AHIP Examination Preparation Practice Answer Question
Sample Test Questions Complete Preparation 100% Success ************************
(100 Question Answer)
Q1-Ms. Moore plans to retire when she turns 65 in a few months. She is in
excellent health and will have considerable income when she retires. She is
concerned that her income will make it impossible for her to qualify for
Medicare. What could you tell her to address her concern?
A. 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.
B. Medicare is a program for people age 65 or older
and those under age 65 with certain disabilities, end stage renal disease or
Lou Gehrig's disease, so she will be eligible for Medicare.
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. Eligibility for Medicare is based on whether or not a person has ever been employed by the federal government. If she or her husband were ever employed by the federal government, she can enroll in Medicare
Source: Medicare Program Basics
Q2-Ms. Goldstein is required by the plan she represents to obtain enrollment forms that have carbon copies in the back. She gives one to the beneficiary, sends another to the plan and retains the third. What should she do with her copies of the enrollment forms?
A. She should make every effort to safeguard the beneficiary information on those enrollment forms.
B. She should retain them for six years and then throw them in the garbage, as is, without shredding them.
C. There is no specific requirements to which she is subject with regard to safekeeping the information.
D. She should retain them until she is informed by the plan that they have been successfully processed and then she can throw them in the garbage, as is, without shredding them.
Q3-Mr. Lopez takes several high-cost prescription drugs. He would like to enroll in a stand-alone Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan can he enroll?
A. Medicare Advantage (MA) HMO that does not include drug coverage.
B Private Fee-for-Service (PFFS) plan that does not include drug coverage.
C. Medicare Advantage (MA) PPO that does not include drug coverage.
D. Medicare Advantage (MA) HMO-POS plan that does not include drug coverage.
Q4-Mrs. Raskin is a widow who will attain aged 65 and enroll in Medicare in just a few weeks. She concerned about having prescription drug coverage. Which of the following statements provides the best advice?
Prescription drug coverage can be obtained by enrolling in a Medicare Advantage plan that includes Part D coverage.
Q6-Mr. Meoni's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr.Meoni?
Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.
Q7-Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her?
Choose one answer.
a. 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.
b. Most individuals who are citizens and over age 65 and wish to be covered under Part A must enroll in a Medicare Health Plan.
c. Most individuals who are citizens and over age 65 and are covered under Part A must pay a monthly premium for that coverage.
d. All individuals who are citizens and over age 65 will be covered under Part A.
Q8-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?
a. He became eligible for Medicare when his disability eligibility determination was first made.
b. Individuals who become eligible for such disability payments only have to wait 12 months before they can apply for coverage under Medicare.
c. 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.
d. After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.
Q9-Mr. Davis is 49 years old and has been receiving disability benefits from the Social Security Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescription Drug policy?
No, he cannot purchase a Medicare Advantage or Part D policy because he has not received Social Security or Railroad Retirement disability benefits for 24 months.
Q10-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?
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. 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.
c. In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for
individuals with higher incomes.
d. Medicare beneficiaries only pay a Part B premium if they are enrolled in a Medicare Health Plan.
Q11-Mr. Diaz continued working with his company and was insured under his employer's group plan until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know how much he will have to pay. What should you tell him?
a. Mr. Diaz will pay a penalty, which will be a flat amount each year, paid during the first month of coverage.
b. The penalty will be a permanent 10% increase in his Part B premium for every 12 month period that passed during which he could have enrolled and did not.
c. Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan.
d. During the first year he is covered under Part B, his premiums will be 10% higher than they otherwise would be, after which point they will return to normal.
Q12-Mrs. Peňa is 66 years old, has coverage under an employer plan and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her?
a. 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.
b. She must wait at least 30 days after her employment terminates before she may enroll in Medicare Part B.
c. She may only enroll in Part B during the general enrollment period whether she is retired or not.
d. She may not enroll in Part B while covered under an employer group health plan and must wait until the standard general enrollment period after she retires.
Q13-Mrs. Kelly is entitled to Part A, but is not yet enrolled in Part B. She is considering enrollment in a Medicare health plan. What should you advise her to do before she will be able to enroll into a Medicare health plan?
In order to join a Medicare health plan, she also must enroll in Part B.
Q14-Mrs. Park has a low, fixed income. What could you tell her that might be of assistance?
She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible.
Q15-Mr. Yu has limited income and resources so you have encouraged him to see if he qualifies for some type of financial assistance. Mr. Yu is not sure it is worth the trouble to apply and wants to know what the assistance could do for him if he qualifies. What could you tell him?
He might qualify for help with Part D prescription drug costs and help paying Part A and/or Part B premiums, deductibles, and/or cost sharing.
