AHIP Final Exam Test Questions and
Answers (2022/2023) (Verified Answers)
Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease
(ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under
Medicare. What should you tell him?correct answersHe may sign-up for Medicare at
any time however coverage usually begins on the fourth month after dialysis treatments
start.
Juan Perez, who is turning age 65 next month, intends to work for several more years at
Smallcap, Incorporated. Smallcap has a workforce of15 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?correct answersJuan 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.
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?correct answersMedicare
Supplemental Insurance would help cover his Part A and Part B deductibles or
coinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly some
services that Medicare does not cover.
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?correct answersShe may enroll at any time while
she is covered under her employer plan, but she will have a special eight-month
enrollment period after the last month on her employer plan that differs from the
standard general enrollment period, during which she may enroll in Medicare Part B.
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?correct answersMost individuals who are citizens and age 65 or over 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.
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?correct answersMrs. 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.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from
arthritis through massage therapy. She is concerned about whether or not Medicare will
cover these items and services. What should you tell her?correct answersMedicare
does not cover massage therapy, or, in general, glasses or dentures.
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?correct answersUnder 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.
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?correct answersTo obtain Part B coverage,
she must pay a standard monthly premium, though it is higher for individuals with higher
incomes.
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 MedicarePart D prescription drug plan. What should you tell him?correct
answersHe generally would pay a monthly premium, annual deductible, and per-
prescription cost-sharing.
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?correct answersMedicare is a program for people age 65 or older and
those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's
disease so she will be eligible for Medicare.
Mr. Xi will soon turn age 65 and has come to you for advice as to what services are
provided under Original Medicare. What should you tell Mr. Xi that best describes the
health coverage provided to Medicare beneficiaries?correct answersBeneficiaries under
Original Medicare have no cost-sharing for most preventive services which include
immunizations such as annual flu shots.
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed
her Medicare Summary Notice (MSN) and disagrees with a determination that partially
denied one of her claims for services. What advice would you give her?correct
answersMrs. Duarte should file an appeal of this initial determination within 120 days of
the date she received the MSN in the mail.
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?correct answersIt 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.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell
Mrs. Park that might be of assistance?correct answersShe should contact her state
Medicaid agency to see if she qualifies for one of several programs that can help with
Medicare costs for which she is responsible.
Mr. 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?correct answersMedicare
will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire
lifetime.
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?correct answersPart
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.
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?correct answersTell
prospect Jerry Smith that he should consider adding a standalone Part D prescription
drug coverage policy to his present coverage.
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?correct answersAfter receiving such disability payments for 24 months, he will be
automatically enrolled in Medicare, regardless of age.
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?correct answersMedicare covers the periodic performance of
a range of screening tests that are meant to provide early detection of disease. Mr.
Buck will need to check specific tests before obtaining them to see if they will be
covered.
Which of the following statement 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.correct answersI, II, and IV only
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?correct answersHe could enroll either in one of the MA plans
that include prescription drug coverage or Original Medicare with a Medigap plan and
standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO
plan and a stand-alone prescription drug plan.
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?correct
answersMrs. Ramos can obtain care from any provider who participates in Original
Medicare, but generally will have a higher cost-sharing amount if she sees a provider
who/that is not a part of the PPO network.
Mr. 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?correct
answersHe 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.
Dr. Elizabeth Brennan does not contract with the ABC 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?correct answersDr. 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% of the Medicare rate.
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 as his
current HMO plan requires him to do. What should you tell him?correct answersHe 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.
Mr. Wells is trying to understand the difference between Original Medicare and
Medicare Advantage. What would be the correct description?correct answersMedicare
Advantage is a way of covering all the Original Medicare benefits through private health
insurance companies.
Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She
wishes to enroll in a 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. Chi?correct answersMrs. Chi may enroll in a
MA MSA plan and remain in her current standalone Part D prescription drug plan.
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?correct answers.
C-SNP
Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and
was disappointed with the service she received from her primary care physician
because she was told she would have to wait five weeks to get an appointment when
she was feeling ill. She called you to ask what she could do so she would not have to
put up with such poor access to care. What could you tell her?correct answersShe
could file a grievance with her plan to complain about the lack of timeliness in getting an
appointment.
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?correct
answersSNPs 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.
Mrs. Radford asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her?correct answersMrs. Radford must be entitled to
Part A and enrolled in Part B to enroll in Medicare Advantage.
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?correct answersMedicaid may provide additional benefits, but
Medicaid will coordinate benefits only with Medicaid participating providers.
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has
recently stopped paying his Part B premium. Mr. Castillo 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?correct answersHe is not eligible to enroll in a Medicare
Advantage plan until he re-enrolls in Medicare Part B.
Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago.
In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease
(ESRD). What options will Mrs. Davenport have regarding her MA plan during the next
open enrollment season?correct answersShe may remain in her ABC MA plan, enroll in
another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for
individuals suffering from ESRD if one is available in her area.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his
ability to access providers. What should you tell him?correct answersIn 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).ur clients, Lauren Nichols, has heard about a Medica
Mr. Barker 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 MA-PD coverage has been very good.
However, when he received the bill, he was surprised to see large charges in excess of
his maximum out-of-pocket 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?correct answersYou can offer to review the plans appeal process to help him ask
the plan to review the coverage decision.
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?correct answersSNPs
have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they
provide prescription drug coverage that could be very helpful as well.
Mr. 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?correct answersThey are Medicare health plans such as
HMOs, PPOs, PFFS, and MSAs.
Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B
because he has coverage through an employer plan. If he wants to enroll in a Medicare
Advantage plan, what will he have to do?correct answersHe will have to enroll in Part B.
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?correct answersMr. Zachow has
a right to request a formulary exception to obtain coverage for his Part D drug. He or his
physician could obtain the standardized request form on the plan's website, fill it out,
and submit it to his plan.
Mr. Bickford did not quite qualify for the extra help low-income subsidy under the
Medicare Part D Prescription Drug program and he is wondering if there is any other
option he has for obtaining help with his considerable drug costs. What should you tell
him?correct answersHe could check with the manufacturers of his medications to see if
they offer an assistance program to help people with limited means to obtain the
medications they need. Alternatively, he could check to see whether his state has a
pharmacy assistance program to help him with his expenses.
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?correct answersMedicare 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.
Mr. Wingate 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?correct answersNone 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.
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 the prescriptions that she
has lost. How would you advise her?correct answersShe may fill prescriptions for
covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-
network pharmacy.
Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost
creditable coverage previously available through her husband's employer. She is
interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should
you tell her?correct answersIf a Part D benefit is offered through her plan she may
choose to enroll in that plan or a standalone PDP.
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?correct answersMedicare prescription drug plans are required to cover drugs in
each therapeutic category. She should be able to enroll in a Medicare prescription drug
plan that covers the medications she needs.
Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income.
She uses no medications and sees no reason to spend money on a Medicare
prescription drug plan if she does not need the coverage. She currently does not have
creditable coverage. What could you tell her about the implications of such a
decision?correct answersIf 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.
Mr. Shultz was still working when he first qualified for Medicare. At that time, he had
employer group coverage that was creditable. During his initial Part D eligibility period,
he decided not to enroll because he was satisfied with his drug coverage. It is now a
year later and Mr. Shultz has lost his employer group coverage within the last two
weeks. How would you advise him?correct answersMr. Schultz should enroll in a Part D
plan before he has a 63-day break in coverage in order to avoid a premium penalty.
Mrs. Mulcahy, 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?correct answersAn 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. Mulcahy is entitled to Part A, she does not need
to enroll under Part B before enrolling in a prescription drug plan.
