Preview Extract
2022 AHIP MODULE EXAM TEST UPDATED QUESTIONS AND ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
1. 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?
Answer: Mr. Bauer may indeed be eligible for Medicare coverage. Generally, individuals who
have received Social Security Disability Insurance (SSDI) benefits for 24 months automatically
qualify for Medicare. Since Mr. Bauer has been receiving disability payments for eighteen
months, he may need to wait another six months before becoming eligible for Medicare coverage.
Rationale:
• Medicare eligibility for individuals under 65 is primarily linked to receiving SSDI benefits.
• The 24-month waiting period typically starts from the onset of disability, which is determined
by the Social Security Administration (SSA).
• Since Mr. Bauer has been receiving disability payments for eighteen months, he may not yet
have completed the full 24-month waiting period.
• Upon completing the 24-month waiting period, individuals like Mr. Bauer can enroll in
Medicare to receive healthcare coverage.
2. Mrs. Pena 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?
Answer: Mrs. Pena's situation triggers a Special Enrollment Period (SEP) when she retires and
loses her employer coverage. She does not need to enroll in Medicare Part B during the Initial
Enrollment Period (IEP) if she's covered under an employer plan, as long as the employer has 20
or more employees. Instead, she can enroll in Part B without penalty during the eight-month
period following the end of her employer coverage. This window begins either the month after
her employment ends or the month after her employer coverage ends, whichever comes first.
Rationale:
• Medicare offers Special Enrollment Periods (SEPs) for certain qualifying events, including the
loss of employer coverage.
• Mrs. Pena's situation qualifies her for a SEP, allowing her to enroll in Medicare Part B without
penalty after she retires and loses her employer coverage.
• The eight-month SEP begins either the month after employment ends or the month after
employer coverage ends, whichever comes first, ensuring no gap in coverage for Mrs. Pena.
3. 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?
Answer: Original Fee-for-Service (FFS) Medicare, also known as Medicare Parts A and B,
provides coverage for a range of healthcare services, but it's essential for Mr. Schmidt to
understand what is covered and any potential out-of-pocket costs. Here's what I can tell him:
1. Medicare Part A (Hospital Insurance):
• Covers inpatient hospital stays, including semi-private rooms, meals, general nursing, and other
hospital services and supplies.
• Also covers skilled nursing facility care (under certain conditions), hospice care, and some home
health care services.
• Most people don't pay a premium for Part A if they or their spouse paid Medicare taxes while
working.
2. Medicare Part B (Medical Insurance):
• Covers medically necessary services like doctor's visits, outpatient care, preventive services
(like screenings, vaccines, and counseling), and durable medical equipment (DME).
• Also covers some home health care services.
• Part B typically requires a monthly premium, and there's usually a yearly deductible and
coinsurance or copayments for covered services.
3. Services Not Covered by Original Medicare:
• Original Medicare doesn't cover everything, including most prescription drugs (Part D coverage
is available separately), routine dental care, routine eye exams, eyeglasses, hearing aids, and longterm care (like assisted living facilities).
• Mr. Schmidt may want to consider additional coverage options like Medicare Advantage plans
(Part C) or Medigap (Medicare Supplement Insurance) policies to help cover some of these
services and lower out-of-pocket costs.
Rationale:
• Providing Mr. Schmidt with an overview of what Original Medicare covers helps him
understand his healthcare options in retirement.
• Knowing what services are covered under Parts A and B can help Mr. Schmidt plan for potential
healthcare needs and associated costs.
• Highlighting services not covered by Original Medicare helps Mr. Schmidt consider additional
coverage options to fill potential gaps in his healthcare coverage.
4. 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?
Answer: Mr. Patel, under Original Medicare, your costs for inpatient hospital services can vary
depending on several factors, but here's a general overview to help you anticipate potential
expenses:
1. Medicare Part A Deductible:
• Each benefit period, you're responsible for paying a deductible. As of 2022, the Medicare Part
A deductible for inpatient hospital services is $1,556 per benefit period.
2. Hospital Stay Costs:
• After you've met the deductible, Medicare typically covers the costs of your inpatient hospital
stay for the first 60 days in full (with some exceptions).
• If your hospital stay extends beyond 60 days, you'll be responsible for daily coinsurance
amounts. For days 61-90, the coinsurance is $389 per day (as of 2022). For days 91 and beyond
(lifetime reserve days), the coinsurance increases to $778 per day.
3. Skilled Nursing Facility (SNF) Costs:
• If you require skilled nursing care after your hospital stay and meet Medicare's eligibility
criteria, Medicare covers some costs for the first 20 days in full. For days 21-100, you'll be
responsible for a daily coinsurance amount (as of 2022, $194.50 per day).
4. Potential Additional Costs:
• While Medicare covers many hospital services, there may be other expenses not covered, such
as private room charges, certain medications, and physician services. These costs could
potentially be covered by supplemental insurance like Medigap or Medicaid, depending on your
situation.
