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Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain co... verage under Medicare. What should you tell him? After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age Mr. Davis is 49 years old and has been receiving disability benefits from the Social Security Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescription Drug policy? No, he cannot purchase a Medicare Advantage or Part D policy because he has not received Social Security or Railroad Retirement disability benefits for 24 months. Ms. Henderson believes that she will qualify for Medicare coverage when she turns 65, without paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her? In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes Mrs. Raskin is a widow who will attain aged 65 and enroll in Medicare in just a few weeks. She concerned about having prescription drug coverage. Which of the following statements provides the best advice? Prescription drug coverage can be obtained by enrolling in a Medicare Advantage plan that includes Part D coverage Mr. Hernandez is concerned that if he signs up for a Medicare Advantage plan, the health plan may, at some time in the future, reduce his benefits below what is available in Original Medicare. What should you tell him about his concern? Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern? Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end stage renal disease or Lou Gehrig’s disease, so she will be eligible for Medicare Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefit package of a Medicare Health Plan before she starts looking at specific plans. What could you tell her? Medicare Health Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services Mr. Meoni’s wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife’s needs. What could you tell Mr.Meoni? Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not coverMrs. 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? Most individuals who are citizens and over age 65 are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-Service (FFS) Medicare? What could you tell him? Part A, which covers hospital, skilled nursing facility, hospice and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare Mr. 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? They are Medicare health plans such as HMOs, PPOs, PFFS, SNPs, and MSAs Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be a correct description? Medicare Advantage is a way of covering all of the Original Medicare benefits through private health insurance companies During a sales presentation in Ms. Sullivan’s home, she tells you that she has heard about a type of Medicare health plan known as Private Fee-for-Service (PFFS). She wants to know if this would be available to her. What should you tell her about PFFS plans? A PFFS plan is one of various types of Medicare Advantage plans offered by private entities and she may enroll in one if it is available in her area. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Mrs. Billings enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs. Billings have in regard to her MA plan during the next open enrollment season? She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? In most Medicare Advantage HMOs, Mr. Kumar must obtain his services only from providers who have a contractual relationship with the plan (except in an emergency)Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can go to for her health care. What should you tell her? Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will be charged a lower co-payment if she goes to one of the plan’s preferred providers. Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him? SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well. Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that plan. What should you tell him? SNPs limit enrollment to certain sub-populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP 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 like his current HMO plan requires him to do. What should you tell him? 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 Mrs. Lee is discussing with you the possibility of enrolling in a Private Fee-for-Service (PFFS) plan. As part of that discussion, what should you be sure to tell her? If she uses non-network providers, her doctors and hospital could decide whether to treat her on a visit-by-visit basis Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know what makes them different from an HMO or a PPO. What should you tell him? Enrollees in a PFFS plan can obtain care from any provider in the U.S. who accepts Original Medicare, as long as the provider has a reasonable opportunity to access the plan’s terms and conditions and agrees to accept them If Dr. Elizabeth Brennan does not contract with the PFFS plan, but accepts the plan’s terms and conditions for payment, how will she be paid? Generally, the PFFS plan will pay Dr. Brennan directly the same amount Original Medicare would pay her. Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA), but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan? 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 planMr. Davies is turning 65 next month. He would like to enroll in a Medicare health plan, but does not want to be limited in terms of where he obtains his care. What should you tell him about how a Medicare Cost Plan might fit his needs? Cost plan enrollees can choose to receive Medicare covered services under the plan’s benefits by going to plan network providers and paying plan cost sharing, or may receive services from non-network providers and pay cost-sharing due under Original Medicare Which statement best describes PACE plans? It includes comprehensive medical and social service delivery systems using an interdisciplinary team approach in an adult day health center, supplemented by in-home and referral services 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? Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep Mrs. Walters is enrolled in her state’s Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Health Plan? Medicaid will coordinate benefits only with Medicaid participating providers. Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her? Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. Mr. Rivera has QMB-Plus eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later in the year, Mr. Rivera needs dentures, a service only covered under Medicaid. What action would you recommend he take in order to have this cost covered? He should go to a Medicaid provider or obtain the services through a Medicaid manage care plan if he is enrolled in one Module 2: Quick Review 6 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? He could enroll in one of the MA plans that include prescription drug coverage or a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug planMrs. Chou likes a PFFS plan available in her area that does not offer drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her? She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. 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 notwant to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him? Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. Mrs. Mulcahy is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her? Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. In order to join a Medicare health plan, she also must enroll in Part B Mrs. Lopez is enrolled in a Medicare Advantage cost plan. 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? If a Part D benefit is offered through her plan she may choose in enroll in that plan or a standalone PDP [Show More]

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