AHIP-Question

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?

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.

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.

Generally, employers prefer retirees to enroll in a stand-alone PDP, so he should consider that instead of the MA-PD.

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.

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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?

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.

Inpatient psychiatric services are not covered under Original Medicare.

Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime.

Medicare inpatient psychiatric coverage is limited to the same number of days covered for typical inpatient stays.

Question 3

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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, because you represent a Medicare health plan, you therefore work for Medicare, and the information you offer her is a good basis of any decision she makes.

Tell her that the Medicare agency does not endorse or recommend any plan.

Tell her that Medicare recommends that beneficiaries enroll in a Medicare Advantage plan because it will serve her better than Original Medicare.

Tell her that Medicare or CMS (the Medicare agency) has approved and endorsed the plan.

Question 4

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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 should contact his neighbors and family members and let them know that any contributions they make toward his drug expenses will be tax deductible.

The only option available is to reduce his income so that he can qualify for the Part D extra help or wait until next year to see if the annual limits change.

He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to 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.

He should look into the possibility of purchasing his medications through the internet from off-shore pharmacies.

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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?

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.

The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval.

The government bases its payments to Part D plans on the standard benefit model. For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries.

The Part D standard model’s importance is that it is the only type of plan into which low-income beneficiaries can enroll and still receive any extra help for which they may qualify.

Question 6

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A client wants to give you an enrollment application on October 1 before the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him?

You must tell him you are not permitted to take the form and if he sends it to the plan, the application will be rejected and he will need to fill out another form and submit it after the Annual Election Period begins.

You must accept the application, but hold it until the annual election period begins, after which you must send it to the plan for processing.

You must tell him you are not permitted to take the form. If he sends the form directly to the plan, the plan will process the enrollment on the day the Annual Election Period begins.

You must send it to the plan for immediate processing, although the enrollment will not become effective until January 1.

Question 7

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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?

Medigap plans that cover costs not paid for by an MA plan are available only in Massachusetts, Minnesota, and Wisconsin.

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.”

Medigap plans are a form of Medicare Advantage, so purchasing both would be redundant coverage.

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.

Question 8

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Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him?

He can enroll in a Medicare Advantage plan if he has dropped Part B less than 90 days ago.

He can enroll in a Medicare Advantage plan but it will pay only the benefits associated with Medicare Part A.

He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B.

He is not eligible to enroll in a Medicare Advantage as a naturalized citizen.

Question 9

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Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard certain MA plans might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him?

If there is a special needs plan (SNP) in Mr. Wendt’s area that specializes in caring for individuals with diabetes, he may enroll in the SNP at any time under a special election period (SEP)

Mr. Wendt must wait until the next annual open enrollment period (AEP) before he can enroll in a special needs plan (SNP).

If there is a special needs plan (SNP) in Mr. Wendt’s area that specializes in caring for individuals with diabetes, he may enroll in the SNP during the MA Open Enrollment Period which takes place between January 1 and March 31.

Because of the severity of his condition, Mr. Wendt must remain enrolled in Original Medicare and also enroll in a Medigap plan to supplement his additional medical needs.

Question 10

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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.

Mr. Carlini can obtain drug coverage through the Federal government’s fallback plans, which are designed to provide an alternative to privately sponsored Medicare Advantage plans.

Mr. Carlini can keep Original Medicare, but if he does not sign up for an MA plan that includes prescription drug coverage, he will only be able to obtain prescription drug coverage through a Medigap plan.

To obtain prescription drug coverage, Mr. Carlini must enroll in an MA plan. The plan will cover his Part A and Part B services, as well as provide him with the desired prescription drug coverage.

Question 11

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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?

All individuals who are citizens and age 65 or over will be covered under Part A.

Most individuals who are citizens and age 65 or over and are covered under Part A must pay a monthly premium for that coverage.

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.

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.

Question 12

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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?

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.

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.

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.

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.

Question 13

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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?

He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start.

He may sign-up for Medicare at any time and coverage usually begins immediately.

He may not sign-up for Medicare until he reaches age 62, the date he first becomes eligible for Social Security benefits.

He may sign-up for Medicare at any time however coverage usually begins on the sixth month after dialysis treatments start.

Question 14

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Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual?

Her name will be reported to a publicly accessible database and could be advertised in local newspapers.

Plans must immediately terminate their contracts with such individuals.

