AHIP Questions & Answers Graded A+ 2025

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? a. Medicare covers glasses, but not dentures or massage therapy. b. Medicare does not cover massage therapy, or, in general, glasses or dentures. Correct: Neither Medicare Part A nor Part B covers massage therapy, dentures, or routine eye examinations to prescribe eyeglasses. c. Medicare covers 80% of the cost of these three services. d. Medicare covers 50% of the cost of these three services. Feedback Source: Module 1, Slide - Not Covered by Medicare Part A & B 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? a. Medigap plans that cover costs not paid for by an MA plan are available only in Massachusetts, Minnesota, and Wisconsin. b. Medigap policies designed to cover costs not paid for by an MA plan can be purchased, but only if the MA plan’s design is considered to be the “defined standard benefit.” c. Medigap plans are a form of Medicare Advantage, so purchasing both would be redundant coverage. d. 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. Correct: The purpose of Medigap plans is to supplement Original Medicare benefits. Medigap plans do not work with Medicare Advantage plans. It is illegal to sell a Medigap plan to someone already in a Medicare Advantage health plan. Feedback Source: Module 1, Slide - Medigap is NOT 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? a. He became eligible for Medicare when his disability eligibility determination was first made. b. After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. Correct: Individuals with disabilities who are under age 65 are automatically enrolled in Medicare Parts A and B the month after they have received Social Security or Railroad Retirement disability benefits for 24 months. c. Individuals receiving such disability payments from the Social Security Administration continue to receive those payments but only become eligible for Medicare upon reaching age 65. d. Individuals who become eligible for such disability payments only have to wait 12 months before they can apply for coverage under Medicare. Feedback Source: Module 1, Slide - Medicare Enrollment Part A & B 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? a. She must wait at least 30 days after her employment terminates before she may enroll in Medicare Part B. b. 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. Correct: As long as Mrs. Peňa is covered under her employer’s plan, she can enroll in Part B at any time. If she retires, she will be able to enroll in Part B during a special enrollment period that lasts 8 months following the last month of her employer coverage. c. She may not enroll in Part B while covered under an employer group health plan and must wait until the standard general enrollment period after she retires. d. She may only enroll in Part B during the general enrollment period whether she is retired or not Feedback Source: Module 1, Slide - Enrollment in Parts A & B After the Initial Enrollment Period 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? a. Mrs. Gonzalez should purchase a K or L Medigap plan. b. Mrs. Gonzalez can purchase a Medigap plan that covers drugs, but it likely won’t offer coverage that is equivalent to that provided under Part D. c. 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. Correct: Individuals who are enrolled in Medigap plans may only obtain Medicare drug coverage (Part D) through a stand-alone prescription drug plan. d. Medigap is a replacement for Original Medicare and she has been paying for double coverage. She should simply drop her Medigap policy. Feedback Source: Module 1, Slide - Beneficiaries with Medigap Plans with Drug Coverage Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance? a. She should not sign up for a Medicare Advantage plan. b. She should only seek help from private organizations to cover her Medicare costs. c. She can apply to the Medicare agency for lower premiums and cost-sharing. d. 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. Correct: Mrs. Park can apply for programs through her State Medicaid office that could assist with her Medicare costs, such as Medicare Savings Programs, Part D low-income subsidies, and Medicaid. Feedback Source: Module 1, Slide - Help for Individuals with Limited Income/Resources 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? a. He generally would pay only a per-prescription co-payment. Medicare covers all other costs. b. He generally would pay only a monthly premium. Medicare covers all other costs. c. He generally would pay only a monthly premium and deductible. Medicare covers all other costs. d. He generally would pay a monthly premium, annual deductible, and per-prescription cost- sharing. Correct: Costs for Part D beneficiaries typically include a monthly premium, annual deductible, and per-prescription cost-sharing. Feedback Source: Module 1, Slide - Original Medicare and Part D Prescription Drug Coverage. 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? a. 