My AHIP Questions & Answers correct

My AHIP Questions & Answers correct Mr.Gomez notes that a Private Fee for Service (PFFS) plan avaliable in his area has an attractive preminum. 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? 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? 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? 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 apart of the PPO network. Mr. McTaggert notes that a Private Fee for-Service (PFFS) plan avaliable 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? 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? 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 satisified 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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. 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? 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? 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? 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 III. Locking an at-risk beneficiary into one prescriber IV. Increasing deductibles and copays for at-risk beneficiaries. FALSE Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawl from his savings account until it is exhausted and then have his premiums withheld from his Social Security check. What should you tell him? Any person who knowingly submits false claims to the Government is liable for five times the Governments damages caused by the violator plus a penalty. Mr. Chan is one of your clients and in excellent health. He is enrolled in a Medicare prescription drug plan rhat you represent. He recently heard about a Medication Therapy Management (MTM) program in which his friend is enrolled. What should you tell him? To be eligible for a MTM program, a Medicare beneficiary must have multiple chronic diseases, be taking multiple Part D prescription drugs, and likely to incur considerable drug costs Since 2004 Ms. Eisenberg has had a Medigap plan that provides soem drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her? The letter is to inform her that the drug coverage offered through her Medigap plan does not offer drug coverage that is a least comparable to that provided under the Medicare Part D prescription drug program. If she does not have such creditable coverage during periods when she is first eligible for the Part D program, she will face a premium penalty if she enrolls in a Part D plan at a later date Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for her services. What advice would you give her? Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. Mr. Alonso receives some help payinf for his two generic prescription drugs from his employer's retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him? He generally would pay a monthly premium, annual deductible, and per-prescription cost sharing. Mr. Singh would like drug coverage, but does not want to be enrolled in a Medicare Advantage plan. What should you tell him? Mr. Singh can enroll in a stand-alone prescription drug plan and continue to be covered for Part A and Part B services through Original Fee-for Service Medicare 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 the Medicare Advantage program? They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when hr turns 56. He wants to understand the health care costs he might be expected if he were to require hospitalization as a result of an illness. In general terms, what could you tell him costs for impatient hospital services under Original Medicare? Under Original Medicare, there is a single deductible amount due for the first 60 days of any impatient hospital stay after which it converts into a per-day consurance amount through day 90. After day 90, he would pay a daily amount up to 50 days over his lifetime, after which he would be responsible for all costs. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplementsl 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 costs sharing in Original Fee for Service (FFS) Medicare as well as possibly some services that Medicare does not cover. Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern? Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's disease, so she will be eligible for Medicare. Agent Willis had several clients who disenrolled from the plans he represents during the AEP to try new Medicare Advantage plans. Agent Willis believes that the choices they made are not ideal for them and would like to get their business back during the Medicare Advantage Open Enrollment Period (MA-OEP). What can agent Willis do? He can call them to let them know that if they do not like their new plans, they can change back during the MA-CEP Mr. Hernandez is concerned that if he signs up for a Medicare Advantage plan, the health plan may, at some time in the future, reduce his benefits below what is available in Original Medicare. What should you tell him about his concern? Medicare Advantage plans must cover all benefits vailable under Medicare Part A and Part B. Many also cover Part D prescription drugs. Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-Service (FFS) Medicare? What could you tell him? Part A, which covers hospital, skilled nursing facility, hospice, and the home health services, and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Health Plan before she starts looking specific plans. What could you tell her? Medicare Health Plans mau 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. Roberts has just received a new Medicare identity card in the mail. She is concerned that it is forgery since it does not have her Social Security number on it. What should you tell her? The card she received is valid, the change has been made to protect Medicare beneficiaries from identity theft and she should destroy her old card. 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 over age 65 are covered under Part A by virute of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled 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. 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 Mr. Denton is 52 years old and has recently been diagonosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him? He may sign up for Medicare at any time, however coverage usually begins on the fourth month after dialysis treatments start Ms. Henderson believes that she will qualify for Medicare coverage when she turns 65, without paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her? In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. Mrs. Park is an elderly retiree. Mrs. Park has a low, fixed income. What could you tell Mrs. Park that might be of assistance? She should contact her state Medicaid agency to see if she qualifies forprograms that can help with Medicare costs for which she is responsible. Mrs. Pena is 66 years old, has coveerage under an employer plan and will retire next year. She heard she must enroll in Part B at the beginning of the yeear to ensure no gap in coverage. What can you tell her? She may enroll at any timr ehile she is covered under her employer plan, but she will have a special eight month enrollment period that differes from the standard general enrollment period, during which she may enroll in Medicare Part B Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollement in a Medicare health plan (Part C). What should you advise her to do before she will be able to enroll into a Medicare health plan In order to join a Medicare health plan, she also must enroll in Part B Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the part D low-income subsidy. Where might he turn for help with his prescription drug costs? Mr.Wu may still qualify for help in payinf Part D costs through his State Pharmaceutical Assistance Program For which of the following individuals would a Cost Plan be most appropriate? Ms. Baler who is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan premiums Which statement best describes PACE plans? It includes comprehensive medical and sovial service delivery systems using an interdisciplinary team approach in an adult day health center, supplemented by in-home and referral services Mrs. Walters is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Health Plan? She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account 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? Beneficiaries should check with their employer or union group benefits adminstrator before changing plans to avoid losing the coverage they want to keep 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 should you tell her? Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participatinf providers 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? He could enroll in one of the MA plans that include perscription drug coverage or a Medigap plan and a stand-alone prescription drug plan Mr. Rivera has Qualified Medicare Beneficiary (QMB) eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) PPO plan. Later he sees an out-of-network doctor to receive a Medicare covered service. How much may the doctor collect from Mr. Rivera? The doctor may only collect from Mr.Rivera the cost sharing allowable under the state's Medicaid program. Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him? Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries Mrs. Chou likes a PFFS plan available in her area that does not offer drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her? She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. Mrs. Mulcahy is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her? Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll and eligible beneficiary who applies regardless of health status except in limited circumstances II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain benefits through a standalone PDP IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan I, II, and III only