UHC-CSNP-Mary

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?

Medicare will cover Mrs. Schmidt’s 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. Park is an elderly retiree. She has a low, fixed income. What could you tell Mrs. Park that might be of assistance?

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.

Mrs. Fiore was in the Army for 35 years and is now retired. She has drug coverage through the VA. What issues might she consider with regard to whether to enroll in a Medicare prescription drug plan?

She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the VA for the specific medications she needs and whether any additional benefits are worth the Part D premium costs.

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?

Medicare does not cover acupuncture, or, in general, glasses or dentures.

Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard?

Implying that only seniors can enroll in a Medicare Advantage plan when meeting with Mr. Hernandez, who is 58 but qualifies for Medicare because she is disabled. Correct

Mr. Bickford 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?

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

Mrs. Pena 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.
Module 1

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.

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?

all msa cover part a and b

Mrs. McIntire is enrolled in her state’s Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen with respect to her drug coverage?

Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.

Agent Mary Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational in nature. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational?

Yes. When an event has been advertised as “educational,” discussing plan-specific premiums is impermissible.

Mr. Albert has heard about something called the Star Rating system for Medicare Advantage plans. He asks you to explain it to him since he is interested in enrolling in a plan that is newly available in his area. After you explain that it is way for consumers to judge plan performance, what else would you say?

Beneficiaries who live in the service area of a 5-star plan and are enrolled in an MA or PDP plan, or beginning in 2013, a Cost plan
Beneficiaries who live in the service area of a 5-star plan, are enrolled in Original Medicare, and meet the eligibility requirements for Medicare Advantage or Part D plans
The SEP is available each year beginning on December 8 and may be used once through November 30 of the following year. For example, the SEP for calendar year 2018 can be
used from December 8, 2017 through November 30, 2018.
Disenroll from an MA plan, PDP or Cost plan or
leave Original Medicare
Enroll in a 5-star MA plan, PDP or Cost plan
Eligible individuals may enroll in a 5-star plan
through 1-800-MEDICARE, Medicare.gov, or
directly through the 5-star plan.

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. Correct

BUSHMAN has two homes in different states and is concerned about restrictions on where she can get her medications.

Part D Rx plan use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states.

BestCare Health Plan has received a request from a state insurance department in connection with the investigation of several marketing representatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response?

Agent Armstrong is an independent agent under contract with MarketCo, a third party marketing organization. MarketCo has a contract with BestChoice health plan, a Medicare Advantage organization, to offer marketing services through its contracted agents and agencies. Agent Armstrong returns calls to individuals who call
MarketCo in response to its mailers promoting
BestChoice health plan. Agent Armstrong is a marketing representative of BestChoice. Thus, he is obligated to comply with all marketing requirements, including those regarding using only approved call scripts.

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?

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. Correct

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?

In order to join a Medicare health plan, she also must enroll in Part B.

This year you decide to focus your efforts on marketing to employer and union groups. Which of the following statements best describes what you can and cannot do in order to stay in compliance?

You are not required to submit copies of disseminated materials to CMS at the time of use, but CMS may request and review copies if employee complaints occur.

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?

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.

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. Correct

Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for Medicare as well. He is concerned about changes in his cost-sharing. What should you tell him?

He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers.

Which of the following statements is correct about the appeal and grievance processes?

I. Enrollees have a right to obtain a review (appeal) of certain decisions about prescription drug coverage.
II. The grievance process is used for reviews of coverage decisions on plan benefits.
III. Plans must provide a link to the Medicare.gov website where an enrollee can enter a complaint.
IV. Enrollees have a right to file complaints (sometimes called grievances) about the quality of their care.

I. Enrollees have a right to obtain a review (appeal) of certain decisions about prescription drug coverage.
III. Plans must provide a link to the Medicare.gov website where an enrollee can enter a complaint.
IV. Enrollees have a right to file complaints (sometimes called grievances) about the quality of their care.

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?

Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs.

You 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 min

You may request RSVPs, but you are not permitted to require contact information.

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.

Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services’ Marketing Guidelines to ensure he is compliant for which type of products?

Medicare Advantage (MA) and Prescription Drug (PDP) plans Correct

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?

He generally would pay a monthly premium, annual deductible, and per-prescription cost sharing.

Mr. Rivera has QMB-Plus eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later in the year, Mr. Rivera needs dentures, a service only covered under Medicaid. What action would you recommend he take in order to have this cost covered?

has QMB-Plus eligibility. She has
decided to enroll in a Medicare Advantage plan.
Ms. Jones can receive all Medicare covered
services through her Medicare Advantage plan cost sharing. However, in order to receive
coverage of services that are only covered under
Medicaid, for example, dentures, she must go to a
Medicaid provider or obtain the services through a
Medicaid managed care plan if she is enrolled in
one
Categories of dual eligible beneficiaries and out-of pocket costs that must be paid by Medicaid:
QMB Plus – Medicare Part A and Part B premiums; cost sharing for Part A & Part B benefits; Full Medicaid benefits.When a dual eligible individual enrolls in an MA plan, if the individual has coverage for Part A and B
cost sharing, they will not have to pay more than the cost sharing that would apply under Medicaid.
This rule applies to all types of Medicare Advantage plans, including dual eligible SNPs.
Dual eligible beneficiaries may enroll in any type of MA plan except an MA MSA.
Some MA plans, known as dual eligible Special
Needs Plans, are tailored to dual eligible individuals, depending on the category (see prior slide) to which they belong.

Mr. Robinson was quite ill recently and forgot to pay his monthly premium for his MA-PD plan. He is worried that he will lose his coverage now when he
needs it the most. He is certain his plan will disenroll him because that is what happened to a friend of his in a similar type of plan. What can you tell Mr.
Robinson about his situation?

Plan sponsors have the option to disenroll members who do not pay their premiums, but they must first provide each member
with a grace period of not less than 2 months.
c. Plan sponsors must disenroll members who do

Alice is enrolled in a MA-PD plan. She makes a permanent move across the country and wonders what her options are for continuing MA-PD coverage. What would you say to her in regard to a special enrollment period (SEP)?

She is likely to qualify for a SEP. She can choose an effective date of up to six months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than 30 days prior to the date of her move.

Ms. Gardner is currently enrolled in an MA-PD plan. However, she wants to disenroll from the MA-PD plan and instead enroll in a Part D only plan and go back to Original Medicare. According to Medicare’s enrollment guidelines, when could she do this?

She
may do it only during the MA Disenrollment Period, which runs from January 1 to
February 14 of each year.

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?

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
Administratio

FORD enrolled in a MA only plan in mid November. On December 1, he calls you up and says that he has changed his mind and would like to enroll into a MA-PD plan. What enrollment rules would apply in this case?

He can make as many enrollment changes as he likes during the Annual Election Period and the last choice made prior to the end of the period will be the effective one as of January 1.

W) Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?

Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage

Mr. Wong is a single individual. He has a successful business career and is now able to retire with a comfortable income. Mr. Wong’s taxable income is in excess of $80,000. Mr. Wong has health coverage through his employer but will sign-up for Medicare Part A, Part B and Part D when he leaves the workforce. How would you advise him as he budgets for Medicare premiums?

Due to his participation in the workforce he will not have to pay a premium for Part A but he will pay higher premiums for Part B and Part D due to the amount of his income

He generally would pay a monthly premium, annual deductible, and per-prescription cost sharing.

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?

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.