Q16- Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare?
a. 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.
b. 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 nonparticipating provider.
c. 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.
d. 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 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
Q17- Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled nursing facility?
a. Mrs. Shields will have to apply for Medicaid to have her skilled nursing services covered because Medicare does not provide such a benefit.
b. Medicare will cover Mrs. Schmidt's skilled nursing services provided during the first 20 days of her stay, after which she would have a coinsurance until she has been in the facility for 100 days.
(Skilled nursing and rehabilitative care only after a three day hospital stay, up to 100 days in a benefit period (as defined by Medicare). In 2017, beneficiaries pay $164.50 coinsurance for days 21-100 each benefit period.Inpatient psychiatric care (up to 190 lifetime days) Part A does not cover custodial or long-term care Cost-sharing may differ for enrollees of Medicare)
c. Once she has expended her liquid assets, Medicare will cover 80% of Mrs. Shields' long-term care costs.
d. Medicare will cover an unlimited number of days in a skilled-nursing facility, as long as a physician certifies that such care is needed.
Q18- 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?
a. Medicare inpatient psychiatric coverage is limited to the same number of days covered for typical inpatient stays
b. Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime.
c. Inpatient psychiatric services are not covered under Original
Medicare.
d. Medicare will cover, at its allowable amount, as many stays as are needed throughout Mr. Rainey’s life, as long as no single stay exceeds 190 days.
Source: Medicare Part A Benefits, Continued
Q19- Mrs. Quinn has just turned 65 and received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn?
c. 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.
Q20- 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?
a. Medicare covers treatments for existing disease, injury and malformed limbs or body parts. As such, it does not cover any screening tests and these must be paid for by the beneficiary out of pocket.
b. Medicare covers some screening tests that must be performed within the first year after enrollment. Beyond that point expenses for screening tests are the responsibility of the beneficiary.
c. Medicare covers periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered. (Preventive & screening services)
d. Medicare covers all screening tests that have been approved by the FDA on a frequency determined by the treating physician.
Q21- 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?
a. Original Medicare covers routine foot care.
b. Original Medicare covers orthopedic shoes.
c. Original Medicare covers ambulance services.
d. Original Medicare covers cosmetic surgery.
Q22-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?
a. Medicare covers 50% of the cost of these three services.
b. Medicare covers glasses, but not dentures or acupuncture.
c. Medicare does not cover acupuncture, or, in general, glasses or dentures.
d. Medicare covers 80% of the cost of these three services.
Q23- 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?
a. Medicare health plans have the option of deciding, each year, what services they will cover. He is correct that the health plan could eliminate some benefits covered by Medicare and he should think carefully before enrolling in a Medicare health plan.
b. He should not be concerned because Medicare health plans must cover all IRS-approved health care expenses, which means that all of them provide substantially greater benefits than are available under Medicare Part A and Part B.
c. Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs.
d. Medicare health plans offer a menu of benefits, from which he may choose, so if he ever wants to increase his coverage, he need only contact the plan and select other options.
Source: Different Ways to Get Medicare, continued
Q24-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?
a. Part C, which always covers dental and vision services, is covered under Original Medicare.
b. Part D, which covers prescription drug services, is covered under Original Medicare.
c. Part A, which covers long term custodial care services, is covered under Original Medicare
d. 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.
( Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs.)
Source: Different Ways to Get Medicare
Q25- 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?
a. Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program.
b. Mr. Wu may still qualify for help in paying for Part D costs through the local Office of the Aging.
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 Federal Pharmaceutical Assistance Program.
Q26-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?
a. 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.
b. All Medicare Health Plans offer cost-sharing that is lower than Original Medicare for all Part A and Part B covered services, but the maximum out-of-pocket limit is higher than in Original Medicare.
c. Medicare Health Plans are not permitted to offer any benefits beyond those available under the Original Medicare program and must have the same maximum out-of-pocket limit on Part A and Part B services as FFS Medicare.
d. Medicare Health Plans do not necessarily have to cover all of the Original Medicare Part A and Part B services, but must include a maximum out-of-pocket limit. Source: Part C Medicare Health Plans
Source: Part C Medicare Health Plans
Q27- Anita Magri will turn age 65 in August 2020. Anita intends to enroll in Original Medicare Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel has told her about the Medigap Part F plan in which he is enrolled. It not only provides foreign travel emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What should you tell her?
You are sorry to disappoint Anita but a Medigap Part F plan is no longer available to those who turn age 65 after January 1,2020. Anita might instead consider other Medigap plans that offer foreign travel benefits but do not cover the Part B deductible.
Q28- If Dr. Elizabeth Brennan does not contract with the PFFS plan, but accepts the plan's terms and conditions for payment, how will she be paid?
