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? -ANS-He may sign-up for Medicare at any time however coverage usually begins on the fourth ...
2023-2024 AHIP
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? -ANS-He 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? -ANS-Juan 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? -ANS-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. 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? -
ANS-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.
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? -ANS-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.
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? -ANS-Mrs. Gonzalez cannot purchase a Medigap
plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug
plan.
,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? -ANS-Medicare 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? -ANS-Under Original Medicare, there is a single deductible amount due for the
first 60 days of any inpatient hospital stay, after which it converts into a per-day 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? -ANS-To 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? -ANS-He 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? -ANS-Medicare 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? -ANS-Beneficiaries 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? -ANS-Mrs. 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? -ANS-It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled
in an MA plan, and besides, Medigap only works with Original Medicare.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that
might be of assistance? -ANS-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.
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? -ANS-Medicare 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? -ANS-Part A, which covers hospital, skilled nursing
facility, hospice, and home health services and Part B, which covers professional services such as those
provided by a doctor are covered under Original Medicare.
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? -ANS-Tell 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? -ANS-After 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? -ANS-Medicare 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. -ANS-I, 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? -ANS-He 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? -ANS-Mrs. Ramos can obtain care from any provider
who participates in Original Medicare, but generally will have a higher cost-sharing amount if she sees a
provider who/that is not 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? -ANS-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.
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