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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?
- may do it only during the MA Disenrollment Period, which runs from January 1 to
- February 14 of each year.
You have finished a sales presentation with Mrs. Slade, who
chose to enroll into a Part D plan you represent. At the end of the
presentation, she asks you to stay in contact to ensure that she is being well
served by the plan. How would Medicare's guidelines for making contact with
Mrs. Slade apply in this situation?
- may initiate a call to Mrs. Slade to conduct normal business related to her
- enrollment in the Part D plan and to discuss other products her plan sponsor
Several agents you work with are planning sales events in
your area. One plans on giving door
prizes worth $5, refreshments valued at $8 per anticipated attendee, and coupon
books with discounts worth $10. Since no
gift or prize exceeds the $15 limit he believes his plan is acceptable. What should you tell them?
- He can give away more than one gift during a single event,
- but the aggregate retail value cannot exceed $15.
Mr. Yu is concerned that his neighbor, Gladys, has not
scheduled an appointment to review Medicare Advantage plan options for this
year, even though she sent you a reply card requesting a call from you. You
have not yet been successful in reaching Gladys and Mr. Yu would like to see
that happen, so that her needs can be well served. What could you offer to do?
- You could continue calling Gladys until you reach her and
- offer to either schedule an in-home presentation to explain the plans you
- represent or provide her with the plan enrollment kit to review herself.
Mr.Bush is 49 years old and has been receiving disability
benefits from the Social Security Administration for 12 months. Can you sell
him a Medicare Advantage or Part D Prescription Drug policy?
- No, he cannot
- purchase a Medicare Advantage or Part D policy because he has not received
- Social Security or Railroad Retirement disability benefits for 24 months.
You are accustomed to obtaining names and contact
information through a variety of means, and then calling potential clients in
an attempt to set up a sales appointment. Under the rules applicable to
marketing Medicare Advantage and Part D plans, what sorts of activities can you
engage in with respect to beneficiaries who have not previously given you
permission to contact them?
- You may not make any unsolicited call or visit to any
- beneficiary, unless explicit permission was given by the beneficiary for a call
- or visit.
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
- could enroll in one of the MA plans that include prescription drug coverage or
- a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll
- in the MA-only PPO plan and a stand-alone prescription drug plan.
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?
- 1. For Medicaid beneficiaries, Medicare reduces its
- cost-sharing amounts to match those charged by the state Medicaid program so
- there will be no change in his cost-sharing amounts.
- 2. He
- should know that Medicaid will pay cost sharing only for services provided by
- Medicaid participating providers.
- Medicaid will cover his cost-sharing, regardless of from which physician or
- hospital he receives his Medicare-covered services.
- Medicaid will no longer pay any cost sharing once he is eligible for Medicare,
- so he will need to rely only on Medicare providers.
Ms. Deboy was a homemaker and was 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?
- Since her husband paid Medicare taxes during the entire time
- he was working, she will automatically qualify for Medicare Part A without
- having to pay any premiums.
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?
- 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
You have scheduled a sales event at a local shopping center,
targeting individual enrollees. Unfortunately, the marketing materials from the
plan have not arrived in time for the event. Other agents suggest that you
create your own materials and give you some suggestions for what sorts of
things work. What should you do?
- You may develop and use your own materials, as long as they
- are generic, refer only to the types of Medicare plans you represent, and do
- not misrepresent any material facts.
Mr. Mayhew accepted an invitation to present information on
the MA plans he represents for a local Chamber of Commerce. The Chamber
advertised the event in their monthly newsletter and asked anyone interested to
call to RSVP. The sales event is now five days away, only three people
responded, and the Chamber decided to cancel the event. What should Mr. Mayhew
- Mr. Mayhew should report the cancellation to the
- plan with which he contracts immediately, and he must make sure everyone who
- responded is called to inform them of the cancellation.
You are meeting with Ms. Blum 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?
- may correct this information as long as you add your initials and date next to
- the correction
Ms. Jefferson 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?
- plans are a type of Medicare Advantage plan offered by private companies.
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?
- Medicare is a program for people age 65 or older and those
- under age 65 with certain disabilities, end stage renal disease, Lou Gehrig’s
- disease, or exposed to certain environmental hazards, so she will be eligible
- for Medicare.
Ms. Bass lives on a limited fixed income and is concerned
about the cost of healthcare. What should you tell her about the sort of help
available to low income individuals under the Medicare program?
- As a Medicare
- beneficiary with limited income and resources she may contact her state
- Medicaid agency to apply for assistance paying for the Part B premium and cost
- sharing and Part D prescription drug coverage.
