AHIP Exam Answers 2026 Q&A

Module 1 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? Question 1Answer a. 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. b. Medigap plans that cover costs not paid for by an MA plan are available only in Massachusetts, Minnesota, and Wisconsin. c. Medigap policies designed to cover costs not paid for by an MA plan can be purchased, but only if the MA plan’s design is considered to be the “defined standard benefit.” d. You will help Mr. Capadona to select a Medigap plan that is designed to cover gaps in Medicare Advantage. Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him? Question 2Answer a. Mr. Singh must leave Original Medicare to receive drug coverage. b. Part D prescription drug coverage can only be obtained by enrollment into a Medicare Advantage plan that also covers Part A and Part B services. c. Mr. Singh will have to enroll in Medicaid if he wishes to obtain prescription drug coverage through some means other than a Medicare Advantage plan. d. 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. Mildred Savage enrolled in Allcare Medicare Advantage plan several years ago. Mildred recently learned that she is suffering from inoperable cancer and has just a few months to live. She would like to spend these final months in hospice care. Mildred’s family asks you whether hospice benefits will be paid for under the Allcare Medicare Advantage plan. What should you say? Question 10Answer a. Hospice benefits will be paid for under Mildred’s Allcare Medicare Advantage plan which must cover all Medicare Part A and Part B benefits. b. Mildred may remain enrolled in Allcare and make a hospice election. Hospice benefits will be paid for by Original Medicare under Part A and Allcare will continue to pay for any non-hospice services. c. Hospice benefits are not covered under Medicare and must be paid for using private funds. d. Hospice benefits will be available to Mildred but they will be paid for by Original Medicare under Part B. 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? Question 13Answer a. Individuals who become eligible for such disability payments only have to wait 12 months before they can apply for coverage under Medicare. b. He became eligible for Medicare when his disability eligibility determination was first made. c. After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. d. Individuals receiving such disability payments from the Social Security Administration continue to receive those payments but only become eligible for Medicare upon reaching age 65. 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? Question 15Answer a. She is correct because she will be covered under Part A, without paying premiums and she has worked for 40 years so she will not have to pay Part B premiums. b. To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. c. Medicare beneficiaries only pay a Part B premium if they are enrolled in a Medicare Advantage plan. d. She is correct that she will not have to pay a premium because State programs cover the cost of Part B premiums for all Medicare beneficiaries. Edward suffered from serious kidney disease. As a result, Edward became eligible for Medicare coverage due to end-stage renal disease (ESRD). A close relative donated their kidney and Edward successfully underwent transplant surgery 12 months ago. Edward is now age 50 and asks you if his Medicare coverage will continue, what should you say? Question 3Answer a. Individuals eligible for Medicare based on ESRD generally lose eligibility 48 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward may, however, remain enrolled in Part E (Medigap) but solely for coverage of immunosuppressive drugs if he has no other health care coverage that would cover the drugs. b. Individuals eligible for Medicare based on ESRD generally lose eligibility 36 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward should apply for Medicaid if he has no other health care coverage that would cover the drugs regardless of his income level or assets. c. Individuals eligible for Medicare based on ESRD generally lose eligibility 36 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward may, however, remain enrolled in Part B but solely for coverage of immunosuppressive drugs if he has no other health care coverage that would cover the drugs. d. Individuals eligible for Medicare based on ESRD generally lose eligibility 24 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward may, however, remain enrolled in Part A but solely for coverage of immunosuppressive drugs if he has no other health care coverage that would cover the drugs. Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline, who has only worked part-time for the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her? Question 4Answer a. You should tell Madeline that she will need to pay premiums for Part A because of her short work history. You should also tell Madeline that she will pay Part B premiums at the highest rate because her income over the last several years has exceeded $100,000. b. You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband’s long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at more than the standard lowest rate but less than the highest rate due her substantial income. c. You should tell Madeline that she will be able to enroll in both Medicare Part A and Part B without paying monthly premiums due to her husband’s long work record and participation in the Medicare system. d. You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband’s long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at the highest rate because her income over the last several years has exceeded $100,000. Ms. Kumar plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern? Question 5Answer a. 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. b. Eligibility for Medicare is based on whether or not the federal government has ever employed a person. If the federal government ever employed her or her husband, she can enroll in Medicare. c. Medicare is a program for people of all ages with specific mental health disabilities. Since she is in excellent health, she would not qualify, but should instead look into her state’s Medicaid program if she wants further coverage. d. Medicare is a program for people who have incomes and assets below specific limits, so you will have to find out her exact financial situation before telling her whether she can obtain Medicare coverage. Mr. Moy will soon turn age 65. He is slightly younger than his wife. 