The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract.

Plans do not impose penalties. Instead, the Medicare agency has specific authority to fine such individuals for each violation.

Question 15

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Mrs. Tanner is enrolled in a Medicare Advantage HMO that offers a point of service option. This allows Mrs. Tanner to do which of the following?

Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval.

Mrs. Tanner can go to non-plan doctors knowing that cost sharing will generally be the same as with network providers.

Mrs. Tanner can go to non-network doctors without worrying about a cap on the amount of out-of-network services she may receive.

Mrs. Tanner can go to non-plan doctors without receiving prior approval for all services.

Question 16

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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?

Medicare covers glasses, but not dentures or massage therapy.

Medicare covers 50% of the cost of these three services.

Medicare covers 80% of the cost of these three services.

Medicare does not cover massage therapy, or, in general, glasses or dentures.

Question 17

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Who is most likely to be eligible to enroll in a Part D prescription drug plan?

Ms. Davis who is entitled to Part A and has just enrolled in Part B.

Mr. Charles, an undocumented immigrant, entered the country illegally.

Ms. Adams, a healthy early retiree who has just begun to collect Social Security at age 62.

Ms. Bradley is currently living abroad for a multi-year job assignment.

Question 18

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Next week you will be participating in your first “educational event” for prospective enrollees. To be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage?

You should plan to conduct sales presentations and accept enrollment forms.

You should plan to answer questions and accept enrollment forms.

You should plan to ensure that the educational event is an informative event and must not conduct a sales presentation or distribute or accept enrollment forms at the event.

You should plan to conduct sales presentations but must not accept enrollment forms.

Question 19

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What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?

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.

Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market.

Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrict access through prior authorization.

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.

Question 20

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Ms. Gates has recently become dually eligible for Medicare and Medicaid. She is very concerned about how this will affect her prescription drug coverage. What should you tell her?

As a dual eligible beneficiary, her Part D drugs will be covered by Medicare once she is enrolled in a Part D plan. If she doesn’t select a plan, Medicare will select a plan for her.

She can enroll in a Part D plan, which Medicaid will cover.

She need not enroll in a Medicare prescription drug plan but can continue receiving drug coverage through her state’s Medicaid program.

Medicaid will select a Part D plan and enroll for her.

Question 21

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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?

If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor accepts Original Medicare.

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.

He may receive services from any physician, regardless of whether or not that physician participates in the plan or Original Medicare.

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.

Question 22

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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?

I-SNP

C-SNP

D-SNP

FIDE-SNP

Question 23

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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?

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.

Mrs. Gonzalez should purchase a K or L Medigap plan.

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.

Medigap is a replacement for Original Medicare and she has been paying for double coverage. She should simply drop her Medigap policy.

Question 24

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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?

He must wait until the next Annual Election Period, at which time he can enroll in a Medicare Advantage plan.

As long as his employer offers coverage that is equivalent to Medicare’s, he cannot enroll in Part B.

He will have to enroll in Part B.

He will not need to do anything. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan.

Question 25

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ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees’ information to market non-health related products such as life insurance and annuities. Which statement best describes ABC’s obligation to its enrollees regarding marketing such products?

It must obtain a HIPAA compliant authorization from an enrollee that indicates the plan or plan sponsor may use their information for marketing purposes.

Once a plan sends out a written request for consent, a beneficiary can authorize consent by simply failing to reply within 21 days.

The request for authorization may include a brief synopsis of non-health related content.

It is not necessary for ABC to obtain an authorization to simply explain pending state or federal legislation since there is no anticipation of selling a non-health related product in these circumstances.

Question 26

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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?

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.

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.

This is not a possibility. If Mrs. Berkowitz wants health coverage and drug coverage through a plan, she must purchase an MA-PD plan.

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.

Question 27

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Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application before the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams?

This is a good idea. The plan will retain Mrs. Young’s application and process it when the AEP begins.

This is a good idea. This locks Mrs. Young into a plan and protects Agent Adams’ commission.

This is a bad idea. Mrs. Young should complete an online application now so that Agent Adams will be given immediate credit for his work once the AEP begins.

This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form before the start of the AEP.

Question 28

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Ms. Brooks has an aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her?

Medicare covers hospice services and they will be available for her.

Medicare does not cover hospice services. Hospice services are only available through state Medicaid programs, if the state offers such coverage.