Rationale:
• Providing Mr. Patel with an overview of potential costs for inpatient hospital services helps him
budget and plan for healthcare expenses in retirement.
• Understanding Medicare's deductible, coinsurance, and coverage limits for hospital stays allows
Mr. Patel to anticipate his out-of-pocket costs in various scenarios.
• Mentioning the availability of supplemental insurance options like Medigap helps Mr. Patel
consider additional coverage to potentially lower his out-of-pocket expenses.
5. Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs.
Park that might be of assistance?
Answer: Mrs. Park, there are several programs and resources available that could potentially help
you manage your expenses and improve your financial situation:
1. Medicare Savings Programs (MSP):
• These programs help low-income Medicare beneficiaries by paying for some or all of their
Medicare premiums, deductibles, coinsurance, and copayments. There are different levels of MSP
based on income and assets.
2. Extra Help (Low-Income Subsidy) for Medicare Part D:
• Extra Help assists with the costs of prescription drugs for Medicare beneficiaries with limited
income and resources. It can help cover premiums, deductibles, and coinsurance or copayments
for Medicare Part D prescription drug coverage.
3. Supplemental Security Income (SSI):
• SSI provides monthly cash assistance to low-income individuals who are aged (65 or older),
blind, or disabled. The program helps meet basic needs for food, clothing, and shelter.
4. Food Assistance Programs:
• Programs like the Supplemental Nutrition Assistance Program (SNAP) provide eligible
individuals with funds to purchase food, helping stretch limited budgets further.
5. Utility Assistance Programs:
• Various state and local programs offer assistance with utility bills, such as heating and cooling
costs, which can help alleviate financial strain on fixed incomes.
6. Community Resources and Nonprofit Organizations:
• Many communities have local organizations and nonprofits that offer assistance with various
needs, including food, housing, transportation, and healthcare.
7. Medicaid:
• If you meet certain income and asset requirements, you may be eligible for Medicaid, which
provides comprehensive health coverage, including long-term care services, at little to no cost.
Rationale:
• Mrs. Park's low fixed income makes it crucial to explore programs and resources that can help
alleviate financial strain and improve her quality of life.
• Mentioning specific programs like MSP, Extra Help, SSI, and SNAP provides Mrs. Park with
actionable steps to access financial assistance for healthcare, prescription drugs, food, and other
basic needs.
• Highlighting community resources and nonprofit organizations encourages Mrs. Park to seek
support within her local community, where she may find additional assistance tailored to her
specific needs and circumstances.
6. Mr. Gonzales 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?
Answer: Mr. Gonzales, if you want to keep your Original Medicare coverage and switch to a
Medigap policy that includes prescription drug coverage, here's what you should consider:
1. Review Your Options:
• Start by researching different Medigap plans in your area that offer prescription drug coverage
(also known as Medigap Plan C or Plan F with the Part D rider).
• Compare the coverage, premiums, deductibles, copayments, and out-of-pocket expenses of
these plans to ensure they meet your healthcare needs and budget.
2. Timing of Enrollment:
• Before making any changes, ensure that you're within the Open Enrollment Period (OEP) for
Medigap, which is typically a six-month period starting from the first day of the month you're
both 65 or older and enrolled in Medicare Part B.
• During the OEP, insurance companies cannot deny you coverage or charge you higher premiums
based on your health status or pre-existing conditions.
3. Consider Prescription Drug Coverage:
• Since your current Medigap policy doesn't include drug coverage, you may also want to enroll
in a standalone Medicare Part D prescription drug plan to complement your new Medigap policy.
• Compare Part D plans based on their formularies (list of covered drugs), monthly premiums,
annual deductibles, copayments, and preferred pharmacies to find the most suitable option for
your medication needs.
4. Medigap Policy Application:
• Once you've chosen a new Medigap plan with prescription drug coverage, contact the insurance
company offering the plan to apply for coverage.
• You may need to provide information about your current Medigap policy and confirm your
enrollment in Medicare Parts A and B.
5. Cancellation of Existing Medigap Policy:
• Before canceling your existing Medigap policy, ensure that your new policy is active and
effective to avoid any coverage gaps.
• Contact your current Medigap insurance provider to request cancellation and confirm the
effective date of termination.
Rationale:
• Reviewing your options allows you to make an informed decision about switching to a Medigap
policy with prescription drug coverage that aligns with your healthcare needs and financial
situation.
• Enrolling during the Open Enrollment Period ensures that you have access to Medigap coverage
without facing restrictions or higher premiums based on your health status.
• Adding a standalone Medicare Part D plan provides comprehensive prescription drug coverage,
ensuring you have access to the medications you need while maintaining your Original Medicare
and Medigap coverage.
7. 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?
