Medicare Agent & Broker Certification

Medicare Agent & Broker Certification A prospective beneficiary asks an agent if plan XYZ has an urgent care benefit and if so, what the benefit includes. Where would the agent find this information for plan XYZ? - Evidence of Coverage Because the beneficiary asked if plan XYZ has an urgent care benefit and what the benefit includes. If the beneficiary only wanted to know if plan XYZ has an urgent care benefit, the answer would be Summary of Benefits & Evidence of Coverage. If a beneficiary who is enrolled in an HMO tells you that she wants to see a specialist, you should tell her: - You will likely need a referral from your primary care physician (PCP) to see a specialist. If you see your specialist without this referral, the plan may not pay for your visit. Because the beneficiary is enrolled in an HMO, she should work with her PCP prior to seeing a specialist (except in an emergency). True or False? Once a beneficiary is enrolled in an MA plan and has paid his plan-specific monthly premium, he no longer needs to pay his Part B premium. - False Beneficiaries are required to continue paying their Part B premium (unless they receive Extra Help) in addition to any plan-specific premium. Define: Medicare Part A - Part A of Medicare covers hospital inpatient care, some SNF care, and home health and hospice care Define: Medicare Part B - Part B of Medicare covers physician services, outpatient hospital care, lab tests, mental health services, some preventative services, and medical equipment considered medically necessary to treat a disease or condition Define: Medicare Part C - Part C of Medicare provides an option for beneficiaries to receive private health plan coverage in lieu of Original Medicare Define: Medicare Part D - Part D of Medicare provides prescription drug benefit Mrs. Doe will turn 65 at the end of March and signed up for an MA plan in January during her Initial Coverage Election Period (ICEP). When will her coverage begin? - On March 1 The ICEP coverage begins the first day of the month of entitlement to Medicare Part A and Part B, OR the first of the month following the month the enrollment request was made (if after entitlement has occurred). What enrollment period provides an opportunity for a beneficiary to move from Original Medicare to an MA plan? - The Annual Election Period (AEP) for enrolling in an MA Plan is October 15 through December 7. The beneficiary is already enrolled in Original Medicare, so there is no Initial Coverage Election Period (ICEP) that is applicable. What is the enrollment period for enrolling in an MADP? - January 1 through February 14 This period only allows a beneficiary to change from an MA plan to Original Medicare (with/without a stand-alone PDP). Which conditions would qualify an MA plan member to switch plans during a Special Enrollment Period? - The member recently moved into a nursing home The member's plan was terminated The member has moved to another state If an individual moves into, resides in, or moves out of a long-term care facility, such as a nursing home, he or she is eligible for a SEP. He/She would also be eligible for an SEP as a result of moving out of the plan's service area or if his/her current plan is terminated. During a formal sales event held on October 5, an agent tells attendees, "You can enroll in Acme's Traditional Medicare Advantage HMO plan between October 15 and December 7, but the plan won't take effect until January 1. However, if you don't like the plan after you enroll, you have until March 1 to switch back to Original Medicare." Following the presentation, the agent assists a couple in filling out an enrollment form for Acme's Traditional HMO plan, and tells the couple that she will "hold on to it" until the October 15 enrollment date. What is inaccurate? - The agent is not allowed to accept an enrollment prior to October 15 The presenter provided incorrect Medicare Advantage Disenrollment Period (MADP) information Although agents may assist beneficiaries in completing their forms, an agent may not accept, collect, or take possession of completed enrollment forms before October 15 and may not encourage beneficiaries to mail the enrollment form to the plan prior to October 15. Further, although the agent provided the correct dates for the AEP (October 15 - December 7), she misstated the window for which a beneficiary may disenroll and revert back to Original Medicare. In 2015, the MADP is January 1 - February 14. Mrs. Doe has decided to file a grievance because she feels that she was treated with disrespect while communicating with a plan's customer services representative (CSR). What is the first step Mrs. Doe should take to file a grievance? - Contact the plan in writing or by telephone to file a grievance is the first step. An appeal is intended to handle different circumstances involving coverage decisions or organizational determinations. True or False? For all MA plans, an enrollee that chooses to join a PDP will be automatically disenrolled from his/her current plan. - FALSE A person who is enrolled in an MSA or an MA-PFFS plan without drug coverage and is joining a PDP will not be automatically disenrolled from the MSA or MA-PFFS plan. To disenroll, the beneficiary must call 1-800-MEDICARE or submit a written disenrollment request to the plan. A person enrolled in any MA coordinated care plan (HMO, PPO), or an MAPFFS plan that includes drug coverage, who is joining a PDP will be automatically disenrolled from their current plan upon enrolling in a PDP. A plan may end an enrollee's membership if... - The enrollee is away from the service area for more than 6 months The enrollee does not stay continuously enrolled in Medicare Part A or Part B The enrollee is no longer eligible for the plan's SNP category A plan may end an enrollee's membership for any of the reasons listed (involuntary disenrollment), so long as the enrollee