While marketing Medicare Advantage and Part D plans, you
collected a large number of scope of appointment forms from your clients,
wherein they indicated their interest in specific products and their wish for
you to provide information on those products in their homes. What should you do
with those forms?
- scope of appointment forms must be retained for a period of ten (10) years.
Mrs. Grant uses several very expensive drugs and anticipates
that she will enter catastrophic coverage at some point during the year. To
help her determine when she is likely to qualify for catastrophic coverage, she
asked which expenses count toward the out-of-pocket limit that qualifies her
for catastrophic coverage. Which one of the following would count?
- Prescription drugs she purchases on her own
- that are not on her Part D plan’s formulary.
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?
- appreciate the opportunity and would just need to complete scope of appointment
- forms on behalf of all the residents who would like to attend.
You market many different types of insurance and ordinarily
you spend time each evening calling potential clients. To be in compliance with requirements for
marketing Medicare Advantage and Part D plans, what must you do about
contacting potential clients to market those plans?
- You will have to avoid calling any potential client, unless
- he or she initiates contact with you and specifically asks that you give him or
- her a call.
Mrs. Turner is comparing her employer's retiree insurance to
Original Medicare and would like to know which of the following services
Original Medicare will cover if the appropriate criteria are met? What could
you tell her?
- Original Medicare covers ambulance services.
Mr. Rice has coverage for medical services and medications
through his employer's retiree plan. He is considering switching to a Medicare
prescription drug plan because his retiree plan does not cover two important
medications. What should he consider before making a change?
- If Mr. Rice drops his drug coverage through
- the retiree plan, he may not be able to get it back and he also may lose his
- medical health coverage.
Medicare health plans establish provisions in marketing
representative contracts to ensure compliance with applicable laws and
policies. If non-compliance occurs, CMS can penalize a plan in which of the
- CMS requires plan sponsors to create and complete a
- corrective action plan and may terminate a sponsor’s contract.
Ms. McCutcheon 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?
- Yes. All SNPs are required to provide Part D coverage for
- prescription drugs.
Mrs. Murphy has been very ill and has been in the hospital
multiple times this year. She is concerned that her expenses have reached the
maximum out-of-pocket costs and now her special needs plan (SNP) will disenroll
her. What can you tell her?
- There is no limit on the expenses a plan can incur on behalf
- of any one beneficiary and a plan sponsor may not end a member’s enrollment
- just because of high costs, so she should not be concerned.
Mrs. Reid requested that you call her to discuss a Part D
plan she is interested in learning about to determine if she wants to
enroll. However, she is concerned about
identity theft and does not want to give you her Social Security number. What should you tell her?
- When you call
- her, you should indicate that she is not required to provide any information to
- you, and failure to do so will not affect her membership in the plan.
Another agent working for your agency claims that because
you are not employed by the Medicare Advantage plans that you represent, you
are not subject to the same requirements as the plans themselves. How should
you respond to such a statement?
- 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.
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?
- You should tell your colleague no because participation in
- an educational event may not include a sales presentation.
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?
- You must have her sign a scope of appointment form,
- indicating which products she wishes to discuss, and note on the form that she
- is a “walk in.” You may then proceed with the discussion.
Mrs. Paterson is concerned about the deductibles and
co-payments associated with Original Medicare. What can you tell her about
Medigap as an option to address this concern?
- . Medigap plans help beneficiaries cover coinsurance,
- co-payments, and/or deductibles for medically necessary services.
***? Mr. Alonso receives some help paying for his two
generic prescription drugs from his employer's retiree coverage, but he wants
to compare it to a Part D prescription drug plan. He asks you what costs he
would generally expect to encounter when enrolling into a standard Medicare
Part D prescription drug plan. What should you tell him?
- He generally would pay a monthly premium, annual deductible,
- and per-prescription cost sharing.
Mr. Yu has limited income and resources so you have
encouraged him to see if he qualifies for some type of financial assistance.
Mr. Yu is not sure it is worth the trouble to apply and wants to know what the
assistance could do for him if he qualifies. What could you tell him?
- He might qualify for help with Part D prescription drug costs and help paying
- Part A and/or Part B premiums, deductibles, and/or cost sharing.
A large physician group in your area contracts with the
plans you represent. You have an opportunity to work with them to market the
plans, but want to be sure you follow the CMS requirements. What can you ask
the physician group to do?
- names of the plans they contract with along with information from the CMS
Mr. Cotter is enrolled in his employer's group health plan
and will be retiring soon. He would like to know his options since he has
decided to drop his retiree coverage and is eligible for Medicare. What should
you tell him?
- Mr. Cotter can disenroll from his employer-sponsored
- coverage to elect a Medicare Advantage or Part D plan within 2 months of his
- disenrollment, but he should revaluate if he really wants to drop his employer
Ms. Lowman 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?