Generally, the PFFS plan will pay Dr. Brennan directly the same amount Original Medicare would pay her.
Q29-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 understand what this means. What should you tell Mrs. Quinn?
a. Part B will cover her dental and vision needs.
b. 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.
c. She should disenroll if she does not want to pay the monthly premiums. There is no disadvantage to doing so.
d. 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.
Q30-Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA), but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan?
a. MSA enrollees may only receive covered health care services from a limited panel of network providers because otherwise some providers may charge more than Original Medicare rates.
b. All beneficiaries enrolled in an MSA pay a plan premium in addition to their Part B premium.
c. For enrollees in an MSA, after the annual deductible is met, the MSA plan generally pays 75% of covered services.
d. 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.
Q31- You have come to Mrs. BROWN's home for a sales presentation. At the beginning of the presentation, Mrs. Brown 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 will know which questions to ask her about her health status in order to best assist her in selecting a plan.
You can only ask Mrs. Brown 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.
Q32-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?
a. If Mrs. Paterson applies during the Medigap open enrollment period, she will have to undergo a medical review to determine if she has a pre-existing condition that would increase the premium for a Medigap policy.
b. Medigap plans are not sold by private companies and are a government insurance product.
c. Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services.
d. All costs not covered by Medicare are covered by some Medigap plans.
Q33- Mr. Rivera has QMB-Plus eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later in the year, Mr. Rivera needs dentures, a service only covered under Medicaid. What action would you recommend he take in order to have this cost covered?
Ans: He should go to a Medicaid provider or obtain the services through a Medicaid manage care plan if he is enrolled in one. (has QMB-Plus eligibility. She has decided to enroll in a Medicare Advantage plan.
Ms. Jones can receive all Medicare covered services through her Medicare Advantage plan cost sharing. However, in order to receive coverage of services that are only covered under
Medicaid, for example, dentures, she must go to a Medicaid provider or obtain the services through a
Medicaid managed care plan if she is enrolled in one Categories of dual eligible beneficiaries and out-of pocket costs that must be paid by Medicaid:
QMB Plus - Medicare Part A and Part B premiums; cost sharing for Part A & Part B benefits; Full Medicaid benefits.When a dual eligible individual enrolls in an MA plan, if the individual has coverage for Part A and B
cost sharing, they will not have to pay more than the cost sharing that would apply under Medicaid.
This rule applies to all types of Medicare Advantage plans, including dual eligible SNPs.
Dual eligible beneficiaries may enroll in any type of MA plan except an MA MSA. Some MA plans, known as dual eligible Special Needs Plans, are tailored to dual eligible individuals, depending on the category (see prior slide) to which they belong.)
Q34- 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?
a. She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan.
b. She could enroll in the PFFS plan and a Medigap plan that offer drug coverage, but not in 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 nit in a stand-alone drug plan.
Q35- Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost creditable coverage previously available through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her?
a. If a Part D benefit is offered through her plan she may choose in enroll in that plan or a standalone PDP.
b. Mrs. Lopez must first seek COBRA benefits under her husband’s plan before she can apply for Part D coverage.
c. If a Part D benefit is offered through her plan she must enroll in this plan.
d. Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage.
Q36- 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 2018 under the standard coverage?
Ans. Standard Part D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a portion of costs for both generics and brand-name drugs in the coverage gap, and co-pays or co-insurance after the coverage gap.
Q37- GRANT has just entered his MA ICEP. What action could you help him take during this time?
He will have one opportunity to enroll in a MA plan.
Q38- Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug mid-way through the year?
Ans When a new generic drug for the same condition becomes available or when the FDA or manufacturer withdraws the drug from the market, a brand name drug can be replaced.
Q39- Mr. Jenkins has coverage for medical services and medications through his employer's retiree plan. He is considering switching to a Medicare prescription drug plan because his retiree plan does not cover two important medications. What should he consider before making a change?
Ans If Mr. Jenkins 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.
Q40-Mr. Singh would like drug coverage, but does not want to be enrolled into a health plan. What should you tell him?
a. Mr. Singh must leave Original Medicare to receive drug coverage.
b. 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.
c. Part D prescription drug coverage can only be obtained by enrollment into a Medicare Health Plan that also covers Part A and Part B services.
d. Mr. Singh will have to enroll in Medicaid if he wishes to obtain prescription drug coverage through some means other than a Medicare Health Plan.
Q41-Mr. Alonso receives some help paying for his two generic prescription drugs from his employer's retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him?
a. He generally would pay only a monthly premium. Medicare covers all other costs.
b. He generally would pay only a monthly premium and deductible. Medicare covers all other costs.
c. He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing.
d. He generally would pay only a per-prescription co-payment. Medicare covers all other costs.