Hospice services are currently only offered under a limited demonstration project. Whether they will eventually become available nationally depends on the outcomes of the demonstration.

The Federal government facilitates competition between hospice programs to lower the price of their services for Medicare beneficiaries, but does not offer coverage for hospice services through the Medicare program.

Question 29

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Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong?

Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located.

Agent Armstrong needs to be licensed and appointed only in his state of residence.

Agent Armstrong needs to be licensed and appointed only in the state where XYZ Agency is headquartered.

Agent Armstrong needs to be licensed and appointed only in the state where ABC Health Plan is headquartered.

Question 30

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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?

Part D, which covers prescription drug services, is covered under Original Medicare.

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.

Part A, which covers long-term custodial care services, is covered under Original Medicare.

Part C, which always covers dental and vision services, is covered under Original Medicare.

Question 31

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Mrs. Mulcahy, age 65, 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?

Like all Medicare beneficiaries, Mrs. Mulcahy will be automatically enrolled in a Medicare prescription drug plan when she turns 65. She will have a six-month window during which she can select a plan other than the one into which she has been automatically enrolled.

An individual 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.

As long as Mrs. Mulcahy is 65, eligibility for a Medicare prescription drug plan is not dependent on entitlement to Part A or enrollment under Part B, so she should not be concerned.

To qualify for enrollment into a Medicare prescription drug plan, Mrs. Mulcahy must be entitled to Part A and enrolled under Part B. She should contact her local Social Security office and decide to enroll in Part B prior to selecting a prescription drug plan.

Question 32

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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?

Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication.

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.

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.

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.

Question 33

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Mr. Johannsen is entitled to Medicare Part A and Part B. He gains the Part D low-income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan?

He can apply the subsidy amount to his existing plan immediately, but he cannot enroll in a different plan.

He can enroll in a different plan or disenroll from his current plan during the next Annual Election Period.

He qualifies for a special election period and can enroll in or disenroll from a Part D plan once during that period.

He can only enroll in or disenroll from an MA-PD plan.

Question 34

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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?

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.

SNPs only serve individuals in long-term care facilities, so he cannot enroll.

SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll.

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.

Question 35

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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?

You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.

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.

You could suggest he call the doctor who performed the surgery to complain about the costs and ask for a discount on the charges.

You could remind him that he cannot do anything until the next Annual Election Period when he will have an opportunity to change plans.

Question 36

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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 if a plan obtains permission from CMS for a marketing event in a provider facility, the event may go forward, regardless of where it occurs in the facility.

Tell her that Medicare guidelines only allow you to conduct marketing activities in areas of the facility where individuals are waiting to receive health care services, but not in places where they would be receiving health care such as an examining room.

Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider’s facility.

Tell her that Medicare guidelines allow you to conduct marketing activities anywhere in the facility, so long as the affected providers agree to that event.

Question 37

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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.

Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States.

Mrs. Radford must be enrolled in both Medigap and Part A to enroll in a Medicare Advantage plan.

Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, before being accepted and enrolled.

Question 38

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You are working several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do?

You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event.

You must state in the advertisement that it will be an educational event and that the education will consist of specific information about the participating plans.

Plans may not participate in advertising such an event. All advertising must be done by community organizations.

You must only ensure that the advertisement is factually accurate.

Question 39

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Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan’s formulary he takes several other medications. These include a prescription drug not on his plan’s formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say?

The cost of the prescription drugs that are not on his plan’s formulary as well as the cost of the drug(s) to reduce joint swelling from the Canadian pharmacy will count toward TrOOP but the other medications in question will not count toward TrOOP.

None of the costs of Mr. Wingate’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary.

The cost of the prescription drug that is not on his plan’s formulary will count toward TrOOP but the other medications in question will not count toward TrOOP.

The cost of all medications bought within the United States not covered by his plan would count toward TrOOP. The cost of the Canadian bought medications would not count toward TrOOP.

Question 40

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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?

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.

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.

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.

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.

Question 41

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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 will ask the facility to provide a plan brochure and enrollment application in every resident’s room before the meeting to promote interest in the event.

You appreciate the opportunity and would ask the facility to provide enrollment applications for the MA-PD plans you represent.

You appreciate the opportunity and your friend would just need to complete scope of appointment forms on behalf of all the residents who would like to attend.

You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request.

Question 42

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Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time?

