You will learn about the following in this module:
| Started on | Friday, January 3, 2025, 10:52 PM |
|---|---|
| State | Finished |
| Completed on | Friday, January 3, 2025, 11:14 PM |
| Time taken | 21 mins 52 secs |
| Points | 20.00/20.00 |
| Grade | 100.00 out of 100.00 |
| Feedback |
You have completed this Knowledge Check. To proceed, please return to the training dashboard and select the next available section. |
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?
Source: Module 1, Slide - Medicare Enrollment Part A & B
Source: Module 1, Slide - Further Information on Medigap (Medicare Supplement Insurance), Slide – Medigap Rules for Individuals Who Become Eligible for Medicare After December 31, 2019, and Slide – Medigap Plans and Medigap Plans
Source: Module 1, Slide – Not Covered by Medicare Part A & B
Source: Module 1, Slide - Beneficiaries with Medigap Plans with/without Drug Coverage
Source: Module 1, Slide - Medicare Part A Benefits
Source: Module 1, Slide - Medicare Part A – Original Medicare Cost-Sharing for Skilled Nursing and Rehabilitative Care and Slide – Medicare Part A Benefits.
Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to Medicare beneficiaries?
Source: Module 1, Slide – Medicare Part A Benefits, slide – Medicare Part B Benefits, slide – Not Covered by Medicare Part A & B
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 because of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare?
Source: Module 1, Slide – Medicare Part A – Original Medicare Cost-Sharing for Inpatient Hospital Care
What impact, if any, have recent regulatory changes had on Medigap plans?
Source: Module 1, Slide - Medigap Rules for Individuals who became Eligible for Medicare after December 31, 2019
Source: Module 1, Slide - Medicare Part A Benefits
Source: Module 1, Slide - Original Medicare and Part D Prescription Drug Coverage
Source: Module 1, Slide - Help for Individuals with Limited Income/Resources
Source: Module 1, Slide – Appeals related to Original Medicare Part A and Part B Coverage and Payment Determinations
Source: Module 1, Medigap (Medicare Supplement Insurance); Slide – Further information on Medigap; Slide – Medigap Coverage
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?
Source: Module 1, Slide - Eligibility for Part A & B Benefits and Slide - Medicare Premiums Part A
Source: Module 1, Slide - Original Medicare and Part D Prescription Drug Coverage
You will learn about the following in this module:
| Started on | Friday, January 3, 2025, 11:19 PM |
|---|---|
| State | Finished |
| Completed on | Friday, January 3, 2025, 11:41 PM |
| Time taken | 21 mins 53 secs |
| Points | 19.00/20.00 |
| Grade | 95.00 out of 100.00 |
| Feedback |
You have completed this Knowledge Check. To proceed, please return to the training dashboard and select the next available section. |
Source: Part 2, Slide -- MA Plan Types Medicare Savings Account (MSA) Plans, and Slide – MA Plan Types: MSA Plans, continued.
Source: Module 2, Slide - Employer/Union Plans
I. MSAs may have either a partial network, full network, or no network of providers.
II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits.
III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation.
IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full.
Source: Module 2, Slide - MA Plan Types: Medical Savings Account (MSA) Plans.
Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description?
Source: Module 2, Slide - Part C: Medicare Advantage Plans (Overview).
Source: Module 2, Slide - Part C: Medicare Advantage Plans: Overview, and Slide - Part C: Medicare Advantage Plan Benefits
Source: Module 2, Slide – Medicare Advantage Eligibility
Source: Module 2, Slide - MA & Prescription Drugs
Source: Module 2, Slide - MA Plan Types: Private Fee-for-Service (1 of 2); Slide - MA Plan Types: Private Fee-for-Service Plans (2 of 2).
Source: Module 2, Slide - Elegibilidad para Medicare Advantage
Source: Module 2, Slide - MSAs: Special Eligibility Rules, Slide – MA Plan Types: Medical Savings Account (MSA) Plans, and Slide – MA Plan Types: MSA Plans
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?
Source: Module 2, Slide - Part C: Medicare Advantage Plans: Overview.
Source: Module 2, Slide - Medicare Advantage Eligibility
Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was disappointed with 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 would not have to put up with such poor access to care. What could you tell her?
Source: Module 2, Slide - Enrollee Protections: Grievances and Slide - Grievance Example
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?
Source: Module 2, Slide - Enrollee Protections: Appeals; Slide - Enrollee Protections: Coverage Decisions, and Slide – Enrollee Protections: Appeals
Source: Module 2, Slide - MA & Prescription Drugs
Source: Module 2, Slide - Medicare Advantage Eligibility
You will learn about the following in this module:
| Started on | Saturday, January 4, 2025, 12:11 AM |
|---|---|
| State | Finished |
| Completed on | Saturday, January 4, 2025, 12:14 AM |
| Time taken | 2 mins 35 secs |
| Points | 19.00/20.00 |
| Grade | 95.00 out of 100.00 |
| Feedback |
You have completed this Knowledge Check. To proceed, please return to the training dashboard and select the next available section. |
Source: Module 3, Slide - New for 2025: The Medicare Prescription Payment Plan (1 of 3)
Source: Module 3, Slide - Other Help for Low Income - Pharmaceutical Assistance Programs.
Source: Module 3, Slide - Enrollee Rights: Requesting Exceptions for Drugs
Source: Module 3, Slide - Part D Standard Benefits for 2025; Slide – True Out-of-Pocket Costs (TrOOP)
Source: Module 3, Slide - Covered Part D Drugs and Slide – Formularies
Source: Module 3, Slide - Medicare Part D Eligibility
Source: Module 3, Slide - Part D Drug Management Tools, slide – Formularies, and Slide – Tiering
Source: Module 3, Slide - Employer/Union Coverage of Drugs
Source: Module 3, Slide - New for 2025: The Medicare Prescription Payment Plan (1 of 3)
Source: Module 3, Slide - Employer/Union Coverage of Drugs; Slide – Part D Late Enrollment Penalty, Slide – Late Enrollment Penalty: Examples, and Slide - Employer Coverage of Drugs
Source: Module 3, Slide – The Medicare Prescription Payment Plan (2 of 3)
Source: Module 3, Slide - True Out-of-Pocket Costs (TrOOP)
Source: Module 3, Slide - Part D Pharmacy Networks
Mr. Shapiro gets by on a very small amount of 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?
Source: Module 3, Slide - Help for Individuals with Limited Income and Limited Resources and Slide - Encourage Individuals with Limited Income/Resources to Apply to the State Medicaid Office
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?
Source: Module 3, Slide - Part D Plan Benefits and Slide – Part D Benefits: Alternative Coverage
Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him?
Source: Module 3, Slide - Part D Premiums
Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. 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?
Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics, and Slide – Medicare Part D Prescription Drug Eligibility
Source: Module 3, Slide - Transition Requirements, and Slide – Transition Requirements
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?
Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basic and Slide - Medicare Prescription Drug Eligibility
Source: Module 3, Slide - Drugs Excluded from Part D Coverage
You will learn about the following in this module:
| Started on | Saturday, January 4, 2025, 12:33 AM |
|---|---|
| State | Finished |
| Completed on | Saturday, January 4, 2025, 12:35 AM |
| Time taken | 2 mins 15 secs |
| Points | 19.00/20.00 |
| Grade | 95.00 out of 100.00 |
| Feedback |
You have completed this Knowledge Check. To proceed, please return to the training dashboard and select the next available section. |
Source: Module 4, Slide - Prohibited Practices: Discriminatory Activity, Superlatives, and Comparisons (p.23)
Source: Module 4, Slide - Gifts and Promotional Items; Slide – Gifts and Promotion Items
You plan to participate in an educational event sponsored by a large regional health care system. One of your colleagues suggests that you do a presentation on one of the Medicare Health plans you market and modify it to include information about preventive screening tests showcased at the event. How should you respond to your colleague’s suggestion?
Source: Module 4, Slide - Educational Events, Prohibited Activities (p.17)
You are meeting with Mrs. Hall in her home. On her scope of appointment form, she asked to discuss Medicare Advantage plans. During the meeting, she asked to discuss a stand-alone prescription drug plan. She is leaving the next day to visit her family for a week in another state, so she needs to decide before she leaves. What must happen before that additional discussion can take place?