Answer: Mr. Davis, if you've been diagnosed with end-stage renal disease (ESRD), you may be
eligible for Medicare coverage, but there are some important considerations:
1. Waiting Period:
• Typically, individuals with ESRD must undergo a waiting period before Medicare coverage
begins. However, there are exceptions:
• You can qualify for Medicare immediately if you're already receiving or are eligible to receive
Social Security or Railroad Retirement Board benefits.
• If you're under 65 and have Medicare based on disability, you can also qualify for ESRD
Medicare coverage without the usual waiting period.
2. Medicare Coverage for ESRD:
• Medicare provides coverage for certain services related to the treatment of ESRD, including
dialysis treatments (hemodialysis or peritoneal dialysis), kidney transplants, and some
medications.
• Medicare coverage extends to services provided by dialysis facilities or hospitals and includes
necessary equipment and supplies for dialysis treatments.
3. Coordination of Benefits:
• If you have other health insurance coverage, such as through an employer or a spouse's
employer, Medicare will typically become the primary payer for your ESRD-related services once
you qualify for coverage.
4. Medicare Advantage Plans:
• In addition to Original Medicare (Part A and Part B), you may have the option to enroll in a
Medicare Advantage plan (Part C) that provides coverage for ESRD-related services. These plans
may offer additional benefits and care coordination.
5. Enrollment Process:
• To enroll in Medicare due to ESRD, you'll need to contact the Social Security Administration
(SSA) or visit their website to complete an application for Medicare benefits. Provide
documentation of your ESRD diagnosis and treatment plan to support your application.
Rationale:
• Individuals diagnosed with end-stage renal disease (ESRD) are eligible for Medicare coverage,
but there may be waiting periods and specific enrollment requirements to consider.
• Providing Mr. Davis with information about Medicare coverage for ESRD and the enrollment
process empowers him to navigate his healthcare options effectively.
• Highlighting the coordination of benefits and the potential for Medicare Advantage plans
ensures that Mr. Davis understands his coverage choices and can make informed decisions about
his healthcare.
8. 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?
Answer: Ms. Moore, having considerable income does not necessarily disqualify you from
qualifying for Medicare. Here's what you need to know:
1. Medicare Eligibility Based on Age:
• You are eligible for Medicare based on age if you are 65 or older, regardless of your income or
health status. As long as you meet the age requirement, you can enroll in Medicare.
2. Part A Eligibility:
• Most individuals qualify for Medicare Part A (Hospital Insurance) without paying a premium if
they or their spouse paid Medicare taxes while working. Even if you don't qualify for premiumfree Part A, you can still enroll and pay a premium.
3. Part B Enrollment:
• Medicare Part B (Medical Insurance) is optional and requires payment of a monthly premium.
Your income level may affect the amount you pay for Part B premiums through Income-Related
Monthly Adjustment Amounts (IRMAA), but it does not prevent you from enrolling.
4. Considerations for Higher Income:
• If you have higher income, you may be subject to higher premiums for Medicare Part B and
Part D (prescription drug coverage) through IRMAA. These additional costs are based on your
modified adjusted gross income (MAGI) reported on your federal tax return from two years ago.
5. Medicare Advantage Plans and Medigap Policies:
• In addition to Original Medicare (Parts A and B), you may have the option to enroll in Medicare
Advantage plans (Part C) or purchase a Medigap (Medicare Supplement) policy to supplement
your coverage. These options are available regardless of your income level.
Rationale:
• Clarifying that Medicare eligibility is primarily based on age reassures Ms. Moore that her
income will not prevent her from enrolling in Medicare when she turns 65.
• Explaining the potential impact of higher income on Part B and Part D premiums through
IRMAA ensures Ms. Moore understands the financial implications of her Medicare coverage.
• Mentioning additional coverage options like Medicare Advantage plans and Medigap policies
provides Ms. Moore with choices to enhance her Medicare coverage if she desires additional
benefits beyond Original Medicare.
9. 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?
Answer: Mr. Buck, Medicare does cover certain cancer screenings to help detect cancer early
when treatment is often more effective. Here's what you should know:
1. Medicare Coverage for Cancer Screenings:
• Medicare covers several cancer screenings, including:
• Breast Cancer Screening: Mammograms are covered once every 12 months for women aged 40
and older.
• Cervical and Vaginal Cancer Screening: Pap tests and pelvic exams are covered every 24
months, or every 12 months for high-risk women.
• Colorectal Cancer Screening: Various tests such as fecal occult blood tests, flexible
sigmoidoscopies, and colonoscopies are covered at different intervals based on risk factors and
test type.
• Prostate Cancer Screening: Prostate-specific antigen (PSA) tests are covered once every 12
months for men aged 50 and older.
2. Coverage Details:
• Medicare typically covers these cancer screenings at no cost to you if your healthcare provider
accepts Medicare assignment. This means you won't have to pay deductibles, copayments, or
coinsurance for the screenings themselves.