He may change or drop MA plans, but may not drop drug coverage.

He will have one opportunity to enroll in a Medicare Advantage plan.

If he has a disability, he must enroll in Original Fee-for-Service Medicare during the MA Initial Coverage Election Period.

He will have a nine month period during which he may enroll in as many Medicare Advantage plans as he chooses, with the last enrollment being the effective one.

Question 43

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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.

Marketing representatives may only use internet pop-up ads providing plan-specific information that have been approved by CMS when soliciting prospects through electronic means of communication.

Marketing representatives may initiate electronic contact through e-mail and as long as an e-mail is opened marketing representatives may also follow-up with unsolicited telephone calls.

While unsolicited contacts may be made through print media such as direct mail, marketing representatives may not initiate electronic contact.

Question 44

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Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D. What could you tell him?

He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may only add stand-alone Medicare prescription drug coverage.

He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may only enroll in an MA-PD plan.

He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may make one Part D enrollment choice, including enrollment in a stand-alone Part D plan or an MA-PD plan.

He must first enroll in a Medicare Part D plan, before enrolling in a Medicare Advantage plan.

Question 45

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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?

Individuals who become eligible for such disability payments only have to wait 12 months before they can apply for coverage under Medicare.

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.

After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.

He became eligible for Medicare when his disability eligibility determination was first made.

Question 46

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Mr. Yoo’s employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a Special election period. Mr. Yoo contacted you to find out more about what this means. What can you tell him?

It means that he will be able to enroll in a state-funded pharmacy assistance program for retirees that will cover 80 percent of his drug costs.

It means that he qualifies for a one-time opportunity to enroll in an MA-PD or Part D prescription drug plan.

It means that he will be able to purchase continued drug coverage from the insurer that had provided it to the company retirees, but that he will not have to pay the entire premium himself.

It means that he will have a one time opportunity to enroll in a Medigap policy with drug coverage.

Question 47

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You are meeting with Ms. Berlin and she has completed an enrollment form for a MA-PD plan you represent. You notice that her handwriting is illegible and as a result, the spelling of her street looks incorrect. She asks you to fill in the corrected street name. What should you do?

You may correct the information since it was a simple mistake. You do not need to do anything further to the application form.

Under no circumstances may you make corrections to information a beneficiary has provided. Review of enrollment forms is the sole responsibility of the plan sponsor.

You may correct this information as long as you add your initials and date next to the correction.

You may correct the information, but she will need to write a brief statement indicating she authorized you to make the change.

Question 48

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Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable income only sporadically. Her husband worked full-time throughout his long career. She has heard that to qualify for Medicare Part A she has to have worked and paid Medicare taxes for a sufficient time. What should you tell her?

Because her husband paid Medicare taxes, and she rarely did, she will have to pay Part A premiums but will do so at a reduced rate.

She will have to pay the monthly Part A premium in order to obtain the coverage.

She will have to obtain a job and work enough years to qualify for Medicare Part A.

Since her husband paid Medicare taxes during the entire time he was working, she will automatically qualify for Medicare Part A without having to pay any premiums.

Question 49

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All plans must cover at least the standard Part D coverage or its actuarial equivalent. Which of the following statements best describes some of the costs a beneficiary would incur for prescription drugs under the standard coverage?

Standard Part D coverage would require payment of only fixed per-prescription co-payments.

Standard Part D coverage would require payment of an annual deductible, fixed per-prescription co-payments, and once catastrophic coverage begins, the plan covers 100% of all costs.

Standard Part D coverage would require payment of an annual deductible, and once past the catastrophic coverage threshold, the beneficiary pays whichever is greater of either the co-pays for generic and brand name drugs or coinsurance of 5%.

Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap.

Question 50

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Mr. Roberts is enrolled in an MA plan. He recently suffered complications following hip replacement surgery. As a result, he has spent the last three months in Resthaven, a skilled nursing facility. Mr. Roberts is about to be discharged. What advice would you give him regarding his health coverage options?

His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility.

His open enrollment period as an institutionalized individual will continue for 12 months following his date of discharge.

Mr. Roberts has two months following his discharge to continue under his current MA plan before he must return to Original Medicare for the remainder to the calendar year.

Mr. Roberts must return to Original Medicare within two months of discharge, but he may continue to enroll and disenroll in Part D for 12 months following discharge.