Source: Module 4, Slide - Required Practices: Scope of Appointment, slide - Individual Marketing Appointments, Prohibited Activities
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?
Source: Module 4, Slide - What are Communications Only Materials and Activities? , and, Slide –What are Examples of Communication Only Materials (p 8)
Source: Module 4, Slide - Educational Events, Required and Permitted Activity
Source: Module 4, Slide - Rules that apply to all Communications (including Marketing) Materials and Activities, and slide – Prohibited Practices: Discriminatory Activity, Superlatives, and Comparisons (p.29)
During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5-star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the best statement to say to her?
Source: Module 4, Slide - Plan Ratings: Required Practices and slide - Required Practices: Plan Ratings - Prohibitions (p.27)
If you are to comply with Medicare’s guidance regarding educational events, which of the following would be acceptable activities?
Source: Module 4, Slide - Educational Events, Permitted Activities, and Educational Events, Prohibited Activities (pp.16-17)
When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?
Source: Module 4, Slide - Gifts and Promotional Items, and slide – Gifts and Promotional Items (p.18)
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 mind?
Source: Module 4, Slide - Marketing/Sales Events, Prohibited Activity (p.15)
Source: Module 4, Slide - Required Practices: Scope of Appointment (p.19)
Source: Module 4, Slide – Requirements to act as Agents and Brokers; Slide – Applicability of Medicare Communications and Marketing Rules to Marketing Representatives, and Slide – Applicability of Medicare Communications and Marketing Rules when Marketing to Employer/Union Groups
Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services (CMS) Communication and Marketing Guidelines to ensure he is compliant with which type of products.
Source: Module 4, Slide - Medicare Marketing and Communication Rules
Source: Module 4, Slide - Marketing and Communications, and slide – Prohibited Practices: Marketing and Communications, (continued)
You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To comply with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plansl?
Source: Module 4, Slide - Unsolicited Contacts. (p.11)
Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational. 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?
Source: Module 4, Slide - Educational Events, Prohibited Activities (p.17)
You have set up an appointment for an in-home sales presentation with Mrs. Fernandez, who expressed interest in the Medicare plans you represent. In preparation for the sales presentation, what must you do?
Source: Module 4, Slide - Individual Marketing Appointments, slide - Required Practices: Scope of Appointment, slide - Scope of Appointment: Documentation (pp.19-20)
Source: Module 4, Slide - Marketing Activities: Marketing in a Health Care Setting
While making an appointment to discuss Medicare Advantage (MA) and Part D plans with a potential enrollee, you are asked to describe other types of insurance products that your client might wish to purchase. What additional types of insurance can you present during the MA and Part D marketing appointments?
Source: Module 4, Slide - Individual Marketing Appointments and - Individual Marketing Appointments, Prohibited Activities; Slide - Required Practices: Scope of Appointment and Scope of Appointment: Documentation
After completing this module, you will be able to:
Started onStateCompleted onTime takenPointsGradeFeedback
| Saturday, January 4, 2025, 4:56 PM |
| Finished |
| Saturday, January 4, 2025, 5:00 PM |
| 4 mins 8 secs |
| 16.00/20.00 |
| 80.00 out of 100.00 |
|
You have completed this Knowledge Check. To proceed, please return to the training dashboard and select the next available section. |
Correct
Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period (AEP). On December 1, he calls you up and says that he has changed his mind and would like to enroll in a MA-PD plan. What enrollment rules would apply in this case?
Question 1Answer
a.
He can make as many enrollment changes as he likes during the Annual Election Period and the last choice made before the end of the period will be the effective one as of January 1.
Correct. Beneficiaries may make more than one enrollment choice during the AEP, but the last one made before the end of the AEP, as determined by the date the plan or marketing representative receives the completed enrollment form, will be the election that takes effect.
b.
He should wait for at least six months into the plan year to be sure that he wants to make the change. If he still wants to do so, he can make any sort of change he likes at that point.
c.
He can only make a single enrollment change during the Annual Election Period, so he will not be able to change his enrollment.
d.
He must return to Original Medicare but must then enroll in a Part D plan if he wants prescription drug coverage through Medicare.
Source: Part 5, Slide -Election Periods: Annual Election Period – Overview
Correct
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?
Question 2Answer
a.
If Mr. Block wants to enroll in both a MA-PD and a stand-alone PDP, he may buy the extra coverage without any adverse effect.
b.
Mr. Block will have to wait until the annual election period, beginning October 15, and then he can add the stand-alone coverage to the MA-PD.
c.
If Mr. Block enrolls in a stand-alone Medicare prescription drug plan, he can request that his Medicare Advantage plan remove the drug benefit from the package they offer and reduce his premium accordingly.
d.
If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan.
Correct: When an applicant enrolls in an MA plan, they acknowledge that they understand enrollment in another MA plan, PDP, or MA-PD automatically disenrolls them from their current plan. If Mr. Block enrolls in a standalone PDP, he will be disenrolled from his current MA plan.
Source: Part 5, Slide – Beneficiary Acknowledgements when Enrolling [Pg. 25].
Correct
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?
Question 3Answer
a.
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.
b.
It means that he will have a one time opportunity to enroll in a Medigap policy with drug coverage.
c.
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.
d.
It means that he qualifies for a one-time opportunity to enroll in an MA-PD or Part D prescription drug plan.
Correct. Beneficiaries eligible for Part D who involuntarily lose creditable prescription drug coverage have a special election period (SEP) allowing them to enroll in a prescription drug plan or MA-PD plan. During the SEP, he has one opportunity to drop, add, or change his Part D coverage.
Source: Part 5, Election Periods – SEPs, continued (Involuntary loss of creditable coverage), Slide – Election Periods – SEP, Limitations and Slide – Typical SEPs – Employer/ Union Coverage Change.
Correct
Ms. Claggett is sixty-six (66) years old. She has been covered under Original Medicare for the last six years due to her disability and 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” (IEP) 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?
Question 4Answer
a.
Ms. Claggett has had two IEPs and missed them both. The first occurred three months before and three months after the month when she was first entitled to Part A OR enrolled in Part B. Because she was eligible for Medicare before age 65, Ms. Claggett had a second IEP based on turning age 65, which has also expired.
Correct: The Part D IEP begins three months before the month an individual meets the eligibility requirements for Part B and ends three months after the month of eligibility. Individuals eligible for Medicare before age 65 due to disability have a second IEP when attaining age 65. Mrs. Claggett is now 66 years old, and her Part D IEP based on attaining age 65 has now expired so she will not be able to use it to enroll in Part D.
b.
It occurs from October 15 to December 7 of each year, so she will have to wait until that point to utilize that particular enrollment period.
c.
The Part D Initial Enrollment Period occurs only when a beneficiary turns 62 so it cannot be used as the justification for allowing her to enroll at this point.
d.
It occurs from January 1 to February 14 of each year, so she will have to wait until that point to utilize that particular enrollment period.
Source: Part 5, Slide – Election Periods - Part D Initial Enrollment Period (IEP). See also, Part 1, -Medicare Enrollment - Parts A and B (automatic enrollment for disabled)
Correct
Ms. Lee is enrolled in an MA-PD plan but will be moving out of the plan’s service area next month. She is worried that she will not be able to enroll in another plan available in her new residence until the Annual Election Period. What should you tell her?
Question 5Answer
a.
She will be able to enroll in a new plan because she qualifies for a special election period that begins 30 days after a plan’s written communications are returned by the United States Postal Service with a notification that the resident has moved. So, she should be sure to notify the Postal Service immediately.
b.
She may continue to keep her existing plan, because all Medicare health plans are required to provide coverage to anyone, no matter where they live.
c.
She is eligible for a special election period (SEP) that begins either the month before her permanent move, if the plan is notified in advance, or the month she provides notice of the move, and this period typically lasts an additional two months.
