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 t
Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's disease so she will be eligible for Medicare.
Mr. Schmidt would like to plan for retirement and has asked you want 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. 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 Advantage plans must cover all benefits available under medicare Part A and Part B. Many also cover Part D prescription drugs.
Mrs. Roberts has just received a new Medicare identity card in the mail. She is concerned that it is a forgery since it does not have her Social Security number on it. What should you tell her?
The card she received is valid, the change has been made to protect Medicare beneficiaries from identity theft, and she should now destroy her old card.
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. Moy'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. Moy?
Medicare Supplemental insurance would help covers 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 cover.
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
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. 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.
Mr. Denton 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?
He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start.
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.
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 wi
Mr. Diaz will not pay any penalty because she had continuous coverage under his employer's plan.
Mrs. Pena is 66 years old, had 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.
Mrs. Kelly, age 65, is entitled to Part A, but has not yet enrolled in Part B. She is considering enrollment in a Medicare health plan (Part C). 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 is an elderly retiree. Mrs. Park has a low, fixed income. What could you tell Mrs. Park 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.
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?
Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program.
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. I
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 hi
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 rehabili
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.
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. 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 underst
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.
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 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.
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-for-Service Medicare.
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 i
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 ta
Part D covers prescription drugs and she would look at her premium, formulary, and cost-sharing amount other factors to see if they have changed.
Mrs. Duarte is enrolled in Original Medicare Part A and B. She was 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?
Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail.
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?
Medigap plans help beneficiaries cover coinsurance, co-payment, 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 tel
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 fo
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.
What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have upon Medigap plans?
The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1,2020.
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 M
They are Medicare health plans such as HMOs, PPOs, PFFS, 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 the Original Medicare benefits through private health insurance companies.
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 plan.
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. Davenport 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. Davenport have regarding her MA plan during the next open enrollment sea
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.
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?
C-SNP
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
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. 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 generally obtain his services only from providers who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network).
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 have a higher cost-sharing amount if she sees a provider who/that is not a part of the PPO network.
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?
PFFS plans may choose to offer Part D benefits but are not required to do so.
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 US 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.
Dr. Elizabeth Brennan does not contract with the 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?
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 percent of the Medicare rate.
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 h
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.
Which of the following statement is 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
I,II,and IV only
Mr. 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 form non-network providers and pay cost-sharing due under Original Medica
For which of the following individuals would a Cost Plan be most appropriate?
Ms. Baker who is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan premiums.
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 prescr
Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing the 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 Advantage Plan?
She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account (MSA) plan.
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 hasQualified Medicare Beneficiary (QMB)eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later he sees an out-of-network doctor to receive a Medicare covered service. How much
The doctor may only collect from Mr. Rivera the cost sharing allowable under the state's Medicaid program.
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. Lombard
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 plan.
Mrs. 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 Medigap plan that offers drug coverage, but not in 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 not want to sign up for an MA product, but
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.
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 y
If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP.
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
I,II, and III only
All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a beneficiary incur for prescription drugs in 2020 under the standard coverage?
Standard Part D coverage would require payment of an annual deductible of $435, 25% cost-sharing between $435 and %4,020, and once through the catastrophic coverage threshold, the beneficiary pays either co-pays for generic and brand name drugs or co-insu
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 the
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 Vaughn's could look into that possibility.
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
Medicare Part D drug plans may have different structures, but on average, they must all be at least as good as the standard model established by the government.
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 her prescriptions hat she has lost. How would you advise her?
She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy.
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 Pa
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.
Mrs. Quinn has just turned 65, is in excellent health, and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. What could you tell her about the im
If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covere
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 shou
In general, he must select a single Part D premium payment mechanism that will be used throughout the year.
What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?
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.
Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year?
When a formulary change is in response to a drug's removal from the market.
Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of misusing or abusing frequently abused drugs?
I. Identifying at-risk Individuals by using criteria that includes the number of opioid prescriptions the beneficiary
I,II and III only
Mrs. Roswell is a new Medicare beneficiary and 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 do
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.
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?
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.