What types of tools can Medicare Part D prescription drug plans use that affect the way
their enrollees can access medications?correct answersPart 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.
All plans must cover at least the standard Part D coverage or its actuarial equivalent.
Which of the following statements best describes some of the costs a beneficiary would
incur for prescription drugs under the standard coverage?correct answersStandard Part
D coverage would require payment of an annual deductible, and once past the
catastrophic coverage threshold, the beneficiary pays whichever is greater of either the
co-pays for generic and brand name drugs or coinsurance of 5%.
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?correct answersMedicare 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.
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?correct
answersMr. 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.
Which of the following individuals is most likely to be eligible to enroll in a Part D
Plan?correct answersJose, a grandfather who was granted asylum and has worked in
the United States for many years.
Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is
concerned about the Part D premium penalty if he does not enroll in a Medicare
prescription drug plan, but does not want to purchase extra coverage that he will not
need. What should you tell him?correct answersIf the drug coverage he has is not
expected to pay, on average, at least as much as Medicare's standard Part D coverage
expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility
period to avoid the late enrollment penalty.
Mrs. McIntire 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?correct
answersUnless she chooses a Medicare Part D prescription drug plan on her own, she
will be automatically enrolled in one available in her area.
Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug
coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what
circumstances can she do this?correct answersIf 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. Berkowitz can do this.
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.correct answersI, II, and III only
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?correct answersIn general, he must select a single Part D premium
payment mechanism that will be used throughout the year.
You will be holding a sales event soon, at which you would like to offer door prizes to
attendees. Under guidelines from the Medicare agency, what types of gifts or prizes
would not be allowed in this situation?correct answersGift cards or gift certificates of
$15 or less that can be readily converted to cash.
Another agent working for your agency claims that because you are not employed by
the Medicare Advantage plans that you represent, you are not subject to the same
marketing requirements as the plans themselves. How should you respond to such a
statement?correct answersYour coworker is not correct. Marketing on behalf of a plan is
considered marketing by the plan and requires that all contracted and employed agents
comply with all Medicare marketing rules.
Mrs. Lu is turning 65 in November and called to ask for your help deciding on a
Medicare Advantage plan. She agreed to sign a scope of appointment form and meet
with you on October 15. During the appointment, what are you permitted to do?correct
answersYou may provide her with the required enrollment materials and take her
completed enrollment application.
One of your colleagues argues that it is better to focus your time and energy exclusively
in neighborhoods with single-family homes. He further argues that their older owners
are more likely to have higher incomes and purchase the Medicare Advantage products
you represent compared to those living in apartment complexes. How should you
respond?correct answersThis could be considered discriminatory activity and a
prohibited practice.
A Medicare beneficiary has walked into your office and requested that you sit down with
her and discuss her options under the Medicare Advantage program. Before engaging
in such a discussion, what should you do?correct answersYou must have her sign a
scope of appointment form, indicating which products she wishes to discuss. You may
then proceed with the discussion.
Your friend's mother just moved to an assisted living facility and he asked if you could
present a program for the residents about the MA-PD plans you market. What could you
tell him?correct answersYou appreciate the opportunity and would be happy to
schedule an appointment with anyone at their request.
Melissa Meadows is a marketing representative for Best Care which has recently
introduced a Medicare Advantage plan offering comprehensive dental benefits for $15
per month. Best Care has not submitted any potential posts to CMS for approval.
Melissa would like to use the power of social media to reach potential prospects. What
advice would you give her?correct answersAs soon as CMS approves Best Care's
social media posts, Agent Meadows could post a tweet stating that "Best Care offers an
array of Medicare Advantage benefit packages. One might be right for you. Call me to
find out more!"
Agent Jennings makes a presentation on Medicare advertised as an educational event.
Agent Jennings distributes materials that are solely educational. However, she gives a
brief presentation that mentions plan-specific premiums. Is this a prohibited activity at
an event that has been advertised as educational?correct answersYes. When an event
has been advertised as "educational," discussing plan-specific premiums is
impermissible.
Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks
you for advice as to whether this is possible. What should you tell her?correct
answersMarketing representatives may initiate electronic contact through e-mail but an
opt-out process must be provided.
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?correct answersDuring the MA-OEP, Miguel can have
one-on-one meetings with beneficiaries who have requested such meetings.
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?correct answersIt must obtain a HIPAA complaint authorization from an
enrollee that indicates the plan or plan sponsor may use their information for marketing
purposes.
You have approached a hospital administrator about marketing in her facility. The
administrator is uncomfortable with the suggestion. How could you address her
concerns?correct answersTell her that Medicare guidelines allow you to conduct
marketing activities in common areas of a provider's facility.
During a sales presentation, your client asks you whether the Medicare agency
recommends that she sign up for your plan or stay in Original Medicare. What should
you tell her?correct answersTell her that the Medicare agency does not endorse or
recommend any plan.
Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health
Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency
maintains a website marketing the MA plans with which it has contracts. Agent
Armstrong follows up with individuals who request more information about ABC MA
plans via the website and tries to persuade them to enroll in ABC plans. What statement
best describes the marketing and compliance rules that apply to Agent
Armstrong?correct answersAgent Armstrong needs to be licensed and appointed in
every state in which beneficiaries to whom he markets ABC MA plans are located.
You have been providing a pre-Thanksgiving meal during sales presentations in
November for many years and your clients look forward to attending this annual event.
When marketing Medicare Advantage and Part D plans, what are you permitted to do
with respect to meals?correct answersYou may provide light snacks, but a Thanksgiving
style meal would be prohibited, regardless of who provides or pays for the meal.
Next week you will be participating in your first "educational event" for prospective
enrollees. To be sure that you do not violate any of the applicable guidelines, in what
activities should you plan to engage?correct answersYou should plan to ensure that the
educational event is an informative event and must not conduct a sales presentation or
distribute or accept enrollment forms at the event.
You are working several plans and community organizations to sponsor an educational
event. When putting together advertisements for this event, what should you do?correct
answersYou must ensure that the advertisements indicate it is an educational event,
otherwise it will be considered a marketing 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?correct
answersThe plan may withhold commission, require retraining, report the misconduct to
a state department of insurance or terminate the contract.
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?correct answersYou 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.
Plan sponsors may undertake the following marketing activities with current Medicare
Advantage plan members?correct answersMarket non-health related items or services
such as life insurance or annuities policies to current members as permitted following
HIPAA Privacy Rules.
Mr. Rockwell, age 67, is enrolled in Medicare Part A, but because he continues to work
and is covered by an employer health plan, he has not enrolled in Part B or Part D. He
receives a notice on June 1 that his employer is cutting back on prescription drug
benefits and that as of July 1 his coverage will no longer be creditable. He has come to
you for advice. What advice would you give Mr. Rockwell about special election periods
(SEPs)?correct answersMr. Rockwell is eligible for a SEP due to his involuntary loss of
creditable drug coverage; the SEP begins in June and ends on September 1- two
months after the loss of creditable coverage.
Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been
working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is
mid-September, and Mrs. Young is going on vacation. Agent Adams is considering
suggesting that he and Mrs. Young complete the application together before she leaves.
He will then submit the paper application before the start of the annual enrollment
period (AEP). What would you say If you were advising Agent Adams?correct
answersThis is a bad idea. Agents are generally prohibited from soliciting or accepting
an enrollment form before the start of the AEP.
Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug
coverage. He found a stand-alone Medicare prescription drug plan in his area that offers
better coverage than that available through his MA-PD plan and in addition, has a low
premium. It won't cost him much more and, because he has the means to do so, he
wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan.
