AHIP Module 1-5 With Complete Solutions 100%
Correct
Mr. Sanchez has just turned 65 and became entitled to Part A; however, he did not enroll
in Part B because he has coverage under a plan provided by his employer. What does he
need to do if he wants to enroll in a Medicare Advantage plan? - ANSWER He will have to
enroll in Part B.
Mrs. Walters has Medicaid through her state in addition to Medicare. What should she
know when looking into joining an MA plan? - ANSWER She cannot join an MA MSA plan.
Mr. Gomez sees that a PFFS plan offered in his area has a premium that seems fairly
reasonable. He would like to know if he will be required to use network doctors as his
current HMO plan requires him to do now. What do you tell him? - ANSWER He can see
any physician who can bill Medicare, provided he presents the physician with his
identification card for that plan and the physician agrees to accept the PFFS plan's
terms and conditions of payment, which may include balance billing.
Ms. Gibson has just lost her employer group health and drug coverage. She wants to
enroll in a PPO that does not include drug coverage. What do you tell Ms. Gibson about
drug coverage? ANSWER She may enroll in the PPO, but will be ineligible to purchase a
stand-alone Medicare Part D prescription drug plan.
Mrs. Kelly is a 65-year-old who has Part A but has not enrolled in Part B. She would like
to enroll in a Medicare Advantage plan, Part C. What would you counsel her she must do
before she can enroll in a Medicare Advantage plan? - ANSWER She will have to enroll in
Part B before she can enroll in a Medicare Advantage plan.
Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access
to services since she receives some assistance for her health care costs from the State.
What do you tell her? - ANSWER Medicaid may provide additional benefits but Medicaid
will only pay for these services if they are furnished by Medicaid participating providers.
,Mr. Kumar is considering a Medicare Advantage HMO and has some questions for you
about how he can access providers. What do you tell him? - ANSWER For most Medicare
Advantage HMOs, Mr. Kumar must receive his services from only providers who belong
to the HMO's network except in an emergency or where care is unavailable within the
network.
Juan Perez turns 65 years old next month and desires to continue working for several
more years for Smallcap, Incorporated. Smallcap employs 15 employees and offers
health care coverage under an employer plan. Juan is a naturalized United States
citizen who has paid into the Medicare fund for over 20 years. Juan comes to you and
asks if he will be eligible for Medicare and, if so, what will occur under the employer plan
if he enrolls in Medicare. How would you respond? - ANSWER Juan would be eligible for
Medicare upon attaining age 65 and upon his enrollment, Medicare would be the primary
payor of his healthcare claims. Smallcap would no longer be required to continue
offering him coverage comparable to those individuals who were under age 65 under its
employer-sponsored group health plan.
Dr. Elizabeth Brennan does not have a contract with the ABC PFFS plan, but accepts the
plan's terms and conditions for payment. Mary Rodgers goes to see Dr. Brennan for
treatment. How much can 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 placing him
at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of
SNP would 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 have drug coverage while the other two do. Mr. Lombardi wants a
PPO that does not have drug coverage and is going to get his drug coverage through a
stand-alone Medicare prescription drug plan. What would you tell him regarding this? -
ANSWER He can either enroll in one of the MA plans that include prescription drug
coverage or Original Medicare with a Medigap plan along with stand-alone Part D
prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a
stand-alone prescription drug plan.
, Mr. Romero, 64 years of age, will soon retire and is considering enrolling in his
employer-sponsored retiree group health plan, which also has drug coverage with very
low copays. He has a neighbor who has an MA-PD plan that you represent. He takes a lot
of prescription drugs and is thinking about signing up with your company. What do you
say to him? - ANSWER He will need to compare the benefits in his employer-sponsored
retiree group health plan to the benefits in his neighbor's MA-PD plan to see which plan
will adequately cover his prescription needs.
Mrs. Lyons is relatively healthy, takes only one prescription medication, and lives alone
in her own home. She is initially attracted to the concept of maintaining control over an
MSA but is less sure if the plan supporting the account will suit her needs. What would
be one key thing for her to be aware of regarding a Medicare MSA plan, 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, generally, has felt satisfied with the
care he has received under Original Medicare, but he would like to know more about
Medicare Advantage SNPs. What might you say? - 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 would like to generally understand 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? - ANSWER Medicare
Advantage Plans may offer extra benefits that Original Medicare does not offer such as
vision, hearing, and dental services and must include a maximum out-of-pocket limit on
Part A and Part B services.
Mrs. Chi is a 75-year-old lady who has a comfortable income, but not real high. She
would like to join a MA MSA plan that her neighbor recently told her about, and get
prescription drug coverage as her doctor has recently prescribed some very costly
medications. She presently is enrolled in Original Medicare with a stand-alone Part D
plan. How would you counsel Mrs. Chi? - ANSWER Mrs. Chi is eligible to enroll in a MA
MSA plan and continue her current stand-alone Part D prescription drug plan.