Mr. Shapiro gets by on a very small 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?
The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government.
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?
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.
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
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 pro
Mrs. Fiore was in the Army for 35 years and is now retired. She has drug coverage through the VA. What issues might she consider with regard to whether to enroll in a Medicare prescription drug plan?
She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the VA for the specific medications she needs and whether any additional benefits are worth the Part D premium costs.
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. W
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 penal
Mr. Rice has coverage for medical services and medications through his employer's retiree plan. He is considering switching to Medicare prescription drug plan because his retiree plan does not cover two important medications. What should he consider befor
If Mr. Rice drops his drug coverage through the retiree plan, he may not be able to get it back and he also may lose his medical health coverage.
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. I
Mr. Schultz should immediately enroll in a Part D plan but he can expect to pay a premium penalty because he failed to enroll when first eligible.
Mrs. Mclntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen with respect to her drug coverage?
Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.
Your friend's mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him?
You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request.
Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services' Marketing Guidelines to ensure he is compliant for which type of products?
Medicare Advantage (MA) and Prescription Drug (PDP) plans
Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same requirements as the plans themselves. How should you respond to such a statement?
Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all medicare marketing rules.
Your work for a company that has marketed Medigap products for many years. The company has added Medicare Advantage and Part D plans and you will begin marketing those plans this fall. You are planning what materials to use to easily show the differences
You must submit your materials to the plan you represent, so CMS can review and approve the materials to ensure they are accurate.
You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What
You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score, although you will not have to take a test if you exclusively market employer/union group plans and the companies do not
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 TMO, mot the plans that have the produ
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.
Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstron
Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located.
Which of the following is a correct statement about state laws as they pertain to marketing representatives?
Medicare health plans must comply with requests for information from state insurance departments investigating complaints about a marketing representative.
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?
You may request RSVPs, but you are not permitted to require contact information.
Next week you will be participating in your first "educational event" for prospective enrollees. In order to be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage?
You should plan to ensure that the educational event is a social event and must not conduct a sales presentation or distribute or accept enrollment forms at the event.
If you are to be in compliance with Medicare's guidance regarding educational events, which of the following would be acceptable activities.
You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent.
You are working with a number of plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do?
You must ensure that the advertisements indicate it is an educational event, otherwise, it will be considered a marketing event.
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 prevent
You should tell your colleague no because participation in an educational event may not include a sales presentation.
Agent Mary Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational in nature. However, she gives a brief presentation that mentions plan-specific premiums. Is this a pr
Yes. When an event has been advertised as "educational," discussing plan-specific premiums is impermissible.
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?
Prior to conducting the presentation, obtain, and document having obtained her permission to visit, along with her interest in the specific products you will present.
Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you October 15. During the appointment, what are you permitted to do?
You may provide her with the required enrollment materials and take her completed enrollment application.
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 with to purchase, What additional types of insurance can you pres
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.
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
Since Mrs. Hall specifically asked that you discuss the stand-alone Part D, 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.
Ordinarily, you obtain referrals from a third-part that initiates contact with potential clients and usually sets up appointments for you. How would the guidelines for marketing Medicare Advantage and Part D plans apply to this practice?
Third parties may not make unsolicited calls to potential Medicare enrollees in order to set up such appointments, or for any other reason related to the marketing of Medicare Advantage or Part D plans.
You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To be in compliance with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients
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.
Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her?
Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided.
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 obl
Winthrop Brokerage does not need to submit the advertisement to CMS for prior approval because it does not include information about the plans' benefits structure, cost-sharing, or information about measures or ranking standards.
ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees' protected health information to market non-health related products such as life insurance and annuities. To do so it must obtain authorization from the enrollees. Which sta
Authorization may be obtained by directing a beneficiary to a website to provide consent as long as the website includes a mechanism for an electronic signature that is valid under applicable law.
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 correct statement t
The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4-stars.
During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her?
Tell her that the Medicare agency does not endorse or recommend any plan.
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 benefit package. What should you do to make s
You may make comparison between plans if you can support them by studies or statistical data and such comparisons are factually based.