What should you tell him?correct answersIf Mr. Block enrolls in the stand-alone
Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage
plan.
Mrs. Reeves is newly eligible to enroll in a Medicare Advantage plan and her MA Initial
Coverage Election Period (ICEP) has just begun. Which of the following can she not do
during the ICEP?correct answersShe can enroll in a Medigap plan to supplement the
benefits of the MA plan that she's also enrolling in.
Mr. Johannsen is entitled to Medicare Part A and Part B. He gains the Part D low-
income subsidy. How does that affect his ability to enroll or disenroll in a Part D
plan?correct answersHe qualifies for a special election period and can enroll in or
disenroll from a Part D plan once during that period.
Mr. Yoo's employer has recently dropped comprehensive creditable prescription drug
coverage that was offered to company retirees. The company told Mr. Yoo that,
because he was affected by this change, he would qualify for a Special election period.
Mr. Yoo contacted you to find out more about what this means. What can you tell
him?correct answersIt means that he qualifies for a one-time opportunity to enroll in an
MA-PD or Part D prescription drug plan.
Mrs. Schmidt is moving and a friend told her she might qualify for a "Special election
period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a
special election period is. What could you tell her?correct answersIt is a period, outside
of the Annual Election Period, when a Medicare beneficiary can select a new or different
Medicare Advantage and/or Part D prescription drug plan. Typically the Special election
period is beneficiary specific and results from events, such as when the beneficiary
moves outside of the service area.
Mrs. Margolis contacts you in August because she will become eligible for Medicare for
the first time in November. She would like to meet and discuss plan choices with you.
What advice should you give her?correct answersTell her to wait until October to
discuss plan choices with you so that you can share plan benefits for the current year as
well as any changes for the following year that may impact her choice.
Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. He
would like to know his options since he has decided to drop his retiree coverage and is
eligible for Medicare. What should you tell him?correct answersMr. Chen can disenroll
from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan
within 2 months of his disenrollment.
Mrs. Kumar would like her daughter, who lives in another state, to meet with you during
the Annual Election Period to help her complete her enrollment in a Part D plan. She
asked you when she should have her daughter plan to visit. What could you tell
her?correct answersHer daughter should come in November.
Mr. Roberts is enrolled in an MA plan. He recently suffered complications following hip
replacement surgery. As a result, he has spent the last three months in Resthaven, a
skilled nursing facility. Mr. Roberts is about to be discharged. What advice would you
give him regarding his health coverage options?correct answersHis open enrollment
period as an institutionalized individual will continue for two months after the month he
moves out of the facility.
Mr. White has Medicare Parts A and B with a Part D plan. Last year, he received a
notice that his plan sponsor identified him as a "potential at-risk" beneficiary. This
month, he started receiving assistance from Medicaid. He wants to find a different Part
D plan that's more suitable to his current prescription drug needs. He believes he's
entitled to a SEP since he is now a dual eligible. Is he able to change to a different Part
D plan during a SEP for dual eligible individuals?correct answersNo. Once he is
identified by the plan sponsor as a "potential at-risk" beneficiary, he cannot use the dual
eligible SEP to change plans while this designation is in place.
Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he
must do it, with respect to enrolling in Part D. What could you tell him?correct
answersHe is currently in the Part D Initial Enrollment Period (IEP) and, during this time,
he may make one Part D enrollment choice, including enrollment in a stand-alone Part
D plan or an MA-PD plan.
A client wants to give you an enrollment application on October 1 before the beginning
of the Annual Election Period because he is leaving on vacation for two weeks and does
not want to forget about turning it in. What should you tell him?correct answersYou must
tell him you are not permitted to take the form. If he sends the form directly to the plan,
the plan will process the enrollment on the day the Annual Election Period begins.
Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action
could you help him take during this time?correct answersHe will have one opportunity to
enroll in a Medicare Advantage plan.
You are meeting with Ms. Berlin and she has completed an enrollment form for a MA-
PD plan you represent. You notice that her handwriting is illegible and as a result, the
spelling of her street looks incorrect. She asks you to fill in the corrected street name.
What should you do?correct answersYou may correct this information as long as you
add your initials and date next to the correction.
You have come to Mrs. Midler's home for a sales presentation. At the beginning of the
presentation, Mrs. Midler tells you that she has a copy of her medical records 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. What should you do?correct answersYou can only ask Mrs. Midler
questions about conditions that affect eligibility, specifically, whether she has one of the
conditions that would qualify her for a special needs plan.
Mr. and Mrs. Nunez attended one of your sales presentations. They've asked you to
come to their home to clear up a few questions. During the presentation, Mrs. Nunez
feels tired and tells you that her husband can finish things up. She goes to bed. At the
end of your discussion, Mr. Nunez says that he wants to enroll both himself and his
wife. What should you do?correct answersAs long as she can do so, only Mrs. Nunez
can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so
at another time.
When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts
A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a
Medicare Advantage (MA) plan and approaches you about her options. What advice
would you give her?correct answersShe should remain in Original Medicare until the
annual election period running from October 15 to December 7, during which she can
select an MA plan.
Mr. Wendt suffers from diabetes which has gotten progressively worse during the last
year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D
prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the
last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard
certain MA plans might provide him with more specialized coverage for his diabetes and
wants to know if he must wait until the next annual open enrollment period (AEP) before
enrolling in such a plan. What should you tell him?correct answersIf there is a special
needs plan (SNP) in Mr. Wendt's area that specializes in caring for individuals with
diabetes, he may enroll in the SNP at any time under a special election period (SEP)
Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage.
She has recently received a letter from her Medigap carrier informing her that her drug
coverage is not "creditable." She wants to know what this means. What should you tell
her?correct answersThe letter is to inform her that the drug coverage offered through
her Medigap plan does not offer drug coverage that is at least comparable to that
provided under the Medicare Part D prescription drug program. If she does not have
such creditable coverage during periods when she is first eligible for the Part D
program, she will face a premium penalty if she enrolls in a Part D plan at a later date.
Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for
Medicare as well. He is concerned about changes in his cost-sharing. What should you
tell him?correct answersHe should know that Medicaid will pay cost sharing only for
services provided by Medicaid participating providers.
Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable
income only sporadically. Her husband worked full-time throughout his long career. She
has heard that to qualify for Medicare Part A she has to have worked and paid Medicare
taxes for a sufficient time. What should you tell her?correct answersSince her husband
paid Medicare taxes during the entire time he was working, she will automatically qualify
for Medicare Part A without having to pay any premiums.
A Medicare beneficiary has walked into your office and requested that you sit down with
her and discuss her options under the Medicare Advantage program. Before engaging
in such a discussion, what should you do?correct answersYou must have her sign a
scope of appointment form, indicating which products she wishes to discuss. You may
then proceed with the discussion.
Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though
he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan
but is concerned that he will have to sign up for Part B as well in order to qualify for
enrollment in a Part D plan. What should you tell him?correct answersHe does not have
to enroll in Part B but, must pay a penalty for his failure to do so when he first turned 65.
After that, he can enroll in a Part D prescription drug plan.
Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or
list of covered drugs. He is suspicious about how plans establish these formularies.
What should you tell him?correct answersFormularies must be developed with input
from pharmacists, doctors, and other experts.
ACA Section 1557 rules for disability concerncorrect answersPolicies and procedures,
physical access, and communication.
Under ACA Section 1557, a health plan premium sold through a state exchange may,
based on an individual's age,correct answerscharge higher premiums.
Which of the following statements best describes Section 1557 of the Affordable Care
Act (ACA)?correct answersSection 1557 incorporates earlier civil rights protections in
regard to race, color, national origin, disability, age and sex.