Correct. Ms. Lee’s move is a change in residence, which makes her eligible for a special election period (SEP) that begins either the month before the move if she gives her plan advanced notice, or the month she provides notice of the move. The SEP continues for two months either after it begins or the month of the move, whichever is later.
d.
She will have to wait until the next Annual Election Period to be able to enroll in a plan available in her new location.
Source: Part 5, Slide – Typical SEPs – Change in Residence
Correct
Mr. Liu turns 65 on June 19. He has never previously qualified for Medicare so his first Medicare eligibility date will be June 1. Mr. Liu’s ICEP and Part D IEP begin on March 1 and end on September 30. He wants prescription drug coverage with his Part A and Part B benefits. What advice can you provide him?
Question 6Answer
a.
He must wait until the next Annual Election Period to enroll in a MA-PD plan.
b.
Since this is his first time qualifying for Medicare, he will have to enroll in Original Medicare with a Part D plan this year and change his enrollment to a MA-PD plan next year.
c.
He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to Part A.
Correct: As long as he enrolls in Part B and is entitled to Part A, he may enroll in a MA-PD.
d.
He can enroll in a MA plan now, but he will have to wait until the next Annual Election Period to obtain prescription drug coverage.
Source: Module 5, Slide – Election Periods – Part D Initial Enrollment Period (IEP), slide – MA and Part D Enrollment/Election Periods – Brief Summary, and Slide - Election Periods – MA Initial Coverage Election Period (ICEP)
Correct
Mrs. Pierce would like to enroll in a Medicare Cost plan that offers Part D prescription drug coverage. She comes to you for advice about when she can enroll in a plan you have previously discussed. What should you tell her?
Question 7Answer
a.
Enrollment in Cost plans offering Part D coverage is generally available only 30 days per year, because of the more generous benefits of these plans.
b.
Enrollment in Cost plans offering Part D coverage is generally available year-round, so she can immediately enroll and have prescription drug coverage.
c.
Enrollment in Cost plans offering Part D prescription drug coverage is not necessary because Cost plans offer more generous Part B benefits.
d.
Enrollment in Cost plans offering Part D coverage is available only during enrollment periods under the Part D program, and Cost plans must accept enrollments during these periods.
Correct. Cost plans offering Part D coverage may only make this benefit available during the enrollment periods available under the Part D program, and they are required to accept Part D enrollments during these periods.
Source: Part 5, Slide - Cost Plan Enrollment Periods [Pg.17]
Correct
Which of the following individuals are likely to qualify for a special election period (SEP) for either a MA and/or 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 to a new state providing him with new MA and Part D options.
Question 8Answer
a.
II, III, and IV only.
Correct. Edward is not likely to qualify for either a MA or Part D SEP because he has moved within his existing plan’s service area. Fiona is likely to qualify for both a MA and Part D SEP due to her move across country outside her current plan’s service area. Gilbert is likely to qualify for a Part D SEP because he has gained the opportunity to enroll in Part D prescription drug coverage. Henry also is likely to qualify for both a MA and Part D SEP since he has moved to a new state which is likely to be outside his current plan’s service area.
b.
I and II only.
c.
I, II, III and IV.
d.
II and III only.
Source: Part 5, Slide -Typical SEPs – Change in Residence.
Correct
Mrs. Kendrick is in good health, has worked for many years, and is six months away from turning 65. She wants to know what she will have to do to enroll in a Medicare Advantage (MA) plan as soon as possible. What could you tell her?
Question 9Answer
a.
She must first enroll in a Medicare Part D plan, before enrolling in a Medicare Advantage plan.
b.
She must have previously been enrolled in Original Fee-for-Service Medicare for at least one year before she may enroll in an MA plan.
c.
She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B.
Correct: Mrs. Kendrick will soon enter her MA Initial Coverage Election Period (ICEP) which begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B. Mrs. Kendrick will become eligible for Part A and Part B upon turning age 65. Therefore, she may enroll in a MA plan three months before her 65th birthday.
d.
MA plans are only available to those who have been enrolled in a Medigap plan for at least six months. Therefore, before enrolling in an MA plan, she must first use a Medigap plan to supplement her Original Medicare coverage.
Source: Part 5,Slide - Election Periods - MA Initial Coverage Election Period (ICEP).
Correct
Mr. Chen is enrolled in his employer’s group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him?
Question 10Answer
a.
Mr. Chen can disenroll from the employer-sponsored plan and his only option is to choose a Medigap plan.
b.
Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment.
Correct: Individuals disenrolling from employer-sponsored coverage to elect an MA plan have a SEP that ends 2 months after the month the employer-sponsored coverage ends.
c.
Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan, but he must wait until the next Annual Election Period.
d.
Mr. Chen must convert his current coverage to employer-sponsored retiree coverage and wait one year before enrolling in a MA or Part D plan.
Source: Part 5, Slide – Typical SEPs – Employer/Union Group Coverage Change
Incorrect
Mr. Anderson is a very organized individual and has filled out and brought to you an enrollment form on October 10 for a new plan available on January 1 next year. He is currently enrolled in Original Medicare. What should you do?
Question 11Answer
a.
Tell Mr. Anderson that you cannot accept an enrollment form for coverage to begin on January 1 of next year before December 15.
b.
Accept the form and immediately send it to the plan for processing.
Incorrect. October 10th is before the start of the Annual Election Period (AEP), which begins October 15th and ends December 7th. Marketing representatives may not accept enrollment forms before October 15th for enrollment under the AEP.
c.
Accept the form and wait until the Annual Election Period begins to send it to the plan for processing.
d.
Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins.
Source: Part 5, Slide -Enrollment Periods - Annual Election Period, Timeframe for Submitting Enrollment Forms
Incorrect
Mr. Rodriguez is currently enrolled in a MA plan, but his plan doesn’t sufficiently cover his prescription drug needs. He is interested in changing plans during the upcoming MA Open Enrollment Period. What are his options during the MA OEP?
Question 12Answer
a.
He can only switch to Original Medicare with a PDP.
b.
He can switch to a MA-PD plan.
c.
He can only switch to another MA plan.
d.
He can change to Original Medicare with a PDP. But if he later finds a better MA-PD plan he likes, he can switch to that as long as the change is before the end of the MA OEP.
Incorrect: He is permitted to change to Original Medicare with a PDP during the MA OEP. However, beneficiaries may only change plans once during this period.
Source: Part 5, Slide – Election Periods – MA Open Enrollment Period (MA OEP); Slide - Election Periods – MA OEP
Incorrect
Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirement 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?
Question 13Answer
a.
She qualifies for a special election period (SEP) that will allow her to make a one-time election to return to Original Medicare and she also has a guaranteed eligibility period to rejoin her Medigap plan.
b.
She must wait until the next MA Open Enrollment Period (OEP) during which she can elect to return to Original Medicare.
c.
She qualifies for a special election period (SEP) that will allow her to make a one-time election to return to Original Medicare, but she may or may not qualify to rejoin her Medigap plan based on medical underwriting.
Incorrect: Mrs. Ridgeway does qualify for a SEP to return her to her Original Medicare. However, this SEP also provides her with guaranteed eligibility to rejoin a Medigap plan.
d.
She must wait until the next Annual Election Period (AEP) during which she may select another MA plan.
Source: Part 5, Slide – Other Common SEPs (Medigap SEP)
Correct
Which of the following individuals has enrolled in a plan based on a fixed enrollment period?
Question 14Answer
a.
Lucy enrolls in a Medicare Advantage plan after moving into a skilled nursing facility institution.
b.
Jorge enrolls in a Medicare Advantage plan during a special election period after special circumstances arose.
c.
Ben enrolls in a Medicare Advantage plan during the Medicare Advantage Open Enrollment Period (MA OEP).
Correct: The Medicare Advantage Open Enrollment Period (MA OEP) is a fixed annual enrollment period that occurs annually between January 1 through March 31.
d.
Josephine enrolls in Original Medicare when she first becomes eligible for Medicare.
Source: Part 5, Roadmap to Election Periods and Slide -Election Periods-MA Open Enrollment Period (MA OEP)
Correct
Mrs. Schmidt is moving and a friend told her she might qualify for a “special election period” to enroll in a new Medicare Advantage plan. She contacted you to ask what a special election period is. What could you tell her?
