AHIP QUESTIONS WITH COMPLETE SOLUTIONS

AHIP QUESTIONS WITH COMPLETE SOLUTIONSYou are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs. What should you keep in mind? ou may request RSVPs, but you are not permitted to require contact information. 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 paying Part D costs through his State Pharmaceutical Assistance Program. 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 Dr. Elizabeth Brennan does not contract with the 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? 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 percent of the Medicare rate. 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 statement 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 eligible for health care benefits through the Veteran's Administration may enroll in an MSA. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. I, II, and IV only For which of the following individuals would a Cost Plan be most appropriate? Ms. Baker who is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan premiums. 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 (MSA) 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. Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any 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 Part D 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 All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a beneficiary incur for prescription drugs in 2019 under the standard coverage? Standard Part D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a portion of costs for both generics and brand-name drugs in the coverage gap, and co-pays or co-insurance after the coverage gap. Mrs. Andrews was preparing a budget for next year because she takes quite a few prescription drugs, she will reach the coverage gap, and wants to be sure she has enough money set aside for those months. She received assistance calculating her projected expenses from her daughter who is a pharmacist, but she doesn't think the calculations are correct because her out-of-pocket expenses would be lower than last year. She calls to ask if you can help. What might you tell her? It would not be unusual for her costs to be a bit less because the Bipartisan Budget Act of 2018 moved up the date for closing the so-called "donut hole" for brand name drugs to 2019. 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. I, II and III only Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year? When a formulary change is in response to a drug's removal from the market. What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? 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. Mr. Rice has coverage for medical services and medications through his employer's retiree plan. He is considering switching to a Medicare prescription drug plan because his retiree plan does not cover two important medications. What should he consider before making a change? If Mr. Rice drops his drug coverage through the retiree plan, he may not be able to get it back and he also may lose his medical health coverage. Your colleague works at a third party marketing organization (TMO) and she said she did not need to take the Medicare training for brokers and agents or pass a test to market Medicare plans since her contract is with the TMO, not the plans that have the products she sells. What could you say to her? You could tell her she is wrong, and that only agents selling employer/union group plans are permitted an exemption from testing, but some employer/union group plans may require testing to promote agent compliance with CMS marketing requirements. You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation? You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score, although you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing. Which of the following is a correct statement about state laws as they pertain to marketing representatives? Medicare health plans must comply with requests for information from state insurance departments investigating complaints about a marketing representative. You work for a company that has marketed Medigap products for many years. The company has added Medicare Advantage and Part D plans and you will begin marketing those plans this fall. You are planning what materials to use to easily show the differences in benefits, premiums and cost sharing for each of the products. What do you need to do with your materials before using them for marketing purposes? Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules. While making an appointment to discuss Medicare Advantage (MA) and Part D plans with a potential enrollee, you are asked to describe other types of insurance products that your client might wish to purchase. What additional types of insurance can you present during the MA and Part D marketing appointment? You can present only health care related lines of business, but must obtain the beneficiary's permission to do so before the presentation occurs and document that you have obtained that permission. A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do? You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion You are meeting with Mrs. Hall in her home. On her scope of appointment form she asked to discuss Medicare Advantage plans. During the meeting, she asks to discuss a stand-alone prescription drug plan. She is leaving the next day to visit her family for a week in another state, so it is important to her to make a decision before she leaves. What must happen before that additional discussion can take place? Since Mrs. Hall specifically asked that you discuss the stand-alone Part D plan, you may do so, as long as she signs a new scope of appointment form first, indicating that she wants to discuss the Part D plan. You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To be in compliance with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plans? You will have to avoid calling any potential client, unless he or she initiates contact with you and specifically asks that you give him or her a call. Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her? Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. Correct Winthrop Brokerage wishes to place an advertisement in the local newspaper that says: "We offer Medicare Advantage plans offered by AB Health and Top Choice Health. Contact us if you would like to learn more." Which of the following best describes the obligation(s) of Winthrop Brokerage regarding the advertisement? Winthrop Brokerage does not need to submit the advertisement to CMS for prior approval because it does not include information about the plans' benefit structures, cost sharing, or information about measures or ranking standards During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5-star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the correct statement to say to her? The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4-stars. During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her? Tell her that the Medicare agency does not endorse or recommend any plan. By contacting plans available in your area, you have learned that the plan you represent has a significantly lower monthly premium than the others. Furthermore, you see that the plan you represent has a unique benefit package. What should you do to make sure your clients know about these pieces of information? you may make comparisons between plans if you can support them by studies or statistical data and such comparisons are factually based You have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respect to meals? You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal. When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan? You may provide gifts or prizes to all potential enrollees during an event that do not exceed $15 in retail value. One of your colleagues argues that it is better to focus your time and energy exclusively in neighborhoods with single family homes. He further argues that their older owners are more likely to have higher incomes and purchase the Medicare Advantage products you represent compared to those living in apartment complexes. How should you respond? This could be considered discriminatory activity and a prohibited practice. You are scheduled to give a sales presentation at a local senior center. At the beginning of the presentation, which of the following must you do? Clearly state that no obligation exists to enroll if a gift or prize is being provided. You will be holding a sales event in the near future, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation? Gift cards or gift certificates of $15 or less that can be readily converted to cash. You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns? Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facility. You would like to market an MA plan at a neighborhood pharmacy. What should you keep in mind to comply with the marketing requirements for MA plans? You must set up your table, make marketing presentations, and accept enrollment applications only in common areas outside of where the patient waits for services from the pharmacist. You have sought permission from a hospital to place brochures for your product in their gift shop and cafeteria. The hospital administration expresses some hesitation about allowing marketing in a health care facility. What should you tell them? Marketing in health care facilities is an acceptable practice, as long as it takes place in common areas where patients are not receiving or waiting to receive health care Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members? Market non-Medicare health-related products, such as dental insurance, to current members as permitted by HIPAA Privacy Rules Your friend's mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him? You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request. This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do? You may go ahead and call them.