Download Medicare Advantage and Original Medicare: A Comprehensive Q&A and more Exams Nursing in PDF only on Docsity!
AHIP FINAL EXAM 2023/.
177 QUESTIONS WITH ANSWER
Medicare Advantage - ANSWER -Cover all Part A and Part B benefits; -Provide plan cost-sharing actuarially equivalent to cost sharing under Medicare Parts A and B, but may be different for specific services; and -Include an annual maximum out-of-pocket (MOOP) limit on total enrollee cost sharing (deductibles, coinsurance, and copayments) for Part A and Part B services. -Cover the following services even when provided by non-network providers: emergency services: out-of-area urgently needed services; and out-of-area renal dialysis 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.
Mr. Styles 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? - ANSWER 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. Mr. Hudson is concerned that if he signs up for a Medicare health 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. Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her? - ANSWER Part D covers prescription drugs and she should look at her premiums, formulary, and cost sharing to see if they have changed. Mrs. Weems 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
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. 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. 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. 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. Mrs. Kelly is entitled to Part A, but is not yet enrolled in Part B. She is considering enrollment in a Medicare health plan. What should you advise her to do before she will be able to enroll into a Medicare health plan? - ANSWER In order to join a Medicare health plan, she must be enrolled in Parts A, B and D Mrs. Toma has a low, fixed income. What could you tell her 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. Mr. Yu has limited income and resources so you have encouraged him to see if he qualifies for some type of financial assistance. Mr. Yu is not sure it is worth the trouble to apply and wants to know what the assistance could do for him if he qualifies. What could you tell him? - ANSWER He might qualify for help with Part D prescription drug costs and help paying Part A and/or Part B premiums, deductibles, and/or cost sharing.
Mrs. Quigley 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. Quigley? - 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. 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. Badeau 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. 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. Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern? - ANSWER Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. Mrs. Schlick 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. Schlick cannot purchase
Mr. Whalen 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. Sully'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 exactly the same as Original Medicare, only offered by a private entity and she may enroll in one if it is available in her area. 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. Ms. Bass lives on a limited fixed income and is concerned about the cost of healthcare. What should you tell her about the sort of help available to low income individuals under the Medicare program? - ANSWER As a Medicare beneficiary with limited income and resources she may contact her state Medicaid agency to apply for assistance paying for the Part B premium and cost sharing and Part D prescription drug coverage.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? - ANSWER In most Medicare Advantage HMOs, Mr. Kumar must obtain his services only from providers who have a contractual relationship with the plan (except in an emergency). 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? - ANSWER Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will be charged a lower co- payment if she goes to one of the plan's preferred providers. 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? - ANSWER 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. 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
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.
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 It is always the best option to talk with his benefits administrator to see whether he needs both an employer sponsored plan and a private MA-PD and what might happen if he were to sign up for both. 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? 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? - ANSWER Medicaid will coordinate benefits only with Medicaid participating providers. 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? - ANSWER Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers.
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. 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 2017 under the standard coverage? - ANSWER 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? Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums and cost sharing. How can you explain this to him? - 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. Different benefit structures
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. Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums and cost sharing. How can you explain this to him? - ANSWER Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? - ANSWER 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.
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. Mr. Shapiro gets by on a very small fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him? - ANSWER The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Mrs. Fields wants to know whether applying for the Part D low income subsidy will be worth the time to fill out the paperwork. What could you tell her? - ANSWER The Part D low income subsidy could substantially lower her overall costs. She can apply by contacting her state Medicaid office, or calling the Social Security Administration. Mr. Fitzgerald did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him? - ANSWER He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses.
