AHIP 2022-2023 Module 2

AHIP 2022-2023 Module 2 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 Nee ...

AHIP 2022-2023 Module 2 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. 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? - ✔✔b. She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. 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? - ✔✔d. In order to join a Medicare Advantage plan, she also must enroll in Part B. 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? - ✔✔c. They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. 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? - ✔✔c. 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. 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? - ✔✔c. 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. Correct 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. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease (ESRD). What options will Mrs. Davenport have regarding her MA plan during the next open enrollment season? - ✔✔a. She may remain in her ABC MA plan, enroll in another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. 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? - ✔✔b. She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. 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? - ✔✔b. SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? - ✔✔a. He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. 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 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? - ✔✔b. 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. 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 a number of services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? - ✔✔c. You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Mrs. Chou likes a Private Fee-for-Service (PFFS) p