You have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respe
You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of who provides or pays for the meal.
When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan?
You may provide gifts or prizes to all potential enrollees during an event that do not exceed $15 in retail value.
One of your colleagues argues that it is better to focus your time and energy exclusively in neighborhoods with single- family homes. He further argues that their older owners are more likely to have higher incomes and purchase the Medicare Advantage prod
This could be considered a discriminatory activity and a prohibited practice.
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
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.
Mr. Murphy is an agent. A neighbor invited him to discuss the Medicare Advantage (MA) and Part D plans he sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Mr. Murphy tell his neighbor about the kinds of food that can
The neighbors may not provide a meal, but light snacks would be permitted.
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 at a cost of $200 to entertain attendees. Can he do this in a way that complies with guidance
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 doesn't exceed $15.
You will be holding a sales event in the near future, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation?
Gift cards or gift certificates of $15 or less that can be readily converted to cash.
Your are scheduled to give a sales presentation at a local senior center. At the beginning of the presentation, which of the following must you do?
Clearly, state that no obligation exists to enroll if a gift or prize is being offered.
Several agents with whom you work with are planning a sales events in your area. One agent plans on giving door prizes worth $5, refreshments valued at $8 per anticipated attendee, and coupon books with discounts worth $10. Since no gift or prize exceeds
He can give away more than one gift during a single event, but the aggregate retail value cannot exceed $15.
You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns?
Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facility.
You would like to market an MA plan at a neighborhood pharmacy. What should you keep in mind to comply with the marketing requirements for MA plans?
You must set up your table, make marketing presentations and accept enrollment applications only on common areas outside of where the patient waits for services from the pharmacist.
You have sought permission from a hospital to place brochures for your product in their gift shop and cafeteria. The hospital administration expresses some hesitation about allowing marketing in a health care facility. What should you tell them?
Marketing in health care facilities is an acceptable practice, as long as it takes place in common areas where patients are not receiving or waiting to receive health care.
Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members?
Market non-Medicare health-related products, such as dental insurance, to current members as permitted by HIPAA Privacy Rules.
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?
You may go ahead can call them
Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual?
The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract.
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 respons
Cooperate with the state and supply requested information.
Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted with regard to 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 scrutin
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. Furthermo
Medicare health plans establish provisions in marketing representative contracts to ensure compliance with applicable laws and policies. If non-compliance occurs, CMS can penalize a plan in which of the following ways?
CMS requires plan sponsors to create and complete a corrective action plan and may terminate a sponsor's contract.
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?
I. Commissions
II. Bonuses
III. Mileage reimburseme
I, II, and IV only
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 t
Betty and Denise, but not Alice (the employee) or Carl or Edward (to whom exceptions apply).
Wendy Park becomes eligible for Medicare for the first time in July. With the help of Agent James Chan, she enrolls in FeelBetter Medicare Advantage plan with an effective date of July 1st. How will Agent Chan be compensated under CMS rules?
FeelBetter will pay Agent Chan initial year compensation for the months of July through December. Renewal amounts will be paid starting in January if Ms. Park remains enrolled the following year.
Agent Lopez helps Ralph to enroll in Top Choice Medicare Advantage plan during the Annual Open Enrollment Period. Ralph's effective enrollment date is January 1st. Ralph disenrolls on February 12th because he did not understand that the plan did not cover
Agent Lopez's entire compensation must be recouped because Ralph disenrlled within 3 months of enrollment.
Agent Higgins helps Mrs. O'Malley to enroll in AB Medicare Advantage (MA) plan during the Annual Open Enrollment Period. Mrs. O'Malley's effective enrollment date is January 1st. Subsequently, Mrs. O'Malley disenrolls on February 12th following a move out
AB MA plan does not have to recoup Agent Higgins' compensation because she has moved away from its service area.
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 dr
Yes. Mrs. Walters must be entitled to Part A or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program.
Mr. Sanchez 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?
He will have to enroll in Part B.
