Which statement best describes a care management program that varies depending upon the level of the member’s health risk?
Mr. and Mrs. Nunez attended one of your sales presentations. They’ve asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do?
Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare’s efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment site, which of the following must Phiona consider?
I. If a legal representative is completing an electronic enrollment request, he or she must first upload proof of his or her authority.
II. All data elements required to complete an enrollment request must be captured.
III. The process must include a clear and distinct step that requires the applicant to activate an “Enroll Now” or “I Agree” type of button or tool.
IV. The mechanism must capture an accurate time and date stamp at the time the applicant enters the online site.
Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He found a stand-alone Medicare prescription drug plan in his area that offers better coverage than that available through his MA-PD plan and in addition has a low premium. It won’t cost him much more and, because he has the means to do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan. What should you tell him?
You have come to Mrs. Midler’s home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical record available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan. What should you do?
Ms. Claggett is sixty-six (66) years old. She has been covered under both Parts A and B of Original Medicare for the last six years due to her disability, has never been enrolled in a Medicare Advantage or a Part D plan before. She wants to enroll in a Part D plan. She knows that there is such a thing as the “Part D Initial Enrollment Period” and has concluded that, since she has never enrolled in such a plan before, she should be eligible to enroll under this period. What should you tell her about how the Part D Initial Enrollment Period applies to her situation?
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 prior the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams?
Ms. Gonzales decided to remain in Original Medicare (Parts A and B) and Part D during the Annual Enrollment Period (AEP). At the beginning of January, her neighbor told her about the Medicare Advantage (MA) plan he selected. He also told her there was an open enrollment period that she might be able to use to enroll in a MA plan. Ms. Gonzales comes to you for advice shortly after speaking to her neighbor. What should you tell her?
a. It is a time period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically the Special Election Period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area. Correct
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 that there are certain MA plans that 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?
Which of the following individuals are likely to qualify for a special enrollment period (SEP) for both MA and Part D due to a change of residence?
I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan’s service area.
II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan’s service area.
III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area where no Part D plan was available.
IV. Henry makes a permanent move providing him with new MA and Part D options.
Mr. Rockwell, age 67, is enrolled in Medicare Part A, but because he continues to work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special enrollment periods (SEPs)?
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?
Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirements several years ago. Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the first time. Unfortunately, Mrs. Ridgeway has found that many of her providers are not in the MA plan’s network. She has come to you for advice? What should you tell her?
Mary Samuels recently suffered a stroke while visiting her daughter and grandchildren. As a result, Mary has been admitted to a rehabilitation hospital where she is expected to reside for several months. The rehabilitation hospital is located outside the geographic area served by her current Medicare Advantage (MA) plan. What options are available to Mary regarding her health plan coverage?
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?
Mrs. Lenard is enrolled in a Medicare Cost plan. Recently the cost plan announced its intention to end its cost contract and transition to a Medicare Advantage (MA) Mrs. Lenard received a letter indicating that unless she chooses another plan or opts out she will be automatically enrolled in the new Medicare Advantage plan operated by an organization affiliated with her cost plan. What does this mean?
d. If Mrs. Lenard wants to enroll in a Medicare Advantage plan affiliated with her cost plan effective January 1, she should do nothing and she will be automatically enrolled. If she does not want to enroll in that MA plan, she should choose another plan or otherwise opt out of the automatic enrollment. Correct
You meet with Mrs. Wilson to complete her enrollment in a Medicare Advantage plan. You tell her that there will be an enrollment verification process to confirm that she is enrolled in the plan that she requested and understands the plan features and rules. What should Mrs. Wilson expect regarding the verification process?
Mrs. Burton is in an MA-PD plan and was disappointed in the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she wouldn’t continue to have to put up with such poor access to care. What could you tell her?
Mr. Barker had surgery recently 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 a number of services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him?
Mrs. Disraeli is enrolled in Original Medicare (Parts A and B) and a standalone Part D prescription drug plan. She has recently developed diabetes and has suffered from heart disease for several years. She has also recently learned that her area is served by a SNP for individuals suffering from such a combination of chronic diseases (C-SNP). Mrs. Disraeli is concerned however, that she will have few rights or protections if she enrolls in a C-SNP. How would you respond?
Ms. O’Donnell learned about a new MA-PD plan that her neighbor suggested and that you represent. She plans to switch from her old MA HMO plan to the new MA-PD plan during the Annual Election Period. However, she wants to make sure she does not end up paying premiums for two plans. What can you tell her?
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?