Question 15Answer
a.
It is a 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. MA eligible and Part D eligible beneficiaries who experience certain qualifying events, such as a change in residence, are provided a special period to change their election, known as a special election period or “SEP.”
b.
It is a period when beneficiaries who are newly eligible for Medicare may make their first choice of a Medicare prescription drug plan.
c.
It is a single period from January 1 – March 31, created by statute, when any Medicare beneficiary who has moved out of the area of their Medicare Advantage or Part D plan can add, drop, or change their Medicare prescription drug coverage.
d.
It is a period when only Medicare beneficiaries who have moved out of the area and are dually eligible for Medicaid may add, drop, or change their prescription drug coverage.
Source: Part 5, Slide – Enrollment Periods – SEPs and slide – Typical SEPs – Change in Residence
Correct
Ms. Thomas has worked for many years and is turning 68 in June. She is eligible for Medicare Part A and did not enroll for Part B when first eligible because she has insurance through her employer – Coffee Brew, Inc. She also did not enroll in Part D because she had creditable coverage. She would like to retire in June and enroll in a Medicare Advantage plan. She has been informed that her group coverage will end on her retirement effective date. How would you advise Ms. Thomas?
Question 16Answer
a.
Ms. Thomas can enroll in Part B without a late penalty at any time she is still covered by her employer group and 8 months after her last month of employer group coverage without a penalty. However, because she wants to enroll in a MA plan after retirement, she should make sure her Part B coverage is effective in time to use the Medicare Advantage/Part D special election period for individuals changing from employer group coverage to enroll in a MA plan or MA-PD. The SEP begins while she has employer group coverage and will last until 2 months after the month after the month her employer coverage ends. If she wants Part D coverage she should enroll in an MA-PD or a PDP (depending on how she decides to receive her Part A and B benefits) during this time.
Correct: To enroll in a MA or MA-PD plan, Ms. Thomas must be not only eligible for Part A but also enrolled in Part B. This will allow her to review her options and select coverage comparable to employer group coverage. Those disenrolling from employer-sponsored coverage to elect a MA or MA-PD plan have a SEP that ends 2 months after the employer-sponsored coverage ends in June.
b.
Ms. Thomas should enroll in Part B, which would enable her to use the SEP for individuals changing from employer group coverage to enroll in a MA plan or MA-PD. The SEP will last until 3 months after the month her employer coverage ends.
c.
Ms. Thomas should request continued COBRA coverage under her employer group plan. This coverage will last 18 months and provide her with time to select either a MA plan or MA-PD plan when her COBRA coverage ends. The SEP will last 6 months after the month the COBRA coverage ends.
d.
Ms. Thomas should enroll in Part D to obtain prescription drug coverage under a PDP. It will not be necessary for Ms. Thomas to enroll in Part B since it offers drug coverage that duplicates most PDP plans.
Source: Module 5, Slide - Typical SEPs Employer/Union Group Coverage Change
Incorrect
Mr. Garcia was told he qualifies for a special election period (SEP), but he lost the paper that explains what he could do during the SEP. What can you tell him?
Question 17Answer
a.
If the SEP is for MA coverage, he may only use the SEP to disenroll from his MA plan and return to Original Medicare.
b.
If the SEP is for MA coverage, he may make as many changes to his MA enrollment as he wants and the last choice made before the end of the SEP period will be the effective one.
Incorrect: Under a Medicare Advantage (MA) SEP, beneficiaries generally have one opportunity to change their MA coverage. On the other hand, during the annual open enrollment period, an individual may make as many changes to his MA enrollment as he wants but the last choice before the end of the period will be the effective one.
c.
If the SEP is for Part D coverage, he may only drop, but not add or change, his Part D coverage one time before the SEP expires.
d.
If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage.
Source: Part 5, Election Periods - SEPs, Limitations
Correct
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?
Question 18Answer
a.
You can countersign Mrs. Nunez’s application, along with her husband, indicating that she approved this choice verbally. This witness signature is sufficient to make the enrollment valid.
b.
Legal spouses can sign enrollment forms for one another under federal law. You may enroll both Mr. and Mrs. Nunez, as long as her husband signs on her behalf.
c.
You should sign the form for Mrs. Nunez yourself, since she informed you, as the plan’s representative, that she wanted to enroll.
d.
As long as she can do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time.
Correct: A Medicare beneficiary is generally the only individual who may execute a valid request for enrollment in an MA plan. CMS will allow a legal representative or another individual to execute an enrollment request on behalf of the beneficiary if authorized under state law. Depending on state law, this may include court appointed legal guardians, and individuals with a durable power of attorney for health care decisions. A spouse does not automatically fall into these sanctioned categories.
Source: Part 5, Slide – Who May Complete the Enrollment
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 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?
Question 19Answer
a.
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.
b.
Mr. Wendt must wait until the next annual open enrollment period (AEP) before he can enroll in a special needs plan (SNP).
c.
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.
d.
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).
Correct. Beneficiaries who have severe or disabling chronic conditions and wish to enroll in a SNP designed to serve individuals with their specific condition have a SEP during which they can enroll in a SNP designed to serve individuals with their condition. The SEP lasts as long as the individual has the qualifying condition and ends once the individual enrolls in a C-SNP.
Source: Part 5, Slide – Other Common SEPs (Severe or Disabling Chronic Conditions) (p.14)
Correct
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?
Question 20Answer
a.
This is a good idea. The plan will retain Mrs. Young’s application and process it when the AEP begins.
b.
This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form before the start of the AEP.
Correct: Marketing representatives may not accept enrollment forms before October 15 for enrollments under the Annual Election Period..
c.
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.
d.
This is a good idea. This locks Mrs. Young into a plan and protects Agent Adams’ commission.
Source: Part 5, Slide - Election Periods – Annual Election Period – Overview and Slide – Enrollment Periods Annual Election Period, Timeframe for Submitting Enrollment Forms
Q: 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?
A: Mr. Diaz will not pay any penalty because he had continuous coverage under his employer’s plan.
Q: 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?
A: He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing.
Q: Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her?
A: Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail.
Q: 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?
A: To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes.
Q: 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?
A: Medicare covers the 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.
Q: 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?
A: Original Medicare covers ambulance services.
Q: Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him?
A: 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.
Q: Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline, who has only worked part-time for the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her?
A: You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband’s long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at more than the standard lowest rate but less than the highest rate due her substantial income.
Q: 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?
A: 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.
Q: Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance?
A: 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.
Q: Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-income subsidy. Where might he turn for help with his prescription drug costs?
A: Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program.
Q: Mrs. Quinn recently turned 66 and decided after many years of work to begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn 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?
A: 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% coinsurance for these services, in addition to an annual deductible.
Q: Anita Magri will turn age 65 in August 2022. Anita intends to enroll in Original Medicare Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita’s older neighbor Mel has told her about the Medigap Part F plan in which he is enrolled. It not only provides foreign travel emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What should you tell her?
A: You are sorry to disappoint Anita but a Medigap Part F plan is no longer available to those who turn age 65 after January 1,2020. Anita might instead consider other Medigap plans that offer foreign travel benefits but do not cover the Part B deductible.
Q: 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?
A: Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime.
Q: 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?
A: Part D covers prescription drugs and she should look at her premiums, formulary, and cost-sharing among other factors to see if they have changed.
Q: 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?
A: Medigap plans help beneficiaries cover Original Medicare benefits, but they coordinate with Original Medicare coverage.
Q: 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?
A: Medicare will cover Mrs. Shield’s skilled nursing services provided during the first 20 days of her stay, after which she would have a copay until she has been in the facility for 100 days.
Q: 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?
A: Medicare does not cover massage therapy, or, in general, glasses or dentures.
Q: 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?
A: She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period after the last month on her employer plan that differs from the standard general enrollment period, during which she may enroll in Medicare Part B.
Q: What impact, if any, have recent regulatory changes had upon Medigap plans?
A: The Part B deductible is no longer covered for individuals newly eligible for Medicare starting January 1, 2020.