• However, if additional tests or procedures are necessary as a result of a screening, you may incur
costs such as copayments or coinsurance, depending on your specific Medicare coverage.
3. Early Detection Importance:
• Regular cancer screenings are essential, especially for individuals like yourself with a family
history of cancer. Early detection through screenings can significantly increase the chances of
successful treatment and improve outcomes.
4. Discuss with Healthcare Provider:
• It's crucial for Mr. Buck to discuss his family history of cancer with his healthcare provider.
Based on this information, the provider can recommend appropriate cancer screenings and a
screening schedule tailored to his individual risk factors.
Rationale:
• Informing Mr. Buck about Medicare's coverage of cancer screenings helps him understand the
preventive services available to him.
• Emphasizing the importance of regular screenings, particularly given his family history of
cancer, encourages Mr. Buck to prioritize his health and undergo recommended screenings.
• Advising Mr. Buck to discuss his family history with his healthcare provider ensures that
screenings are tailored to his individual risk factors and healthcare needs.
10. 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?
Answer: Mr. Rainey (or his representative), Medicare covers inpatient psychiatric hospital stays
under certain conditions. Here's what you should know about the length of coverage:
1. Initial Coverage Period:
• Medicare covers up to 190 days of inpatient psychiatric hospital services during your lifetime.
This initial coverage period resets after a 60-day break in inpatient psychiatric hospital care.
2. Payment for Services:
• During the initial coverage period, Medicare typically pays for 80% of the Medicare-approved
amount for inpatient psychiatric hospital services, leaving you responsible for the remaining 20%,
unless you have supplemental insurance (like Medigap) or Medicaid to help cover these costs.
3. Additional Coverage:
• If necessary, you may qualify for additional coverage beyond the initial 190 days through a
psychiatric hospital benefit extension. This extension allows for up to 60 additional days of
inpatient psychiatric hospital care per lifetime, with the same 80/20 cost-sharing arrangement.
4. Review by Physicians:
• Medicare requires that your treating physician or mental health professional certify the need for
continued inpatient psychiatric hospital care throughout your stay. They must document your
condition and treatment plan to support the medical necessity of the services provided.
5. Outpatient Services:
• Medicare also covers outpatient mental health services, including individual and group therapy,
medication management, and partial hospitalization programs, which can be beneficial in
transitioning back to community living after an inpatient stay.
Rationale:
• Providing information about Medicare's coverage for inpatient psychiatric hospital stays helps
Mr. Rainey (or his representative) understand the extent of coverage available for his mental
health needs.
• Highlighting the initial coverage period and benefit extensions ensures that Mr. Rainey is aware
of the potential duration of Medicare coverage for inpatient psychiatric care.
• Emphasizing the importance of certification by healthcare professionals underscores the
necessity of medical documentation to support the need for continued care, helping Mr. Rainey
navigate the Medicare coverage process effectively.
11. Juan Perez, who is turning age 65 next month, intends to work for several more years at
Smallcap, Incorporated. Smallcap has a workforce of 15 employees and offers employersponsored 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?
Answer: Juan, as a naturalized citizen who has contributed to the Medicare system for over 20
years and is turning 65 next month, you will indeed be entitled to Medicare benefits. However,
your eligibility for Medicare and its impact on your employer-sponsored healthcare coverage can
vary depending on the size of your employer's workforce and other factors. Here's what you need
to know:
1. Medicare Eligibility:
• You qualify for Medicare based on age, regardless of your employment status or employersponsored coverage. Since you're turning 65 next month, you can enroll in Medicare during your
Initial Enrollment Period (IEP), which begins three months before your 65th birthday month and
extends for three months afterward.
2. Employer Size and Medicare Enrollment:
• If Smallcap, Incorporated has fewer than 20 employees, Medicare generally becomes your
primary insurance when you turn 65, and you may be required to enroll in Medicare Parts A and
B to maintain your health coverage. In this case, you would use Medicare as your primary
insurance and your employer-sponsored coverage as secondary insurance.
• If Smallcap, Incorporated has 20 or more employees, your employer-sponsored coverage may
continue to be your primary insurance, and you may have the option to delay enrolling in
Medicare Parts A and B without facing penalties. However, it's important to confirm this with
your employer's benefits administrator or with Medicare to ensure you understand your specific
situation.
3. Impact on Employer-Sponsored Coverage:
• Enrolling in Medicare may impact the coverage provided by your employer-sponsored
healthcare plan, particularly if your employer has fewer than 20 employees. In this case, your
employer-sponsored plan may coordinate benefits with Medicare, and your coverage may change
accordingly.
• It's essential to review the details of your employer-sponsored healthcare plan and consult with
your benefits administrator or human resources department to understand how enrolling in
Medicare will affect your coverage and any associated costs.
Rationale:
• Clarifying Juan's entitlement to Medicare based on his age and contributions to the Medicare
system helps him understand his healthcare options as he approaches age 65.