Which Medicare programs are covered by ACA Section 1557?correct answersParts A,
C, and D, but not B.
As a result of violations of ACA Section 1557 nondiscrimination rules,correct answersa
health plan may revoke an agent or broker's appointment with the health plan.
Which of the following statements best describes the scope of operations subject to
Section 1557 under the 2020 Final Rule?correct answersHealth insurers under the 2020
Final Rule are not considered to be principally engaged in delivering health care, and
thus lines of business that do not receive federal funding or administered under Title I of
the ACA, such as life insurance, do not fall under the scope of 1557.
Section 1557 of the Affordable Care Act applies tocorrect answersall health programs
and activities administered by or receiving federal financial assistance from HHS
Under Section 1557, 2020 Final Rule issued during the Trump Administration sex was
initially defined____________correct answersas biologic sex only, meaning whether a
person was determined to be male or female at birth.
Which of the following would be considered permissible under Section 1557 and the
2020 Final Rule?correct answersBroker Mary Jones has recruited a diverse workforce.
She encourages her agents to prospect through community-based marketing and within
their community of influence.
Auxiliary aids and services must be provided to individuals with disabilities, such as
those suffering from vision or hearing impairments, free of charge, and in a timely
manner. Auxiliary aids and services include which of the following:
I. large print materials
II. qualified sign language interpreters
III. braille materials and displays
IV. screen reader softwarecorrect answersI, II, III, and IV
Which entity enforces Section 1557 for programs that receive funding from on are
administered by HHS?correct answersThe Office of Civil Rights (OCR) of HHS.
Which of these actions is most likely to be permitted in dealing with a person with limited
English proficiency?correct answersAllowing a child to interpret in an emergency.
Under ACA Section 1557, a health plancorrect answerscannot deny coverage to LEP
individuals and is required to provide language assistance to them, free of charge.
For a health plan, what are the possible consequences of violations of ACA Section
1557?correct answersLoss of federal business and compensatory damages.
Which of the following is NOT potentially a penalty for violation of a law or regulation
prohibiting fraud, waste, and abuse (FWA)?correct answersDeportation
Which of the following requires intent to obtain payment and the knowledge the actions
are wrong?correct answersFraud
You are performing a regular inventory of the controlled substances in the pharmacy.
You discover a minor inventory discrepancy. What should you do?correct
answersFollow your pharmacy's procedures
Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services
(CMS) for the purpose of payment. As part of this job, you use a process to verify the
data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process
and to adjust or add risk diagnosis codes for certain individuals. What should you
do?correct answersReport the incident to the compliance department (via compliance
hotline or other mechanism)
You are in charge of paying claims submitted by providers. You notice a certain
diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large
number of members. Many of these claims are for a certain procedure. You review the
same type of procedure for other diagnostic providers and realize Doe Diagnostics'
claims far exceed any other provider you reviewed. What should you do?correct
answersConsult with your immediate supervisor for next steps or contact the
compliance department (via compliance hotline, Special Investigations Unit [SIU], or
other mechanism)
A person drops off a prescription for a beneficiary who is a "regular" customer. The
prescription is for a controlled substance with a quantity of 160. This beneficiary
normally receives a quantity of 60, not 160. You review the prescription and have
concerns about possible forgery. What is your next step?correct answersCall the
prescriber to verify the quantity
Waste includes any misuse of resources, such as the overuse of services or other
practices that directly or indirectly result in unnecessary costs to the Medicare
Program.correct answersTrue
Bribes or kickbacks of any kind for services that are paid under a Federal health care
program (which includes Medicare) constitute fraud by the person making as well as the
person receiving them.correct answersTrue
These are examples of issues that should be reported to a Compliance Department:
suspected fraud, waste, and abuse (FWA); potential health privacy violation, unethical
behavior, and employee misconduct.correct answersTrue
Abuse involves payment for items or services when there is no legal entitlement to that
payment and the provider has not knowingly or intentionally misrepresented facts to
obtain payment.correct answersTrue
Ways to report potential fraud, waste, and abuse (FWA) include:
a. Mail drops
b. Special Investigative Units (SIUs)
c. Tekephone hotlines
d. All of the above
e. In-person reporting to the compliance department/supervisorcorrect answersAll of the
above
Once a corrective action plan is started, the corrective action plan must be monitored
annually to ensure they are effective.correct answersFalse
What are some of the penalties for violating fraud, waste, and abuse (FWA) laws?
a.Civil Monetary Penalties
b.Imprisonment
c.All of the above
d.Exclusion from participation in all Federal health care programscorrect answersAll of
the above
Any person who knowingly submits false claims to the Government is liable for five
times the Government's damages caused by the violator plus a penalty.correct
answersFalse
Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA)
include the Health Insurance Portability and Accountability Act (HIPAA), the False
Claims Act the Anti-Kickback Statute, and the Health Care Fraud Statute.correct
answersFalse
You can help prevent fraud, waste, and abuse (FWA) by doing all the following:
Look for suspicious activity
Conduct yourself in an ethical manner
Ensure accurate and timely data and billing
Ensure you coordinate with other payers
Keep up to date with FWA policies and procedures, standards of conduct, laws,
regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance
Verify all information provided to youcorrect answersTrue
You are performing a regular inventory of the controlled substances in the pharmacy.
You discover a minor inventory discrepancy. What should you do?correct
answersFollow your pharmacy's procedures
You work for a Sponsor. Last month, while reviewing a Centers for Medicare & Medicaid
Services (CMS) monthly report, you identified multiple individuals not enrolled in the
plan but for whom the Sponsor is paid. You spoke to your supervisor who said don't
worry about it. This month, you identify the same enrollees on the report again. What
should you do?correct answersAlthough you know about the Sponsor's non-retaliation
policy, you are still nervous about reporting to be safe, you submit a report through —
your compliance department's anonymous tip line to avoid identification
You discover an unattended email address or fax machine in your office receiving
beneficiary appeals requests. You suspect no one is processing the appeals. What
should you do?correct answersContact your compliance department (via compliance
hotline or other mechanism)
A sales agent, employed by the Sponsor's first-tier, downstream, or related entity (FDR),
submitted an application for processing and requested two things: 1) to back-date the
enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary.
What should you do?correct answersProcess the application properly (without the
requested revisions) inform your supervisor and the compliance officer about the sales —
agent's request
Ways to report a compliance issue include:
a.In-person reporting to the compliance department/supervisor
b.Report on the Sponsor's website
c.Telephone hotlines
d.All of the abovecorrect answersAll of the above
Compliance is the responsibility of the Compliance Officer, Compliance Committee, and
Upper Management only.correct answersFalse
What is the policy of non-retaliation?correct answersProtects employees, who in good
faith report suspected non-compliance
Medicare Parts C and D sponsors are not required to have a compliance
program.correct answersFalse
At a minimum, an effective compliance program includes four core requirements.correct
answersFalse
Correcting non-compliance________correct answersProtects enrollees, avoids
recurrence of same non-compliance, and promotes efficiency
These are examples of issues that can be reported to a Compliance Department:
suspected fraud, waste, and abuse (FWA), potential health privacy violation, and
unethical behavior/employee misconduct.correct answersTrue
Once a corrective action plan begins addressing non-compliance for fraud, waste, and
abuse (FWA) committed by a Sponsor's employee or first-tier, downstream, or related
entity's (FDR's) employee, ongoing monitoring of the corrective actions is not
necessary.correct answersFalse
Standards of Conduct are the same for every Medicare Parts C and D sponsor.correct
answersFalse
What are some of the consequences for non-compliance, fraudulent, or unethical
behavior?
a.Exclusion from participating kin all Federal health care programs
b.Termination of employment
c.Disciplinary action
d.All of the abovecorrect answersAll of the above
Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her
area. Ms. Levi often travels to visit relatives and is concerned that she may need
emergency care outside of her plan's service area. What should you tell her about
coverage of emergency care?correct answersPlans are required to cover out-of-network
emergency care.