Q: 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?
A: 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.
Q: Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her?
A: She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan.
Q: 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?
A: 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.
Q: 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?
A: They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.
Q: 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?
A: 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.
Q: Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollment in a Medicare Advantage plan (Part C). What should you advise her to do before she will be able to enroll in a Medicare Advantage plan?
A: To join a Medicare Advantage plan, she also must enroll in Part B.
Q: Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr. Lombardi’s area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell him about this situation?
A: He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan.
Q: Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of 15 employees and offers employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employer-sponsored healthcare coverage. How would you respond?
A: Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan.
Q: Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him?
A: In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network).
Q: 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?
A: C-SNP
Q: Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi?
A: Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan.
Q: 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?
A: Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers.
Q: Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug coverage. What should you tell her about obtaining drug coverage?
A: She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan.
Q: 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?
A: 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.
Q: Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?
A: Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.
Q: 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?
A: He will have to enroll in Part B.
Q: Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could you tell her?
A: Medicare Advantage 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.
Q: 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?
A: 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.
Q: 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 Advantage (MA) plan?
A: She cannot enroll in an MA Medical Savings Account (MSA) plan.
Q: Which of the following statement(s) is/are correct about a Medicare Savings Account (MSA) Plans?
I. MSAs may have either a partial network, full network, or no network of providers.
II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits.
III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation.
IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full.
A: I, II, and IV only
Q: Mr. Schultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Schultz has lost his employer group coverage within the last two weeks. How would you advise him?
A: Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty.
Q: 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?
A: 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.
Q: Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to?
A: Yes. Mrs. Walters must be entitled to Part A and/or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program.
Q: 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?
A: 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.
Q: Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her?
A: She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy.
Q: What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?
A: 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.
Q: 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?
A: 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.
Q: Mr. Shapiro gets by on a very small amount of 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?
A: The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government.
Q: Mrs. Roswell is a new Medicare beneficiary who has just retired from retail work. She 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?
A: Every Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90-day transition period.
Q: 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?
A: 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.
Q: Mr. Rice has is 68, actively working and has coverage for medical services and medications through his employer’s group health plan. He is entitled to premium free Part A and thinking of enrolling in Part B and switching to an MA-PD because he is paying a very large part of his group coverage premium and it does not provide coverage for a number of his medications. Which of the following is NOT a consideration when making the change?
A: Mr. Rice’s retiree plan is required to take him back if, within 63 days of having voluntarily quit the employer’s plan, he decides that he prefers it to his Medicare Part D plan.
Q: Mr. Hutchinson has drug coverage through his former employer’s retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him?
A: If the drug coverage he has is not expected to pay, on average, at least as much as Medicare’s standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty.
Q: 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?
A: 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%.
Q: Which of the following statements about Medicare Part D are correct?
I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances.
II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one.
III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP.
IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan.
A: I, II, and III only
Q: Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her?
A: 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.
Q: One of your clients, Lauren Nichols, has heard about a Medicare concept from one of her neighbors called TrOOP. She asks you to explain it. What do you say?
A: TrOOP stands for true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances drug manufacturer discounts.
Q: 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?
A: 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.
Q: 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?
A: 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.
Q: Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan?
A: A Medicare Advantage Prescription Drug (MA-PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone prescription drug plan.
Q: Mrs. Fiore is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan?
A: She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution.
Q: You are scheduled to give a sales presentation at a local senior center at which a drawing will be held for a prize. At the beginning of the presentation, which of the following must you do?
A: Clearly state that no obligation exists to enroll if a gift or prize is being offered.
Q: Your colleague works at a third-party marketing organization (TMO) and she said she did not need to take the Medicare training for brokers and agents or pass a test to market Medicare plans since her contract is with the TMO, not the plans that have the products she sells. What could you say to her?
A: You could tell her she is wrong, and that only agents selling employer/union group plans are permitted an exemption from testing, but some employer/union group plans may require testing to promote agent compliance with CMS marketing requirements.
Q: 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?
A: Winthrop Brokerage does not need to submit the advertisement to CMS for prior approval because it does not include information about the plans’ benefits structures, cost-sharing, or information about measures or ranking standards.
Q: Alice is a marketing representative employed by a health plan. Betty is a captive agent of a health plan who markets to multiple plans and sponsors. Carl is a captive agent who markets to only one plan/sponsor. Denise is an independent agent who markets to different types of groups. Edward is an independent agent who markets only to employer and union groups. CMS marketing representative compensation rules generally apply to:
A: Betty and Denise, but not Alice (the employee) or Carl or Edward (to whom exceptions apply).
Q: When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?
A: You may provide gifts or prizes to all potential enrollees during an event that does not exceed $15 in retail value.
Q: Mr. Edwards, a marketing representative of the ACME Insurance Company, scheduled a marketing event and expects about 40 people to attend. He has hired a magician for $200 to entertain attendees. Can he do this in a way that complies with guidance from the Medicare agency?
A: He can do this because the estimated number of attendees is based on the venue size and response rate and the value of the gift does not exceed $15.
Q: 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 mind?
A: You may request RSVPs, but you are not permitted to require contact information.
Q: Monica is an agent focused on serving seniors eligible for Medicare. As she reviews her records, she is trying to determine which of the following items are considered compensation. What do you tell her?
A: I, II and IV only
Q: If you are to comply with Medicare’s guidance regarding educational events, which of the following would be acceptable activities?
A: You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent.
Q: Agent Harriet Walker has recently begun marketing Medicare Advantage and related products aimed at meeting the needs of senior citizens. Client Mildred Jones has expressed interest in a Medicare Advantage plan. It is now the beginning of September. If you were in Agent Walker’s position, what would you do?
A: Inquire whether the client qualifies for a special enrollment period, and if not, solicit an enrollment application once the annual open enrollment election period begins on October 15th.
Q: By contacting plans available in your area, you have learned that the plan you represent has a significantly lower monthly premium than the others. Furthermore, you see that the plan you represent has a unique benefits package. What should you do to make sure your clients know about these pieces of information?
A: You may make comparisons between plans if you can support them by studies or statistical data and such comparisons are factually based.
Q: This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do?
A: You may go ahead and call them.
Q: You plan to participate in an educational event sponsored by a large regional health care system. One of your colleagues suggests that you do a presentation on one of the Medicare Health plans you market and modify it to include information about preventive screening tests showcased at the event. How should you respond to your colleague’s suggestion?
A: You should tell your colleague no, because participation in an educational event may not include a sales presentation.
Q: You have set up an appointment for an in-home sales presentation with Mrs. Fernandez, who expressed interest in the Medicare plans you represent. In preparation for the sales presentation, what must you do?
A: Before conducting the presentation, obtain, and document having obtained her permission to visit, along with her interest in the specific products you will present.
Q: While making an appointment to discuss Medicare Advantage (MA) and Part D plans with a potential enrollee, you are asked to describe other types of insurance products that your client might wish to purchase. What additional types of insurance can you present during the MA and Part D marketing appointment?
A: You can present only health care related lines of business but must obtain the beneficiary’s permission to do so before the presentation occurs and document that you have obtained that permission.
Q: You are meeting with Mrs. Hall in her home. On her scope of appointment form, she asked to discuss Medicare Advantage plans. During the meeting, she asks to discuss a stand-alone prescription drug plan. She is leaving the next day to visit her family for a week in another state, so it is important for her to make a decision before she leaves. What must happen before that additional discussion can take place?
A: Since Mrs. Hall specifically asked that you discuss the stand-alone Part D plan, you may do so, as long as she signs a new scope of appointment form first, indicating that she wants to discuss the Part D plan.
Q: You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To comply with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plans?
A: You will have to avoid calling any potential client unless he or she initiates contact with you and specifically asks that you give him or her a call.
Q: 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?
A: Cooperate with the state and supply requested information.
Q: During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5-star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the best statement to say to her?
A: The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4-stars.
Q: Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted concerning the marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise him concerning the type of scrutiny he will be under?
