AHIP
1. 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?: She could file a grievance with her plan to complain about the lack of
timeliness in getting an appointment.
2. Edward IP suffered from serious kidney disease. As a result. Edward be-
came eligible for Medicare coverage due to end-stage renal disease (ESRD).
A close relative donated their kidney and Edward successfully underwent
transplant surgery 12 months ago. Edward is now age 50 and asks you if his
Medicare coverage will continue, what should you say?: Individuals eligible for
Medicare based on ESRD generally lose eligibility 36 months after the month in
,which the individual receives a kidney transplant unless they are eligible for Medicare
on another basis such as age or disability. Edward may, however, remain enrolled in
Part B but solely for coverage of immunosuppressive drugs if he has no other health
care coverage that would cover the drugs.
3. Mildred Savage enrolled in Allcare Medicare Advantage plan several years
ago. Mildred recently learned that she is suffering from inoperable cancer and
has just a few months to live. She would like to spend these final months in
hospice care. Mildred's family asks you whether hospice benefits will be paid
for under the Allcare Medicare Advantage plan. What should you say?: Mildred
may remain enrolled in Allcare and make a hospice election. Hospice benefits will
be paid for by Original Medicare under Part A and Allcare will continue to pay for
any non-hospice services.
4. 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?: Mr.
,Diaz will not pay any penalty because he had continuous coverage under his
employer's plan.
5. Mr. Moy's wife has a Medicare Advantage plan, but he wants to under-
stand what coverage Medicare Supplemental Insurance provides since his
health care needs are different from his wife's needs. What could you tell Mr.
Moy?: Medicare Supplemental Insurance would help cover his Part A and Part B
deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as
possibly some services that Medicare does not cover.
6. 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?: Most 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.
7. Mr. Bauer is 49 years old, but eighteen months ago he was declared dis-
abled by the Social Security Administration and has been receiving disability
payments. He is wondering whether he can obtain coverage under Medicare.
What should you tell him?: After receiving such disability payments for 24 months,
he will be automatically enrolled in Medicare, regardless of age.
8. 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?: Ben-
eficiaries under Original Medicare have no cost-sharing for most preventive services
which include immunizations such as annual flu shots.
1. 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?: She could file a grievance with her plan to complain about the lack of
timeliness in getting an appointment.
2. Edward IP suffered from serious kidney disease. As a result. Edward be-
came eligible for Medicare coverage due to end-stage renal disease (ESRD).
A close relative donated their kidney and Edward successfully underwent
transplant surgery 12 months ago. Edward is now age 50 and asks you if his
Medicare coverage will continue, what should you say?: Individuals eligible for
Medicare based on ESRD generally lose eligibility 36 months after the month in
,which the individual receives a kidney transplant unless they are eligible for Medicare
on another basis such as age or disability. Edward may, however, remain enrolled in
Part B but solely for coverage of immunosuppressive drugs if he has no other health
care coverage that would cover the drugs.
3. Mildred Savage enrolled in Allcare Medicare Advantage plan several years
ago. Mildred recently learned that she is suffering from inoperable cancer and
has just a few months to live. She would like to spend these final months in
hospice care. Mildred's family asks you whether hospice benefits will be paid
for under the Allcare Medicare Advantage plan. What should you say?: Mildred
may remain enrolled in Allcare and make a hospice election. Hospice benefits will
be paid for by Original Medicare under Part A and Allcare will continue to pay for
any non-hospice services.
4. 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?: Mr.
,Diaz will not pay any penalty because he had continuous coverage under his
employer's plan.
5. Mr. Moy's wife has a Medicare Advantage plan, but he wants to under-
stand what coverage Medicare Supplemental Insurance provides since his
health care needs are different from his wife's needs. What could you tell Mr.
Moy?: Medicare Supplemental Insurance would help cover his Part A and Part B
deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as
possibly some services that Medicare does not cover.
6. 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?: Most 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.
7. Mr. Bauer is 49 years old, but eighteen months ago he was declared dis-
abled by the Social Security Administration and has been receiving disability
payments. He is wondering whether he can obtain coverage under Medicare.
What should you tell him?: After receiving such disability payments for 24 months,
he will be automatically enrolled in Medicare, regardless of age.
8. 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?: Ben-
eficiaries under Original Medicare have no cost-sharing for most preventive services
which include immunizations such as annual flu shots.