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. Correct: Beneficiaries are responsible for a single deductible amount for each benefit period, followed by a per day coinsurance amount through day 90. For day 91 and beyond, there is a charge for each “lifetime reserve day” up to 60 days over a beneficiary’s lifetime. After this, he would be responsible for all costs. b. Under Original Medicare, the inpatient hospital co-payment is a percentage of allowed charges. The percentage increases after 60 days and again after 90 days. c. Under Original Medicare, if the inpatient hospital service is provided by a participating Medicare provider, the co-payment is waived. Co-payments are only charged when a beneficiary opts to receive care from a non-participating provider. d. Under Original Medicare, the inpatient hospital co-payment is a flat per-day amount that remains the same throughout the first 60 days of a beneficiary’s stay. After day 60 the amount gradually increases until day 90. After 90 days he would pay the full amount of all costs. Feedback Source: Module 1, Slide - Medicare Part A - Original Medicare Cost-Sharing for Inpatient Hospital Care 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? a. All individuals who are citizens and age 65 or over will be covered under Part A. b. Most individuals who are citizens and age 65 or over and are covered under Part A must pay a monthly premium for that coverage. c. Most individuals who are citizens and age 65 or over and wish to be covered under Part A must enroll in a Medicare Advantage Plan. d. 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. Correct: Most individuals who are citizens and age 65 or older may qualify for coverage either because they pay a monthly premium or because they paid Medicare taxes while working for a specific duration. Feedback Source: Module 1, Slide - Eligibility for Part A & B Benefits and Slide - Medicare Premiums Part A Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed? a. Tell prospect Jerry Smith that he should keep his Medigap plan but he should supplement his healthcare coverage by purchasing a Medicare Advantage plan that offers prescription drug coverage (MA-PD). b. Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage. Correct: Agent John Miller can help prospect Jerry select a standalone Part D prescription drug plan that complements his current Original Medicare and Medigap coverage. Alternatively, Agent Miller can suggest that Jerry drop his Medigap coverage and enroll in a MA-PD plan. c. Tell prospect Jerry Smith that he should drop his Medigap coverage and put those premium dollars toward the purchase of a standalone Part D prescription drug plan because he can always reactivate his Medigap policy on a guaranteed issue basis. Furthermore, because he has had Medigap Jerry will not incur a Part D late enrollment penalty. d. Tell prospect Jerry Smith that Medigap is simply a variation of a Medicare Advantage plan and the companies John represents offer more comprehensive coverage for a lower price. Feedback Source: Module 1, Slide - Medigap (Medicare Supplement Insurance) and Slide - Medigap is NOT Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him? a. Medicare covers all screening tests that have been approved by the FDA on a frequency determined by the treating physician. b. Medicare covers some screening tests that must be performed within the first year after enrollment. Beyond that point expenses for screening tests are the responsibility of the beneficiary. c. Medicare covers the periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered. Correct: Original Medicare and Medicare Advantage plans cover most preventive services, such as screening tests, but beneficiaries must confirm coverage of specific tests with their plans. d. Medicare covers treatments for existing disease, injury, and malformed limbs or body parts. As such, it does not cover any screening tests and these must be paid for by the beneficiary out-of-pocket. Feedback Source: Module 1, Slide - Medicare Part B Benefits - Preventive Services and Screenings 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? Correct: a. 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. b. 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 but Smallcap must continue to offer him coverage under its employer-sponsored group health plan and would become a secondary payor. Incorrect: small GHPs do not have to continue to offer their age 65 and over employees and their spouses the same benefits under the GHP as individuals under age 65. Nor do they have to offer such coverage under the same conditions as for individuals under age 65. c. Juan is likely to be ineligible for Medicare since he was born outside the United States and has only contributed to the Medicare system for 20 years. d. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls his employer- sponsored coverage would continue to be the primary payor while Medicare would be considered a secondary payor of his healthcare claims. Feedback Source: Module 1, Slide - Eligibility for Part A and Part B Benefits and Slide - Medicare for Individuals Who Are Still Working - Small GHPs and Slide - Medicare Coordination with Employer Group Health Plans 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? a. Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots. Correct: Beneficiaries enrolled in both Original Medicare (Parts A and B) have no cost-sharing for most preventive services. These services include immunizations such as annual flu shots. b. Medicare Part A generally covers medically necessary physician and other health care professional services. c. Benefits covered by Medicare Parts A and B include routine dental care, hearing aids, and routine eye care. d. Medicare Part B generally provides prescription drug coverage. Feedback Source: Module 1, Slide - Medicare Part A & B Benefits, Slide - Medicare Part B Benefits: Preventive Services and Screening, and Slide - Not Covered by Medicare Part A & B 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? a. Part C, which always covers dental and vision services, is covered under Original Medicare. b. Part A, which covers hospital, skilled nursing facility, hospice, and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare. Correct: Original Medicare consists of Part A and Part B. c. Part A, which covers long-term custodial care services, is covered under Original Medicare. d. Part D, which covers prescription drug services, is covered under Original Medicare. Feedback Source: Module 1, Slide - Overview of Medicare Benefits and Coverage - Parts A, B, C, and Slide - Overview of Different Ways to Get Medicare 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? a. He may sign-up for Medicare at any time however coverage usually begins on the sixth month after dialysis treatments start. b. He may not sign-up for Medicare until he reaches age 62, the date he first becomes eligible for Social Security benefits. c. He may sign-up for Medicare at any time and coverage usually begins immediately. d. He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Correct: Individuals with ESRD may sign up for Medicare at any time. Coverage typically begins on the fourth month after dialysis treatments start, but it could be earlier if certain conditions are met. Feedback Source: Module 1, Slide - Medicare Enrollment Part A & B 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? a. Medicare Supplemental Insurance would cover his long-term care services. b. 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. Correct: Medicare Supplement Insurance (Medigap) fills "gaps" in Original Medicare coverages, such as all or part of the deductibles or coinsurance as well as possibly offering some services such as medical care when a beneficiary travels outside the United States. c. Medicare Supplemental Insurance would cover all of his IRS approved health care expenditures not covered under Original Fee-for-Service (FFS) Medicare. d. Medicare Supplemental Insurance would cover his dental, vision and hearing services only. Feedback Source: Module 1, Slide - Medigap (Medicare Supplement Insurance) 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? a. Medicare is a program for people of all ages with specific mental health disabilities. Since she is in excellent health, she would not qualify, but should instead look into her state’s Medicaid program if she wants further coverage. b. Eligibility for Medicare is based on whether or not a person has ever been employed by the federal government. If she or her husband were ever employed by the federal government, she can enroll in Medicare. c. 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. Correct: Individuals that meet these criteria may be eligible to participate in Medicare. It is not based on income. d. Medicare is a program for people who have incomes and assets below specific limits, so you will have to find out her exact financial situation before telling her whether she can obtain Medicare coverage. Feedback Source: Module 1, Slide - Eligibility for Part A and Part B Benefits Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover? a. Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime. Correct: Medicare Part A provides coverage for inpatient psychiatric care for up to 190 lifetime days. b. Medicare will cover, at its allowable amount, as many stays as are needed throughout Mr. Rainey’s life, as long as no single stay exceeds 190 days. c. Inpatient psychiatric services are not covered under Original Medicare. d. Medicare inpatient psychiatric coverage is limited to the same number of days covered for typical inpatient stays. Feedback Source: Module 1, Slide - Medicare Part A provides coverage for inpatient psychiatric care for up to 190 lifetime days. 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? a. She is correct because she will be covered under Part A, without paying premiums and she has worked for 40 years so she will not have to pay Part B premiums. b. Medicare beneficiaries only pay a Part B premium if they are enrolled in a Medicare Advantage plan. c. She is correct that she will not have to pay a premium because State programs cover the cost of Part B premiums for all Medicare beneficiaries. d. To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. Correct: Typically, people eligible for Medicare pay the standard monthly premium rate for Part B. However, this amount may vary based on an individual's income. Feedback Source: Module 1, Slide - Medicare Premiums for Part B 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? a. Mrs. Duarte has no right to appeal this determination since her claim has been partially paid. b. Mrs. Duarte should request a reconsideration of the decision by a qualified independent party within 60 days of the date she received the MSN in the mail. c. Mrs. Duarte should file an appeal of this initial determination within 90 days of the date she received the MSN in the mail. If she still disagrees with Medicare Administrative Contractor's (MAC's) further decision she should request a reconsideration by a qualified independent party within 10 days. Incorrect: Beneficiaries must file an appeal related to Part A or B services within 120 days of the date they get the MSN in the mail. If a beneficiary disagrees with the Medicare Administrative Contractor’s decision, he/she has 180 days after getting the decision notice to request a reconsideration by a Qualified Independent Contractor. d. Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. FeedbackSource: Module 1, Slide - Appeals related to Part A and Part B Coverage and Payment Determinations. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? a. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Correct: Medicare Advantage is a way of covering Original Medicare, Part A and Part B benefits, through private health insurance plans. b. Medicare Advantage is designed to pick up where Original Medicare leaves off, covering those health care services that would not normally be covered by Original Medicare. c. Medicare Advantage is a health insurance program operated jointly by the states with the Federal government. d. Medicare Advantage is a new name for the Original Medicare program. Feedback Source: Module 2, Slide - Part C: Medicare Advantage Plans (Overview). 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? a. She must write to the plan and wait for a response and then, if she is still dissatisfied, she could file an appeal with her state Medicaid office requesting transfer to one of its managed care plans. b. She should call the doctor’s office to complain since the plan cannot do anything about the doctor’s schedule. c. She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Correct: Enrollees or their representatives may file a grievance if they experience problems with their health care services, such as timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. d. She should not expect to get in to see her doctor any more quickly since she is a Medicare patient. Feedback Source: Module 2, Slide - Enrollee Protections, Slide - Enrollee Protections: Complaints, Coverage Decisions, Appeals and Slide - Enrollee Protections: Grievances. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid- February of 2021, her doctor confirms a diagnosis of end-stage renal disease (ESRD). What options will Mrs. Davenport have regarding her MA plan during the next open enrollment season? a. She must immediately drop her ABC MA plan and enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. b. She must remain enrolled in her ABC MA plan unless the plan terminates. c. She may remain in her ABC MA plan, enroll in another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. Correct: Mrs. Davenport has three clear choices: (1) remain in the ABC MA plan, (2) enroll in another MA plan in her service area, or (3) enroll in a Special Needs Plan (SPN) for persons suffering from ESRD if one is available in her area. d. She must immediately drop her ABC MA plan and enroll in Original Medicare. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility and Slide - Medicare Advantage Eligibility: SNPs 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? a. 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. Correct: MA-PPO enrollees may seek care from any provider who accepts Medicare. However, enrollees are typically responsible for higher cost-sharing payments if their provider is out-of- network. b. In general, Mrs. Ramos can obtain care from any provider who participates in Original Medicare but will have to pay the difference between the plan’s allowed amount and the provider’s usual and customary charge. c. Mrs. Ramos should be aware that generally plan providers can decide, on a case-by-case basis, whether they will treat her. d. In general, Mrs. Ramos will need a referral to see specialists. Feedback Source: Module 2, Slide - MA Plan Types Coordinated Care Plans - PPOs. 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? a. Generally, employers prefer retirees to enroll in a stand-alone PDP, so he should consider that instead of the MA-PD. b. 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. Correct: The type of Medicare Advantage plans offered vary by employers. Therefore, beneficiaries should compare their employer’s retiree plan with other available plan options. c. When possible, it is always the best option to have both the employer’s plan and the MA-PD, so he would have no out-of-pocket expenses. d. Generally, employers prefer retirees to have both the retiree group plan and the MA-PD plan to fill in the gaps, but he would be better off with just the MA-PD plan. Feedback Source: Module 2, Slide - Employer/Union Plans. 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 current HMO plan requires him to do. What should you tell him? a. 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. Correct: Mr. Gomez may receive health care services from any doctor allowed to bill Medicare, provided he shows the doctor the plan’s identification card, and the doctor accepts the PFFS’s payment terms and conditions. These terms may include balance billing up to 15% of the Medicare rate. b. If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor accepts Original Medicare. c. He may receive services from any physician, regardless of whether or not that physician participates in the plan or Original Medicare. d. If he enrolls in the PFFS plan and shows his card to a doctor who participates in Original Medicare, then that doctor is required to accept the plan’s terms and conditions, which could include balance billing. Feedback Source: Module 2, Slide - MA Plan Types Private Fee-for-Service (PFFS) Plans, MA Plan Types Private Fee-for-Service Plans (2 of 3) and MA Plan Types Private Fee-for-Service Plans (3 of 3). Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? a. With any Medicare Advantage HMO, Mr. Kumar will be able to see any provider he likes, so long as that provider participates in Original Medicare. b. Mr. Kumar will be able to obtain routine care outside of the plan’s service area but will pay a higher co-payment (except in an emergency). c. In Medicare Advantage HMO plans, services provided by primary care physicians are covered at 100%, but those of specialists are covered at 80%. d. In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network). Correct: In most Medicare Advantage HMOs, as a general rule, an enrollee must obtain services only from providers within the plan's network, otherwise known as participating providers. An exception is made for emergency care. Feedback Source: Module 2, Slide - MA Plan Types Coordinated Care Plans - HMOs 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? a. 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. Correct: If a beneficiary enrolls in a MA PPO plan that does not include Part D coverage, the beneficiary cannot join a stand-alone Prescription Drug Plan (PDP). b. He could enroll in the MA-only PPO plan and a stand-alone Medicare prescription drug plan. c. He cannot enroll in a stand-alone prescription drug plan because you do not represent such a plan. d. He could enroll in the MA-only plan and purchase a Medigap plan with drug coverage. Feedback Source: Module 2, Slide - MA & Prescription Drugs. 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? a. If Mrs. Andrews joins a PFFS plan, the State will not cover any of her medical expenses because she will be using only Medicare providers. b. Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. Correct: Dual eligible beneficiaries may enroll in any type of MA plan (except an MA MSA). However, Medicaid will only pay for items and services if they are furnished by Medicaid participating providers. Therefore, Mrs. Andrews should consider these factors when enrolling in a MA plan. c. Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state’s Medicaid program. d. Medicaid will cover all of her PFFS out-of-pocket costs and Medicaid providers will accept amounts paid by the PFFS plan as payment in full. Feedback Source: Part 2, Slide -MA Plans and Dual Eligible Beneficiaries, continued and Slide - MA Plans and Dual Eligible Beneficiaries, continued Which of the following statement is/are correct about a 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. a. I, II, and III only b. II and III only c. I, II, and IV only Correct: MSAs may not have a network or may have a full or partial network of providers. MSAs cover Part A and Part B benefits after the deductible. All non-network providers must accept the same amount that Original Medicare would pay them as payment in full. This is the amount the enrollee will pay the provider before the deductible is met. d. I and II only Feedback Source: Module 2, Slide - MA Plan Types: Medical Savings Account (MSA) Plans. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? a. Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States. b. Mrs. Radford must be enrolled in both Medigap and Part A to enroll in a Medicare Advantage plan. c. Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, before being accepted and enrolled. d. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Correct: To be eligible to enroll in Medicare Advantage, an individual must be entitled (not enrolled) to Part A and enrolled in Part B. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility Mr. Greco is in excellent health, lives in his own home, and has a 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 cost-sharing amounts and Mr. Greco would like to join that plan. What should you tell him? a. SNPs only serve individuals in long-term care facilities, so he cannot enroll. b. SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll. c. SNPs do not provide Part D prescription drug coverage, so if he does enroll, he should be aware that he will not have coverage for any medications he may need now or in the future. d. SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. Correct: Mr.Greco’s circumstances would not meet the eligibility criteria to qualify him for any of the SNPs. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility: SNPs, Medicare Advantage Eligibility: SNP Description (1 of 2) and Medicare Advantage Eligibility: SNP Description (2 of 2). 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? a. Since SNPs don’t cover prescription drugs Mr. Sinclair should consider a different option. b. SNPs offer care from any doctor or hospital Mr. Sinclair would like to use and his costs will always be lower than in Original Medicare. c. SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. d. 