A: Organizations sponsoring Medicare health plans are responsible for the behavior of their contracted representatives and will be conducting monitoring activities to ensure compliance with all applicable federal law and guidance and plan policies. Furthermore, state agent licensure laws are not preempted and he must abide by their requirements.
Q: Mrs. Johnson calls to tell you she has not received her new plan ID card yet, but she needs to see a doctor. What can she expect to receive from the plan after the plan has received her enrollment form?
A: Evidence of plan membership, information on how to obtain services, and the effective date of coverage.
Q: Ms. Claggett is sixty-six (66) years old. She has been covered under Original Medicare for the last six years due to her disability and 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” (IEP) 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?
A: Ms. Claggett has had two IEPs and missed them both. The first occurred three months before and three months after the month when she was first entitled to Part A OR enrolled in Part B. Because she was eligible for Medicare before age 65, Ms. Claggett had a second IEP based on turning age 65, which has also expired.
Q: Mr. Anderson is a very organized individual and has filled out and brought to you an enrollment form on October 10 for a new plan available January 1 next year. He is currently enrolled in Original Medicare. What should you do?
A: Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins.
Q: Mrs. Jenkins is enrolled in both Part A and Part B of Medicare. She has recently also become eligible for Medicaid and would like to enroll in a MA-PD plan. Since this is her first experience with Medicare Advantage, she is concerned that she will be locked into a plan and unable to make any coverage changes for at least a year if not longer. What should you tell her?
A: Since Mrs. Jenkins has Medicare Part A and Part B and receives Medicaid, she has a special election period (SEP) that will allow her to enroll or disenroll from an MA or MA-PD plan during the first 9 months of each calendar year.
Q: Mrs. Parker likes to handle most of her business matters through telephone calls. She currently is enrolled in Original Medicare Parts A and B but has heard about a Medicare Advantage plan offered by Senior Health from a neighbor. Mrs. Parker asks you whether she can enroll in Senior Health’s MA plan over the telephone. What can tell her?
A: II and III only
Q: Ms. Thomas has worked for many years and is turning 68 in June. She is eligible for Medicare Part A and did not enroll for Part B when first eligible because she has insurance through her employer - Coffee Brew, Inc. She also did not enroll in Part D because she had creditable coverage. She would like to retire in June and enroll in a Medicare Advantage plan. She has been informed that her group coverage will end on her retirement effective date. How would you advise Ms. Thomas?
A: Ms. Thomas can enroll in Part B without a late penalty at any time she is still covered by her employer group and 8 months after her last month of employer group coverage without a penalty. However, because she wants to enroll in a MA plan after retirement, she should make sure her Part B coverage is effective in time to use the Medicare Advantage/Part D special election period for individuals changing from employer group coverage to enroll in a MA plan or MA-PD. The SEP begins while she has employer group coverage and will last until 2 months after the month after the month her employer coverage ends. If she wants Part D coverage she should enroll in an MA-PD or a PDP (depending on how she decides to receive her Part A and B benefits) during this time.
Q: You work for Caring Health, a Medicare Advantage (MA) plan sponsor. Recently, Mrs. Garcia has completed an enrollment application for a plan offered by Caring Health, which is waiting for a reply from CMS indicating whether or not Mrs. Garcia’s enrollment has been accepted. Once CMS replies, how long does Caring Health have to notify Mrs. Garcia that her enrollment has been accepted and in what format? 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 election periods (SEPs)?
A: The plan has 10 calendar days to notify Mrs. Garcia in writing.
Q: Which of the following individuals has enrolled in a plan based on a fixed enrollment period?
A: Ben, who enrolls in a Medicare Advantage plan during the Medicare Advantage Open Enrollment Period (MA OEP).
Q: 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?
A: 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)
Q: Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard?
A: Implying that only seniors can enroll in a Medicare Advantage plan when meeting with Mr. Hernandez, who is 58 but qualifies for Medicare because he is disabled.
Q: Miles is a licensed agent who represents Colgate Health and its Medicare Advantage (MA) plans. Miles has several clients who have recently come to him for help. They are in their initial coverage period9s) (ICEP) and are interested in enrolling in one of Colgate Health’s MA plans. Adam will soon turn 68 and has decided to retire. Betty is about to turn 65 and has also decided to retire. Adam and Betty both currently have coverage through Colgate Health. Charles had health coverage through Colgate but dropped the coverage when he retired early to travel to Europe. Charles has just turned age 65 and is now back in the United States. Diedre, who will turn 65 next month, currently has coverage through Ditmas Health – a company that Miles also represents. Who qualifies for the opt-in simplified enrollment mechanism?
A: Adam and Betty because each of them will not have a break between their non-Medicare and Medicare coverage through Colgate Health Plan.
Q: Mr. Liu turns 65 on June 19. He has never previously qualified for Medicare so his first Medicare eligibility date will be by June 1. Mr. Liu’s ICEP and Part D IEP begin March 1 and end on September 30. He wants prescription drug coverage with his Part A and Part B benefits. What advice can you provide him?
A: He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to Part A.
Q: Mrs. Kendrick is in good health, has worked for many years and is six months away from turning 65. She wants to know what she will have to do to enroll in a Medicare Advantage (MA) plan as soon as possible. What could you tell her?
A: She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B.
Q: Mr. Wilcox has been enrolled in Lexington Private Fee-for-Service (PFFS) Medicare Advantage Health Plan (Lexington) for several years. Recently, Mr. Wilcox decided to spend time with his children who live in another state that is not in Lexington’s service area. In the future, he may relocate near his children permanently. How does this move to another service area impact his PFFS MA coverage?
A: Lexington can allow for Mr. Wilcox’s continued enrollment for up to 12 months whether or not he is in a visitor/traveler (V/T) program since it is a PFFS plan.
Q: 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?
A: Plan sponsors have the option to do nothing when a plan member does not pay their premiums or disenroll the member after a grace period and notice.
Q: Mr. Rodriguez is currently enrolled in a MA plan, but his plan doesn’t sufficiently cover his prescription drug needs. He is interested in changing plans during the upcoming MA Open Enrollment Period. What are his options during the MA OEP?
A: He can switch to a MA-PD plan.
Q: Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period (AEP). 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?
A: 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.
Q: 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?
A: She only needs to enroll in the new MA-PD plan and she will automatically be disenrolled from her old MA plan.
Q: Mr. Fitzgerald is selling his home to permanently move into a retirement facility near his daughter in a neighboring state before the Annual Election Period. He has a stand-alone prescription drug plan and has learned it is not available where he is moving. He doesn’t know what he should do. What can you tell him?
A: Because he is moving outside of the service area, the plan must automatically disenroll him. He will have a special election period to select a new plan.
Q: Mrs. Reynolds is in her Medicare initial coverage election period (ICEP) and the date of her entitlement to Part A and B has already occurred. Mrs. Reynolds has just signed up for a Medicare Advantage plan on the second of the month. She is leaving for vacation in two weeks and wants to know if her new coverage will start before she leaves. What should you tell her?
A: Typically, her coverage would begin on the first day of the next month, so she should not expect her coverage to begin before she leaves.
Q: You are doing a sales presentation for Ms. Duarte and her son. Ms. Duarte has some cognitive impairment and her son informs you that he has power of attorney to only make financial not health care decisions for her. Can he execute the enrollment for her?
A: No, he cannot execute the enrollment for her. He must have a legal authorization, under state law that explicitly allows him to make health care decisions for his mother.
Q: Mr. Polanski likes the cost of an HMO plan available in his area but would like to be able to visit one or two doctors who aren’t participating providers. He wants to know if the Point of Service (POS) option available with some HMOs will be of any help in this situation. What should you tell him?
A: The POS option might be a good solution for him as it will allow him to visit out-of-network providers, generally without prior approval. However, he should be aware that it is likely he will have to pay higher cost-sharing for services from out-of-network providers.
Q: 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 the way for consumers to judge plan performance, what else would you say?
A: New plans and part D sponsors must provide a projection of the Star Rating they will receive until they have been officially awarded an overall Star Rating by CMS.
Q: Ms. Morris will turn 65 on June 10th. She has never previously qualified for Medicare. She is entitled to Medicare Part A and intends to enroll in Part B. She wants to know if she is eligible to enroll in a Medicare Advantage plan that includes prescription drug coverage. What do you tell her?