Ms. Morris will turn 65 on June 10th. She has never previously qualified for Medicare.
She is entitled to Medicare Part A and intends to enroll in Part B. She wants to know if
she is eligible to enroll in a Medicare Advantage plan that includes prescription drug
coverage. What do you tell her?correct answersMs. Morris can enroll in an MA-PD plan
now since her initial election period (IEP) for Part D prescription drug coverage and
initial coverage period are occurring together beginning March 1st and ending
September 30th.
Agent Marvin Millner wants to reach out to his current clients for referrals. What advice
would you give to Marvin?correct answersMarvin should understand that under CMS
guidelines he can no longer provide gifts, even of minimal value, in exchange for
referrals. NOT SURE
Mr. Chen has heard about a Medical Savings Account (MSA) but wants to know if it is
just about saving money, or if he will get insurance coverage for his health care
expenditures as well. What should you tell him?correct answersUnder the Medicare
Advantage program, a MSA plan involves the combination of a high deductible health
plan and a savings account for health expenses. Medicare will make contributions to
this savings account to help him pay his health care expenses while in the deductible.
NOT SURE
Ms. Lewis understands that Medicare prescription drug plans may use various methods
to control the use of specific drugs. She has heard about a technique called "step
therapy" and is wondering if you can explain what that is. What should you tell
her?correct answersStep therapy involves using one or more lower priced drugs before
trying a more expensive drug when all are used to treat the same condition.
Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is
enrolled in and is interested in that product. She wants to be sure she also has
coverage for prescription drugs. Would she be able to obtain drug coverage if she
enrolled in the SNP?correct answersYes. All SNPs are required to provide Part D
coverage for prescription drugs.
Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA)
Medicare health plan. The MSA plan does not offer prescription drug coverage, so
Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP).
What CMS compensation rules apply to this situation?correct answersThis situation is
considered a "dual enrollment," and CMS compensation rules are applied to the two
plans at once and independently of each other.
Mr. Olsen is concerned that a Medicare Advantage plan will not cover the same range
of services that would be covered under Original fee-for-service Medicare. What should
you tell him?correct answersThough their cost-sharing may differ from Original
Medicare's, Medicare Advantage plans are required to cover all services covered by
original Medicare.
Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told
her that there is an excellent Medicare Advantage (MA) plan with a five-star rating
serving her area. On January 15 she comes to you for advice as to what options, if any,
she has. What should you say regarding special enrollment periods (SEPs)?correct
answersMrs. Wellington is eligible for a SEP that may be used once until November 30
to enroll in the five-star plan.
Ms. Gardner is currently enrolled in an MA-PD plan. However, she wants to disenroll
from the MA-PD plan and instead enroll in a Part D only plan and go back to Original
Medicare. According to Medicare's enrollment guidelines, when could she do
this?correct answersShe may make such a change during the Annual Election Period
that runs from Oct. 15 to December 7, or during the MA Open Enrollment Period which
takes place from January 1- March 31 of each year.
Mr. Lopez, who is fairly well-off financially, would like to enroll in a Medicare prescription
drug plan you represent and simply give you a check to cover his premiums for the
entire year. What should you tell him?correct answersEnrollees should pay using
automatic withdrawal from a bank account or credit or debit card, direct monthly billing
from the plan, or deductions from their Social Security check.
Ms. Jensen has heard about "Original Fee-for-Service Medicare" and "Private Fee-for-
Service" plans. She wants to know what the difference is if any. What should you tell
her?correct answersPFFS plans are a type of Medicare Advantage plan offered by
private companies.
Ms. Bushman has two homes in different states and is concerned about restrictions on
where she can get her medications. What should you tell her?correct answersPart D
prescription drug plans use networks of pharmacies within their service areas. She
could look for a plan that maintains a network in both states. NOT SURE
Who is most likely to be eligible to enroll in a Part D prescription drug plan?correct
answersMs. Davis who is entitled to Part A and has just enrolled in Part B.a sales
presentation, your client asks you wh
Mr. Lopez takes several high-cost prescription drugs. He would like to enroll in a
standalone Part D prescription drug plan that is available in his area. In what type of
Medicare Health Plan can he enroll?correct answersPrivate Fee-for-Service (PFFS)
plan that does not include drug coverage.
If a beneficiary is enrolled in a stand-alone prescription drug plan and wants to keep that
plan, what type of Medicare health plan could the individual also enroll in, without being
automatically disenrolled from the stand-alone prescription drug plan?correct
answersThe beneficiary could enroll in a private fee-for-service (PFFS) plan that does
not include prescription drug coverage; a cost plan; or a Medicare Medical Savings
Account (MSA) plan.
Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage
(MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the
neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about
the kinds of food that can be provided to potential enrollees who attend the sales
presentation?correct answersA meal cannot be provided, but light snacks would be
permitted
Which of the following is/are most likely to be characterized as an involuntary
disenrollment from a Medicare Advantage (MA) plan?
I. The enrollee dies.
II. An SNP enrollee loses special needs status due to substantially improved health.
III. It is determined that the member is not lawfully present in the United States.
IV. The member enrolls in another plan during the Annual Open Enrollment
period.correct answersI, II, and III only
Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare
Advantage plan. What should you tell himcorrect answersMr. 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.
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?correct answersYou 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.
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?correct answersMr. Wu may still qualify for help in paying Part D costs
through his State Pharmaceutical Assistance Program.
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?correct answersPart D covers prescription drugs
and she should look at her premiums, formulary, and cost-sharing among other factors
to see if they have changed.
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?correct answersMr. Diaz will not pay any
penalty because he had continuous coverage under his employer's plan.
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?correct answersMedigap plans help beneficiaries cover Original Medicare
benefits, but they coordinate with Original Medicare coverage.
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?correct answersOriginal Medicare
covers ambulance services.
Anita Magri will turn age 65 in August 2022. 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?correct answersYou 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.
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?correct answersPart 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.
What impact, if any, have recent regulatory changes had upon Medigap plans?correct
answersThe Part B deductible is no longer covered for individuals newly eligible for
Medicare starting January 1, 2020.
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?correct answersMedicare will cover Mrs. Shield's skilled nursing services
provided during the first 20 days of her stay, after which she would have a copay until
she has been in the facility for 100 days.
Mrs. Willard wants to know generally how the benefits under Original Medicare might
compare to the benefits package of a Medicare Advantage Plan before she starts
looking at specific plans. What could you tell her?correct answersMedicare Advantage
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.
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?correct answersMedicaid may provide additional benefits, but
Medicaid will only pay for these services if they are furnished by Medicaid participating
providers.
Mrs. Walters is enrolled in her state's Medicaid program in addition to Medicare. What
should she be aware of when considering enrollment in a Medicare Advantage (MA)
plan?correct answersShe can submit any bills she has for co-payments under Medicare
to the state's Medicaid program and they will always be fully covered.
Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is
considering enrollment in a Medicare Advantage plan (Part C). What should you advise
her to do before she will be able to enroll in a Medicare Advantage plan?correct
answersTo join a Medicare Advantage plan, she also must enroll in Part B.