• Explaining the impact of employer size on Medicare enrollment and coordination of benefits
ensures Juan is aware of how his employer-sponsored coverage and Medicare interact.
• Advising Juan to consult with his employer's benefits administrator or human resources
department provides him with the necessary guidance to make informed decisions about his
healthcare coverage.
12. 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?
Answer: Mrs. Duarte, if you disagree with a determination on your Medicare Summary Notice
(MSN), here's what you can do to address the issue:
1. Review the Explanation of Benefits (EOB):
• Carefully review the explanation of benefits (EOB) provided in your Medicare Summary Notice
(MSN) to understand why the claim was partially denied. Pay attention to any codes,
explanations, or reasons provided for the denial.
2. Contact the Provider:
• If you believe there has been an error or misunderstanding, contact the healthcare provider who
rendered the services. They can help clarify the billing and provide additional information about
the claim.
3. Appeal the Decision:
• If you still disagree with the determination after speaking with the provider, you have the right
to appeal the decision. You can appeal if Medicare doesn't pay for a service you think should be
covered, or if you believe Medicare didn't pay the correct amount for a service.
• To initiate an appeal, follow the instructions provided on your MSN or contact Medicare directly
for assistance. You typically have 120 days from the date on your MSN to file an appeal.
4. Provide Additional Information:
• When appealing, you may need to provide additional documentation or information to support
your case. This could include medical records, letters from your healthcare provider, or any other
relevant documentation.
5. Monitor the Appeal Process:
• Stay informed about the status of your appeal by regularly checking the progress with Medicare
or your Medicare Administrative Contractor (MAC). They will notify you of any updates or
decisions regarding your appeal.
6. Seek Assistance if Needed:
• If you need help understanding the appeals process or navigating the appeal, you can contact
your State Health Insurance Assistance Program (SHIP) or seek assistance from a Medicare
advocate or counselor.
Rationale:
• Providing Mrs. Duarte with guidance on how to address the issue helps her take proactive steps
to resolve the dispute and potentially obtain coverage for the denied claim.
• Advising her to contact the provider first allows for direct communication and clarification,
which may resolve the issue more efficiently.
• Explaining the appeals process empowers Mrs. Duarte to exercise her rights and pursue further
action if necessary to ensure fair and accurate coverage under Medicare.
13. 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?
Answer: Agent John Miller should advise Jerry Smith to consider enrolling in a Medicare Part D
prescription drug plan to complement his existing Medicare coverage and Medigap plan. Here's
how John can proceed:
1. Evaluate Prescription Drug Needs:
• John should discuss Jerry's current prescription drug needs and any future medication
requirements to determine the most suitable Medicare Part D plan.
• They should consider factors such as the specific medications Jerry takes, preferred pharmacies,
and monthly premium costs.
2. Research Part D Plans:
• John should help Jerry research available Medicare Part D plans in his area. They can compare
plans based on formularies (list of covered drugs), monthly premiums, annual deductibles,
copayments, and coinsurance.
3. Consider Enrollment Timing:
• John should advise Jerry to enroll in a Medicare Part D plan during his Initial Enrollment Period
(IEP) to avoid late enrollment penalties. Jerry's IEP for Part D begins three months before his
Medicare Part B effective date and extends for three months afterward.
4. Explain Coordination with Medigap Plan:
• John should explain to Jerry that his Medigap plan will not provide coverage for prescription
drugs. However, having a separate Part D plan will ensure he has access to affordable medication
coverage while maintaining his comprehensive Medicare and Medigap coverage for other
healthcare services.
5. Review Costs and Coverage:
• John should review the costs associated with the Medicare Part D plan, including monthly
premiums, deductibles, and copayments. They should ensure the plan provides coverage for
Jerry's specific medications at a reasonable cost.
6. Assist with Enrollment:
• John can assist Jerry with the enrollment process for a Medicare Part D plan. They can complete
the enrollment online through the Medicare website, over the phone with Medicare, or by
submitting a paper application.
7. Provide Ongoing Support:
• John should offer ongoing support to Jerry, ensuring he understands how to use his Medicare
Part D plan effectively and assisting him with any questions or issues that may arise.
Rationale:
• Advising Jerry to enroll in a Medicare Part D plan helps him access prescription drug coverage
to complement his existing Medicare and Medigap coverage.
• Coordinating with Jerry's Medigap plan ensures he maintains comprehensive healthcare
coverage while addressing his prescription drug needs separately.
• Offering support throughout the enrollment process demonstrates John's commitment to
providing personalized assistance to his clients.
14. 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?
Answer: Ms. Henderson, while your years of working and paying Medicare taxes are
commendable, Medicare coverage typically includes premiums for certain parts of the program.
Here's what you should know:
1. Medicare Part A (Hospital Insurance):
• Most individuals do not pay a premium for Medicare Part A if they or their spouse have worked
and paid Medicare taxes for at least 10 years (40 quarters).