Mr. Kelly wants to know whether he is eligible to sign up for a Private fee-for-service (PFFS) plan. What questions would you need to ask to determine his eligibility?
You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if he lives in the PFFS plan's service area.
Mr. Gonzalez is entitled to Part A, but has not yet enrolled in Part B. If he wants to enroll in a Medicare Advantage (MA) plan, what will he have to do?
He will have to enroll in Part B prior to enrolling in a MA plan.
Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this?
If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical saving account, Mrs. Berkowitz can do this.
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 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.
Which of the following individuals is most likely to be eligible to enroll in a Medicare Advantage or Part D Plan?
Jose, a grandfather who was granted asylum and has worked in the United States for many years.
Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time?
He will have one opportunity to enroll in a Medicare Advantage plan.
Mrs. Kendrick 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?
She may enroll in an MA plan beginning three months immediately before her fi
Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D. What could you tell him?
He is currently in the Part D initial Enrollment Period (IEP) and, during this time, he may make one Part D enrollment choice, including enrollment in a stand-alone Part D plan or an MA-PD plan.
Ms. Claggett is sixty-six (66) years old. She has been covered under both Parts A and B of Original Medicare for the last six years due to her disability, has never been enrolled in a Medicare Advantage or a Part D plan before. She wants to enroll in a Pa
It occurs three months before and three months after the month when a beneficiary meets the eligibility requirements for Part B, so she will not be able to use it as a justification for......
When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice wou
She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA plan.
Mr. Ford enrolled in an MA-only plan in mid November. On December 1, he calls you up and says that he has changed his mind and would like to enroll into an MA-PD plan. What enrollment rules would apply in this case?
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.
Mrs. Kumar would like her daughter, who lives in another state, to meet with you during the Annual Election Period to help her complete her enrollment in a Part D plan. She asked you when she should have her daughter plan to visit. What could you tell her
Her daughter should come in November.
Mr. Anderson is a very organized individual and has filled out and brought to you an enrollment from on October 10 for a new plan available January 1 next year. He is currently enrolled in Original Medicare. What should you do?
Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins.
A client wants to give you an enrollment application on October 1 prior to the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him?
You must tell him you are not permitted to take the form. If he sends the form directly to the plan, the plan will process the enrollment on the day the annual election period begins.
Mrs. Goodman enrolled in an MA-PD plan during the Annual Election Period. In mid-January of the following year, she wants to switch back to Original Medicare and enroll in a stand-alone prescription drug plan. What should you tell her?
During the MA Open Enrollment Period, from January 1- March 31, she may disenroll from the MA-PD plan into Original Medicare and also may add a stand-alone prescription drug plan.
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
This is a bad idea. Agents are generally prohibited form soliciting or accepting an enrollment form prior to the start of the AEP.
Ms. Gonzales decided to remain in Original Medicare (Parts A and B) and Part D during the Annual Enrollment Period (AEP). At the beginning of January, her neighbor told her about the Medicare Advantage (MA) plan he selected. He also told her there was an
There is a MA Open Enrollment Period (OEP) that takes place between January 1 and March 31, but Ms. Gonzales cannot use it because eligibility to use OEP is available only to MA enrollees.
Mrs.Schmidt is moving and a friend told her she might qualify for a "Special Enrollment Period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a Special Enrollment Period is. What could you tell her?
It is a time period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically the Special Enrollment Period is beneficiary specific and results from
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?
If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage.
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 l
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 enrollment period (SEP).
Which of the following individuals are likely to qualify for a special enrollment period (SEP) for both MA and Part D due to a change of residence?
I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan
II, III, and IV only
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 dru
Mr. Rockwell is eligible for a SEP due to is involuntary loss of creditable drug coverage; the SEP begins in June and ends on September 1-two months after the loss of creditable coverage.
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 he
She is eligible for a Special Election Period 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.
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. Yo
It means that he will have a one time opportunity to enroll in an MA-PD or Part D prescription drug plan.