Ms. Gibson recently lost her employer group health and drug coverage and now she
wants to enroll in a PPO that does not include drug coverage. What should you tell her
about obtaining drug coverage?correct answersShe can enroll in the PPO, but she will
not be able to purchase a stand-alone Medicare Part D prescription drug plan.
Mrs. Chou 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?correct answersShe could enroll in a
PFFS plan and a stand-alone Medicare prescription drug plan.
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?correct answersAll 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.
Mrs. Fiore 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?correct answersShe 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.
Mrs. Roswell 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 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?correct
answersEvery Part D drug plan is required to cover a single one-month fill of her
existing medications sometime during a 90-day transition period.
Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service
(PFFS) plan. All types of PFFS plans are available in her area. Which options could
Mrs. Roberts consider before selecting a PFFS plan?correct answersA 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. Walters is entitled to Part A and has medical coverage without drug coverage
through an employer retiree plan. She is not enrolled in Part B. Since the employer plan
does not cover prescription drugs, she wants to enroll in a Medicare prescription drug
plan. Will she be able to?correct answersYes. Mrs. Walters must be entitled to Part A
and/or enrolled in Part B to be eligible for coverage under the Medicare prescription
drug program.
Mrs. Fields wants to know whether applying for the Part D low-income subsidy will be
worth the time to fill out the paperwork. What could you tell her?correct answersThe
Part D low-income subsidy could substantially lower her overall costs. She can apply by
contacting her state Medicaid office or calling the Social Security Administration.
One of your clients, Lauren Nichols, has heard about a Medicare concept from one of
her neighbors called TrOOP. She asks you to explain it. What do you say?correct
answersTrOOP stands for true out-of-pocket expenses that count toward the Medicare
Part D catastrophic limit and include not only expenses paid by a beneficiary but also in
some instances drug manufacturer discounts.
Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be
extra help paying for Part D prescription drugs for Medicare beneficiaries with limited
income. He wants to know whether he might qualify. What should you tell him?correct
answersThe extra help is available to beneficiaries whose income and assets do not
exceed annual limits specified by the government.
Mr. Rice is 68, actively working and has coverage for medical services and medications
through his employer's group health plan. He is entitled to premium free Part A and
thinking of enrolling in Part B and switching to an MA-PD because he is paying a very
large part of his group coverage premium and it does not provide coverage for a
number of his medications. Which of the following is NOT a consideration when making
the change?correct answersMr. Rice's retiree plan is required to take him back if, within
63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his
Medicare Part D plan.
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?correct
answersYou may go ahead and call them.
Alice is a marketing representative employed by a health plan. Betty is a captive agent
of a health plan who markets to multiple plans and sponsors. Carl is a captive agent
who markets to only one plan/sponsor. Denise is an independent agent who markets to
different types of groups. Edward is an independent agent who markets only to
employer and union groups. CMS marketing representative compensation rules
generally apply to:correct answersBetty and Denise, but not Alice (the employee) or
Carl or Edward (to whom exceptions apply).
During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5-
star rating in customer service and care coordination, and received an overall plan
performance rating of a 4-star, which of the following would be the best statement to say
to her?correct answersThe Medicare Advantage plan received a 5-star rating in
customer service and care coordination with an overall performance rating of 4-stars.
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?correct answersCooperate with the state and supply requested information.
You are mailing invitations to new Medicare beneficiaries for a marketing event. You
want an idea of how many people to expect, so you would like to request RSVPs. What
should you keep in mind?correct answersYou may request RSVPs, but you are not
permitted to require contact information.
You market many different types of insurance and ordinarily you spend time each
evening calling potential clients. To comply with requirements for marketing Medicare
Advantage and Part D plans, what must you do about contacting potential clients to
market those plans?correct answersYou will have to avoid calling any potential client
unless he or she initiates contact with you and specifically asks that you give him or her
a call.
Monica is an agent focused on serving seniors eligible for Medicare. As she reviews her
records, she is trying to determine which of the following items are considered
compensation. What do you tell her?
I. Commissions
II. Bonuses
III. Mileage reimbursement
IV. Awardscorrect answersI, II and IV only
Your colleague works at a third-party marketing organization (TMO) and she said she
did not need to take the Medicare training for brokers and agents or pass a test to
market Medicare plans since her contract is with the TMO, not the plans that have the
products she sells. What could you say to her?correct answersYou could tell her she is
wrong, and that only agents selling employer/union group plans are permitted an
exemption from testing, but some employer/union group plans may require testing to
promote agent compliance with CMS marketing requirements.
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?correct answersOrganizations 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.
You have set up an appointment for an in-home sales presentation with Mrs.
Fernandez, who expressed interest in the Medicare plans you represent. In preparation
for the sales presentation, what must you do?correct answersBefore conducting the
presentation, obtain, and document having obtained her permission to visit, along with
her interest in the specific products you will present.
You are meeting with Mrs. Hall in her home. On her scope of appointment form, she
asked to discuss Medicare Advantage plans. During the meeting, she asks to discuss a
stand-alone prescription drug plan. She is leaving the next day to visit her family for a
week in another state, so it is important for her to make a decision before she leaves.
What must happen before that additional discussion can take place?correct
answersSince Mrs. Hall specifically asked that you discuss the stand-alone Part D plan,
you may do so, as long as she signs a new scope of appointment form first, indicating
that she wants to discuss the Part D plan
Agent Harriet Walker has recently begun marketing Medicare Advantage and related
products aimed at meeting the needs of senior citizens. Client Mildred Jones has
expressed interest in a Medicare Advantage plan. It is now the beginning of September.
If you were in Agent Walker's position, what would you do?correct answersInquire
whether the client qualifies for a special enrollment period, and if not, solicit an
enrollment application once the annual open enrollment election period begins on
October 15th.
You plan to participate in an educational event sponsored by a large regional health
care system. One of your colleagues suggests that you do a presentation on one of the
Medicare Health plans you market and modify it to include information about preventive
screening tests showcased at the event. How should you respond to your colleague's
suggestion?correct answersYou should tell your colleague no, because participation in
an educational event may not include a sales presentation.
By contacting plans available in your area, you have learned that the plan you represent
has a significantly lower monthly premium than the others. Furthermore, you see that
the plan you represent has a unique benefits package. What should you do to make
sure your clients know about these pieces of information?correct answersYou may
make comparisons between plans if you can support them by studies or statistical data
and such comparisons are factually based
When you market Medicare Advantage and Part D plans, what may you offer as a gift to
induce enrollment in a plan?correct answersYou may provide gifts or prizes to all
potential enrollees during an event that does not exceed $15 in retail value.
You are scheduled to give a sales presentation at a local senior center at which a
drawing will be held for a prize. At the beginning of the presentation, which of the
following must you do?correct answersClearly state that no obligation exists to enroll if a
gift or prize is being offered.
Winthrop Brokerage wishes to place an advertisement in the local newspaper that says:
"We offer Medicare Advantage plans offered by AB Health and Top Choice Health.
Contact us if you would like to learn more." Which of the following best describes the
obligation(s) of Winthrop Brokerage regarding the advertisement?correct
answersWinthrop Brokerage does not need to submit the advertisement to CMS for
prior approval because it does not include information about the plans' benefits
structures, cost-sharing, or information about measures or ranking standards.
If you are to comply with Medicare's guidance regarding educational events, which of
the following would be acceptable activities?correct answersYou may distribute
business cards to individuals who request information on how to contact you for further
details on the plan(s) you represent.
While making an appointment to discuss Medicare Advantage (MA) and Part D plans
with a potential enrollee, you are asked to describe other types of insurance products
that your client might wish to purchase. What additional types of insurance can you
present during the MA and Part D marketing appointment?correct answersYou can
present only health care related lines of business but must obtain the beneficiary's
permission to do so before the presentation occurs and document that you have
obtained that permission.