Mr. Lopez has been informed that he may enroll in something called "Medicare
Advantage" but is fuzzy about what types of plan designs are available under this
Correct
Mr. Sanchez has just turned 65 and became entitled to Part A; however, he did not enroll
in Part B because he has coverage under a plan provided by his employer. What does he
need to do if he wants to enroll in a Medicare Advantage plan? - ANSWER He will have to
enroll in Part B.
Mrs. Walters has Medicaid through her state in addition to Medicare. What should she
know when looking into joining an MA plan? - ANSWER She cannot join an MA MSA plan.
Mr. Gomez sees that a PFFS plan offered in his area has a premium that seems fairly
reasonable. He would like to know if he will be required to use network doctors as his
current HMO plan requires him to do now. What do you tell him? - ANSWER He can see
any physician who can bill Medicare, provided he presents the physician with his
identification card for that plan and the physician agrees to accept the PFFS plan's
terms and conditions of payment, which may include balance billing.
Ms. Gibson has just lost her employer group health and drug coverage. She wants to
enroll in a PPO that does not include drug coverage. What do you tell Ms. Gibson about
drug coverage? ANSWER She may enroll in the PPO, but will be ineligible to purchase a
stand-alone Medicare Part D prescription drug plan.
Mrs. Kelly is a 65-year-old who has Part A but has not enrolled in Part B. She would like
to enroll in a Medicare Advantage plan, Part C. What would you counsel her she must do
before she can enroll in a Medicare Advantage plan? - ANSWER She will have to enroll in
Part B before she can enroll in a Medicare Advantage plan.
Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access
to services since she receives some assistance for her health care costs from the State.
What do you tell her? - ANSWER Medicaid may provide additional benefits but Medicaid
will only pay for these services if they are furnished by Medicaid participating providers.
,Mr. Kumar is considering a Medicare Advantage HMO and has some questions for you
about how he can access providers. What do you tell him? - ANSWER For most Medicare
Advantage HMOs, Mr. Kumar must receive his services from only providers who belong
to the HMO's network except in an emergency or where care is unavailable within the
network.
Juan Perez turns 65 years old next month and desires to continue working for several
more years for Smallcap, Incorporated. Smallcap employs 15 employees and offers
health care coverage under an employer plan. Juan is a naturalized United States
citizen who has paid into the Medicare fund for over 20 years. Juan comes to you and
asks if he will be eligible for Medicare and, if so, what will occur under the employer plan
if he enrolls in Medicare. How would you respond? - ANSWER Juan would be eligible for
Medicare upon attaining age 65 and upon his enrollment, Medicare would be the primary
payor of his healthcare claims. Smallcap would no longer be required to continue
offering him coverage comparable to those individuals who were under age 65 under its
employer-sponsored group health plan.
Dr. Elizabeth Brennan does not have a contract with the ABC PFFS plan, but accepts the
plan's terms and conditions for payment. Mary Rodgers goes to see Dr. Brennan for
treatment. How much can 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 placing him
at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of
SNP would 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 have drug coverage while the other two do. Mr. Lombardi wants a
PPO that does not have drug coverage and is going to get his drug coverage through a
stand-alone Medicare prescription drug plan. What would you tell him regarding this? -
ANSWER He can either enroll in one of the MA plans that include prescription drug
coverage or Original Medicare with a Medigap plan along with stand-alone Part D
prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a
stand-alone prescription drug plan.
, Mr. Romero, 64 years of age, will soon retire and is considering enrolling in his
employer-sponsored retiree group health plan, which also has drug coverage with very
low copays. He has a neighbor who has an MA-PD plan that you represent. He takes a lot
of prescription drugs and is thinking about signing up with your company. What do you
say to him? - ANSWER He will need to compare the benefits in his employer-sponsored
retiree group health plan to the benefits in his neighbor's MA-PD plan to see which plan
will adequately cover his prescription needs.
Mrs. Lyons is relatively healthy, takes only one prescription medication, and lives alone
in her own home. She is initially attracted to the concept of maintaining control over an
MSA but is less sure if the plan supporting the account will suit her needs. What would
be one key thing for her to be aware of regarding a Medicare MSA plan, 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, generally, has felt satisfied with the
care he has received under Original Medicare, but he would like to know more about
Medicare Advantage SNPs. What might you say? - 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 would like to generally understand 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? - ANSWER Medicare
Advantage Plans may offer extra benefits that Original Medicare does not offer such as
vision, hearing, and dental services and must include a maximum out-of-pocket limit on
Part A and Part B services.
Mrs. Chi is a 75-year-old lady who has a comfortable income, but not real high. She
would like to join a MA MSA plan that her neighbor recently told her about, and get
prescription drug coverage as her doctor has recently prescribed some very costly
medications. She presently is enrolled in Original Medicare with a stand-alone Part D
plan. How would you counsel Mrs. Chi? - ANSWER Mrs. Chi is eligible to enroll in a MA
MSA plan and continue her current stand-alone Part D prescription drug plan.
Mr. Lopez has been informed that he may enroll in something called "Medicare
Advantage" but is fuzzy about what types of plan designs are available under this
