AHIP Module 2 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? - C-SNP 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? - 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. 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? - 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 emplo yer-sponsored group health 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? - 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. 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 generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network) 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? - He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone
sponsored healthcare coverage. How would you respond? - 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 emplo yer-sponsored group health 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? - 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. 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 generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network) 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? - He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone
