Ahip 2025 Module 2
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? - ANS-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.
\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? - ANS-Hank'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. 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? - ANS-You can offer to review the plans appeal process to help him ask the
plan to review the coverage decision.
\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? -
ANS-You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if his
doctor will accept the terms and conditions of payment of the PFFS plan.
\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? - ANS-He 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.
\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
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? - ANS-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.
\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? - ANS-Hank'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. 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? - ANS-You can offer to review the plans appeal process to help him ask the
plan to review the coverage decision.
\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? -
ANS-You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if his
doctor will accept the terms and conditions of payment of the PFFS plan.
\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? - ANS-He 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.
\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