Mr. Edwards, a marketing representative of the ACME Insurance Company, scheduled
a marketing event and expects about 40 people to attend. He has hired a magician for
$200 to entertain attendees. Can he do this in a way that complies with guidance from
the Medicare agency?correct answersHe can do this because the estimated number of
attendees is based on the venue size and response rate and the value of the gift does
not exceed $15.
Willard works as a representative focused on the senior marketplace. What would be
considered prohibited activity by Willard?correct answersImplying that only seniors can
enroll in a Medicare Advantage plan when meeting with Mr. Hernandez, who is 58 but
qualifies for Medicare because he is disabled.
Which of the following individuals has enrolled in a plan based on a fixed enrollment
period?correct answersBen, who enrolls in a Medicare Advantage plan during the
Medicare Advantage Open Enrollment Period (MA OEP).
Mr. Wilcox has been enrolled in Lexington Private Fee-for-Service (PFFS) Medicare
Advantage Health Plan (Lexington) for several years. Recently, Mr. Wilcox decided to
spend time with his children who live in another state that is not in Lexington's service
area. In the future, he may relocate near his children permanently. How does this move
to another service area impact his PFFS MA coverage?correct answersLexington can
allow for Mr. Wilcox's continued enrollment for up to 12 months whether or not he is in a
visitor/traveler (V/T) program since it is a PFFS plan.
Miles is a licensed agent who represents Colgate Health and its Medicare Advantage
(MA) plans. Miles has several clients who have recently come to him for help. They are
in their initial coverage periods) (ICEP) and are interested in enrolling in one of Colgate
Health's MA plans. Adam will soon turn 68 and has decided to retire. Betty is about to
turn 65 and has also decided to retire. Adam and Betty both currently have coverage
through Colgate Health. Charles had health coverage through Colgate but dropped the
coverage when he retired early to travel to Europe. Charles has just turned age 65 and
is now back in the United States. Diedre, who will turn 65 next month, currently has
coverage through Ditmas Health - a company that Miles also represents. Who qualifies
for the opt-in simplified enrollment mechanism?correct answersAdam and Betty
because each of them will not have a break between their non-Medicare and Medicare
coverage through Colgate Health Plan.
Mr. Fitzgerald is selling his home to permanently move into a retirement facility near his
daughter in a neighboring state before the Annual Election Period. He has a stand-
alone prescription drug plan and has learned it is not available where he is moving. He
doesn't know what he should do. What can you tell him?correct answersBecause he is
moving outside of the service area, the plan must automatically disenroll him. He will
have a special election period to select a new plan.
Mrs. Jenkins is enrolled in both Part A and Part B of Medicare. She has recently also
become eligible for Medicaid and would like to enroll in a MA-PD plan. Since this is her
first experience with Medicare Advantage, she is concerned that she will be locked into
a plan and unable to make any coverage changes for at least a year if not longer. What
should you tell her?correct answersSince Mrs. Jenkins has Medicare Part A and Part B
and receives Medicaid, she has a special election period (SEP) that will allow her to
enroll or disenroll from an MA or MA-PD plan during the first 9 months of each calendar
year.
Mr. Rodriguez is currently enrolled in a MA plan, but his plan doesn't sufficiently cover
his prescription drug needs. He is interested in changing plans during the upcoming MA
Open Enrollment Period. What are his options during the MA OEP?correct answersHe
can switch to a MA-PD plan.
Mrs. Parker likes to handle most of her business matters through telephone calls. She
currently is enrolled in Original Medicare Parts A and B but has heard about a Medicare
Advantage plan offered by Senior Health from a neighbor. Mrs. Parker asks you
whether she can enroll in Senior Health's MA plan over the telephone. What can tell
her?
I. Enrollment requests can only be made in face-to-face interviews or by mail.
II. Telephone enrollment request calls must be recorded.
III. Telephonic enrollments must include all required elements necessary to complete an
enrollment.
IV. The signature element must be completed via certified mail.correct answersII and III
only
Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election
Period (AEP). On December 1, he calls you up and says that he has changed his mind
and would like to enroll into a MA-PD plan. What enrollment rules would apply in this
case?correct answersHe can make as many enrollment changes as he likes during the
Annual Election Period and the last choice made prior to the end of the period will be
the effective one as of January 1.
Ms. Thomas has worked for many years and is turning 68 in June. She is eligible for
Medicare Part A and did not enroll for Part B when first eligible because she has
insurance through her employer - Coffee Brew, Inc. She also did not enroll in Part D
because she had creditable coverage. She would like to retire in June and enroll in a
Medicare Advantage plan. She has been informed that her group coverage will end on
her retirement effective date. How would you advise Ms. Thomas?correct answersMs.
Thomas can enroll in Part B without a late penalty at any time she is still covered by her
employer group and 8 months after her last month of employer group coverage without
a penalty. However, because she wants to enroll in a MA plan after retirement, she
should make sure her Part B coverage is effective in time to use the Medicare
Advantage/Part D special election period for individuals changing from employer group
coverage to enroll in a MA plan or MA-PD. The SEP begins while she has employer
group coverage and will last until 2 months after the month after the month her
employer coverage ends. If she wants Part D coverage she should enroll in an MA-PD
or a PDP (depending on how she decides to receive her Part A and B benefits) during
this time.
Mr. Liu turns 65 on June 19. He has never previously qualified for Medicare so his first
Medicare eligibility date will be by June 1. Mr. Liu's ICEP and Part D IEP begin March 1
and end on September 30. He wants prescription drug coverage with his Part A and
Part B benefits. What advice can you provide him?correct answersHe can enroll in a
MA-PD as long as he enrolls in Part B and is entitled to Part A.
Ms. Claggett is sixty-six (66) years old. She has been covered under Original Medicare
for the last six years due to her disability and has never been enrolled in a Medicare
Advantage or a Part D plan before. She wants to enroll in a Part D plan. She knows that
there is such a thing as the "Part D Initial Enrollment Period" (IEP) and has concluded
that, since she has never enrolled in such a plan before, she should be eligible to enroll
under this period. What should you tell her about how the Part D Initial Enrollment
Period applies to her situation?correct answersMs. Claggett has had two IEPs and
missed them both. The first occurred three months before and three months after the
month when she was first entitled to Part A OR enrolled in Part B. Because she was
eligible for Medicare before age 65, Ms. Claggett had a second IEP based on turning
age 65, which has also expired.
Ms. O'Donnell learned about a new MA-PD plan that her neighbor suggested and that
you represent. She plans to switch from her old MA HMO plan to the new MA-PD plan
during the Annual Election Period. However, she wants to make sure she does not end
up paying premiums for two plans. What can you tell her?correct answersShe only
needs to enroll in the new MA-PD plan and she will automatically be disenrolled from
her old MA plan.
You work for Caring Health, a Medicare Advantage (MA) plan sponsor. Recently, Mrs.
Garcia has completed an enrollment application for a plan offered by Caring Health,
which is waiting for a reply from CMS indicating whether or not Mrs. Garcia's enrollment
has been accepted. Once CMS replies, how long does Caring Health have to notify Mrs.
Garcia that her enrollment has been accepted and in what format?correct answersThe
plan has 10 calendar days to notify Mrs. Garcia in writing.
Mrs. Kendrick is in good health, has worked for many years and is six months away
from turning 65. She wants to know what she will have to do to enroll in a Medicare
Advantage (MA) plan as soon as possible. What could you tell her?correct answersShe
may enroll in an MA plan beginning three months immediately before her first
entitlement to both Medicare Part A and Part B.
