2024 AHIP (100 out of 100) Questions and Verified Answers with Rationales 100% Correct, Exams of Nursing

Download 2024 AHIP (100 out of 100) Questions and Verified Answers with Rationales 100% Correct and more Exams Nursing in PDF only on Docsity! 2024 AHIP (100 out of 100) | Questions and Verified Answers with Rationales | 100% Correct Edward IP suffered from serious kidney disease. As a result. Edward became eligible for Medicare coverage due to end-stage renal disease (ESRD). A close relative donated their kidney and Edward successfully underwent transplant surgery 12 months ago. Edward is now age 50 and asks you if his Medicare coverage will continue, what should you say? Individuals eligible for Medicare based on ESRD generally lose eligibility 36 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward may, however, remain enrolled in Part B but solely for coverage of immunosuppressive drugs if he has no other health care coverage that would cover the drugs. Mildred Savage enrolled in Allcare Medicare Advantage plan several years ago. Mildred recently learned that she is suffering from inoperable cancer and has just a few months to live. She would like to spend these final months in hospice care. Mildred's family asks you whether hospice benefits will be paid for under the Allcare Medicare Advantage plan. What should you say? Mildred may remain enrolled in Allcare and make a hospice election. Hospice benefits will be paid for by Original Medicare under Part A and Allcare will continue to pay for any non-hospice services. 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? Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's 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? Medicare 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. 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? Most 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. 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? After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. 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? Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots. 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? She 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. 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? He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. 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? You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband's long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at more than the standard lowest rate but less than the highest rate due her substantial income. 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? He should compare the benefits in his employer-sponsored retiree group health plan with the benefits in his neighbor's MA-PD plan to determine which one will provide sufficient coverage for his prescription needs. 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? SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well. 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? Dr. Brennan can charge Mary Rogers no more than the cost sharing specified in the PFFS plan's terms and condition of payment which may include balance billing up to 15%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? He may receive health care services from any doctor allowed to bill Medicare, as long as he shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing. Juan Hernandez is turning 65 next month, Juan legally entered the United States over twenty years ago but is not a citizen. Since his entry into the country, Juan has worked at Smallcap Incorporated and contributed to the Medicare system. Juan suffers from diabetes. He will soon retire and asks you if he can enroll in a Medicare Advantage plan that you represent. How would you respond? Juan is eligible to enroll in a Medicare Advantage as long as he is entitled to Part A and enrolled in Part B. Juan should go to the Social Security website to enroll in Medicare Part A and B if he has not done so already. Once he is enrolled, he can choose a Medicare Advantage plan. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. 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? You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. 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? She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Which of the following statement(s) is/are correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. I, II, and IV only 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? SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. 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? C-SNP 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? He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. 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? Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. Mrs. Wang 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? Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part A and Part B services. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Mr. Kelly wants to know whether he is eligible to sign up for a Private fee-for-service (PFFS) plan. What questions would you need to ask to determine his eligibility? You would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area. 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? If 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. 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? Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. 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? Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Mrs. Cantwell is enrolled in a prescription drug plan. She has heard about something called True-Out-Pocket costs or "TrOOP" and asks you if any of the following count toward reaching the catastrophic coverage phase. What do you say? I. Her annual PDP deductible II. A drug manufacturer's discount for brand name drugs after her initial coverage period III. The off formulary drug her doctor prescribed but she pays for because the plan denied her exception request IV. Her over-the-counter (OTC) allergy medication. I and II only 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? She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution. 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? If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. 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? In general, he must select a single Part D premium payment mechanism that will be used throughout the year. 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? He 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. 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? The 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. 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. I, II, and III only 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? If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. Agent Daniel Webber has properly set up a sales appointment to meet with client Edward Young at Agent Webber's office. At the agreed upon appointment time, Mr. Young arrives with his elderly neighbor - Clara Burton, who wants to learn about her Medicare Advantage options. What should Agent Daniel Webber do? After executing a scope of appointment (SOA) with Clara Burton, meet with Edward Young and Clara Burton to discuss their Medicare Advantage options. 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? You may provide her with the required enrollment materials and take her completed enrollment application. You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns? Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facility. You are working several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do? You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel? During the MA-OEP, Miguel can have one-on-one meetings with beneficiaries who have requested such meetings. Wendy Park becomes eligible for Medicare for the first time in July. With the help of Agent James Chan, she enrolls in FeelBetter Medicare Advantage plan with an effective date of July 1st. Which statement best describes how Agent Chan may be compensated under CMS rules? FeelBetter will pay Agent Chan initial year compensation for July through December. The renewal amounts will be paid starting in January if Ms. Park remains enrolled the following year. 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? As 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!" Sal should conduct the education seminar as an early morning meeting and the marketing meeting on the following day in the late afternoon so that there are at least 12 hours between the two meetings. 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? She can enroll in a Medigap plan to supplement the benefits of the MA plan that she's also enrolling in. You are visiting with Mr. Tully and his daughter at her request. He has advanced Alzheimer's and is incapable of understanding the implications of choosing a Medicare Advantage or prescription drug plan. Can his daughter fill out the enrollment form and sign it for him? Mr. Tully's daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has a durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions. 