Q42-Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her?
a. Part D covers long-term care services and she shouldn’t worry because there has been no change in coverage.
b. Part D covers physician and non-physician practitioner services and the deductible has not changed this year, but the physician charges may go up.
c. Part D covers hospital and home health services and the cost sharing has changed this year.
d. Part D covers prescription drugs and she should look at her premiums, formulary, and cost sharing among other factors to see if they have changed.
Q43- While marketing Medicare Advantage and Part D plans, you collected a large number of scope of appointment forms from your clients, wherein they indicated their interest in specific products and their wish for you to provide information on those products in their homes. What should you do with those forms?
The scope of appointment forms must be retained for a period of ten (10) years.
Q44-Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has, but replace her existing Medigap plan with one that provides drug coverage. What should you tell her?
a. 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.
b. Mrs. Gonzalez should purchase a K or L Medigap plan.
c. Medigap is a replacement for Original Medicare and she has been paying for double coverage. She should simply drop her Medigap policy.
d. Mrs. Gonzalez can purchase a Medigap plan that covers drugs, but it likely won’t offer coverage that is equivalent to that provided under Part D.
Q45-Mr. Kelly has substantial financial means. He enrolled in Original Medicare and purchased a Medigap policy many years ago that offered prescription drug coverage. The prescription drug coverage has not been comparable to that offered by Medicare Part D for several years and despite notification, Mr. Kelly took no action. Which of the following statements best describes what will occur if Mr. Kelly now decides to enroll in Medicare Part D?
a. He will incur a late enrollment penalty.
b. He will not be able to enroll in Part D unless he decides to also enroll in a Medicare Advantage plan.
c. He will avoid any financial penalty or late enrollment fee under the grandfathering provisions of Medicare Part D.
d. He will incur a one-time financial penalty equal to 30 percent of the annual Part D premium.
Q46-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?
a. Medigap plans that cover costs not paid for by a MA plan are available only in Massachusetts, Minnesota, and Wisconsin.
b. 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.
c. Medigap plans are a form of Medicare Advantage, so purchasing both would be redundant coverage.
d. Medigap policies designed to cover costs not paid for by a MA plan can be purchased, but only if the MA plan’s design is considered to be the “defined standard benefit.”
Q47-What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have upon Medigap plans?
a. MACRA provides funding to help individuals age 59 and above enroll in Medigap plans.
b. The Part A deductible is no longer covered under Medigap plans for all enrollees staring January 1, 2020.
c. The Part A deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020.
d. The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020.
(The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020.The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will make changes to Medigap plans effective 2020. Specifically, for individuals newly eligible to Medicare, the Part B deductible cannot be covered. Therefore, Plans C and F will no longer be an option for newly eligible individuals starting January 1, 2020. However, individuals who already have Plans C and F will be able to keep their current versions of the plans and individuals eligible for Medicare prior to January 1, 2020, can purchase the current version of Plans C and F on or after January 1, 2020)
Q48-Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but is not sure about what type of plan designs are available through this program. What should you tell him about the types of health plans that are available through the Medicare Advantage program?
a. They are Medigap Supplemental plans that fill in the gaps not covered by Medicare.
b. They are long-term care plans for people with Medicare.
c. They are major medical policies, but are only for low-income beneficiaries with Medicare.
d. They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.
Q49-Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be a correct description?
a. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies.
b. Medicare Advantage is a new name for the Original Medicare program.
c. Medicare Advantage is a health insurance program operated jointly by the states with the Federal government.
d. Medicare Advantage is designed to pick up where Original Medicare leaves off, covering those health care services that would not normally be covered by Original Medicare.
Q50-Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?
a. Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States
b. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.
c. Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, prior to being accepted and enrolled.
d. Even if Mrs. Radford has end stage renal disease, she will be able to enroll in any Medicare Advantage plan in her service area.
Q51- 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 understand what this means. What should you tell Mrs. Quinn?
Part B primarily covers physician services. She will be paying a monthly premium and, with the exception of many preventive and screening tests, generally will have 20% coinsurance for these services, in addition to an annual deductible.
Q52-Mrs. Billings enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs. Billings have in regard to her MA plan during the next open enrollment season?
a. She must immediately drop her ABC MA plan and enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area.
b. She must remain enrolled in her ABC MA plan unless the plan terminates.
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.
d. She must immediately drop her ABC MA plan and enroll in Original Medicare.
Q53-Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him?
a. E-SNP b. D-SNP c.C-SNP d. I-SNP
Q54-Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him?
a. 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).
b. In most Medicare Advantage HMOs, Mr. Kumar must obtain his services only from providers who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network).
c. In Medicare Advantage HMO plans, services provided by primary care physicians are covered at 100%, but those of specialists are covered at 80%.
d. 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.