Mrs. Schneider has Original Medicare Parts A and B and has just qualified for her state's Medicaid program, so the state is now paying her Part B premium. Will gaining eligibility for this program affect her ability to enroll in a Medicare Advantage or Me
Yes. Qualifying for this state program gives Mrs. Schneider access to a Special Enrollment Period that allows her to make changes to her MA and/or Part D enrollment during the first 9 months of each calendar year beginning in 2019
If Mr. Johannsen gains the Part D low-income subsidy, how does that affect his ability to enroll or disenroll in a Part D plan?
He qualifies for a special enrollment period and can enroll in or disenroll from a Part D plan and the subsidy will apply to the plan he chooses.
Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirements several years ago. Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the first time. Unfortunately, Mrs. Rid
She qualifies for a special enrollment 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.
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?
Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment, but he should revaluate if he really wants to drop his employer coverage.
Mary Samuels recently suffered a stroke while visiting her daughter and grandchildren. As a result, Mary has been admitted to a rehabilitation hospital where she is expected to reside for several months. The rehabilitation hospital is located outside the
Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan.
Mr. Roberts is enrolled in an MA plan. He recently suffered complications following hip replacement surgery. As a result, he has spent the last three months in Resthaven, a skilled nursing facility. Mr. Roberts is about to be discharged. What advice would
His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility.
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?
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.
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
As long as she is able to 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.
You are visiting with Mr. Tully and his daughter at her request. He has advanced Alzheimer's and is incapable of understanding the implications of choosing a Medicare Advantage or prescription drug plan. Can his daughter fill out the enrollment form and s
Mr. Tully's daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has a durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions.
You are meeting with Ms. Berlin and she has completed an enrollment form for a MA-PD plan you represent. You notice that her handwriting is illegible and as a result, the spelling of her street looks incorrect. She asks you to fill in the corrected street
You may correct this information as long as you add your initials and date next to the correction.
Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare's efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment site, which of the following must Phiona consider
II and III only
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 p
If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan.
You are doing a sales presentation for Mrs. Pearson. You know that Medicare marketing guidelines prohibit certain types of statements. Apply those guidelines to the following statements and identify which would be prohibited.
If you're not in very good health, you will probably do better with a different product.
You have come to Mrs. Midler's home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical record available because she thinks this will help you understand her needs. She suggests that you
You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has end-stage renal disease or one of the conditions that would qualify her for a special needs plan.
Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard?
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.
You are completing a PFFS plan sale to Mr. West who is new to Medicare and prefers to be contacted by telephone. As you are finishing up, what should you tell him about the next steps in the enrollment process?
You need to get Mr. West's phone number and include it on the enrollment form because the plan must call him after you leave to ensure that the understood the nature of the PFFS plan he selected and to verify his intent to enroll.
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?
Evidence of plan membership, information on how to obtain services, and the effective date of coverage.
Mrs. Reynolds 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?
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.
You meet with Mrs. Wilson to complete her enrollment in a Medicare Advantage plan. You tell her that there will be an enrollment verification process to confirm that she is enrolled in the plan that she requested and understands the plan features and rule
Mrs. Wilson will be contacted by the plan sponsor within 15 calendar days of receipt of the enrollment request.
Mrs. Burton is in an MA-PD plan and was disappointed in the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do
She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment.
Mr. Barker had surgery recently and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see larg
You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.
Mrs. Disraeli is enrolled in Original Medicare (Parts A and B) and a standalone Part D prescription drug plan. She has recently developed diabetes and has suffered from heart disease for several years. She has also recently learned that her area is served
Enrollees in SNPs must have access to provider networks that include enough doctors, specialists, and hospitals to provide all covered services necessary to meet enrollee needs within reasonable travel time.
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 payi
She only needs to enroll in the new MA-PD plan and she will automatically be disenrolled from her old MA plan.
Mr. Fitzgerald is selling his home to permanently move into a retirement facility near his daughter in a neighboring state. 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
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.
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 o
Plan sponsors have the option to disenroll members who do not pay their premiums, but they must first provide each member with a grace period of not less than 2 months.
Mrs. Valentino is currently enrolled in a Medicare Cost plan. This plan is no longer meeting her needs, but it is now mid-year and past the annual election period (AEP). What would you say to Mrs. Valentino regarding her options?
Mrs. Valentino can submit a written request to Medicare to be disenrolled from the Cost plan and enroll in Original Medicare.
Mr. Wilcox has enrolled in Lexington 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 r
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.
Ms. Gates is dually eligible for Medicare and Medicaid. She is very concerned about being locked into a
specific Medicare prescription drug plan for the entire year. What should you tell her?
Individuals who are enrolled in Medicaid can change their Part D plans throughout
the year, so if she is not satisfied with her prescription drug plan, she can change to a
different Part D plan.
Mr.Chan is one of your clients and in excellent health. He is enrolled in a Medicare prescription drug plan that you represent. He recently heard about a Medication Therapy Management (MTM) program in which his friend is enrolled. What should you tell him
To be eligible for a MTM program, a Medicare beneficiary must have multiple
chronic diseases, be taking multiple Part D prescription drugs, and likely to incur
considerable drug costs.
Which of the following statements is correct about the appeal and grievance processes?
I. Enrollees have a right to obtain a review (appeal) of certain decisions about prescription drug coverage.
II. The grievance process is used for reviews of coverage d
I, III, and IV only (not sure)
Mr. Shultz 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
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.
Mr. Jenkins is interested in enrolling in a Medicare cost plan and has sought your advice. What would you tell
him?
Cost plans are required to be open to enrollment at least 30 days per year, and many are open for enrollment all year. So open enrollment will be dependent on the plan he chooses.
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
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 coverag
Mrs. Quinn has 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 und
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.
Ms. Lopez is an independent agent under contract with MarketCo, a third-party marketing organization.
MarketCo has a contract with BestCare health plan, a Medicare Advantage (MA) organization, to offer
marketing services through its contracted agents and
Ms. Lopez is considered a marketing representative of BestCare and thus is
obligated to comply with CMS marketing requirements, including those regarding
using only approved call scripts. (not sure)
Ms. Brooks has an aggressive cancer and would like to know if Medicare will cover hospice services in case
she needs them. What should you tell her?
Medicare covers hospice services and they will be available for her.
Mr. Rivera has Qualified Medicare Beneficiary (QMB) eligibility and is thus covered by both Medicare and
Medicaid. He decides to enroll in a Medicare Advantage (MA) PPO plan. Later he sees an out-of-network doctor to receive a Medicare covered service. Ho
The doctor may only collect from Mr. Rivera the cost-sharing allowable under the state's Medicaid program
Mr. James has end-stage renal disease (ESRD). He has been covered under Original Medicare but would like
to know if he can enroll in a Medicare Advantage plan. What should you tell him?
He will not be able to enroll in a Medicare Advantage plan because he has endstage
renal disease unless a special needs plan for beneficiaries with ESRD is available in his service area.
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 c
New plans and Part D sponsors that do not have any Star Rating are not required to provide Star Rating information until the next contract year.
You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA) plans you
represent. Before you conduct such sales presentations, what must you do?
You must receive an invitation from the beneficiary and document the specific types
of products the beneficiary wants to discuss prior to making an in-home presentation. (not sure)
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
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-networ
Mr. Decaro has looked at Medicare prescription drug plans available in his area and noted a wide range in
premiums. He thought that all the drug plans were required to offer the same standard benefits and would like you to explain why there is such a rang
Some prescription drug plans may have higher operating costs and/or may offer enhanced coverage in return for an additional premium amount. He could look at plan designs to see if one of the enhanced plans would serve his needs better than a plan based on
Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a
meeting so that she can learn about Medicare and the products you represent. How should you respond?
Tell Julia that you will meet with her to explain Medicare and should she be
interested you can accept and submit an enrollment request, since this is an initial
enrollment qualifying her for a special enrollment period.
Mr. Lopez takes several high-cost prescription drugs. He would like to enroll in a standalone Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan can he enroll?
Private Fee-for-Service (PFFS) plan that does not include drug coverage.
Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable income only sporadically. Her husband worked full-time throughout his long career. She has heard that to qualify for Medicare Part A she has to have worked and paid Medicare taxe
Since her husband paid Medicare taxes during the entire time he was working, she will automatically qualify for Medicare Part A without having to pay any premiums.
Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her area. Ms. Levi often travels to visit relatives and is concerned that she may need emergency care outside of her plan's service area. What should you tell her about coverag
Plans are required to cover out-of-network emergency care
Who is most likely to be eligible to enroll in a Part D prescription drug plan?
Ms. Davis who recently turned age 65 and is eligible for Part A and has just enrolled
in Part B.
Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He
would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to q
He does not have to enroll in Part B but, must pay a penalty for his failure to do so when he first turned 65. After that, he can enroll in a Part D prescription drug plan.
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 make financial decisions for her. Can he execute the
enrollment for her?
Yes, he can execute the enrollment for her. A financial power of attorney is sufficient.
During an appointment scheduled to discuss a Medicare Advantage Prescription Drug plan (MA-PD), Mr. Peters asked his agent to describe a stand-alone prescription drug plan (Part D plan) that his neighbor told him about. What should his agent do?
Since Mr. Peters requested a description of the Part D plan, his agent must have
Mr. Peters sign a new scope of appointment form that includes Part D, and then the
agent may discuss the Part D plan so Mr. Peters can compare plans and make an
informed enro
Mr. Chen has heard about a Medical Savings Account (MSA), but wants to know if it is just about saving money, or if he will get insurance coverage for his health care expenditures as well. What should you tell him?
Under the Medicare Advantage program, a MSA plan involves the combination of a high deductible health plan and a savings account for health expenses. Medicare will make contributions to this savings account to help him pay his health care expenses while i
Able, Baker, and Charles are engaged in the marketing to and enrollment of beneficiaries into Medicare health
plans. Mr. Able is an independent agent paid directly by a health plan. Ms. Baker is an independent agent paid through a field marketing organiza
Able is subject to CMS compensation rules because he is paid directly by a health plan. Agents Baker and Charles are not because they are paid by third parties ( not sure)
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?
Enrollees should pay using automatic withdrawal from a bank account or credit or
debit card, direct monthly billing from the plan, or deductions from their Social Security
check
Eleanor takes several high-cost prescription drugs. She would like to enroll in a standalone Part D prescription
drug plan that is available in her area. In what type of Medicare Health Plan can she enroll if she also wishes to enroll in the standalone Pa
A Cost Plan only if it does not offer drug coverage
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
I, II, and III only
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 pla
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.
You work for a company that has marketed Medigap products for many years. The company has added Medicare Advantage and Part D plans and you will begin marketing those plans this fall. You are planning what materials to use to easily show the differences i
You must submit your materials to the plan you represent, so CMS can review and approve the materials to ensure they are accurate.
Mrs. Patterson is a new enrollee in the HealthBest Medicare Advantage (MA-PD) plan. She is new to this type of coverage and asks you what materials, if any, she should expect to receive. How would you reply?
She should expect to receive hard copies of both the provider and pharmacy directories automatically within 30 days of confirmation of enrollment. (NOT SURE)
Mrs. Patterson is a new enrollee in the HealthBest Medicare Advantage (MA-PD) plan. She is new to this type of coverage and asks you what materials, if any, she should expect to receive. How would you reply?
She should expect to receive hard copies of both the provider and pharmacy directories automatically within 30 days of confirmation of enrollment (NOT SURE)
Agent Willis had several clients who disenrolled from the plans he represents during the AEP to try new
Medicare Advantage plans. Agent Willis believes that the choices they made are not ideal for them and wouldlike to get their business back during the M
He can wait until October and send them information about the plans he represents (NOT SURE)
Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for Medicare as well. He is
concerned about changes in his cost-sharing. What should you tell him?
He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers. (NOT SURE)
Mr. Olsen is concerned that a Medicare Advantage plan will not cover the same range of services that would be covered under Original fee-for-service Medicare. What should you tell him?