- Materials for marketing Medicare health plans to individuals
- are subject to Medicare’s uniform national requirements. They do not need to be
- reviewed by the state, but the company she represents must obtain approval from
- the Medicare agency (CMS) for any materials she uses.
While you market Medicare Advantage and Medicare
Prescription Drug plans, which activity must you do?
- You must ensure that only those who have an equal
- opportunity to enroll receive incentive gifts for enrolling.
Mr. Mattison 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
- must be developed with input from pharmacists, doctors, and other experts.
Mrs. Toma has a low, fixed income. What could you tell her
that might be of assistance?
- She should contact her state Medicaid agency to see if she
- qualifies for one of several programs that can help with Medicare costs for
- which she is responsible.
Under what conditions can a Medicare prescription drug plan
reduce its coverage for a given drug mid-way through the year?
-- When a new generic drug for the same condition becomes available or when the FDA or manufacturer withdraws the drug from the market, a brand name drug can be replaced.
During an appointment scheduled to discuss a Medicare
Advantage-Prescription Drug plan (MA-PD), Mr. Polise asked his agent to
describe a stand-alone prescription drug plan (Part D plan) that his neighbor
told him about. What should his agent
- Mr. Polise requested a description of the Part D plan, his agent must have Mr.
- Polise sign a new scope of appointment form that includes Part D, and then the
- agent may discuss the Part D plan so Mr. Polise can compare plans and make an
- informed enrollment choice during the appointment.
Mr. Fera is selling his home to move into a retirement
facility near his daughter in a neighboring state. He has a stand-alone
prescription drug plan, and has learned it is not available where he is moving.
He doesn't know what he should do. What can you tell him?
- Because he is moving outside of the service area, the plan
- must automatically disenroll him. He will have a special election period to
- select a new plan.
Mr. Decaro has looked at Medicare prescription drug plans
available in his area and noted a wide range in premiums. He thought that all the drug plans were
required to offer the same standard benefits and would like you to explain why
there is such a range in premiums. What
should you tell him?
- Some prescription drug plans may have higher
- operating costs and/or may offer enhanced coverage in return for an additional
- premium amount. He could look at plan designs to see if one of the enhanced
- plans would serve his needs better than a plan based on the standard design.
Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan
available in his area has an attractive premium. He wants to know if he must
use doctors in a network like his current HMO plan requires him to do. What
should you tell him?
- 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.
You are preparing for a marketing presentation and have
created a checklist of tips so you are sure to do a good job of marketing and
at the same time be in compliance with all requirements. Which of the following
should you include on your tip list?
- Use only plan materials that have been
- approved by the Medicare agency and the plan you represent.
Mr. Shapiro gets by on a very small fixed income. He has
heard there may be extra help paying for Part D prescription drugs for Medicare
beneficiaries with limited income. He wants to know whether he might qualify.
What should you tell him?
- The extra help is available only to Medicare beneficiaries
- who are enrolled in Medicaid. He should apply for coverage under his state’s
- Medicaid program to access the extra help with his drug costs.
Mr. Zachow has a condition for which three drugs are
available. He has tried two, but had an allergic reaction to them. Only the
third drug works for him and it is not on his Part D plan's formulary. What
could you tell him to do?
- Mr. Zachow has a
- right to request a formulary exception to obtain coverage for his Part D drug.
- He or his physician could obtain the standardized request form on the plan’s
- website, fill it out, and submit it to his plan.
After a sales presentation, Mr. Buffet announces that he is
ready to enroll in the plan you represent. He would like to know if he can have
his plan premiums deducted from his Social Security check. What should you tell
- He may choose withholding from his Social Security check
- when he completes the enrollment form.
One of your colleagues argues that face-to-face meetings
with potential enrollees should be required because they cannot make an
appropriate decision with the minimal information that can be provided over the
phone or in small brochures. How should
you respond to this argument?
- This is correct. In
- fact, the Medicare agency requires potential enrollees to meet face-to-face
- with an agent, plan representative, or State Health Insurance Assistance
- Program representative before permitting a beneficiary to enroll in a MA or
- Part D plan.
Ms. Townsend wants to understand the relationship between
your Medicare Advantage plan and Original Medicare. Which of the following is
an example of a statement that you could make to explain the relationship?
- If a physician accepts Medicare, s/he must accept the MA
You are doing a sales presentation for Ms. Tranchida and her
son. Ms. Tranchida has some cognitive
impairment and her son informs you that he has power of attorney to make
financial decisions for her. Can he
execute the enrollment for her?
- he can execute the enrollment for her. A financial power of attorney is