A: Ms. Morris can enroll in an MA-PD plan now since her initial election period (IEP) for Part D prescription drug coverage and initial coverage period are occurring together beginning March 1st and ending September 30th.
Q: 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?
A: Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval.
Q: Agent Marvin Millner wants to reach out to his current clients for referrals. What advice would you give to Marvin?
A: Marvin should consult with the health plans he represents to determine whether those plans impose requirements around beneficiary referrals.
Q: Agent Chan is conducting a sales presentation on senior issues where he hopes to enroll some attendees in the Medicare Advantage (MA) plans he represents. What action(s) may Agent Chan take during the event?
A: Discuss plan specific information such as premiums and benefits.
Q: If a beneficiary is enrolled in a stand-alone prescription drug plan and wants to keep that plan, what type of Medicare health plan could the individual also enroll in, without being automatically disenrolled from the stand-alone prescription drug plan?
A: The beneficiary could enroll in a private fee-for-service (PFFS) plan that does not include prescription drug coverage; a cost plan; or a Medicare Medical Savings Account (MSA) plan.
Q: Richard is a licensed agent who represents Spartan Health Plan and its Medicare Advantage (MA) plans. Richard has several clients who have recently come to him for help who are in their initial coverage election period (ICEP) and are interested in enrolling in one of Spartan Health Plan’s MA plans. Alice will soon turn 65 and retire. Alice has coverage through Spartan Health Plan offered by her employer. Bob had health coverage through Spartan but dropped the coverage when he retired early to travel overseas. Bob, who has just turned age 65, is now back in the United States. Charlotte, who will turn 65 next month, has coverage through Athena Health plan – a company Richard also represents. Who qualifies for the opt-in simplified enrollment mechanism?
A: Alice because she will not have a break between her non-Medicare and Medicare coverage through Spartan Health Plan.
Q: Mr. Lopez, who is fairly well-off financially, would like to enroll in a Medicare prescription drug plan you represent and simply give you a check to cover his premiums for the entire year. What should you tell him?
A: He will need to mail in his payment with his enrollment form.
Q: You would like to offer gifts of nominal value to potential enrollees who call for more information about a plan you represent. You would then like to offer additional gifts if they come to a marketing event. Each of the gifts meets the CMS definition of nominal value, but together, the gifts are more than the nominal value. Is this permissible?
A: Yes, as long as each of the gifts meets the CMS definition of nominal value, and the total value of all gifts given to an enrollee in a year does not exceed $75.
Q: Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not “creditable.” She wants to know what this means. What should you tell her?
A: The letter is to inform her that the drug coverage offered through her Medigap plan does not offer drug coverage that is at least comparable to that provided under the Medicare Part D prescription drug program. If she does not have such creditable coverage during periods when she is eligible for the Part D program, she will face a premium penalty if she enrolls in a Part D plan at a later date.
Q: Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him?
A: Formularies must be developed with input from pharmacists, doctors, and other experts.
Q: Under ACA Section 1557, a health plan premium sold through a state exchange may, based on an individual’s age,
A: charge higher premiums.
Q: Which of the following statements best describes Section 1557 of the Affordable Care Act (ACA)?
A: Section 1557 incorporates earlier civil rights protections in regard to race, color, national origin, disability, age and sex.
Q: ACA Section 1557 rules for disability concern
A: Policies and procedures, physical access, and communication.
Q: As a result of violations of ACA Section 1557 nondiscrimination rules,
A: a health plan may revoke an agent or broker’s appointment with the health plan.
Q: Which Medicare programs are covered by ACA Section 1557?
A: Parts A, C, and D, but not B.
Q: Section 1557 of the Affordable Care Act applies to
A: all health programs and activities administered by or receiving federal financial assistance from HHS.
Q: Under ACA Section 1557, a health plan
A: cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge.
Q: Which of these actions is most likely to be permitted in dealing with a person with limited English proficiency?
A: Allowing a child to interpret in an emergency.
Q: For a health plan, what are the possible consequences of violations of ACA Section 1557?
A: Loss of federal business and compensatory damages.
Q: Which entity enforces Section 1557 for programs that receive funding from on are administered by HHS?
A: The Office of Civil Rights (OCR) of HHS.
Q: Under Section 1557, 2020 Final Rule issued during the Trump Administration sex was initially defined____________
A: as biologic sex only, meaning whether a person was determined to be male or female at birth.
Q: Which of the following statements best describes the scope of operations subject to Section 1557 under the 2020 Final Rule?
A: Health insurers under the 2020 Final Rule are not considered to be principally engaged in delivering health care, and thus lines of business that do not receive federal funding or administered under Title I of the ACA, such as life insurance, do not fall under the scope of 1557.
Q: Which of the following would be considered permissible under Section 1557 and the 2020 Final Rule?
A: Broker Mary Jones has recruited a diverse workforce. She encourages her agents to prospect through community-based marketing and within their community of influence.
Q: Auxiliary aids and services must be provided to individuals with disabilities, such as those suffering from vision or hearing impairments, free of charge, and in a timely manner. Auxiliary aids and services include which of the following:
I. large print materials
II. qualified sign language interpreters
III. braille materials and displays
IV. screen reader software
A: I, II, III, and IV
Q: Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly or intentionally misrepresented facts to obtain payment.
A: True
Q: Ways to report potential fraud, waste, and abuse (FWA) include:
A: All of the above
Q: Once a corrective action plan is started, the corrective action plan must be monitored annually to ensure they are effective.
A: False
Q: What are some of the penalties for violating fraud, waste, and abuse (FWA) laws?
A: All of the above
Q: Any person who knowingly submits false claims to the Government is liable for five times the Government's damages caused by the violator plus a penalty.
A: False
Q: Waste includes any misuse of resources, such as the overuse of services or other practices that directly or indirectly result in unnecessary costs to the Medicare Program.
A: True
Q: Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which includes Medicare) constitute fraud by the person making as well as the person receiving them.
A: True
Q: Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA) include the Health Insurance Portability and Accountability Act (HIPAA), the False Claims Act the Anti-Kickback Statute, and the Health Care Fraud Statute.
A: True
Q: You can help prevent fraud, waste, and abuse (FWA) by doing all the following:
Look for suspicious activity
Conduct yourself in an ethical manner
Ensure accurate and timely data and billing
Ensure you coordinate with other payers
Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance
Verify all information provided to you
A: True
Q: These are examples of issues that should be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA); potential health privacy violation, unethical behavior, and employee misconduct.
A: True
Q: You discover an unattended email address or fax machine in your office receiving beneficiary appeals requests. You suspect no one is processing the appeals. What should you do?
A: Contact your compliance department (via compliance hotline or other mechanism)
Q: A sales agent, employed by the Sponsor's first-tier, downstream, or related entity (FDR), submitted an application for processing and requested two things: 1) to back-date the enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary. What should you do?
A: Process the application properly (without the requested revisions)—inform your supervisor and the compliance officer about the sales agent's request
Q: You work for a Sponsor. Last month, while reviewing a Centers for Medicare & Medicaid Services (CMS) monthly report, you identified multiple individuals not enrolled in the plan but for whom the Sponsor is paid. You spoke to your supervisor who said don't worry about it. This month, you identify the same enrollees on the report again. What should you do?
A: Although you know about the Sponsor's non-retaliation policy, you are still nervous about reporting—to be safe, you submit a report through your compliance department's anonymous tip line to avoid identification
Q: You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?
A: Follow your pharmacy's procedures
Q: What are some of the consequences for non-compliance, fraudulent, or unethical behavior?
A: All of the above
Q: Correcting non-compliance________
A: Protects enrollees, avoids recurrence of same non-compliance, and promotes efficiency
Q: Standards of Conduct are the same for every Medicare Parts C and D sponsor.
A: False
Q: At a minimum, an effective compliance program includes four core requirements.
A: False
Q: Medicare Parts C and D sponsors are not required to have a compliance program.