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? Question 9Answer a. Medicare Supplemental Insurance would cover all of his IRS approved health care expenditures not covered under Original Fee-for-Service (FFS) Medicare. b. Medicare Supplemental Insurance would help cover his Part A deductible and Part B coinsurance or copayments in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover. c. Medicare Supplemental Insurance would cover his dental, vision and hearing services only. d. Medicare Supplemental Insurance would cover his long-term care services. Mrs. Cook is an elderly retiree. Mrs. Cook has a low fixed income. What could you tell Mrs. Cook that might be of assistance? Question 6Answer a. She should not sign up for a Medicare Advantage plan. b. She should only seek help from private organizations to cover her Medicare costs. c. She can apply to the Medicare agency for lower premiums and cost-sharing. d. 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. Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed? Question 20Answer a. Tell prospect Jerry Smith that he should drop his Medigap coverage and put those premium dollars toward the purchase of a standalone Part D prescription drug plan because he can always reactivate his Medigap policy on a guaranteed issue basis. Furthermore, because he has had Medigap Jerry will not incur a Part D late enrollment penalty. b. Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage. c. Tell prospect Jerry Smith that he should keep his Medigap plan but he should supplement his healthcare coverage by purchasing a Medicare Advantage plan that offers prescription drug coverage (MA-PD). d. Tell prospect Jerry Smith that Medigap is simply a variation of a Medicare Advantage plan and the companies John represents offer more comprehensive coverage for a lower price. Mrs. Foster 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? Question 14Answer a. Medicare will cover an unlimited number of days in a skilled nursing facility, as long as a physician certifies that such care is needed. b. Once she has expended her liquid assets, Medicare will cover 80% of Mrs. Foster’s long-term care costs. c. Mrs. Foster will have to apply for Medicaid to have her skilled nursing services covered because Medicare does not provide such a benefit. d. Medicare will cover Mrs. Foster’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. Mrs. Ellis recently turned 66 and decided after many years of work to retire and begin receiving Social Security benefits. Shortly thereafter Mrs. Ellis received a letter informing her that she had been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Ellis? Question 12Answer a. Part B will cover her routine dental and vision needs. b. Part B primarily covers physician services. She will be paying a monthly premium and, except for many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible. c. She will need to pay no premiums for Part B as she qualifies for premium-free coverage due to the number of quarters she has worked. d. She should disenroll if she does not want to pay the monthly premiums. There is no disadvantage in doing so. Ms. Lewis has aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her? Question 8Answer a. Medicare does not cover hospice services. Hospice services are only available through state Medicaid programs if the state offers such coverage. b. The Federal government facilitates competition between hospice programs to lower the price of their services for Medicare beneficiaries but does not offer coverage for hospice services through the Medicare program. c. Medicare covers hospice services, and they will be available for her. d. Hospice services are currently only offered under a limited demonstration project. Whether they will eventually become available nationally depends on the outcome of the demonstration. 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? Question 7Answer a. Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program (SPAP). b. Mr. Wu may still qualify for help in paying for Part D costs through the Federal Pharmaceutical Assistance Program. c. Mr. Wu has no alternative but to liquidate his remaining assets and apply for coverage through his state’s Medicaid program. d. Mr. Wu may still qualify for help in paying for Part D costs through the local Office of the Aging. Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-Service (FFS) Medicare. What could you tell him? Question 16Answer a. Part C, which always covers dental and vision services, is covered under Original Medicare. b. 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. c. Part A, which covers long-term custodial care services, is covered under Original Medicare. d. Part D, which covers prescription drug services, is covered under Original Medicare. Anthony Boniface turned 65 in 2024. He was not receiving Social Security or Railroad Retirement Benefits on his 65th birthday. He was interested in obtaining Medicare coverage and is eligible for premiumfree Part A. Before he could enroll in Medicare, his entire area was impacted by a hurricane causing massive flooding and severe wind damage. The Federal government declared this to be a natural disaster which has recently ended. During this period Anthony’s initial enrollment period expired. Anthony asks you how he can now obtain Medicare coverage. What should you say? Question 11Answer a. Anthony will be automatically enrolled in Medicare Part A within one month from the date the Federal government declared the disaster ended. If he wishes Part B coverage he must wait until the next General Enrollment Period. b. Anthony must wait until the next General Enrollment Period (GEP) which runs from January 1 through March 31. c. Anthony will have a special enrollment period (SEP) of 3 months beginning after the end of the emergency declaration, but he will be subject to a late enrollment penalty if he chooses Part B coverage. d. Anthony is eligible for a special enrollment period (SEP) because he missed an enrollment period due to the impact of the Federally declared disaster. This SEP will allow Anthony to enroll in Part B up to six months after the end of the emergency declaration. Anthony may enroll in premium-free Part A at any time and his Part A coverage will be retroactive for up to 6 months. Mr. Vasquez is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization because of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? Question 19Answer a. Under Original Medicare, if the inpatient hospital service is provided by a participating Medicare provider, the co-payment is waived. Co-payments are only charged when a beneficiary opts to receive care from a non-participating provider. b. Under Original Medicare, the inpatient hospital co-payment is a flat per-day amount that remains the same throughout the first 60 days of a beneficiary’s stay. After day 60 the amount gradually increases until day 90. After 90 days he would pay the full amount of all costs. c. Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs. d. Under Original Medicare, the inpatient hospital co-payment is a percentage of allowed charges. The percentage increases after 60 days and again after 90 days. Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of 15 employees and offers employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employersponsored healthcare coverage. How would you respond? Question 17Answer a. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls his employersponsored coverage would continue to be the primary payor while Medicare would be considered a secondary payor of his healthcare claims. b. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls, Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls, Medicare would become the primary payor of his healthcare claims but Smallcap must continue to offer him coverage under its employer-sponsored group health plan and would become a secondary payor. c. Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls, Medicare would become the primary payor of his healthcare claims but Smallcap must continue to offer him coverage under its employer-sponsored group health plan and would become a secondary payor. d. Juan is likely to be ineligible for Medicare since he was born outside the United States and has only contributed to the Medicare system for 20 years. Module 2 Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? Question 6Answer a. With any Medicare Advantage HMO, Mr. Kumar will be able to see any provider he likes, so long as that provider participates in Original Medicare. b. In Medicare Advantage HMO plans, services provided by primary care physicians are covered at 100%, but those of specialists are covered at 80%. c. Mr. Kumar will be able to obtain routine care outside of the plan’s service area but will pay a higher co-payment (except in an emergency). d. In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network). Mr. Abbott 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? Question 15Answer a. There are major medical policies, but these are only for low-income beneficiaries with Medicare. b. There are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. c. There are Medigap Supplemental plans that fill in the gaps not covered by Medicare. d. There are custodial long-term care plans for people with Medicare. Mr. Barrow 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? Question 1Answer a. SNPs offer care from any doctor or hospital Mr. Barrow would like to use and his costs will always be lower than in Original Medicare. b. Since SNPs don’t cover prescription drugs Mr. Barrow should consider a different option. c. SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Barrow receives his care. d. SNPs have special programs for enrollees with chronic conditions, like Mr. Barrow, and they provide prescription drug coverage that could be very helpful as well. Raymond 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? Question 4Answer a. D-SNP b. C-SNP c. I-SNP d. IE-SNP Mrs. Robles 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? Question 17Answer a. Mrs. Robles 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. b. Mrs. Robles should be aware that generally plan providers can decide, on a case-by-case basis, whether they will treat her. c. In general, Mrs. Robles will need a referral to see specialists. d. In general, Mrs. Robles can obtain care from any provider who participates in Original Medicare but will have to pay the difference between the plan’s allowed amount and the provider’s usual and customary charge. Mrs. Joy, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrolling in a Medicare Advantage plan (Part C). What should you advise her to do before she can enroll in a Medicare Advantage plan? Question 13Answer a. To join a Medicare Advantage plan, she also must enroll in Part B. b. To enroll in a Medicare Advantage plan, she only needs to be entitled to Part A, so she does not need to take any further steps. c. Since she is age 65, she may enroll in any Medicare Advantage plan, regardless of whether she is entitled to Part A or Part B coverage. d. To join a Medicare Advantage plan, she must be enrolled in Parts A, B, and D. Which of the following statement(s) is/are correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. Question 10Answer a. I, II, and III only b. I and II only c. I, II, and IV only d. II and III only Mr. Dalton 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. Dalton would like to join that plan. What should you tell him? Question 19Answer a. 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. b. SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll. c. SNPs only serve individuals in long-term care facilities, so he cannot enroll. d. SNPs do not provide Part D prescription drug coverage, so if he does enroll, he should be aware that he will not have coverage for any medications he may need now or in the future. Mr. Trevino notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him? Question 14Answer a. He may receive health care services from any doctor allowed to bill Medicare, if 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. b. If he enrolls in the PFFS plan, he can go to any doctor anywhere if the doctor accepts Original Medicare. c. He may receive services from any physician, regardless of whether or not that physician participates in the plan or Original Medicare. d. If he enrolls in the PFFS plan and shows his card to a doctor who participates in Original Medicare, then that doctor is required to accept the plan’s terms and conditions, which could include balance billing. Mrs. Lester is age 75 and enjoys a comfortable but not extremely highincome level. She wishes to enroll in an MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Lester? Question 11Answer a. Mrs. Lester may enroll in an MA MSA plan and remain in her current standalone Part D prescription drug plan. b. Mrs. Lester may enroll in an MA MSA plan but if she wishes for prescription drug coverage it must be a MSA-PD plan that includes drug coverage. c. Mrs. Lester is ineligible for an MA MSA plan because she is ineligible for Medicaid due to her income level. d. Mrs. Lester may enroll in an MA MSA plan but if she wishes for prescription drug coverage she must also enroll in a Medicare Supplement Plan (Medigap) F plan that covers the Medicare Part B deductible and includes drug coverage. Mr. Anderson 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? Question 18Answer a. You would need to ask Mr. Anderson if he is enrolled in Part A and Part B, if he is healthy, and how often he expects to visit a doctor. b. You would need to ask Mr. Anderson if he is enrolled in Part B and Part D and if his doctor will accept the terms and conditions of payment of the PFFS plan. c. You would need to ask Mr. Anderson if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan’s service area. d. You would need to ask Mr. Anderson if he is enrolled in Part A and Part D if he needs drug coverage. Mr. Bryant enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MAPD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-ofpocket limit that included some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? Question 9Answer a. You could suggest