My AHIP
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? - ANS-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.
Mrs. Lee is discussing with you the possibility of enrolling in a Private Fee- for Service (PFFS)
plan. As part of that discussion, what should you be sure to tell her? - ANS-PFFS plans may
choose to offer Part D benefits but are not required to do so.
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? - ANS-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 is not apart of the PPO network.
Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available in his area has an
attractive premium. He wants to know what makes them different from an HMO or a PPO. What
should you tell him? - ANS-Enrollees in a PFFS plan can obtain care from any provider in the
US who accepts Original Medicare, as long as the provider has a reasonable opportunity to
access the plan's terms and conditions and agrees to accept them.
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? -
ANS-He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare
Part B.
Mr. Sinclar has diabetes and heart trouble and is generally satisfied with the care he has just
received under Original Medicare, but he would like to know more about Medicare Advantage
Special Needs Plans (SNPs). What could you tell him? - ANS-SNPs have special programs
from enrollees with chronic conditions, like Mr. Sinclair and they provide prescription drug
coverage that could be very helpful as well.
Mrs.Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her
doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does
,Mrs.Davenport have regarding her MA plan during the next open enrollment season? -
ANS-She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for
individuals sufferinf from ESRD if one is available in her area.
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? - ANS-C-SNP
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 curreny HMO
plan requires him to do. What should you tell him? - ANS-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.
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? - ANS-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.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him? - ANS-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 emergency or where care is unavailable within the network)
Mr.Greco is in excellent health, lives in his own home, and has aa 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 costs sharing amounts and Mr. Greco
would like to join that plan. What should you tell him? - ANS-SNPs limit enrollment to certain
subpopulations of beneficiaries. Given his current situation, he is unlikelt to qualify and would
not be able to enroll in the SNP.
Dr. Elizabeth Brennan does not contract with the PFFS plan but she accepts the plan's terms
and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr.
Brennan charge? - ANS-Dr. Brennan can charge Mary Rodgers 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 percent of the Medicare rate.
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? - ANS-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.
Mrs.Lee is discussing with you the possibility of enrolling in a Private Fee-for-Service (PFFS)
plan. As part of that discussion, what should you be sure to tell her? - ANS-PFFS plans may
choose to offer Part D benefits but are not required to do so.
Which of the following statements is correct about 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. - ANS-I, II. and IV only.
Mr. Davies is turning 65 next month. He would like to enroll in a Medicare health plan but does
not want to be limited in terms of where he obtains his care. What should you tell him about how
a Medicare Cost Plan might fit his needs? - ANS-Cost plan enrollees can choose to receive
Medicare covered services under the plan's benefits by going to plan network providers and
paying plan cost-sharing or may receive services from non-network providers and pay
cost-sharing due under Original Medicare.
Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. He would like
to know his options since he has decided to drop his retiree coverage and is eligible for
Medicare. What should you tell him? - ANS-Mr. Chen can disenroll from his
employer-sponsored coverage to elect a Medicare Advantage or Part D plan, but he should
revaluate if he really wants to drop his employer coverage.
When soliciting referrals from current members of an MA or Part D plan, what may you do? -
ANS-Enrollment period (SEP) for both MA and Part D due to a change of residence?
I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in
his existing plan's service area.
II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's
service area.
III. Gilbert moves into a plan service area where there is now a Part D plan available to him from
a service area where no Part D plan was available.
IV. Henry makes a permanent move providing him with new MA and Part D options.
Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of
misusing or abusing frequently abused drugs?
I. Identifying at risk individuals by using criteria that includes the number of opioid prescriptions
the beneficiary has and the number of prescribers who have written those prescriptions.
II. Locking an at-risk beneficiary into one pharmacy
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? - ANS-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.
Mrs. Lee is discussing with you the possibility of enrolling in a Private Fee- for Service (PFFS)
plan. As part of that discussion, what should you be sure to tell her? - ANS-PFFS plans may
choose to offer Part D benefits but are not required to do so.
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? - ANS-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 is not apart of the PPO network.
Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available in his area has an
attractive premium. He wants to know what makes them different from an HMO or a PPO. What
should you tell him? - ANS-Enrollees in a PFFS plan can obtain care from any provider in the
US who accepts Original Medicare, as long as the provider has a reasonable opportunity to
access the plan's terms and conditions and agrees to accept them.
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? -
ANS-He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare
Part B.
Mr. Sinclar has diabetes and heart trouble and is generally satisfied with the care he has just
received under Original Medicare, but he would like to know more about Medicare Advantage
Special Needs Plans (SNPs). What could you tell him? - ANS-SNPs have special programs
from enrollees with chronic conditions, like Mr. Sinclair and they provide prescription drug
coverage that could be very helpful as well.
Mrs.Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her
doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does
,Mrs.Davenport have regarding her MA plan during the next open enrollment season? -
ANS-She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for
individuals sufferinf from ESRD if one is available in her area.
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? - ANS-C-SNP
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 curreny HMO
plan requires him to do. What should you tell him? - ANS-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.
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? - ANS-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.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him? - ANS-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 emergency or where care is unavailable within the network)
Mr.Greco is in excellent health, lives in his own home, and has aa 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 costs sharing amounts and Mr. Greco
would like to join that plan. What should you tell him? - ANS-SNPs limit enrollment to certain
subpopulations of beneficiaries. Given his current situation, he is unlikelt to qualify and would
not be able to enroll in the SNP.
Dr. Elizabeth Brennan does not contract with the PFFS plan but she accepts the plan's terms
and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr.
Brennan charge? - ANS-Dr. Brennan can charge Mary Rodgers 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 percent of the Medicare rate.
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? - ANS-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.
Mrs.Lee is discussing with you the possibility of enrolling in a Private Fee-for-Service (PFFS)
plan. As part of that discussion, what should you be sure to tell her? - ANS-PFFS plans may
choose to offer Part D benefits but are not required to do so.
Which of the following statements is correct about 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. - ANS-I, II. and IV only.
Mr. Davies is turning 65 next month. He would like to enroll in a Medicare health plan but does
not want to be limited in terms of where he obtains his care. What should you tell him about how
a Medicare Cost Plan might fit his needs? - ANS-Cost plan enrollees can choose to receive
Medicare covered services under the plan's benefits by going to plan network providers and
paying plan cost-sharing or may receive services from non-network providers and pay
cost-sharing due under Original Medicare.
Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. He would like
to know his options since he has decided to drop his retiree coverage and is eligible for
Medicare. What should you tell him? - ANS-Mr. Chen can disenroll from his
employer-sponsored coverage to elect a Medicare Advantage or Part D plan, but he should
revaluate if he really wants to drop his employer coverage.
When soliciting referrals from current members of an MA or Part D plan, what may you do? -
ANS-Enrollment period (SEP) for both MA and Part D due to a change of residence?
I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in
his existing plan's service area.
II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's
service area.
III. Gilbert moves into a plan service area where there is now a Part D plan available to him from
a service area where no Part D plan was available.
IV. Henry makes a permanent move providing him with new MA and Part D options.
Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of
misusing or abusing frequently abused drugs?
I. Identifying at risk individuals by using criteria that includes the number of opioid prescriptions
the beneficiary has and the number of prescribers who have written those prescriptions.
II. Locking an at-risk beneficiary into one pharmacy