A: False
Q: Once a corrective action plan begins addressing non-compliance for fraud, waste, and abuse (FWA) committed by a Sponsor’s employee or first-tier, downstream, or related entity’s (FDR’s) employee, ongoing monitoring of the corrective actions is not necessary.
A: False
Q: These are examples of issues that can be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA), potential health privacy violation, and unethical behavior/employee misconduct.
A: True
Q: What is the policy of non-retaliation?
A: Protects employees, who in good faith report suspected non-compliance
Q: Ways to report a compliance issue include:
A: All of the above
Q: Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only.
A: False
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Meet Rachael Kathleen Rawlins, your knowledgeable and pleasant insurance agent with expertise in saving you time and money, finding the most comprehensive Medicare Plan for you.
Call your Medicare Agent, Rachael Kathleen Rawlins, now.
I am Rachael Kathleen Rawlins and I serve all of these Missouri counties to find you the most savings in your Medicare Plan or Medicare Advantage Plan.
| Region Code | Region Name | Counties |
|---|---|---|
| 110 | St. Louis MSA | Franklin, Jefferson, Lincoln, St. Charles, St. Louis, Warren, St. Louis city |
| 203 | Kansas City MSA | Cass, Clay, Clinton, Jackson, Lafayette, Platte, Ray |
| 213 | Springfield - Branson | Christian, Dallas, Greene, Polk, Stone, Taney, Webster |
| 302 | Central | Audrain, Boone, Callaway, Cole, Cooper, Gasconade, Howard, Moniteau, Montgomery, Osage, Randolph |
| 401 | Bootheel | Butler, Carter, Dunklin, Mississippi, New Madrid, Pemiscot, Ripley, Scott, Stoddard, Wayne |
| 404 | Lake Ozark Rolla | Camden, Crawford, Dent, Laclede, Maries, Miller, Morgan, Phelps, Pulaski |
| 405 | Lower East Central-Cape | Bollinger, Cape Girardeau, Iron, Madison, Perry, Reynolds, Ste. Genevieve, St. Francois, Washington |
| 406 | North Central | Carroll, Chariton, Grundy, Linn, Livingston, Mercer, Putnam, Sullivan |
| 407 | Northeast | Adair, Clark, Knox, Lewis, Macon, Marion, Monroe, Pike, Ralls, Schuyler, Scotland, Shelby |
| 408 | Northwest | Andrew, Atchison, Buchanan, Caldwell, Daviess, DeKalb, Gentry, Harrison, Holt, Nodaway, Worth |
| 411 | South Central | Douglas, Howell, Oregon, Ozark, Shannon, Texas, Wright |
| 412 | Southwest | Barry, Barton, Cedar, Dade, Jasper, Lawrence, McDonald, Newton, Vernon |
| 414 | West Central | Bates, Benton, Henry, Hickory, Johnson, Pettis, St. Clair, Saline |
| Fipco | county | Region |
|---|---|---|
| 29001 | Adair | Northeast |
| 29003 | Andrew | Northwest |
| 29005 | Atchison | Northwest |
| 29007 | Audrain | Central |
| 29009 | Barry | Southwest |
| 29011 | Barton | Southwest |
| 29013 | Bates | West Central |
| 29015 | Benton | West Central |
| 29017 | Bollinger | Lower East Central-Cape |
| 29019 | Boone | Central |
| 29021 | Buchanan | Northwest |
| 29023 | Butler | Bootheel |
| 29025 | Caldwell | Northwest |
| 29027 | Callaway | Central |
| 29029 | Camden | Lake Ozark Rolla |
| 29031 | Cape Girardeau | Lower East Central-Cape |
| 29033 | Carroll | North Central |
| 29035 | Carter | Bootheel |
| 29037 | Cass | Kansas City MSA |
| 29039 | Cedar | Southwest |
| 29041 | Chariton | North Central |
| 29043 | Christian | Springfield - Branson |
| 29045 | Clark | Northeast |
| 29047 | Clay | Kansas City MSA |
| 29049 | Clinton | Kansas City MSA |
| 29051 | Cole | Central |
| 29053 | Cooper | Central |
| 29055 | Crawford | Lake Ozark Rolla |
| 29057 | Dade | Southwest |
| 29059 | Dallas | Springfield - Branson |
| 29061 | Daviess | Northwest |
| 29063 | DeKalb | Northwest |
| 29065 | Dent | Lake Ozark Rolla |
| 29067 | Douglas | South Central |
| 29069 | Dunklin | Bootheel |
| 29071 | Franklin | St. Louis MSA |
| 29073 | Gasconade | Central |
| 29075 | Gentry | Northwest |
| 29077 | Greene | Springfield - Branson |
| 29079 | Grundy | North Central |
| 29081 | Harrison | Northwest |
| 29083 | Henry | West Central |
| 29085 | Hickory | West Central |
| 29087 | Holt | Northwest |
| 29089 | Howard | Central |
| 29091 | Howell | South Central |
| 29093 | Iron | Lower East Central-Cape |
| 29095 | Jackson | Kansas City MSA |
| 29097 | Jasper | Southwest |
| 29099 | Jefferson | St. Louis MSA |
| 29101 | Johnson | West Central |
| 29103 | Knox | Northeast |
| 29105 | Laclede | Lake Ozark Rolla |
| 29107 | Lafayette | Kansas City MSA |
| 29109 | Lawrence | Southwest |
| 29111 | Lewis | Northeast |
| 29113 | Lincoln | St. Louis MSA |
| 29115 | Linn | North Central |
| 29117 | Livingston | North Central |
| 29119 | McDonald | Southwest |
| 29121 | Macon | Northeast |
| 29123 | Madison | Lower East Central-Cape |
| 29125 | Maries | Lake Ozark Rolla |
| 29127 | Marion | Northeast |
| 29129 | Mercer | North Central |
| 29131 | Miller | Lake Ozark Rolla |
| 29133 | Mississippi | Bootheel |
| 29135 | Moniteau | Central |
| 29137 | Monroe | Northeast |
| 29139 | Montgomery | Central |
| 29141 | Morgan | Lake Ozark Rolla |
| 29143 | New Madrid | Bootheel |
| 29145 | Newton | Southwest |
| 29147 | Nodaway | Northwest |
| 29149 | Oregon | South Central |
| 29151 | Osage | Central |
| 29153 | Ozark | South Central |
| 29155 | Pemiscot | Bootheel |
| 29157 | Perry | Lower East Central-Cape |
| 29159 | Pettis | West Central |
| 29161 | Phelps | Lake Ozark Rolla |
| 29163 | Pike | Northeast |
| 29165 | Platte | Kansas City MSA |
| 29167 | Polk | Springfield - Branson |
| 29169 | Pulaski | Lake Ozark Rolla |
| 29171 | Putnam | North Central |
| 29173 | Ralls | Northeast |
| 29175 | Randolph | Central |
| 29177 | Ray | Kansas City MSA |
| 29179 | Reynolds | Lower East Central-Cape |
| 29181 | Ripley | Bootheel |
| 29183 | St. Charles | St. Louis MSA |
| 29185 | St. Clair | West Central |
| 29186 | Ste. Genevieve | Lower East Central-Cape |
| 29187 | St. Francois | Lower East Central-Cape |
| 29189 | St. Louis | St. Louis MSA |
| 29195 | Saline | West Central |
| 29197 | Schuyler | Northeast |
| 29199 | Scotland | Northeast |
| 29201 | Scott | Bootheel |
| 29203 | Shannon | South Central |
| 29205 | Shelby | Northeast |
| 29207 | Stoddard | Bootheel |
| 29209 | Stone | Springfield - Branson |
| 29211 | Sullivan | North Central |
| 29213 | Taney | Springfield - Branson |
| 29215 | Texas | South Central |
| 29217 | Vernon | Southwest |
| 29219 | Warren | St. Louis MSA |
| 29221 | Washington | Lower East Central-Cape |
| 29223 | Wayne | Bootheel |
| 29225 | Webster | Springfield - Branson |
| 29227 | Worth | Northwest |
| 29229 | Wright | South Central |
| 29510 | St. Louis city | St. Louis MSA |