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. Correct: Chronic condition SNPs (C-SNPs) restrict enrollment and tailor services to individuals with chronic conditions, such as Mr. Sinclair. All SNPs include prescription drug coverage. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description (2 of 2). Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? a. Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage it must be a MSA-PD plan that includes drug coverage. b. Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage she must also enroll in a Medicare Supplement Plan (Medigap) F that covers the Medicare Part B deductible and includes both drug coverage. c. Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. Correct. MA MSA plans are prohibited from offering prescription drug coverage. If an MSA member wants prescription drug coverage, the member must enroll in a standalone PDP. d. Mrs. Chi is ineligible for a MA MSA plan because she is ineligible for Medicaid due to her income level. Feedback Source: Module 2, Slide - MA & Prescription Drugs, Slide - Medicare Advantage Eligibility: MSAs Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do? a. He will not need to do anything. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan. b. He must wait until the next Annual Election Period, at which time he can enroll in a Medicare Advantage plan. c. He will have to enroll in Part B. Correct. To be eligible to enroll in a Medicare Advantage plan, a beneficiary must be entitled to Part A and enrolled in Part B. d. As long as his employer offers coverage that is equivalent to Medicare’s, he cannot enroll in Part B. Feedback Source: Module 2, Slide - Medicare Advantage Eligibility 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? a. Dr. Brennan can charge the beneficiary the same cost-sharing as Original Medicare as long as she sends the claim to Medicare and not the plan. b. Dr. Brennan can charge Mary Rodgers more than the cost sharing specified in the PFFS plan’s terms and conditions as long as she treats all beneficiaries the same. c. Dr. Brennan can charge Mary Rodgers no more than the cost sharing specified in the PFFS plan’s terms and conditions of payment which may include balance billing up to 25% of the Medicare rate. d. 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. Correct: Because Dr. Brennan accepts the plan’s terms and conditions for payment, she is permitted to charge this amount. Feedback Source: Module 2, Slide - MA Plan Types: Private Fee-for-Service Plans (3 of 3). Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? a. You could suggest he call the doctor who performed the surgery to complain about the costs and ask for a discount on the charges. b. You could remind him that he cannot do anything until the next Annual Election Period when he will have an opportunity to change plans. c. You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Correct: Medicare Advantage (MA) plan enrollees have a right to obtain a review (appeal) to certain decisions about health care payment, coverage of services, or prescription drug coverage. Medicare health plans must provide enrollees with a written description of the appeals process. d. You could reassure him that such charges are typical, but if he needs assistance in paying, he should apply to the state for Medicaid assistance. Feedback Source: Module 2, Slide - Enrollee Protections, Slide - Enrollee Protections: Complaints, Coverage Decisions, Appeals 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? a. They are major medical policies but are only for low-income beneficiaries with Medicare. b. They are Medigap Supplemental plans that fill in the gaps not covered by Medicare. c. They are custodial long-term care plans for people with Medicare. d. They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Correct: There are coordinated care Medicare Advantage plans that include HMOs and PPOs. There are also Private-Fee-for-Service (PFFS), Medicare Savings Account (MSA), and Special Needs Plans (SNPs). Feedback Source: Module 2, Slide - Medicare Advantage Plans (Overview). 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? a. C-SNP Correct: Because Daniel’s bronchitis is a chronic condition, a Chronic condition SNP would be most appropriate for him to enroll in. b. I-SNP c. D-SNP d. FIDE-SNP Feedback Source: Module 2, Slide - Medicare Advantage Eligibility, Slide - Medicare Advantage Eligibility: SNP Description (1 of 2) and Slide - Medicare Advantage Eligibility: SNP Description (2 of 2). What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? a. Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrict access through prior authorization. b. Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market. c. The Federal government establishes a set formulary, or list of covered drugs, each year that the Part D plans must use. Beneficiaries should consult the government’s list prior to deciding whether they wish to enroll in a Part D plan during that year. d. Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization. Correct: Part D plans are not required to cover all prescriptions on the market. But they have various methods to manage costs including formularies, cost-sharing tiers, step therapy, prior authorization and substitution. Feedback Source: Module 3, Slide - Part D Drug Management Tools. Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this? a. Mrs. Berkowitz can apply for any Medicare Advantage plan and, if it offers drug coverage, ask to have that element of the coverage eliminated, after which she can enroll in a stand- alone Medicare prescription drug plan in her service area. b. Mrs. Berkowitz can enroll in any Medicare Advantage plan, regardless of whether it offers drug coverage, and enroll in any stand-alone Medicare prescription drug plan. c. This is not a possibility. If Mrs. Berkowitz wants health coverage and drug coverage through a plan, she must purchase an MA-PD plan. d. If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. Correct: An individual may enroll in a stand-alone Medicare Part D prescription drug plan (PDP) if they are enrolled in a PFFS plan that does not include Part D drug coverage or a MSA plan. Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Eligibility. Question 4 Correct Question text Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan’s formulary. What could you tell him to do? a. Mr. Zachow will have to wait until the Annual Election Period when he can switch Part D plans. In the meantime, he will have to pay for his drug out of pocket. b. Mr. Zachow could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him. c. Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication. d. Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan’s website, fill it out, and submit it to his plan. Correct: Formulary exception requests can be used to request coverage of a drug not on a Part D plan’s formulary or to cover a formulary drug at a lower cost formulary tier. Feedback Source: Module 3, Slide - Enrollee Rights: Requesting Exceptions for Drugs. Mr. Hutchinson has drug coverage through his former employer’s retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him? a. He will need to enroll in a Medicare prescription drug plan upon becoming eligible for the program in order to avoid a premium penalty. To reduce his expenses, he should look for a plan with a zero premium. b. If he has any sort of employer coverage, regardless of the level of coverage, he will incur no penalty if he does not enroll in a Part D plan when first eligible. c. If the drug coverage he has is not expected to pay, on average, at least as much as Medicare’s standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Correct: To avoid a late enrollment penalty, Mr. Hutchinson must have “creditable” coverage. If he does not, he must enroll in Medicare Part D during his initial eligibility period to avoid a late enrollment penalty. d. He should drop the employer coverage and enroll in a Medicare prescription drug plan. Employer plans are almost always more costly for beneficiaries and most do not cover the same range of drugs available from a Medicare prescription drug plan. Feedback Source: Module 3, Slide - Employer/Union Coverage of Drugs and Slide - Part D Late Enrollment Penalty. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband’s employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her? a. If a Part D benefit is offered through her plan she must enroll in this plan. b. Mrs. Lopez must first seek COBRA benefits under her husband’s plan before she can apply for Part D coverage. c. Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage. d. If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. Correct: Mrs. Lopez is enrolled in a Cost plan. This provides her with options as to how she secures Part D benefits. Beneficiaries enrolled in a Cost plan may obtain Part D benefits through their plan (if offered) or through a stand-alone Prescription Drug Plan (PDP). Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? a. Medicare prescription drug plans are required to include only a certain percentage of brand name drugs among those they cover. It may be possible that plans available in her area have opted not to include in their formularies the brand name drugs she needs. She may need to pay for this particular medication out of pocket. b. Medicare prescription drug plans are allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medications out of pocket. c. When medication costs exceed a certain threshold amount, which rises each year, a Medicare prescription drug plan is permitted to exclude coverage for all but the least expensive of the medications in a given category. Mrs. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives. d. Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs. Correct: Part D formularies must include at least two drugs in each therapeutic category whether or not generic versions are available. Mrs. Allen should be able to find a plan that covers the medications she needs. Feedback Source: Module 3, Slide - Covered Part D Drugs Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? a. Betsy, a grandmother from overseas who has overstayed her visa. b. Jose, a grandfather who was granted asylum and has worked in the United States for many years. Correct: Jose, having been granted asylum, is legally present in the United States thus meeting one of the criteria for Part D eligibility. c. Helena, an overseas college student who has overstayed her visa. d. Guy, who has illegally crossed the Canadian border. Feedback Source: Module 3, Slide - Medicare Part D Eligibility. Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her? a. She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan’s network.