Though their cost-sharing may differ from Original Medicare's, Medicare Advantage plans are required to cover all services covered by original Medicare.
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?
Discuss plan specific information such as premiums and benefits
Ms. Bushman has two homes in different states and is concerned about restrictions on where she can get her
medications. What should you tell her?
Part D prescription drug plans use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states. (not sure)
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 c
New plans and Part D sponsors that do not have any Star Rating are not required to provide Star Rating information until the next contract year.
Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What C
This situation is considered a "dual enrollment," and CMS compensation rules are applied to the two plans at once and independently of each other.
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 enrolli
Alice because she will not have a break between her non-Medicare and Medicare coverage through Spartan Health Plan.
This year you decide to focus your efforts on marketing to employer and union groups. Which of the following
statements best describes what you can and cannot do in order to stay in compliance?
You are not required to submit communication and marketing materials specific only to those employer plans to CMS at the time of use, but CMS may request and review copies if employee complaints occur
Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an
excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to
you for advice as to what options, i
Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the five-star plan (not sure)
Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage (MA) health plans. This year she has decided to focus on non-MA products. What advice would you give Melanie if she wishes to continue to receive renewal fees?
Melanie must remain trained, tested, licensed, and appointed, regardless of whether she is actively selling MA products
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?
Formularies must be developed with input from pharmacists, doctors, and other experts. (not sure)
Ms. Lewis understands that Medicare prescription drug plans may use various methods to control the use of
specific drugs. She has heard about a technique called "step therapy" and is wondering if you can explain what that is. What should you tell her?
Step therapy involves using one or more lower priced drugs before trying a more expensive drug when all are used to treat the same condition.
Ms. Hernandez has marketed several different types of insurance products in her home state and has typically
sought approval of her materials from her State Department of Insurance. What would you advise her
regarding seeking such approval for materials s
Materials for marketing Medicare health plans to individuals are subject to Medicare's uniform national requirements. They do not need to be reviewed by the state, but the company she represents must obtain approval from the Medicare agency (CMS) for any
Mr. Wong is a single individual. He has had a successful business career and is now able to retire with a comfortable income. Mr. Wong's taxable income is in excess of $100,000. Mr. Wong has health coverage
through his employer but will sign-up Medicare P
Due to his participation in the workforce he will not have to pay premiums for Part A
but he will pay higher premiums for Part B and Part D due to the amount of his
income
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?
She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan.
Ms. Jensen has heard about "Original Fee-for-Service Medicare" and "Private Fee-for-Service" plans. She
wants to know what the difference is, if any. What should you tell her?
PFFS plans are a type of Medicare Advantage plan offered by private companies.
Mrs. Lenard is enrolled in a Medicare Cost plan. Recently the cost plan announced its intention to end its cost contract and transition to a Medicare Advantage (MA) Mrs. Lenard received a letter indicating that unless she chooses another plan or opts out
If Mrs. Lenard wants to enroll in a Medicare Advantage plan affiliated with her cost
plan effective January 1, she should do nothing and she will be automatically enrolled.
If she does not want to enroll in that MA plan, she should choose another plan or
Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds
A meal cannot be provided, but light snacks would be permitted
Mr. Jackson just turned 65. He has been seeing the same general practitioner for annual check-ups for the
past 15 years, likes these yearly visits, and would like to continue obtaining these services as a Medicare
beneficiary. What should you tell him abo
Medicare will cover an annual wellness visit, even if he has no illnesses or injuries.
Mr. Landry is approaching his 65th birthday. He has signed up for Medicare Part A, but he did not enroll in Part B because he has employer-sponsored coverage and intends to keep working for several more years. But he is considering enrolling in Part D pre
Mr. Landry must enroll in Part B to enroll in Part D, and he still has time to do so.
Mrs. Sanchez lives in a state located near Canada. She has recently become eligible for Medicare and is considering enrollment in Part D prescription drug coverage. One of her friends has told her that she needs to be aware of something called TrOOP. What
a. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include the annual deductible(s) and costs for drugs on the plan's formulary purchased at a plan's participating pharmac