AHIP Study Guide (including FWA, Discrimination
& Compliance)
Mr. Davis is 52 years old and has recently been
diagnosed 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? –
Answer: : He may sign-up for Medicare at any time
however coverage usually begins on the fourth month
after dialysis treatments start.
Juan Perez, who is turning age 65 next month, intends to
work for several more years at Smallcap, Incorporated.
Smallcap has a workforce of15 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.
Mr. Moy's wife has a Medicare Advantage plan, but he
wants to understand what coverage Medicare
Supplemental Insurance provides since his health care
needs are different from his wife's needs. What could
you tell Mr. Moy? –
Answer: : 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.
Mrs. Peňa is 66 years old, has coverage under an
employer plan, and will retire next year. She heard she
must enroll in Part B at the beginning of the year to
,ensure no gap in coverage. What can you tell her? –
Answer: : She may enroll at any time while she is
covered under her employer plan, but she will have a
special eight-month enrollment period after the last
month on her employer plan that differs from the
standard general enrollment period, during which she
may enroll in Medicare Part B.
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?
–
Answer: : 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.
Mrs. Gonzalez is enrolled in Original Medicare and has a
Medigap policy as well, but it provides no drug
coverage. She would like to keep the coverage she has
but replace her existing Medigap plan with one that
provides drug coverage. What should you tell her? –
Answer: : Mrs. Gonzalez cannot purchase a Medigap plan
that covers drugs, but she could keep her Medigap policy
and enroll in a Part D prescription drug plan.
Mrs. West wears glasses and dentures and has enjoyed
considerable pain relief from arthritis through massage
therapy. She is concerned about whether or not Medicare
will cover these items and services. What should you tell
her? –
Answer: : Medicare does not cover massage therapy,
or, in general, glasses or dentures.
,Mr. Patel is in good health and is preparing a budget in
anticipation of his retirement when he turns 66. He wants
to understand the health care costs he might be exposed
to under Medicare if he were to require hospitalization as
a result of an illness. In general terms, what could you tell
him about his costs for inpatient hospital services
under Original Medicare? –
Answer: : Under Original Medicare, there is a single
deductible amount due for the first 60 days of any
inpatient hospital stay, after which it converts into a per-
day coinsurance amount through day 90. After day 90,
he would pay a daily amount up to 60 days over his
lifetime, after which he would be responsible for all
costs.
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? –
Answer: : To obtain Part B coverage, she must pay a
standard monthly premium, though it is higher for
individuals with higher incomes.
Mr. Alonso receives some help paying 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? -
Answer: : He generally would pay a monthly premium,
annual deductible, and per- prescription cost-sharing.
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? –
Answer: : 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.
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? –
Answer: : Beneficiaries under Original Medicare
have no cost-sharing for most preventive services
which include immunizations such as annual flu
shots.
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 services. What
advice would you give her? –
Answer: : Mrs. Duarte should file an appeal of this initial
determination within 120 days of the date she received
the MSN in the mail.
Mr. Capadona would like to purchase a Medicare
Advantage (MA) plan and a Medigap plan to pick up
costs not covered by that plan.
What should you tell him? –
Answer: : It is illegal for you to sell Mr. Capadona a
Medigap plan if he is enrolled in an MA plan, and
besides, Medigap only works with Original Medicare.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed
income. What could you tell Mrs. Park that might be of
assistance? –
Answer: : She should contact her state Medicaid agency
to see if she qualifies for one of several programs that
can help with Medicare costs for which she is
responsible.
& Compliance)
Mr. Davis is 52 years old and has recently been
diagnosed 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? –
Answer: : He may sign-up for Medicare at any time
however coverage usually begins on the fourth month
after dialysis treatments start.
Juan Perez, who is turning age 65 next month, intends to
work for several more years at Smallcap, Incorporated.
Smallcap has a workforce of15 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.
Mr. Moy's wife has a Medicare Advantage plan, but he
wants to understand what coverage Medicare
Supplemental Insurance provides since his health care
needs are different from his wife's needs. What could
you tell Mr. Moy? –
Answer: : 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.
Mrs. Peňa is 66 years old, has coverage under an
employer plan, and will retire next year. She heard she
must enroll in Part B at the beginning of the year to
,ensure no gap in coverage. What can you tell her? –
Answer: : She may enroll at any time while she is
covered under her employer plan, but she will have a
special eight-month enrollment period after the last
month on her employer plan that differs from the
standard general enrollment period, during which she
may enroll in Medicare Part B.
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?
–
Answer: : 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.
Mrs. Gonzalez is enrolled in Original Medicare and has a
Medigap policy as well, but it provides no drug
coverage. She would like to keep the coverage she has
but replace her existing Medigap plan with one that
provides drug coverage. What should you tell her? –
Answer: : Mrs. Gonzalez cannot purchase a Medigap plan
that covers drugs, but she could keep her Medigap policy
and enroll in a Part D prescription drug plan.
Mrs. West wears glasses and dentures and has enjoyed
considerable pain relief from arthritis through massage
therapy. She is concerned about whether or not Medicare
will cover these items and services. What should you tell
her? –
Answer: : Medicare does not cover massage therapy,
or, in general, glasses or dentures.
,Mr. Patel is in good health and is preparing a budget in
anticipation of his retirement when he turns 66. He wants
to understand the health care costs he might be exposed
to under Medicare if he were to require hospitalization as
a result of an illness. In general terms, what could you tell
him about his costs for inpatient hospital services
under Original Medicare? –
Answer: : Under Original Medicare, there is a single
deductible amount due for the first 60 days of any
inpatient hospital stay, after which it converts into a per-
day coinsurance amount through day 90. After day 90,
he would pay a daily amount up to 60 days over his
lifetime, after which he would be responsible for all
costs.
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? –
Answer: : To obtain Part B coverage, she must pay a
standard monthly premium, though it is higher for
individuals with higher incomes.
Mr. Alonso receives some help paying 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? -
Answer: : He generally would pay a monthly premium,
annual deductible, and per- prescription cost-sharing.
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? –
Answer: : 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.
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? –
Answer: : Beneficiaries under Original Medicare
have no cost-sharing for most preventive services
which include immunizations such as annual flu
shots.
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 services. What
advice would you give her? –
Answer: : Mrs. Duarte should file an appeal of this initial
determination within 120 days of the date she received
the MSN in the mail.
Mr. Capadona would like to purchase a Medicare
Advantage (MA) plan and a Medigap plan to pick up
costs not covered by that plan.
What should you tell him? –
Answer: : It is illegal for you to sell Mr. Capadona a
Medigap plan if he is enrolled in an MA plan, and
besides, Medigap only works with Original Medicare.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed
income. What could you tell Mrs. Park that might be of
assistance? –
Answer: : She should contact her state Medicaid agency
to see if she qualifies for one of several programs that
can help with Medicare costs for which she is
responsible.