• However, if you haven't worked and paid Medicare taxes for the required period, you may still
be eligible for Part A coverage, but you may need to pay a premium.
2. Medicare Part B (Medical Insurance):
• Medicare Part B typically requires payment of a monthly premium, regardless of your work
history or the number of years you've paid Medicare taxes.
• The premium amount for Part B can vary based on your income level, with higher-income
individuals paying higher premiums through Income-Related Monthly Adjustment Amounts
(IRMAA).
3. Medicare Part D (Prescription Drug Coverage):
• Medicare Part D plans, which provide prescription drug coverage, also require payment of a
monthly premium. The premium amount can vary depending on the specific Part D plan you
choose and your income level.
4. Medicare Advantage Plans:
• While some Medicare Advantage plans may offer $0 premiums, they still require payment of
the Medicare Part B premium. Additionally, you may incur other out-of-pocket costs such as
copayments, coinsurance, and deductibles.
Rationale:
• Clarifying that Medicare coverage typically includes premiums helps Ms. Henderson
understand the financial aspects of Medicare enrollment.
• Highlighting the premium requirements for Medicare Part B and Part D ensures Ms. Henderson
is aware of potential costs associated with these parts of the Medicare program.
• Mentioning the availability of Medicare Advantage plans with varying premium structures
provides Ms. Henderson with options to explore for her healthcare coverage.
15. 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?
Answer: Mr. Xi, under Original Medicare, you'll have access to a range of healthcare services
that provide comprehensive coverage for your medical needs. Here's what you should know about
the health coverage provided to Medicare beneficiaries:
1. Medicare Part A (Hospital Insurance):
• Part A covers inpatient hospital care, including semi-private rooms, meals, nursing services, and
necessary supplies.
• It also includes coverage for skilled nursing facility care, hospice care, and some home health
services.
2. Medicare Part B (Medical Insurance):
• Part B covers medically necessary services and supplies needed to diagnose or treat medical
conditions.
• This includes doctor's visits, outpatient care, preventive services (such as screenings, vaccines,
and annual wellness visits), durable medical equipment (like wheelchairs and walkers), and
ambulance services.
3. Key Points:
• Original Medicare provides coverage for a wide range of healthcare needs, including hospital
care, doctor visits, preventive services, and medical supplies.
• Medicare Part A generally does not require a monthly premium for most individuals, while Part
B typically requires payment of a monthly premium.
• While Original Medicare provides comprehensive coverage, it does not cover all healthcare
services. For example, it does not cover prescription drugs (Part D), routine dental care, vision
care, or hearing aids.
Rationale:
• Providing Mr. Xi with an overview of the services provided under Original Medicare helps him
understand the scope of his healthcare coverage as he approaches age 65.
• Highlighting the distinction between Medicare Parts A and B ensures clarity regarding the types
of services covered under each part of the Medicare program.
• Mentioning the limitations of Original Medicare encourages Mr. Xi to consider additional
coverage options, such as Medicare Advantage plans or standalone prescription drug plans, to
supplement his healthcare coverage as needed.
16. 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?
Answer: Mrs. Chen, citizenship status does not typically affect eligibility for Medicare coverage
under Part A. Here's what you should know:
1. Eligibility for Medicare Part A:
• To qualify for Medicare Part A (Hospital Insurance), you generally need to be:
• A citizen or permanent resident of the United States.
• Age 65 or older, or eligible based on a disability or certain medical conditions.
• Generally, individuals who have worked and paid Medicare taxes for at least 10 years (or 40
quarters) qualify for premium-free Part A coverage.
2. Citizenship Requirement:
• Mrs. Chen's citizenship status as a naturalized citizen for twelve years meets the eligibility
criteria for Medicare coverage, including Part A.
• The fact that she was not born in the United States should not impact her eligibility as long as
she meets the citizenship and residency requirements.
3. Documentation:
• Mrs. Chen may need to provide documentation of her citizenship status, such as a U.S. passport,
Certificate of Naturalization, or other relevant documents, when applying for Medicare benefits.
4. Applying for Medicare:
• Mrs. Chen can apply for Medicare benefits as she approaches age 65 by contacting the Social
Security Administration (SSA) online, by phone, or in person.
• She can apply for Medicare Part A, Part B (Medical Insurance), and any other additional
coverage options she may need.
5. Additional Considerations:
• It's important for Mrs. Chen to understand her Medicare coverage options and any associated
costs, including premiums, deductibles, and copayments.
• Mrs. Chen may also want to explore supplemental coverage options like Medicare Advantage
plans or Medigap policies to help cover out-of-pocket expenses not covered by Original
Medicare.
Rationale:
• Reassuring Mrs. Chen about her eligibility for Medicare coverage under Part A based on her
citizenship status and work history helps alleviate her concerns.