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? Her daughter should come in November. 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? No. 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. No. 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. Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA 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 you 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. II and III only Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? He will have one opportunity to enroll in a Medicare Advantage plan. 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? Tell 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. Ms. Gonzales decided to remain in Original Medicare (Parts A and B) and Part D during the Annual Enrollment Period (AEP). At the beginning of January, her neighbor told her about the Medicare Advantage (MA) plan he selected. He also told her there was an open enrollment period that she might be able to use to enroll in a MA plan. Ms. Gonzales comes to you for advice shortly after speaking to her neighbor. What should you tell her? There is a MA Open Enrollment Period (OEP) that takes place between January 1 and March 31, but Ms. Gonzales cannot use it because eligibility to use the OEP is available only to MA enrollees. 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? His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility. Torie Jones is a new marketing representative. Torie asks you for advice as to what topics must be discussed with a Medicare beneficiary prior to enrollment in a Medicare Advantage (MA-PD) plan. What should you say? Torie, there are many required questions and topics regarding beneficiary needs to be discussed prior to enrollment in an MA plan. These include information regarding primary care providers and specialists whether they are in the plan network, whether or not a beneficiary's current prescriptions are covered as well as premiums, benefits, and costs of health care services. 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? He qualifies for a special election period and can enroll in or disenroll from a Part D plan once during that period. 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? You 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. 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)? Mr. 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. 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? You 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. 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? She 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. 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? He 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. Parts A, C, and D, and as proposed Part B. ACA Section 1557 rules for disability concern policies and procedures, physical access, and communication. Which of these actions is most likely to be permitted in dealing with a person with limited English proficiency? Allowing a child to interpret in an emergency. Under Section 1557, the 2020 Final Rule issued during the Trump Administration sex was initially defined____________ as biologic sex only, meaning whether a person was determined to be male or female at birth. Which of the following statements best describes the scope of operations subject to Section 1557 under the Proposed Rule of the Biden Administration? Health insurers under the Biden Administration's Proposed 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 disability income insurance, do not fall under the scope of 1557. Which entity enforces Section 1557 for programs that receive funding from on are administered by HHS? The Office of Civil Rights (OCR) of HHS. Section 1557 of the Affordable Care Act applies to all health programs and activities administered by or receiving federal financial assistance from HHS. 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 software I, II, III, and IV For a health plan, what are the possible consequences of violations of ACA Section 1557? Loss of federal business and compensatory damages. Loss of federal business and compensatory damages. cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge. cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge. Broker Mary Jones has recruited a diverse workforce. She encourages her agents to prospect through community-based marketing and within their community of influence. 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? Report the incident to the compliance department (via compliance hotline 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? Call the prescriber to verify the quantity Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud, waste, and abuse (FWA)? Deportation Which of the following requires intent to obtain payment and the knowledge the actions are wrong? Fraud You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do? Follow your pharmacy's procedures. 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 patient group. 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? Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or other mechanism) 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. True 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. True Ways to report potential fraud, waste, and abuse (FWA) include: a.Telephone hotlines b.Mail drops c.In-person reporting to the compliance department/supervisor d.Reporting to a Special Investigative Units (SIUs) e.All of the above All of the above 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 you True 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. True Once a corrective action plan is started, the corrective action plan must be monitored annually to ensure they are effective. c.In-person reporting to the compliance department/supervisor d.All of the above All of the above Mary Samuels recently suffered a stroke while visiting her daughter and grandchildren. As a result, Mary has been admitted to a rehabilitation hospital where she is expected to reside for several months. The rehabilitation hospital is located outside the geographic area served by her current Medicare Advantage (MA) plan. What options are available to Mary regarding her health plan coverage? Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan 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? Alice because she will not have a break between her non-Medicare and Medicare coverage through Spartan Health Plan. 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 and paid Medicare taxes. 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. 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? Formularies must be developed with input from pharmacists, doctors, and other experts. 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? The 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. Under ACA Section 1557, a health plan cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge. Which of the following would be considered permissible under Section 1557? Broker Mary Jones has recruited a diverse workforce. She encourages her agents to prospect through community-based marketing and within their community of influence. 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. False You are working with several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do? You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. 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? He 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? A 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. 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? Ms. 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. 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? You must receive an invitation from the beneficiary and document the specific types of products the beneficiary wants to discuss prior to making an in-home presentation. 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? Materials need only be reviewed and approved by the company(s) she represents. Ms. Gates has recently become dually eligible for Medicare and Medicaid. She is very concerned about how this will affect her prescription drug coverage. What should you tell her? As a dual eligible beneficiary, her Part D drugs will be covered by Medicare once she is enrolled in a Part D plan. If she doesn't select a plan, Medicare will select a plan for her. 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? The 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. During an appointment scheduled to discuss a Medicare Advantage Prescription Drug plan (MA- PD), Mr. Peters asked his agent to describe a stand-alone prescription drug plan (Part D plan) that his neighbor told him about. What should his agent do? Since Mr. Peters requested a description of the Part D plan, his agent must have Mr. Peters sign a new scope of appointment form that includes Part D, and then the agent may discuss the Part D plan so Mr. Peters can compare plans and make an informed enrollment choice during the appointment. 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? No, the total value of the gifts given to an enrollee in a year cannot exceed the CMS definition of nominal value.