Q55-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?
a. In general, Mrs. Ramos will need a referral to see specialists.
b. Mrs. Ramos should be aware that generally plan providers can decide, on a case-by-case basis, whether they will treat her.
c. In general, Mrs. Ramos 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.
d. 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 part of the PPO network.
(Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will be charged a lower co-payment if she goes to one of the plan's preferred providers. Preferred Provider Organizations (PPOs), local and regional; PPO enrollees generally may get care from any provider in the U.S. who accepts Medicare, but will pay less if they go to one of the "preferred" providers in the PPO's network. PPOs must have a maximum limit on member out-of pocket costs for network providers of not greater than $6,700 per year and an aggregate limit on network and non-network costs of $10,000. Enrollees do not need a referral to see an out-of-network provider, but may be encouraged to contact the plan to be sure the service is medically necessary and will be covered. Regional PPOs are PPOs that serve an entire region, made up of one or more states.)
Q56-Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him?
a. Since SNPs don’t cover prescription drugs Mr. Sinclair should consider a different option.
b. SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care.
c. SNPs offer care from any doctor or hospital Mr. Sinclair would like to use and his costs will always be lower than in Original Medicare.
d. 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.
Q57-Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that plan. What should you tell him?
a. SNPs only serve individuals in long-term care facilities, so he cannot enroll.
b. SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll.
c. SNPs limit enrollment to certain sub-populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP.
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.
Q58-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?
a. He may receive services from any physician, regardless of whether or not that physician participates in the plan or Original Medicare.
b. 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.
c. 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.
d. If he enrolls in the PFFS plan, he can go to any doctor anywhere as long as the doctor accepts Original Medicare.
Q59-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?
a. PFFS plans may choose to offer Part D benefits but are not required to do so.
b. If she uses non-network providers, she would not be permitted to obtain care outside of her plan’s service area.
c. PFFS plans are not permitted to provide any benefits beyond what is covered under Original Medicare.
d. If she uses non-network providers, her cost sharing would be the same under a PFFS plan as it would be under Original Medicare.
Q60-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?
a. PFFS plans are the same as Medicare supplement plans and he may obtain care from any provider in the U.S.
b. Enrollees in a PFFS plan can obtain care from any provider in the U.S. who accepts Original Medicare, as long as the provider has a reasonable opportunity to access the plan's terms and conditions and agrees to accept them.
c. If a PFFS enrollee shows his/her card when obtaining services from a provider who participates in Original Medicare, then that provider is required to accept the plan’s terms and conditions.
d. If offered, beneficiaries can select a stand-alone Part D prescription drug plan (PDP) with an HMO or a PPO, but not with a PFFS plan.
Q61-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?
a. 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.
b. Dr. Brennan can charge Mary 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 percent of the Medicare rate.
c. Dr. Brennan can charge the beneficiary the same cost sharing as Original Medicare as long as she sends the claim to Medicare and not the plan.
d. Dr. Brennan 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.
Q62- You have received an advertisement from a vendor who says they can provide you with an extensive list of publicly available e-mail addresses for individuals who are Medicare beneficiaries. In addition, one of your Medicare Advantage clients offered to share her e-mail address book with you so you could contact her Medicare-eligible friends. In considering these sources of leads, what rules must you be sure to abide by?
You may send an e-mail to a beneficiary about Medicare Advantage plan information if the beneficiary a
Q63-Which of the following statement is correct about 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 eligible for health care benefits through the Veteran's Administration may enroll in an MSA.
IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full.
a. I, II, and IV only. b. I, II, and III only c. II and III only d. I and II only
Q64-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?
a. Cost plans do not offer optional supplemental benefits, but they also do not maintain networks of providers, so he can obtain services from any provider he wishes to see and the cost-sharing will be the same.
b. Cost plan enrollees can choose to receive Medicare covered services under the plan's benefits by going to plan network providers and paying plan cost sharing, or may receive services from non-network providers and pay cost-sharing due under Original Medicare.
c. Cost plans do not offer Part D prescription drug coverage as an optional benefit, so regardless of which Cost plan he enrolls in, he will need to ensure that he obtains drug coverage in some other way.
d. Cost plan enrollees must receive all their covered services from network providers.
Q65-For which of the following individuals would a Cost Plan be most appropriate?
a. Mr. Charles who is enrolled Medicare Part A but does not want to enroll in Part B.
b. Ms. Darwin who is enrolled in Medicare Parts A and B who also is enrolled in a Medicare Supplement (Medigap) and is unwilling to pay any additional plan premiums.
c. Mr. Able who has retiree health insurance but relatively modest prescription drug benefits.
d. Ms. Baker who is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan premiums.