• Clarifying the documentation requirements for applying for Medicare ensures Mrs. Chen is
prepared to provide the necessary information to complete the application process.
• Advising Mrs. Chen to explore supplemental coverage options underscores the importance of
understanding her healthcare coverage needs and options as she transitions to Medicare.
17. Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis
through acupuncture. She is concerned about whether or not Medicare will cover these items and
services. What should you tell her?
Answer: Mrs. West, Medicare coverage for glasses, dentures, and acupuncture varies depending
on the specific circumstances and the type of Medicare plan you have. Here's what you should
know:
1. Glasses:
• Original Medicare (Part A and Part B) typically does not cover routine vision care, including
eyeglasses for vision correction. However, Medicare may cover glasses after cataract surgery that
includes an intraocular lens implant.
• If you have a Medicare Advantage (Part C) plan, some plans may offer additional vision benefits
that include coverage for eyeglasses. You would need to check your plan's coverage details for
specific benefits.
2. Dentures:
• Original Medicare also does not cover most dental care, including dentures. This includes
routine dental exams, cleanings, fillings, extractions, and denture fittings.
• Some Medicare Advantage plans may offer limited coverage for dental services, including
dentures. Again, you would need to review the details of your specific plan for coverage
information.
3. Acupuncture:
• Acupuncture is generally not covered by Original Medicare for the treatment of arthritis or other
conditions. However, in 2020, Medicare began covering acupuncture for chronic low back pain
under certain circumstances as part of an expanded coverage policy.
• Coverage for acupuncture may vary depending on your specific situation, the severity of your
condition, and whether it meets Medicare's coverage criteria.
• If you're considering acupuncture treatment, it's essential to discuss your options with your
healthcare provider and verify coverage with Medicare or your Medicare Advantage plan.
4. Supplemental Coverage:
• If you need coverage for vision, dental, or other services not covered by Original Medicare, you
may want to consider purchasing a standalone vision or dental plan or enrolling in a Medicare
Advantage plan that offers these benefits.
• Medigap (Medicare Supplement) plans do not typically cover vision, dental, or acupuncture
services, so they may not provide additional assistance in these areas.
Rationale:
• Providing Mrs. West with information about Medicare coverage for glasses, dentures, and
acupuncture helps her understand what services are covered and what options are available to her.
• Explaining the potential for coverage under Medicare Advantage plans underscores the
importance of reviewing plan details to find additional benefits that meet Mrs. West's needs.
• Advising Mrs. West to discuss her options with her healthcare provider ensures she can make
informed decisions about her care and explore alternative treatments or coverage options as
needed.
18. 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?
Answer: Mr. Alonso, when comparing your employer's retiree coverage to a standard Medicare
Part D prescription drug plan, here are some costs you can generally expect to encounter with a
Part D plan:
1. Monthly Premium:
• Medicare Part D plans typically charge a monthly premium. Premium amounts vary depending
on the specific plan you choose and can range from around $10 to $100 or more per month.
• Premium costs may be influenced by factors such as the plan's coverage, formulary, and the
region in which you live.
2. Annual Deductible:
• Many Part D plans have an annual deductible that you must pay out of pocket before the plan
starts to cover prescription drug costs. Deductible amounts vary by plan but cannot exceed $480
in 2022.
• Not all Part D plans have a deductible, so it's essential to compare plans to find one that aligns
with your needs and budget.
3. Copayments or Coinsurance:
• Once you meet the deductible (if applicable), you'll typically pay a copayment or coinsurance
for each prescription filled. These costs vary depending on the specific drug and the plan's costsharing structure.
• Copayments can range from a few dollars to a percentage of the drug's cost (coinsurance), so
it's essential to review the plan's formulary and cost-sharing details.
4. Coverage Gap (Donut Hole):
• If your total drug costs reach a certain threshold ($4,430 in 2022), you'll enter the coverage gap,
also known as the "donut hole." During this phase, you'll pay a higher percentage of the costs for
both brand-name and generic drugs until you reach catastrophic coverage.
• While you're in the coverage gap, you'll receive a discount on brand-name drugs and a higher
percentage of coverage on generic drugs.
5. Catastrophic Coverage:
• Once you've spent a certain amount out of pocket on covered drugs ($7,050 in 2022), you'll
qualify for catastrophic coverage. During this phase, you'll pay a reduced coinsurance or
copayment for covered drugs for the remainder of the year.
Rationale:
• Providing Mr. Alonso with an overview of the costs associated with Medicare Part D helps him
understand what to expect when comparing plans.
• Explaining the various cost-sharing components, such as premiums, deductibles, and
copayments, allows Mr. Alonso to evaluate his potential out-of-pocket expenses under different
plans.
• Mentioning the coverage gap and catastrophic coverage phases ensures Mr. Alonso understands
the potential impact on his drug costs throughout the year and can make an informed decision
about his coverage options.
