AHIP Module 2 - Plans -Module 2 Final Review Exam 2021

Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - CORRECT ANSWER - Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. 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? - CORRECT ANSWER -They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? - CORRECT ANSWER -In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network). 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? - CORRECT ANSWER -He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. 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? - CORRECT ANSWER -She cannot enroll in an MA Medical Savings Account (MSA) plan. 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? - CORRECT ANSWER -C-SNP 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? - CORRECT ANSWER - She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. 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? - CORRECT ANSWER -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. 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? - CORRECT ANSWER -She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug 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? - CORRECT 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. Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her? - CORRECT ANSWER -She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. 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? - CORRECT ANSWER -She may remain in her ABC MA plan, enroll in another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? - CORRECT ANSWER -Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. 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 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? - CORRECT ANSWER -You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.