Q66-Which statement best describes PACE plans?
a. It is an all-inclusive publicly sponsored Medicaid plan for the elderly.
b. It allows enrollees to choose whether to receive Medicare service by going to plan network providers and paying plan cost-sharing, or receiving services from non-network providers and paying cost-sharing due under Original Medicare.
c. It is an all-inclusive Medicare plan widely available throughout the United States.
d. 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.
Q67-Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan that includes drug coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him?
a. Generally, employers prefer retirees to have both the retiree group plan and the MA-PD plan to fill in the gaps, but he would be better off with just the MA-PD plan.
b. Generally, employers prefer retirees to enroll in a stand-alone PDP, so he should consider that instead of the MA-PD.
c. When possible, it is always the best option to have both the employer’s plan and the MA-PD, so he would have no out-ofpocket expenses.
d. Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep.
Q68-Mrs. Walters is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Health Plan?
a. If a provider accepts her Medicare Health Plan coverage, that provider is legally obligated to also accept her Medicaid coverage, so she does not need to worry about finding providers who participate in both Medicare and Medicaid.
b. State Medicaid programs do not coordinate any of their coverage with Medicare Health Plans
c. She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account (MSA) plan.
d. She can submit any bills she has for co-payments under Medicare to the state’s Medicaid program and they will always be fully covered.
Q69-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?
a. Medicaid will cover all of her PFFS out-of-pocket costs and Medicaid providers will accept amounts paid by the PFFS plan as payment in full.
b. If Mrs. Andrews joins a PFFS plan, the State will not cover any of her medical expenses because she will be using only Medicare providers.
c. Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers.
d. Medicaid beneficiaries are not eligible for enrollment into a PFFS plan. They must obtain their care through their state’s Medicaid program.
Q70-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. How much may the doctor collect from Mr. Rivera?
a. The doctor may only collect the amount allowable under Medicare plus 15 percent balance billing.
b. The doctor may only collect from Mr. Rivera the cost sharing allowable under the state's Medicaid program.
c. The doctor may only collect the amount allowable under Medicare Advantage (MA) PPO plan cost sharing for non-QMB enrollees.
d. The doctor may only collect the amount allowable under Medicare plus 25 percent balance billing.
Q71-Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr. Lombardi's area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell him about this situation?
a. He cannot enroll in a stand-alone prescription drug plan because you do not represent such a plan.
b. He could enroll in the MA-only plan and purchase a Medigap plan with drug coverage
c. 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.
d. He could enroll in the MA-only PPO plan and a stand-alone Medicare prescription drug plan.
Q72- 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 employer-sponsored healthcare coverage. How would you respond?
Answer: Juan is likely to be eligible for Medicare once he turns 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 health plan.
Explanation: The common requirements to qualify for Medicare are:
1. US citizen or permanent resident for at least 5 years.
2. Currently receiving social security benefits or qualified to receive them in the future
3. Your spouse is employed by the government and he/she has paid Medicare payroll taxes.
Apparently "J"uan Perez complies with them since he is a US citizen and has been contributing to Medicare for more than 20 years. Therefore, he should be eligible for it and Medicare would become his primary healthcare insurer. After Juan is enrolled in Medicare, his employer will no longer be required to provide sponsored health coverage.
Q73- Agent Mark Andrews would like to employ technology to facilitate the growth of his Medicare Advantage (MA) practice. What step(s) would you recommend that Mark take?
Purchase Internet pop-up ads providing plan-specific information that have been reviewed and approved by CMS.
(Plans/Part D Sponsors must submit to CMS social media (e.g.,Facebook, Twitter, YouTube, LinkedIn, Scan Code, or QR Code)posts that meet the definition of marketing materials, specifically those that contain plan-specific benefits, premiums, cost-sharing,or Star Ratings. Social media posts are subject to marketing requirements, such as those related to testimonials. Generally disclaimers are not required unless a communication written for social media has the potential to be disseminated via other mediums, such as youtube.Plans/Part D Sponsors must not include content on social/electronic media that discusses plan-specific benefits, premiums, cost-sharing, or Star Ratings for products offered in the next contract year prior to October 1.)
Q74-Mrs. Mclntire is enrolled in her state’s medicad plan and has just become elegible for medicare aswel 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
Q75- Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal diease (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
Q76- Mrs. Quinn recently turned 66 and decided after __________ Social Security benefits. Shortly thereafter, Mrs. Quinn received a letter informing her she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell her?
Part B primarily covers physician services. She will be paying a monthly premium &, with the exception of many preventive and screening tests, generally will have 20% coinsurance for these services, in addition to an annual deductible
Q77- Mr. Carter(CHARLES), who is enrolled in a stand-alone Part D plan, receives the Part D low-income subsidy and just received a letter from the Social Security Administration(SSA) informing him that he will no longer qualify for the subsidy? He is wondering if he can switch to a lower cost Part D plan. What should you tell him?