Mrs. Reynolds is in her Medicare initial coverage election period (ICEP) and the date of
her entitlement to Part A and B has already occurred. Mrs. Reynolds has just signed up
for a Medicare Advantage plan on the second of the month. She is leaving for vacation
in two weeks and wants to know if her new coverage will start before she leaves. What
should you tell her?correct answersTypically, her coverage would begin on the first day
of the next month, so she should not expect her coverage to begin before she leaves.
Mr. Robinson was quite ill recently and forgot to pay his monthly premium for his MA-PD
plan. He is worried that he will lose his coverage now when he needs it the most. He is
certain his plan will disenroll him because that is what happened to a friend of his in a
similar type of plan. What can you tell Mr. Robinson about his situation?correct
answersPlan sponsors have the option to do nothing when a plan member does not pay
their premiums or disenroll the member after a grace period and notice.
Mrs. Johnson calls to tell you she has not received her new plan ID card yet, but she
needs to see a doctor. What can she expect to receive from the plan after the plan has
received her enrollment form?correct answersEvidence of plan membership,
information on how to obtain services, and the effective date of coverage.
Mr. Anderson is a very organized individual and has filled out and brought to you an
enrollment form on October 10 for a new plan available January 1 next year. He is
currently enrolled in Original Medicare. What should you do?correct answersTell Mr.
Anderson that you cannot accept any enrollment forms until the annual election period
begins.
Mr. Wendt suffers from diabetes which has gotten progressively worse during the last
year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D
prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the
last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard
certain MA plans might provide him with more specialized coverage for his diabetes and
wants to know if he must wait until the next annual open enrollment period (AEP) before
enrolling in such a plan. What should you tell him?correct answersIf there is a special
needs plan (SNP) in Mr. Wendt's area that specializes in caring for individuals with
diabetes, he may enroll in the SNP at any time under a special election period (SEP)
Richard is a licensed agent who represents Spartan Health Plan and its Medicare
Advantage (MA) plans. Richard has several clients who have recently come to him for
help who are in their initial coverage election period (ICEP) and are interested in
enrolling in one of Spartan Health Plan's MA plans. Alice will soon turn 65 and retire.
Alice has coverage through Spartan Health Plan offered by her employer. Bob had
health coverage through Spartan but dropped the coverage when he retired early to
travel overseas. Bob, who has just turned age 65, is now back in the United States.
Charlotte, who will turn 65 next month, has coverage through Athena Health plan - a
company Richard also represents. Who qualifies for the opt-in simplified enrollment
mechanism?correct answersAlice because she will not have a break between her non-
Medicare and Medicare coverage through Spartan Health Plan. ???????????????
You would like to offer gifts of nominal value to potential enrollees who call for more
information about a plan you represent. You would then like to offer additional gifts if
they come to a marketing event. Each of the gifts meets the CMS definition of nominal
value, but together, the gifts are more than the nominal value. Is this
permissible?correct answersNo, the total value of the gifts given to an enrollee in a year
cannot exceed the CMS definition of nominal value.
You are doing a sales presentation for Ms. Duarte and her son. Ms. Duarte has some
cognitive impairment and her son informs you that he has power of attorney to only
make financial not health care decisions for her. Can he execute the enrollment for
her?correct answersNo, he cannot execute the enrollment for her. He must have a legal
authorization, under state law that explicitly allows him to make health care decisions for
his mother.
Agent Willis had several clients who disenrolled from the plans he represents during the
AEP to enroll in Medicare Advantage plans that are competitors of his. Agent Willis
believes that the choices they made are not ideal for them and would like to get their
business back during the Medicare Advantage Open Enrollment Period (MA-OEP).
What can agent Willis do?correct answersHe can call them to let them know that if they
do not like their new plans, they can change back during the MA-OEP.
During a sales presentation in Ms. Sullivan's home, she tells you that she has heard
about a type of Medicare health plan known as Private Fee-for-Service (PFFS). She
wants to know if this would be available to her. What should you tell her about PFFS
plans?correct answersA PFFS plan is one of the various types of Medicare Advantage
plans offered by private entities and she may enroll in one if it is available in her area.
Mrs. Sanchez lives in a state located near Canada. She has recently become eligible for
Medicare and is considering enrollment in Part D prescription drug coverage. One of her
friends has told her that she needs to be aware of something called TrOOP. What
should you tell her when she asks you about TrOOP?correct answersTrOOP are out-of-
pocket costs that count toward the annual out-of-pocket threshold to move into
catastrophic coverage and generally include the annual deductible(s) and costs for
drugs on the plan's formulary purchased at a plan's participating pharmacy. In some
instances, amounts not directly paid by the enrollee (like manufacturer discounts) count
toward TrOOP.
Mr. Polanski likes the cost of an HMO plan available in his area but would like to be able
to visit one or two doctors who aren't participating providers. He wants to know if the
Point of Service (POS) option available with some HMOs will be of any help in this
situation. What should you tell him?correct answersThe POS option might be a good
solution for him as it will allow him to visit out-of-network providers, generally without
prior approval. However, he should be aware that it is likely he will have to pay higher
cost-sharing for services from out-of-network providers.
Mr. Landry is approaching his 65th birthday. He has signed up for Medicare Part A, but
he did not enroll in Part B because he has employer-sponsored coverage and intends to
keep working for several more years. But he is considering enrolling in Part D
prescription drug coverage because he believes it is superior to his employer plan. How
would you advise him?correct answersMr. Landry is eligible for Part D since he has Part
A, and his initial enrollment period (IEP) for Part D will continue for three months after
his 65th birthday.
You have decided to focus on doing in-home presentations to market the Medicare
Advantage (MA) plans you represent. Before you conduct such sales presentations,
what must you do?correct answersYou 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.
This year you decide to focus your efforts on marketing to employer and union groups.
Which of the following statements best describes what you can and cannot do in order
to stay in compliance?correct answersYou 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.
Agent Chan is conducting a sales presentation on senior issues where he hopes to
enroll some attendees in the Medicare Advantage (MA) plans he represents. What
action(s) may Agent Chan take during the event?correct answersDiscuss plan specific
information such as premiums and benefits.
Ms. Hernandez has marketed several different types of insurance products in her home
state and has typically sought approval of her materials from her State Department of
Insurance. What would you advise her regarding seeking such approval for materials
she uses to market Medicare Advantage plans?correct answersMaterials need only be
reviewed and approved by the company(s) she represents.
Mr. Lee was intending to enroll in MaxCare's Medicare Advantage plan this year.
However, due to his current medical condition, his daughter Debbie has been appointed
as his legal representative over both health and financial matters. Debbie would like to
ensure that her father is still able to enroll in MaxCare's plan, but she is unsure what her
role is to help with his enrollment request. What advice can you give her?correct
answersLegal representatives are only permitted to submit a paper enrollment request.
???????????
Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare
Advantage (MA) health plans. This year she has decided to focus on non-MA products.
What advice would you give Melanie if she wishes to continue to receive renewal
fees?correct answersMelanie must remain trained, tested, licensed, and appointed,
regardless of whether she is actively selling MA products.
Alice is enrolled in a MA-PD plan. She makes a permanent move across the country
and wonders what her options are for continuing MA-PD coverage. What would you say
to her in regard to a special enrollment period (SEP)?correct answersShe is likely to
qualify for a SEP. She can choose an effective date of up to three months after the
month in which the enrollment form is received by the new plan, but the effective date
may not be earlier than the date of her permanent move.
