AHIP MODULES 1 5 MEDICARE CERTIFICATION
FULLY SOLVED EXAM PAPER GRADED A+
◉ Juan Perez, who is turning age 65 next month, intends to work for
several more years at Smallcap, Incorporated. Smallcap has a
workforce of 15 employees and offers employer-sponsored
healthcare coverage. Juan is a naturalized citizen and has
contributed to the Medicare system for over 20 years. Juan asks you
if he will be entitled to Medicare and if he enrolls how that will
impact his employer-sponsored healthcare coverage. How would
you respond?
Answer: Juan is likely to be eligible for Medicare once he turns age
65 and if he enrolls Medicare would become the primary payor of
his healthcare claims and Smallcap does not have to continue to
offer him coverage comparable to those under age 65 under its
employer-sponsored group health 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?
Answer: 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.
,◉ 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?
Answer: C-SNP
◉ 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?
Answer: 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. 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?
Answer: 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.
◉ 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?
Answer: 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.
◉ 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?
Answer: 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. Willard 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?
FULLY SOLVED EXAM PAPER GRADED A+
◉ Juan Perez, who is turning age 65 next month, intends to work for
several more years at Smallcap, Incorporated. Smallcap has a
workforce of 15 employees and offers employer-sponsored
healthcare coverage. Juan is a naturalized citizen and has
contributed to the Medicare system for over 20 years. Juan asks you
if he will be entitled to Medicare and if he enrolls how that will
impact his employer-sponsored healthcare coverage. How would
you respond?
Answer: Juan is likely to be eligible for Medicare once he turns age
65 and if he enrolls Medicare would become the primary payor of
his healthcare claims and Smallcap does not have to continue to
offer him coverage comparable to those under age 65 under its
employer-sponsored group health 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?
Answer: 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.
,◉ 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?
Answer: C-SNP
◉ 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?
Answer: 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. 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?
Answer: 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.
◉ 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?
Answer: 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.
◉ 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?
Answer: 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. Willard 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?
