AHIP FINAL QUESTIONS & ANSWERS

AHIP FINAL QUESTIONS & ANSWERS Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay, she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled nursing facility? - ANSWERMedicare will cover Mrs. Shield's skilled nursing services provided during the first 20 days of her stay, after which she would have a copay until she has been in the facility for 100 days. Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through massage therapy. She is concerned about whether or not Medicare will cover these items and services. What should you tell her? - ANSWERMedicare does not cover massage therapy, or, in general, glasses or dentures. Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance? - ANSWERShe should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible. Mr. Alonso receives some help paying for his two generic prescription drugs from his employer's retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him? - ANSWERHe generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing. Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has but replace her existing Medigap plan with one that provides drug coverage. What should you tell her? - ANSWERMrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan. Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him? - ANSWERHe may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her? - ANSWERMrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because the features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her? - ANSWERPart D covers prescription drugs and she should look at her premiums, formulary, and cost-sharing among other factors to see if they have changed. Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover? - ANSWERMedicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to Medicare beneficiaries? - ANSWERBeneficiaries under Original Medicare have no cost-sharing for most preventive services. Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him? - ANSWERMr. Singh can enroll in a stand-alone prescription drug plan and continue to be covered for Part A and Part B services through Original Fee-for-Service Medicare. Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her? - ANSWERMost individuals who are citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. Mrs. Quinn recently turned 66 and decided after many years of work to retire and begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she had been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn? - ANSWERPart B primarily covers physician services. She will be paying a monthly premium and, except for many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible. Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization because of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? - ANSWERUnder Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs. What impact, if any, have recent regulatory changes had on Medigap plans? - ANSWERThe Part B deductible is no longer covered for individuals newly eligible for Medicare starting January 1, 2020. Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern? - ANSWERMedigap plans do not cover Original Medicare benefits, but they coordinate with Original Medicare coverage. Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met. What could you tell her? - ANSWEROriginal Medicare covers ambulance services. Ms. Brooks has aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her? - ANSWERMedicare covers hospice services, and they will be available for her. Mr. Diaz continued working with his company and was insured under his employer's group plan until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know how much he will have to pay. What should you tell him? - ANSWERMr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. Anita Magri will turn age 65 in August 2023. Anita intends to enroll in Original Medicare Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel has told her about the Medigap Plan F in which he is enrolled. It not only provides foreign travel emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What should you tell her? - ANSWERYou are sorry to disappoint Anita, but a Medigap F plan is no longer available to those who turn age 65 after January 1, 2020. Anita might instead consider other Medigap plans that offer foreign travel benefits but do not cover the Part B deductible. Hank's Fish Store, Inc. is a small company with just 15 employees located in Florida. Hank, the store owner, has provided excellent health benefits to the store's workforce. William, one of the store's long-time employees, will soon be reaching age 65 and eligible for Medicare. William is in good health. He intends to remain an active full-time employee, working several years after becoming eligible for Medicare. What type(s) of retiree health benefit will Hank's Fish Store be able to offer William? - ANSWERHank's can continue to offer William the same employee health benefit plan, or, if William enrolls in Medicare Part B, it can enroll him in a Medicare Advantage plan that is offered to the public. 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? - ANSWERHe will have to enroll in Part B. Mrs. Velasquez cares for her frail elderly mother, Maria, who lives in North Carolina. She is worried that without additional support, her mother will need to go into a nursing home. Mrs. Velasquez asks you if there is any Medicare plan that might allow her mother to remain in the community rather than going into a nursing home. How should you advise Mrs. Velasquez? - ANSWERThere are Programs of All-Inclusive Care for the Elderly (PACE) for frail elderly beneficiaries certified as needing a nursing home level of care but are able to live safely in the community at the time of enrolment. Which of the following statement(s) 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 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. - ANSWERI, II, and IV only 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 doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? - ANSWERMrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. 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? - ANSWERAll 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. 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? - ANSWERShe could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? - ANSWERMrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Mr. Kelly wants to know whether he is eligible to sign up for a private fee-for-service (PFFS) plan. What questions would you need to ask to determine his eligibility? - ANSWERYou would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area. 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? - ANSWERHe 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. 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? - ANSWERShe 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? - ANSWERDr. 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. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollment in a Medicare Advantage plan (Part C). What should you advise her to do before she can enroll in a Medicare Advantage plan? - ANSWERTo join a Medicare Advantage plan, she also must enroll in Part B. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - ANSWERMedicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. 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? - ANSWERHe 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. Mrs. Wang wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could you tell her? - ANSWERMedicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part A and Part B services. 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? - ANSWERShe could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. 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? - ANSWERThere are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. 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? - ANSWERYou can offer to review the plans appeal process to help him ask the plan to review the coverage decision. 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? - ANSWERShe cannot enroll in an MA Medical Savings Account (MSA) plan. Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him? - ANSWERThe extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? - ANSWERMedicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs. Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan's formulary, he takes several other medications. These include a prescription drug not on his plan's formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say. - ANSWERNone of the costs of Mr. Wingate's other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription, not on its formulary. What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? - ANSWERPart D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and step therapy. Mrs. Mulcahy, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her? - ANSWERAn individual who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him? - ANSWERIf the drug coverage he has is not expected to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums, and cost sharing. How can you explain this to him? - ANSWERMedicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. Who is most likely to benefit from the Medicare Prescription Payment Plan? - ANSWERKevin, who suffered a heart attack at the beginning of the year requiring him to take an expensive brand name blood thinner on a daily, as well as an equally expensive injectable cholesterol medication on a bi-weekly basis for which he incurs high out-of-pocket costs. Mr. Rice is 68, actively working, and has coverage for medical services and medications through his employer's group health plan. He is entitled to premium free Part A and thinking of enrolling in Part B and switching to an MA-PD because he is paying a very large part of his group coverage premium, and it does not provide coverage for a number of his medications. Which of the following is NOT a consideration when making the change? - ANSWERMr. Rice's retiree plan is required to take him back if, within 63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his Medicare Part D plan. Mrs. Roswell is a new Medicare beneficiary who has just retired from retail work. She is interested in selecting a Medicare Part D prescription drug plan. She takes several medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her? - ANSWEREvery Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90-day transition period. Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him? - ANSWERHe could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses.