%, but those of specialists are covered at 80%. b.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). c.With any Medicare Advantage HMO, Mr. Kumar will be able to see any provider he likes,so long as that provider participates in Original Medicare. d.Mr. Kumar will be able to obtain routine care outside of the plan’sservice area but will pay a higher copayment (except in an emergency). Source: Module 2, Slide - MA Plan Types Coordinated Care Plans - HMOs Question 17 Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do? a.As long as his employer offers coverage that is equivalent to Medicare’s, he cannot enroll in Part B. b.He will not need to do anything. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan. c.He must wait until the next Annual Election Period, at which time he can enroll in a Medicare Advantage plan. d.He will have to enroll in Part B. Source: Module 2, Slide - Medicare Advantage Eligibility Question 18 Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from hisinvestments. 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? a.SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. b.SNPs do not provide Part D prescription drug coverage, so if he does enroll, he should be aware that he will not have coverage for any medications he may need now or in the future. c.SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll. Incorrect: There are three types of SNPs, but only one of them involves assisting dual eligible individuals. Regardless, Mr.Greco’s circumstances would not meet the eligibility criteria to qualify him for any of the SNPs. d.SNPs only serve individualsin long-term care facilities,so he cannot enroll. Source: Module 2, Slide - Medicare Advantage Eligibility: SNPs, Medicare Advantage Eligibility: SNP Description (1 of 2) and Medicare Advantage Eligibility: SNP Description (2 of 2). Question 19 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? a. In general, Mrs. Ramos will need a referral to see specialists. b. Mrs. Ramos can obtain care from any provider who participatesin Original Medicare, but generally will have a higher cost-sharing amount if she sees a provider who/that is not a part of the PPO network. c.Mrs. Ramos should be aware that generally plan providers can decide, on a case-by-case basis, whether they will treat her. d.In general, Mrs. Ramos can obtain care from any provider who participates in Original Medicare but will have to pay the difference between the plan’s allowed amount and the provider’s usual and customary charge. Source: Module 2, Slide - MA Plan Types Coordinated Care Plans - PPOs. Question 20 Which of the following statement is/are correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexedfor inflation. IV.Non-network providers must accept the same amount that Original Medicare would pay them aspayment in full. a.II and III only b.I and II only Incorrect: It is correct that MSAs may not have a network or may have a full or partial network of providers, and MSAs cover Part A and Part B benefits after the deductible. However, it is also correct thatall non-network providers must accept the same amount that Original Medicare would pay them as payment in full. This is the amount the enrollee will pay the provider before the deductible is met. c. I, II, and III only d. I, II, and IV only Source: Module 2, Slide - MA Plan Types: Medical Savings Account (MSA) Plans.