He qualifies for a SEP which begins the month he was notified of his loss and continues for two more months. This SEP allows him one opportunity to enroll into another PDP or an MA-PD.
(Medicaid: help with health care costs. Medicare Savings Program: help paying for the Medicare Part B premium and, in some cases, deductibles and coinsurance. Part D low-income subsidy: help paying for prescription drug coverage. The State Medicaid office will check eligibility for this and other programs such as the Medicare Savings Program. Persons interested in Part D help only may call the Social Security Administration (SSA) at 1-800-772-1213 or apply online at www.ssa.gov/prescriptionhelp.
Supplemental Security Income (SSI) benefits: help with cash for basic needs. You also may apply through SSA.)
Q78- Mrs. Lenard is enrolled in a Medicare Cost plan. Recently the cost plan has transitioned to a Medicare Advantage (MA) contract, and Mrs. Lenard has been told that she has been subject to "deemed enrollment." What does this mean?
Some cost plans transitioning to MA contracts will have "deemed" or facilitated enrollment. That is,
unless a cost plan enrollee opts out, he/she will be automatically enrolled in an MA plan offered by the same organization.Individuals subject to deemed enrollment will be notified by CMS and the plan and given the opportunity to choose another option.
Q79- You have decided to focus on doing in-home presentation to market the Medicare Advantage (MA) plans you represent. Before you conduct such sales presentations, what must you do?
a. There is no special action that you must take. If they choose, you may go an individual’s house to provide presentation and offer assistance with enrolling in a plan.
b. You must first contact the Medicare agency to ensure that the individual is actually a Medicare beneficiary.
c. 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.
d. A proper introduction at the door that includes a disclaimer regarding your relationship with the plan you represent is the only required action you must take, prior to entering the beneficiary’s home.
Q80- 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.
a. You may only contact the retirees after the employer has notified them that they will be receiving a call.
b. You may not make any unsolicited contact with Medicare beneficiaries. The employer will have to tell its retirees to call you.
c. You may call them, but must record every call.
d. You may go ahead and call them.
Source: Marketing to Employer/Union Groups
Q81- This year you decided 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?
a. 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.
b. You do not need to complete a scope of appointment, but CMS can ask you to reconstruct one if there is a subsequent employee complaint.
c. You are not required to submit copies of disseminated materials to CMS at the time of use, but CMS may request and review copies if employee complains occur.
d. You do not need to take an annual test, but you must not provide potential enrollees with more than light snaks at presentation.
Q82- Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. inaddition to drugs in his plan's formulary he takes several other medications. these include a prescription drug noton his plan's formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an internet-based Canadian pharmacy to promota hair growth and reduce joint swelling. His nieghbor recently told him about a concept called TrOOP should he ever reach the Part D catastrophic limit. What should you say:
None of the costs of Mr. Wingate'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.
Q83- 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 he also wants prescription drug coverage. What should you tell him?
a. Mr. Carlini can keep Original Medicare, but if he does not sign up for an MA plan that includes prescription drug coverage, he will only be able to obtain prescription drug coverage through a Medigap plan.
b. In order to obtain prescription drug coverage, Mr. Carlini must enroll in an MA plan. The plan will cover his Part A and Part B services, as well as provide him with the desired prescription drug coverage.
c. 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.
d. Mr. Carlini can obtain drug coverage through the Federal government’s fallback plans, which are designed to provide an alternative to privately sponsored Medicare Advantage plans.
Q84- 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?
a. 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.
b. As long as Mrs. Mulcahy 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. To qualify for enrollment into a Medicare prescription drug plan, Mrs. Mulcahy must be entitled to Part A and enrolled under Part B. She should contact her local Social Security office and make arrangements to enroll in Part B prior to selecting a prescription drug plan.
d. Like all Medicare beneficiaries, Mrs. Mulcahy will be automatically enrolled into 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.
Q85-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?
a. Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap.
b. Standard Part D coverage would require payment of only fixed per-prescription co-payments
c. 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-insurance of 5%, whichever is greater.
d. Standard Part D coverage would require payment of an annual deductible, fixed per-prescription co-payments, 35% of the costs in the coverage gap, and once catastrophic coverage begins, the plan covers 100% of all costs.
Q86- 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 use a pharmacy network but may choose to have one.
III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP.
IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan.
a. I only b. I and II only c. I, II, III, and IV d. I, II, and III only.