he call the doctor who performed the surgery to complain about the costs and ask for a discount on the charges. b. You could remind him that he cannot do anything until the next Annual Election Period when he will have an opportunity to change plans. c. You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. d. You could reassure him that such charges are typical, but if he needs assistance in paying, he should apply to the state for Medicaid assistance. Mr. Arias, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Arias is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? Question 3Answer a. He can enroll in a Medicare Advantage plan, but it will pay only the benefits associated with Medicare Part A. b. He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. c. He is not eligible to enroll in a Medicare Advantage as a naturalized citizen. d. He can enroll in a Medicare Advantage plan if he dropped Part B less than 90 days ago. Mr. Pham is a Qualified Medicare Beneficiary (QMB). He enrolls in a Medicare Advantage HMO. Shortly thereafter, Mr. Pham visits his primary care provider (PCP), Dr. Maria Sanchez. Mr. Pham complains of a bad cold and receives care – a Medicare-covered service. The normal copayment is $40. How much may Dr. Sanchez collect? Question 2Answer a. Half the normal copayment plus a processing service allowance, which in this case is $2.00. Thus, Dr. Sanchez can collect $22.00 in total since Mr. Pham is a QMB. b. The full $40 copayment. c. The minimal copayment that would apply under Medicaid, regardless of what the plan requires of other enrollees. d. Half the normal copayment - $20 since Mr. Pham is a QMB. Henrietta Ross is an elderly individual enrolled in a fully integrated dual-eligible (FIDE) special needs plan (SNP). Henrietta’s daughter Gladys asks you to explain what a FIDE-SNP offers her mother. What do you say? Question 12Answer a. FIDE-SNPs provide individuals with access to Original Medicare and Medigap benefits under a single organization. b. FIDE-SNPs cover primary care but rely on unaffiliated private clinics to provide acute care services. c. FIDE-SNPs cover acute care and home health services but rely on unaffiliated private clinics to provide primary care services. d. FIDE-SNPs provide individuals access to Medicare and Medicaid benefits under a single organization that has both a Medicare Advantage and Medicaid managed care contract with CMS. Herber Noble is turning 65 next month, Herber legally entered the United States over twenty years ago but is not a citizen. Since his entry into the country, Herber has worked at Smallcap Incorporated and contributed to the Medicare system. Herber suffers from diabetes. He will soon retire and asks you if he can enroll in a Medicare Advantage plan that you represent. How would you respond? Question 16Answer a. Herber cannot enroll in a Medicare Advantage plan because United States citizenship is a requirement for enrollment in a Medicare Advantage plan. b. Herber is eligible to enroll in Medicare Advantage as long as he is entitled to Part A and enrolled in Part B. Herber should go to the Social Security website to enroll in Medicare Part A and B if he has not done so already. Once he is enrolled, he can choose a Medicare Advantage plan. c. Herber cannot enroll in a Medicare Advantage plan since he was born outside the United States. d. Herber cannot enroll in a Medicare Advantage plan because diabetes is a pre-existing condition. Mrs. Nelson likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her? Question 20Answer a. She could enroll in the PFFS plan and a Medigap plan that offers drug coverage but not in a stand-alone Medicare prescription drug plan. b. She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. c. If she wants drug coverage and a PFFS plan, she could only enroll in a PFFS plan that includes Medicare prescription drug coverage. d. She could enroll in a PFFS plan but not in a stand-alone drug plan. Tariq is a Medicare beneficiary who is considering switching to a Medicare Advantage plan during this year’s open enrollment season. He has read about prior authorization and the need for referrals in the newspapers and asks you what type of plans can require prior authorization. What do you say? Question 8Answer a. PFFS plans with networks can require referrals for in-network services and prior authorization for out-of-network services. b. Non-network MSA plans may require prior authorization for services beyond routine primary care. c. PPO plans can require prior authorization for both in-network and out-of-network services. d. HMOs can require prior authorization for out-of-network services except for emergency services and certain other carved-out services. HMOs may also require referrals for in-network specialist services. Dr. Elizabeth Morgan does not contract with the ABC PFFS plan but accepts the plan’s terms and conditions for payment. Mary Rodgers sees Dr. Morgan for treatment. How much may Dr. Morgan charge? Question 7Answer a. Dr. Morgan can charge Mary Rodgers no more than the cost sharing specified in the PFFS plan’s terms and conditions of payment which may include balance billing up to 25% of the Medicare rate. b. Dr. Morgan can charge Mary Rogers no more than the cost sharing specified in the PFFS plan’s terms and condition of payment which may include balance billing up to 15% of the Medicare rate. c. Dr. Morgan can charge Mary Rodgers more than the cost sharing specified in the PFFS plan’s terms and conditions as long as she treats all beneficiaries the same. d. Dr. Morgan can charge the beneficiary the same cost-sharing as Original Medicare as long as she sends the claim to Medicare and not the plan. Mrs. Sanchez cares for her frail elderly mother, Maria, who lives in North Carolina. She is worried that without additional support, her mother will need to go into a nursing home. Mrs. Sanchez asks you if there is any Medicare plan that might allow her mother to remain in the community rather than going into a nursing home. How should you advise Mrs. Sanchez? Question 5Answer a. There are Medicare-Medicaid Plans demonstration plans that are permanently available in all states and are designed for the frail elderly. b. There are Programs of All-Inclusive Care for the Elderly (PACE) for frail elderly beneficiaries certified as needing a nursing home level of care but are able to live safely in the community at the time of enrolment. c. There are Medicare Private Fee-for-Service (PFFS) plans that are not Medicare Advantage plans and are specifically designed for the frail elderly. d. There are Medicare Cost Plans that are widely available nationwide that are designed for the frail elderly. Module 3 What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? Question 7Answer a. Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and step therapy. b. Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrict access through prior authorization. c. Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market. d. The Federal government establishes a set formulary, or list of covered drugs, each year that the Part D plans must use. Beneficiaries should consult the government’s list before deciding whether they wish to enroll in a Part D plan during that year. Mr. Sutton has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him? Question 14Answer a. In general, to pay his Part D premium, he can only have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals. b. As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding should begin, he can change his method of Part D premium payment and withholding will begin the month after his savings account is exhausted. c. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. d. Several years ago, many people experienced significant problems with deductions from their Social Security check for their Part D premium. As a result, this method of payment is no longer an option for Part D premium payments. Mrs. Wood, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her? Question 9Answer a. An individual who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Wood is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. b. As long as Mrs. Wood is 65, eligibility for a Medicare prescription drug plan is not dependent on entitlement to Part A or enrollment under Part B, so she should not be concerned. c. Like all Medicare beneficiaries, Mrs. Wood will be automatically enrolled in a Medicare prescription drug plan when she turns 65. She will have a six-month window during which she can select a plan other than the one into which she has been automatically enrolled. d. To qualify for enrollment into a Medicare prescription drug plan, Mrs. Wood must be entitled to Part A and enrolled under Part B. She should contact her local Social Security office and enroll in Part B before selecting a prescription drug plan. Mr. Chen was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Chen has lost his employer group coverage within the last two weeks. How would you advise him? Question 19Answer a. Mr. Chen can wait up to 180 days after the loss of his creditable employer group coverage before enrolling in a Part D plan without worrying payment a premium penalty. b. Mr. Chen 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. c. Mr. Chen should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty. d. Mr. Chen should seek to continue employer group coverage through COBRA because it is likely to have superior benefits at a more permanent solution. Mrs. Russo is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to? Question 13Answer a. Yes, but Mrs. Russo must drop the employer coverage before enrolling in a Medicare prescription drug plan. b. No. Mrs. Russo will have to enroll in Part B to qualify for enrollment into the Medicare prescription drug program. c. No. As long as her employer offers coverage that is equivalent to that available through Medicare, Mrs. Russo cannot enroll in a Medicare prescription drug plan. d. Yes. Mrs. Russo must be entitled to Part A and/or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program. John Cohen is a Medicare beneficiary who suffers from diabetes. Mr. Cohen is considering enrollment in an MA-PD plan that you represent. He asks you whether his insulin costs will be covered. What should you say? Question 20Answer a. Mr. Cohen’s insulin costs will be covered in full once he reaches catastrophic coverage under the prescription drug plan. Before that phase, he will be responsible for the full retail cost of his insulin. b. Mr. Cohen’s annual cost-sharing for insulin alone could amount to $1,800 ($150 per month). c. Mr. Cohen’s insulin costs will be capped at $50 for a one-month supply. d. Mr. Cohen’s insulin costs for a one-month supply cannot be more than $35 in any coverage phase. Mr. Aguilar is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan’s formulary, he takes several other medications. These include a prescription drug not on his plan’s formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say? Question 18Answer a. None of the costs of Mr. Aguilar’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription, not on its formulary. b. The cost of all medications bought within the United States not covered by his plan would count toward TrOOP. The cost of the Canadian-bought medications would not count toward TrOOP. c. The cost of the prescription drugs that are not on his plan’s formulary, as well as the cost of the drug(s) to reduce joint swelling from the Canadian pharmacy, will count toward TrOOP but the other medications in question will not count toward TrOOP. d. The cost of the prescription drug that is not on his plan’s formulary will count toward TrOOP but the other medications in question will not count toward TrOOP. Mrs. Sharma 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. Sharma consider before selecting a PFFS plan? Question 15Answer a. A stand-alone prescription drug plan in combination with a PFFS plan or a PFFS Medigap Supplemental Insurance plan. b. A PFFS plan offering only medical benefits or a PFFS Medigap Supplemental Insurance plan. c. 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 PFFS Medigap Supplemental Insurance plan. d. 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. Mrs. Willis has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drugs are available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? Question 12Answer a. Medicare prescription drug plans are allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medication out of pocket. b. Medicare prescription drug plans are required to include only a certain percentage of brand name drugs among those they cover. It may be possible that plans available in her area have opted not to include in their formularies the brand name drugs she needs. She may need to pay for this particular medication out of pocket. c. When medication costs exceed a certain threshold amount, which rises each year, a Medicare prescription drug plan is permitted to exclude coverage for all but the least expensive of the medications in a given category. Mrs. Willis will need to encourage her physician to prescribe the least expensive of the two alternatives. d. 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. Which of the following statements about Medicare Part D is/are correct? I. Part D plans must enroll any eligible beneficiary who applies, regardless of health status, except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in an MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in an MA-PPO may obtain Part D benefits through a standalone PDP or through their plan. Question 5Answer a. I and II only b. I, II, and III only c. I, II, III, and IV d. I only Mrs. Castro 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. She currently does not have creditable coverage. What could you tell her about the implications of such a decision? Question 17Answer a. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and 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 covered. b. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will have to pay a one-time penalty equal to 10% of the annual premium amount. c. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will be required to pay a higher premium during the first year that she is enrolled in the Medicare prescription drug program. After that point, her premium will return to the normal amount. d. If she does not sign up for a Medicare prescription drug plan, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications. Mrs. Kelly 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? Question 1Answer a. Mrs. Kelly can enroll in any Medicare Advantage plan, regardless of whether it offers drug coverage, and enroll in any stand-alone Medicare prescription drug plan. b. Mrs. Kelly can apply for any Medicare Advantage plan and, if it offers drug coverage, ask to have that element of the coverage eliminated, after which she can enroll in a stand-alone Medicare prescription drug plan in her service area. c. If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Kelly can do this. d. This is not a possibility. If Mrs. Kelly wants health coverage and drug coverage through a plan, she must purchase an MA-PD plan. Mrs. Nguyen is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan? Question 2Answer a. If Mrs. Nguyen enrolls in a PDP, Medicare will automatically disenroll her from any other drug or health coverage. b. Mrs. Nguyen may incur a Part D premium penalty if she enrolls in a Medicare prescription drug plan at some point after her initial eligibility date. c. If Mrs. Nguyen does not enroll during her initial election period, she will not be able to get Part D at a later date. d. She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution. Ms. Ramos is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her? Question 10Answer a. She may fill both prescriptions and they will be fully covered at in-network pricing since she is traveling. b. She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan’s network c. She may fill one prescription out-of-network per year, and it will be fully covered. Her second prescription will require her to pay the full cost out-of-pocket. d. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Mr. and Mrs. Cole both take a specialized multivitamin prescription each day. Mr. Cole takes a prescription to help regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? Question 3Answer a. Mr. Cole’s hair growth medication would only be covered under Part D if his balding resulted from an illness or was a side effect of a treatment such as chemotherapy. b. Medicare prescription drug plans are not permitted to cover the prescription medications the Coles are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Coles could look into that possibility. c. Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmetic purposes. d. The vitamins the Coles are taking will be covered under Part D because their physician suggested they should take vitamins, but the hair loss medication cannot be covered. Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? Question 8Answer a. Guy, who has illegally crossed the Canadian border. b. Jose, a grandfather who was granted asylum and has worked in the United States for many years. c. Betsy, a grandmother from overseas who has overstayed her visa. d. Helena, an overseas college student who has overstayed her visa. Mrs. McFarren is enrolled in her state’s Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen to her drug coverage? Question 4Answer a. She can expect that all her prescriptions will be automatically delivered on a mail-order basis as a requirement of the Medicare Part D program. b. She will continue to obtain her drug coverage through Medicaid. c. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. d. Medicaid will cover all drugs not covered under the Medicare Part D prescription drug plan into which Mrs. McFarren is enrolled. Mrs. Strickland is a new Medicare beneficiary who has just retired from retail work. She is interested in selecting a Medicare Part D prescription drug plan. She takes several medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her? Question 16Answer a. The Medicare Part D drug plan is required to offer her coverage of the same drugs that she is currently stabilized on, so she does not need to be concerned about transitioning to any new medications. b. 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. c. She should use an existing prescription drug coverage to get as large a supply of her existing drugs as possible, and then personally pick new drugs that are covered under her Medicare plan’s formulary. d. There is no possibility of obtaining coverage for her existing medications once coverage under the Medicare Part D plan begins. She will need to have her physician help her select new drugs that are covered. Mrs. Esmeralda Avila is a Medicare beneficiary enrolled in a MA-PD plan you represent. Her neighbor recently suffered from a painful case of shingles. Mrs. Avila hopes to avoid such an illness through vaccination. She asks you whether the cost of the shingles vaccination will be covered under the plan you represent. What should you say? Question 6Answer a. Yes, provided she has already satisfied her annual deductible before obtaining the vaccination. b. Yes, 25 percent of the cost of the shingles vaccine will be covered under the provisions of the Inflation Reduction Act (IRA). c. Yes, there is no cost sharing for the shingles vaccine even in the deductible phase of her prescription drug plan because it is an adult vaccine recommended by the Advisory Committee on Immunization Practices (AICP). d. No, because the shingles vaccine is considered experimental. Mrs. Avila will be responsible for the full cost of the vaccination out-of-pocket. Mrs. Duran is enrolled in a prescription drug plan. She has heard about something called True-Out-Pocket costs or “TrOOP” and asks you if any of the following count toward reaching the catastrophic coverage phase. What do you say? I. Her annual PDP deductible II. Supplemental coverage provided by an employer group waiver plan III. The off formulary drug her doctor prescribed but she pays for because the plan denied her exception request IV. Her over-the-counter (OTC) allergy medication. Question 11Answer a. I and II only b. I, II, and IV only c. I only d. I, II, III, and IV Moldule 4 Angel is new to the Medicare marketplace having previously been focused on life insurance and disability income protection products. He intends to conduct an educational seminar during the AEP at a local hotel and then invite those who attend to a subsequent marketing meeting to discuss the benefits of next year’s plans. How would you advise Angel? Question 1Answer a. Angel should book the marketing meeting in the same hotel on the same day 1 hour apart for the convenience of those who attend and wish to learn more about the Medicare Advantage plans he represents. b. Angel should conduct the education seminar as an early morning meeting and the marketing meeting on the following day in the late afternoon so that there are at least 12 hours between the two meetings. c. Angel should conduct the educational seminar as a breakfast meeting and the marketing meeting in the same hotel in the afternoon so that there are at least 4 hours between the two meetings. d. Angel should book the marketing meeting in an adjacent building soon after on the same day so that those who attend the educational seminar can easily walk to his presentation on Medicare Advantage. Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted concerning the marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise him concerning the type of scrutiny he will be under? Question 2Answer a. Organizations sponsoring Medicare health plans are not responsible for enforcing compliance with applicable law and guidance. This job belongs solely to the Medicare agency b. Organizations sponsoring Medicare health plans are responsible for the behavior of their contracted representatives and will be conducting monitoring activities to ensure compliance with all applicable federal law and guidance and plan policies. Furthermore, state agent licensure laws are not preempted and he must abide by their requirements. c. The state sets most requirements for marketing Medicare health plans, but each plan has different policies that he must adhere to. d. The Medicare agency conducts only complaint-based oversight and he can market the products he represents as he sees fit, as long as he does so in a manner that would be considered ethical by a reasonable layperson. 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 concerning meals? Question 17Answer a. There is no limitation on meals. You may continue to provide your Thanksgiving style meal, to any individual, in any manner you see fit. b. You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of the total value of the meal. c. As long as the meal is paid for by another person or entity, you are permitted to invite your clients and their friends to take part in the meal at your sales presentation. d. You may offer meals to existing enrollees of the plan(s) you represent, but potential enrollees may not have a meal. Maria Valesquez is a marketing representative with RitzCo, a third-party marketing organization (TPMO). Maria meets with Henry Smythe, who has a website that provides information about different ways to get Medicare. The website allows beneficiaries to put in their name and contact information in order to receive additional information. Henry offers to sell Maria leads obtained through the website. What should Maria do? Question 3Answer a. Maria should pass on Henry’s offer. Henry’s website is a TPMO, and for a TPMO to provide contact information to another TPMO (including an agent/broker or FMO), it has to have prior express written consent that identifies each entity that will receive the information. b. Maria should ask Henry if the beneficiary of each lead has given oral permission for an agent to call them. c. Maria should ask Henry to sell the leads to RitzCo, the TPMO with which she is affiliated so that she does not have to pay for them out-of-pocket. d. Maria should consider buying the leads because the beneficiaries specifically asked to receive additional information, thereby allowing her to call them. BestCare Health Plan has received a request from a state insurance department in connection with the investigation of several marketing representatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response? Question 4Answer a. Under Federal privacy statutes, BestCare is not obligated to provide information about marketing representatives to the state and should refuse to do so. b. Immediately terminate all the agents involved as a precaution against potential legal liability. c. Cooperate with the state and supply requested information. d. Immediately meet with the marketing representatives and suggest they obtain licensing in another jurisdiction 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? Question 5Answer a. You may not make any unsolicited contact with Medicare beneficiaries. The employer will have to tell its retirees to call you. b. You may go ahead and call them. c. You may call them but must not engage in cross-selling other products. d. You may only contact the retirees after the employer has notified them that they will be receiving a call. Mrs. Lewis 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 on October 15. During the appointment, what are you permitted to do? Question 6Answer a. You may leave an enrollment kit and discuss a new life insurance product she might like. b. You may leave enrollment kits for several MA plans and offer to discuss a Medigap and Part D prescription drug plan she might like. c. You may begin her enrollment application and require her to provide names of any of friends who may be interested in enrolling before completing her application. d. You may provide her with the required enrollment materials and take her completed enrollment application. 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 discovers that the plan does not cover services furnished by several of his longtime providers. Which of the following statements best describes the impact of Ralph’s action upon Agent Lopez’s compensation? Question 7Answer a. Agent Lopez’s compensation is not impacted because Ralph’s disenrollment occurred after the Annual Open Enrollment Period. b. Agent Lopez’s compensation is not impacted because Ralph’s disenrollment occurred more than 30 days after the effective date of coverage. c. Agent Lopez is entitled to a pro rata amount of the compensation earned including the full amount for February. d. Agent Lopez’s entire compensation must be recouped because Ralph disenrolled within 3 months of enrollment. You are working with several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do? Question 8Answer a. You must only ensure that the advertisement is factually accurate. b. You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. c. Plans may not participate in advertising such an event. All advertising must be done by community organizations. d. You must state in the advertisement that it will be an educational event and that the education will consist of specific information about the participating plans. ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees’ information to market non-health related products such as life insurance and annuities. Which statement best describes ABC's obligation to its enrollees regarding marketing such products? Question 9Answer a. The request for authorization may include a brief synopsis of non-health related content. b. Once a plan sends out a written request for consent, a beneficiary can authorize consent by simply failing to reply within 21 days. c. It must obtain a HIPAA compliant authorization from an enrollee that indicates the plan or plan sponsor may use their information for marketing purposes. d. It is not necessary for ABC to obtain an authorization to simply explain pending state or federal legislation since there is no anticipation of selling a non-health related product in these circumstances. Your client, Jaime Jones, calls you on December 4th about changing her Medicare Advantage plan during the annual election period which ends December 7th. What should you do? Question 10Answer a. Wait at least 12 hours before completing a scope of enrollment (SOA) to comply with the mandatory “cooling off” period. b. Complete a scope of appointment (SOA) during the call and wait at least two days (48 hours) before meeting with Jaime. c. Inform Jaime that due to new rules, you can no longer meet with her until the beginning of the following year’s open enrollment period on October 15th. d. Complete a scope of appointment (SOA) during the call and indicate that they will meet to discuss Medicare Advantage plans during an appointment the following day. 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 can you do in this situation? Question 11Answer a. Your name will be registered with the Medicare agency by the plans you are seeking to represent and you will be unable to contract with any Medicare Advantage or Part D plan. b. You will have to attend one of several remedial training events sponsored by the Medicare agency before being allowed to retake the test. c. You will have to repeat the tests in three months, but may begin enrolling beneficiaries while you are waiting. d. You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score. However, you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing. Stephanie King 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. Which statement best describes how Agent Chan may be compensated under CMS rules? Question 12Answer a. FeelBetter will pay Agent Chan initial year compensation for July through December. The renewal amounts will be paid starting in January if Ms. King remains enrolled the following year. b. FeelBetter will pay Agent Chan initial year compensation for the 12 months of July through July. Renewal amount will be paid thereafter if Ms. King remains enrolled. Agent Chan's plan has chosen not to apply an exception to the pro rata rule. c. FeelBetter will pay Agent Chan a bonus equal to three months initial year compensation since he has successfully enrolled Ms. King in a MA plan when she is both first eligible and a younger, and likely healthier, enrollee. d. FeelBetter will pay Agent Chan initial year compensation for the period July 1 through October 15th (the date open enrollment begins). If Ms. King remains enrolled in the plan, renewal amounts will be paid. You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns? Question 13Answer a. Tell her that if a plan obtains permission from CMS for a marketing event in a provider facility, the event may go forward, regardless of where it occurs in the facility. b. Tell her that Medicare guidelines only allow you to conduct marketing activities in areas of the facility where individuals are waiting to receive health care services, but not in places where they would be receiving health care such as an examining room. c. Tell her that Medicare guidelines allow you to conduct marketing activities anywhere in the facility, so long as the affected providers agree to that event. d. Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider’s facility. 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 MAPD plans you market. What could you tell him? Question 14Answer a. You appreciate the opportunity and your friend would just need to complete scope of appointment forms on behalf of all the residents who would like to attend. b. You appreciate the opportunity and would ask the facility to provide enrollment applications for the MA-PD plans you represent. c. You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request. d. You appreciate the opportunity and will ask the facility to provide a plan brochure and enrollment application in every resident’s room before the meeting to promote interest in the event. 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? Question 16Answer a. Plans must immediately terminate their contracts with such individuals. b. Her name will be reported to a publicly accessible database and could be advertised in local newspapers. c. The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. d. Plans do not impose penalties. Instead, the Medicare agency has specific authority to fine such individuals for each violation. Agent Higgins helps Mrs. O’Malley 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 outside the plan’s service area. What impact will this have on Agent Higgins’ compensation? Question 18Answer a. Agent Higgins entire compensation must be recouped because Mrs. O’Malley has disenrolled within 3 months of enrollment. b. AB MA plan must recoup a pro rata amount of Agent Higgins’ compensation if Mrs. O’Malley subsequently enrolls in Original Medicare and Part D. c. AB MA plan must recoup a pro rata amount of Agent Higgins’ compensation and pay him only for January. d. AB MA plan does not have to recoup Agent Higgins’ compensation because she has moved away from its service area. Agent Mendez 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? Question 19Answer a. While unsolicited contacts may be made through print media such as direct mail, marketing representatives may not initiate electronic contact. b. Marketing representatives may initiate electronic contact through e-mail and as long as an e-mail is opened marketing representatives may also follow-up with unsolicited telephone calls. c. Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. d. Marketing representatives may only use internet pop-up ads providing plan-specific information that have been approved by CMS when soliciting prospects through electronic means of communication. Steban Marsh is a newly appointed agent. Steban intends to conduct an educational session on Medicare at a senior citizens center near his home. He has advertised the session as an educational event. Steban asks you what is permissible at such an event. What should you say? Question 20Answer a. Steban may provide a meal as long as its value is $15 or less per attendee and he may make available business reply cards (BRCs). b. Steban may distribute benefit information about the plan(s) he represents and set up marketing appointments at the event. c. Steban may provide a meal regardless of its value because this is an educational event, not a marketing event. d. Steban may distribute business cards and scope of appointment (SOA) forms.