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AHIP Questions Bank 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 (W) 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. (W) 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 (W) 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 (W) 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. (W) 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? - ✔✔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. (W) Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him? - ✔✔After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. (W) 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. (W) 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 (W) 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? - ✔✔Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan.(W) 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? - ✔✔She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period that differs from the standard general enrollment period, during which she may enroll in Medicare Part B (W) Mrs. Kelly is entitled to Part A, but is not yet enrolled in Part B. She is considering enrollment in a Medicare health plan. What should you advise her to do before she will be able to enroll into a Medicare health plan? - ✔✔In order to join a Medicare health plan, she also must enroll in Part B Mrs. Park has a low, fixed income. What could you tell her that might be of assistance? - ✔✔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 (W) Mr. Yu has limited income and resources so you have encouraged him to see if he qualifies for some type of financial assistance. Mr. Yu is not sure it is worth the trouble to apply and wants to know what the assistance could do for him if he qualifies. What could you tell him? - ✔✔He might qualify for help with Part D prescription drug costs and help paying Part A and/or Part B premiums, deductibles, and/or cost sharing. (W) Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? - ✔✔Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a perday 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 (W) Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover? - ✔✔Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. 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? - ✔✔Medicare will cover Mrs. Shields' skilled nursing services provided during the first 20 days of her stay, after which she would have a coinsurance until she has been in the facility for 100 days.Mrs. Quinn has just turned 65 and 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? - ✔✔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% co-payments for these services, in addition to an annual deductible. (W) 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? - ✔✔Medicare covers 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. 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? - ✔✔Original Medicare covers ambulance services Mrs. Wolf wears glasses and dentures and has enjoyed considerable pain relief from arthritis through acupuncture. She is concerned about whether or not Medicare will cover these items and services. What should you tell her? - ✔✔Medicare does not cover acupuncture, or, in general, glasses or dentures Mr. Singh would like drug coverage, but does not want to be enrolled into a health plan. What should you tell him? - ✔✔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-forService Medicare. (W) 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? - ✔✔He generally would pay a monthly premium, annual deductible, and per-prescription cost sharing 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? - ✔✔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. 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 thisconcern? - ✔✔Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has, but replace her existing Medigap plan with one that provides drug coverage. What should you tell her? - ✔✔Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan. Mr. Kelly has substantial financial means. He enrolled in Original Medicare and purchased a Medigap policy many years ago that offered prescription drug coverage. The prescription drug coverage has not been comparable to that offered by Medicare Part D for several years and despite notification, Mr. Kelly took no action. Which of the following statements best describes what will occur if Mr. Kelly now decides to enroll in Medicare Part D? - ✔✔He will incur a late enrollment penalty Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him? - ✔✔It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare [Show More]

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