AHIP Medicare - Module 2 -Medicare Health Plans 20 Review Questions

You would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan’s service area.

Correct: Eligibility to enroll in a PFFS plan is based on entitlement to Medicare Part A and enrollment in Part B. In addition, to enroll in a specific PFFS plan, the individual must reside in the plan’s service area.

You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.

Correct: Medicare Advantage (MA) plan enrollees have a right to obtain a review (appeal) to certain decisions about health care payment, coverage of services, or prescription drug coverage. Medicare health plans must provide enrollees with a written description of the appeals process.

She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan.

Correct: Ms. Gibson can enroll in a PPO without drug coverage. However, If a beneficiary enrolls in a MA plan that is an HMO or PPO plan that does not include Part D coverage, the beneficiary cannot join a standalone Prescription Drug Plan (PDP).

Juan is eligible to enroll in a Medicare Advantage as long as he is entitled to Part A and enrolled in Part B. Juan 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.

Correct: The Social Security Administration will determine Juan’s eligibility for Medicare. If Juan is entitled to Part A and enrolled in Part B, he is generally eligible for enrollment in a Medicare Advantage plan.

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-SNP
-Because Daniel’s bronchitis is a chronic condition, a Chronic condition SNP would be most appropriate for him to enroll in.

Given that Daniel has chronic bronchitis, a Chronic Condition Special Needs Plan (C-SNP) would likely be the most appropriate for him1. These plans are designed to serve individuals with specific severe or disabling chronic conditions. They provide tailored healthcare services to help manage those conditions effectively.

Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.

Correct: To be eligible to enroll in Medicare Advantage, an individual must be entitled (not enrolled) to Part A and enrolled in Part B.

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.

Correct: MSA enrollees must enroll in a stand-alone prescription drug plan (PDP) if they want prescription drug benefits.

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.

Correct: Chronic condition SNPs (C-SNPs) restrict enrollment and tailor services to individuals with chronic conditions, such as Mr. Sinclair. All SNPs include prescription drug coverage.

He should compare the benefits in his employer-sponsored retiree group health plan with the benefits in his neighbor’s MA-PD plan to determine which one will provide sufficient coverage for his prescription needs.

The type of Medicare Advantage plans offered vary by employers. Therefore, beneficiaries should compare their employer’s retiree plan with other available plan options.

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.

Based on the information provided, Mr. Greco may not be eligible for a Medicare Advantage Special Needs Plan (SNP). SNPs are designed to provide targeted care and limit enrollment to special needs individuals. An individual must fit into one of the following groups to be eligible for a special needs plan:

-People who live in certain institutions (like nursing homes) or who require nursing care at home.

-People who are eligible for both Medicare and Medicaid.

-People who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease, HIV/AIDS, chronic heart failure, or dementia).

Since Mr. Greco is in excellent health, lives in his own home, and does not appear to have a specific chronic or disabling condition, he may not meet the eligibility requirements for an SNP.

Therefore, the correct answer would be:

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.

Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies.

Correct: Medicare Advantage is a way of covering Original Medicare, Part A and Part B benefits, through private health insurance 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.

IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full.

Correct: MSAs may not have a network or may have a full or partial network of providers. MSAs cover Part A and Part B benefits after the deductible. All non-network providers must accept the same amount that Original Medicare would pay them as payment in full. This is the amount the enrollee will pay the provider before the deductible is met.

She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment.

Correct: Enrollees or their representatives may file a grievance if they experience problems with their health care services, such as timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item.

Mrs. Chi may enroll in an MA MSA plan and remain in her current standalone Part D prescription drug plan.

Correct. MA MSA plans are prohibited from offering prescription drug coverage. If an MSA member wants prescription drug coverage, the member must enroll in a standalone PDP.

Dr. Brennan can charge Mary Rogers no more than the cost-sharing specified in the PFFS plan’s terms and conditions of payment which may include balance billing up to 15% of the Medicare rate.

Correct: Because Dr. Brennan accepts the plan’s terms and conditions for payment, she is permitted to charge this amount.

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).

Correct: In most Medicare Advantage HMOs, as a general rule, an enrollee must obtain services only from providers within the plan’s network, otherwise known as participating providers. An exception is made for emergency care.

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 is not a part of the PPO network.

MA-PPO enrollees may seek care from any provider who accepts Medicare. However, enrollees are typically responsible for higher cost-sharing payments if their provider is out-of-network.

He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B.

In order to enroll in a Medicare Advantage (MA) plan, an individual must be entitled to Part A and enrolled in Part B. Mr. Castillo is covered by Plan A but no longer enrolled in Medicare Part B so he cannot enroll in MA plan until he re-enrolls in Part B.

Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part A and Part B services.

Some Medicare Advantage Plans offer extra benefits that Original Medicare does not cover. Also, Original Medicare does not have a maximum out-of-pocket limit.