2024 AHIP MODULE 2 QUESTIONS WITH
COMPLETE SOLUTION
l 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. 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? - 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.
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
Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is
attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the
plan associated with the account will fit her needs. What specific piece of information about a Medicare
MSA plan would it be important for her to know, prior to enrolling in such a plan? - All MSAs cover Part A
and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling
in a separate 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? - 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. 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 have a higher cost-sharing amount if she sees a
provider who/that is not a part of the PPO network.
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? - She
can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription
drug plan.
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? - He is not eligible to enroll in a
Medicare Advantage plan until he re-enrolls in Medicare Part B.
COMPLETE SOLUTION
l 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. 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? - 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.
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
Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is
attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the
plan associated with the account will fit her needs. What specific piece of information about a Medicare
MSA plan would it be important for her to know, prior to enrolling in such a plan? - All MSAs cover Part A
and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling
in a separate 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? - 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. 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 have a higher cost-sharing amount if she sees a
provider who/that is not a part of the PPO network.
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? - She
can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription
drug plan.
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? - He is not eligible to enroll in a
Medicare Advantage plan until he re-enrolls in Medicare Part B.