Q87-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 2019 under the standard coverage?
a. Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap.
b. Standard Part D coverage would require payment of only fixed per-prescription co-payments
c. Standard Part D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a portion of costs for both generics and brand-name drugs in the coverage gap, and co-pays or co-insurance after the coverage gap.
d. There is likely an error because she will be paying 86 percent of the cost of generic drugs in the coverage gap in 2019
Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel?
During the MA-OEP, Miguel can have one-on-one meetings with beneficiaries who have requested such meetings
Q88-Mrs. Andrews was preparing a budget for next year because she takes quite a few prescription drugs, she will reach the coverage gap, and wants to be sure she has enough money set aside for those months. She received assistance calculating her projected expenses from her daughter who is a pharmacist, but she doesn't think the calculations are correct because her out-of-pocket expenses would be lower than last year. She calls to ask if you can help. What might you tell her?
It would not be unusual for her costs to be a bit less because the Bipartisan Budget Act of 2018 moved up the date for closing the so-called "donut hole" for brand name drugs to 2019.
Q89-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 you explain this to him?
a. The Part D standard model’s importance is that it is the only type of plan into which low-income beneficiaries can enroll and still receive any extra help for which they may qualify.
b. The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval.
c. The government bases its payments to Part D plans on the standard benefit model. For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries.
d. Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government.
Q90-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 that she has lost. How would you advise her?
a. She may fill both prescriptions and they will be fully covered at in-network pricing due the fact that she is traveling.
b. 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.
c. 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.
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.
Q91-What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?
a. Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrict access through prior authorization.
b. 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 prior to deciding whether they wish to enroll in a Part D plan during that year.
c. Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market.
d. 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.
Q92-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 Part D prescription drug plan that covers either one of them. What should you tell her?
a. Medicare prescription drug plans are allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medications out of pocket.
b. 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.
c. 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.
d. 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. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives.
Q93-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 them?
a. 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 the Vaughn's could look into that possibility.
b. Mr. Vaughn’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.
c. Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmetic purposes.
d. The vitamins the Vaughns are taking will be covered under Part D, because their physician suggested they should take vitamins, but the hair loss medication cannot be covered.
Q94-Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year?
a. If the Medicare prescription drug plan can show that reducing coverage early in the year will result in savings for the Part D plan and the Medicare program, generally the plan may make such a change.
b. When the Part D plan can demonstrate to CMS that no enrollee has accessed the medication in the past six months, generally the plan can remove the drug from its formulary within the first 60 days of the year.
c. Under no conditions can a Medicare Part D prescription drug plan reduce its coverage for a given drug at any point during the year.
d. When a formulary change is in response to a drug's removal from the market.
Q95-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 has and the number of prescribers who have written those prescriptions.
II. Locking an at-risk beneficiary into one pharmacy.
III. Locking an at-risk beneficiary into one prescriber.
IV. Increasing deductibles and copays for at-risk beneficiaries.
a. I only b. I, II and III only. c. I, II, III, and IV d. I and II only
Q96-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 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?
a. 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 a new drug that is covered.
b. She should use any existing prescription drug coverage to get as large a supply of her existing drugs as possible, and then pick new drugs that are covered under her Medicare plan’s formulary.
c. The Medicare Part D drug plan is required to offer her coverage of the exact same drugs that she is currently stabilized on, so she does not need to be concerned about transitioning to any new medications.
d. 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.
Q97-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?
a. 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.
b. Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication.
c. Mr. Zachow will have to wait until the Annual Election Period when he can switch Part D plans. In the meantime, he will have to pay for his drug out of pocket.
d. Mr. Zachow could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him.
Q98-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 implications of such a decision?
a. 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, 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.
b. 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, 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, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications.
d. 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 covered.
(If you do not have a Medicare Advantage plan that includes Part D drug coverage, you must sign up for it separately. You should sign up for Medicare Part D at the same time that you enroll in Part B.Do not delay even if you do not take any prescription drugs regularly right now. If you wait until later to sign up, you will be charged extra on your premium for every month that you waited. The amount of the premium penalty changes every year.)
Q99-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 should you tell him?
a. 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.
b. In general, to pay his Part D premium, he only can have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals.
c. During 2017, 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
d. In general, he must select a single Part D premium payment mechanism that will be used throughout the year.
Q100-Mr. Katz reached the Part D coverage gap in August last year. His prescriptions have not changed, he is keeping the same Part D plan and the benefits, cost-sharing, and coverage of his drugs are all the same as last year. He asked what to expect for this year about his out-of-pocket costs. What could you tell him?
a. Because he reached the coverage gap last year, he will probably reach it again this year close to the same time.
b. Because he reached the coverage gap last year, he will not have to go through it again this year.
c. Because he reached the coverage gap in August last year, he probably will reach it much earlier this year.
d. Because he reached the coverage gap in August last year, he probably won’t reach it until much later this year.
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