Download Medicare Advantage and Original Medicare: A Comprehensive Q&A and more Exams Nursing in PDF only on Docsity!
AHIP 2023/
TEST BANK 200
QUESTIONS WITH
ANSWERS
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? - ANSWER They are Medicare health plans such as HMOs, PPOs, PFFS, SNPs, and MSAs (W) Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be a correct description? - ANSWER Medicare Advantage is a way of covering all of the Original Medicare benefits through private health insurance companies.
During a sales presentation in Ms. Sullivan's home, she tells you that she has heard about a type of Medicare health plan known as Private Fee-for- Service (PFFS). She wants to know if this would be available to her. What should you tell her about PFFS plans? - ANSWER A PFFS plan is one of various types of Medicare Advantage plans offered by private entities and she may enroll in one if it is available in her area. (W) Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? - ANSWER Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? - ANSWER He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B (W) Mrs. Billings 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. Billings have in regard to her MA plan during the next open enrollment season? - ANSWER She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area
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? - ANSWER SNPs limit enrollment to certain sub-populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. (W) 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 over age 65 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. (W) 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? - ANSWER After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. (W) Mr. Davis is 49 years old and has been receiving disability benefits from the Social Security Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescription Drug policy? - ANSWER No, he cannot purchase a Medicare Advantage or Part D policy because he has not received Social Security or Railroad Retirement disability benefits for 24 months.
(W) 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 In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes (W) 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? - ANSWER Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. (W) 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 that differs from the standard general enrollment period, during which she may enroll in Medicare Part B
(W) 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? - ANSWER Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled nursing facility? - ANSWER Medicare will cover Mrs. Shields' skilled nursing services provided during the first 20 days of her stay, after which she would have a coinsurance until she has been in the facility for 100 days. Mrs. Quinn has just turned 65 and received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn? - ANSWER Part B primarily covers physician services. She will be paying a monthly premium and, with the exception of many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible.
(W) 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? - ANSWER Medicare covers 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. Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met? What could you tell her? - ANSWER Original Medicare covers ambulance services Mrs. Wolf wears glasses and dentures and has enjoyed considerable pain relief from arthritis through acupuncture. She is concerned about whether or not Medicare will cover these items and services. What should you tell her? - ANSWER Medicare does not cover acupuncture, or, in general, glasses or dentures Mr. Singh would like drug coverage, but does not want to be enrolled into a health plan. What should you tell him? - ANSWER 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.
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. Mr. Kelly has substantial financial means. He enrolled in Original Medicare and purchased a Medigap policy many years ago that offered prescription drug coverage. The prescription drug coverage has not been comparable to that offered by Medicare Part D for several years and despite notification, Mr. Kelly took no action. Which of the following statements best describes what will occur if Mr. Kelly now decides to enroll in Medicare Part D? - ANSWER He will incur a late enrollment penalty 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 What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have upon Medigap plans? - ANSWER The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020
Mrs. Raskin is a widow who will attain aged 65 and enroll in Medicare in just a few weeks. She concerned about having prescription drug coverage. Which of the following statements provides the best advice? - ANSWER Prescription drug coverage can be obtained by enrolling in a Medicare Advantage plan that includes Part D coverage. Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefit package of a Medicare Health Plan before she starts looking at specific plans. What could you tell her? - ANSWER Medicare Health Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services 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? - ANSWER Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs 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 or Lou Gehrig's disease, so she will be eligible for Medicare.
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? - ANSWER If she uses non-network providers, her doctors and hospital could decide whether to treat her on a visit-by-visit basis Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available 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? - ANSWER Enrollees in a PFFS plan can obtain care from any provider in the U.S. 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. If Dr. Elizabeth Brennan does not contract with the PFFS plan, but accepts the plan's terms and conditions for payment, how will she be paid? - ANSWER Generally, the PFFS plan will pay Dr. Brennan directly the same amount Original Medicare would pay her 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? - ANSWER All MSAs cover Part A and Part B benefits, but not Part D prescription drug
benefits, which could be obtained by also enrolling in a separate prescription drug plan Mr. 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? - ANSWER 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. Which statement best describes PACE plans? - ANSWER It includes comprehensive medical and social service delivery systems using an interdisciplinary team approach in an adult day health center, supplemented by in-home and referral services. 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? - ANSWER Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep
could enroll in one of the MA plans that include prescription drug coverage or a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. 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? - ANSWER She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. 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? - ANSWER 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. 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? - ANSWER 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.
Mrs. Lopez is enrolled in a Medicare Advantage cost plan. 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? - ANSWER If a Part D benefit is offered through her plan she may choose in enroll in that plan or a standalone PDP. 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 2018 under the standard coverage? - ANSWER 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? - ANSWER It would not be unusual for her costs to be a bit less because each year until 2020, an enrollee's share of the drug costs in the coverage gap are less
not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? - ANSWER 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. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? - ANSWER Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn's could look into that possibility. Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug mid-way through the year? - ANSWER When a new generic drug for the same condition becomes available or when the FDA or manufacturer withdraws the drug from the market, a brand name drug can be replaced Mrs. Roswell is a new Medicare beneficiary and is interested in selecting a Medicare Part D prescription drug plan. She takes a number of medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her? - ANSWER Every Part D
drug plan is required to cover a 30 day supply of her existing medications sometime during a 90 day transition period 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? - ANSWER 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 Mr. Katz reached the Part D coverage gap in August last year. His prescriptions have not changed, he is keeping the same Part D plan and the benefits, cost-sharing, and coverage of his drugs are all the same as last year. He asked what to expect for this year about his out-of-pocket costs. What could you tell him? - ANSWER Because he reached the coverage gap last year, he will probably reach it again this year close to the same time Mrs. Grant uses several very expensive drugs and anticipates that she will enter catastrophic coverage at some point during the year. To help her determine when she is likely to qualify for catastrophic coverage, she asked which expenses count toward the out-of-pocket limit that qualifies her for catastrophic coverage. Which one of the following would count? - ANSWER Prescription drugs she purchases when in the Part D coverage gap