19. 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?
Answer: Mr. Capadona, while it's not possible to enroll in both a Medicare Advantage (MA) plan
and a Medigap plan simultaneously, I can provide information to help you understand your
options:
1. Medicare Advantage (MA) Plan:
• A Medicare Advantage plan is an alternative to Original Medicare (Part A and Part B) offered
by private insurance companies approved by Medicare. These plans often include additional
benefits such as prescription drug coverage, vision, dental, and hearing services, and may have
lower out-of-pocket costs compared to Original Medicare.
• When you enroll in a Medicare Advantage plan, you agree to receive your Medicare benefits
through the plan instead of through Original Medicare.
2. Medigap (Medicare Supplement) Plan:
• A Medigap plan, on the other hand, works alongside Original Medicare to help cover some of
the out-of-pocket costs that Medicare doesn't pay for, such as deductibles, copayments, and
coinsurance.
• Medigap plans are standardized and labeled with letters (e.g., Plan F, Plan G) and are offered by
private insurance companies. Each plan offers a different level of coverage, but all plans with the
same letter provide the same standardized benefits.
3. Choosing Between MA and Medigap:
• You generally cannot have both a Medicare Advantage plan and a Medigap plan at the same
time. You must choose one or the other.
• When deciding between the two, consider factors such as your healthcare needs, budget,
preferred doctors and hospitals, and whether you're willing to accept network restrictions.
4. Reviewing Coverage Options:
• Compare the coverage and costs of different Medicare Advantage plans and Medigap plans
available in your area.
• Assess the benefits, premiums, copayments, deductibles, and out-of-pocket maximums of each
plan to determine which best meets your needs and preferences.
5. Enrollment and Timing:
• If you choose a Medicare Advantage plan, you can typically enroll during the annual Medicare
Open Enrollment Period (October 15 to December 7) or during a Special Enrollment Period if
you qualify.
• If you choose a Medigap plan, it's generally best to enroll during your Medigap Open Enrollment
Period, which starts when you're 65 or older and enrolled in Medicare Part B. During this period,
you have guaranteed issue rights, meaning insurance companies cannot deny you coverage or
charge you higher premiums based on pre-existing conditions.
Rationale:
• Providing Mr. Capadona with information about Medicare Advantage and Medigap plans helps
him understand the differences between the two types of coverage.
• Advising him to compare coverage options and consider his healthcare needs and budget
empowers him to make an informed decision about which type of plan best suits his
circumstances.
• Highlighting enrollment periods ensures Mr. Capadona knows when he can enroll in his chosen
plan without facing penalties or restrictions.
20. 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?
Answer: Mr. Moy, Medicare Supplemental Insurance, also known as Medigap, provides
additional coverage to help pay for costs not covered by Original Medicare (Part A and Part B).
Here's what you should know about Medigap coverage and how it differs from Medicare
Advantage:
1. Medicare Supplemental Insurance (Medigap):
• Medigap plans are sold by private insurance companies and are designed to fill the gaps in
Original Medicare coverage, such as copayments, coinsurance, and deductibles.
• There are several standardized Medigap plans labeled with letters (e.g., Plan A, Plan F, Plan G),
and each plan offers a different combination of benefits.
• Medigap plans work alongside Original Medicare, so you can see any healthcare provider that
accepts Medicare nationwide without network restrictions.
2. Coverage Benefits:
• Medigap plans typically cover costs such as Medicare Part A and Part B coinsurance,
copayments, and deductibles. Some plans may also cover additional benefits like foreign travel
emergency care or Part B excess charges.
• The specific benefits provided by each Medigap plan are standardized by Medicare, so the
coverage is the same regardless of which insurance company sells the plan.
3. Flexibility and Choice:
• Medigap plans offer flexibility and choice in healthcare providers, allowing you to see any
doctor or specialist who accepts Medicare.
• This can be beneficial if your healthcare needs differ from your wife's and you prefer the
freedom to choose your own healthcare providers without being restricted to a network.
4. Enrollment and Cost:
• You can enroll in a Medigap plan during your Medigap Open Enrollment Period, which starts
when you're 65 or older and enrolled in Medicare Part B. During this period, you have guaranteed
issue rights, meaning insurance companies cannot deny you coverage or charge you higher
premiums based on pre-existing conditions.
• Medigap plans require payment of a monthly premium in addition to the premium for Medicare
Part B. The cost of the premium varies depending on the plan and the insurance company.
Rationale:
• Providing Mr. Moy with information about Medigap coverage helps him understand the purpose
and benefits of this type of insurance.
• Highlighting the flexibility and choice offered by Medigap plans underscores the advantage of
being able to choose healthcare providers freely without network restrictions.
• Explaining the enrollment process and cost considerations ensures Mr. Moy has the information
he needs to make an informed decision about whether Medigap coverage aligns with his
healthcare needs and preferences.
