2024 ATI PN Final Exam with Answers-158 Solved Questions

AHIP 2024 Final Exam Test Updated Questions And Answers With Rationales
(Verified Answers)
1. 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?
Answer: Edward's Medicare coverage should continue even after his successful kidney
transplant surgery. In cases where an individual becomes eligible for Medicare due to endstage renal disease (ESRD) and then receives a kidney transplant, Medicare coverage
typically continues beyond the usual 36-month coordination period. Since Edward's
transplant was successful and he's now age 50, his Medicare coverage should remain intact.
2. 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?
Answer: Under the Allcare Medicare Advantage plan, hospice benefits should be covered.
Medicare Advantage plans, like Allcare, are required to cover all the same services that
Original Medicare covers, including hospice care for individuals with a terminal illness like
inoperable cancer. Mildred should check with her plan provider for specific details on
coverage and any associated costs.
3. 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?
Answer: Mr. Diaz may indeed face a premium penalty for late enrollment in Medicare Part
B. The penalty typically amounts to an additional 10% of the Part B premium for each full
12-month period that he was eligible for Part B but did not enroll. However, it's essential for
Mr. Diaz to consult with Medicare or a licensed insurance agent to get an accurate assessment
of the penalty based on his specific circumstances.
4. 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: Medicare Supplemental Insurance, also known as Medigap, can help cover costs
that Original Medicare doesn't, such as copayments, coinsurance, and deductibles. Unlike
Medicare Advantage plans, Medigap plans work alongside Original Medicare, so Mr. Moy
can keep his current doctors and hospitals. He should explore different Medigap plans to find
one that suits his specific healthcare needs and preferences.
5. 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 should not worry about her citizenship status affecting her eligibility for
Medicare Part A. As long as she meets the other eligibility criteria for Part A, such as having
worked and paid Medicare taxes for at least 10 years (or 40 quarters), she should qualify for
coverage regardless of her citizenship status. Being a lawful permanent resident or having
citizenship is not a requirement for Medicare eligibility based on work history. She should
apply for Medicare as soon as she becomes eligible to ensure she receives the benefits she's
entitled to.
6. 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 be eligible for Medicare coverage due to his disability status.
Typically, individuals who have received Social Security Disability Insurance (SSDI)
benefits for 24 months are automatically enrolled in Medicare. Since Mr. Bauer has been
receiving disability payments for eighteen months already, he should be approaching the
point where he becomes eligible for Medicare coverage. He should receive information from
the Social Security Administration regarding his enrollment in Medicare when he becomes
eligible.
7. 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: Original Medicare provides coverage for essential healthcare services, including
hospital care (Part A) and medical services (Part B). Part A covers inpatient hospital stays,
skilled nursing facility care, hospice care, and some home health care. Part B covers doctor
visits, outpatient care, preventive services, and some medical supplies. It's important for Mr.
Xi to understand that while Original Medicare covers many services, it doesn't cover all

healthcare costs, so he may want to consider additional coverage options like Medicare
Supplement Insurance or Medicare Advantage plans.
8. 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?
Answer: Mrs. Peňa should enroll in Medicare Part B during her initial enrollment period,
which begins three months before the month she turns 65 and ends three months after that
month. Since she's retiring next year, she can enroll in Part B during this period to ensure
there's no gap in coverage when her employer plan ends. If she delays enrollment, she may
face a late enrollment penalty and a gap in coverage.
9. 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 should be eligible for Medicare coverage due to his diagnosis of endstage renal disease (ESRD) and the need for dialysis. Individuals with ESRD are typically
eligible for Medicare regardless of age, as long as they meet certain criteria. He should
contact Medicare or a licensed insurance agent to begin the enrollment process and explore
his coverage options.
10. 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?
Answer: Madeline Martinez should be eligible for Medicare Part A based on her husband's
work history and contributions to the Medicare system. Since she's turning 65 soon, she
should enroll in Original Medicare during her initial enrollment period to avoid any potential
late enrollment penalties. While Part A generally doesn't require premiums for most
beneficiaries, Part B does, so she should carefully consider her coverage needs and budget
when deciding whether to enroll in both parts.
11. 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 may qualify for premium-free Medicare Part A based on her work
history and payment of Medicare taxes for 40 quarters. However, she will still need to pay

premiums for Medicare Part B unless she qualifies for assistance programs that help cover
Part B premiums. It's essential for her to understand the specifics of her coverage options and
any associated costs by contacting Medicare or a licensed insurance agent.
12. 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 could advise Jerry Smith to consider enrolling in a standalone
Medicare Part D plan to add prescription drug coverage to his existing Medicare coverage.
Since Jerry's current Medicare Supplement plan does not provide drug benefits, adding a Part
D plan would help cover his prescription medication costs. John should discuss Jerry's
specific medication needs and budget to find a Part D plan that suits his requirements.
13. 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's income should not affect her eligibility for Medicare. Medicare
eligibility is primarily based on age (65 or older) or disability status, not income level. As
long as she meets the age requirement and is a U.S. citizen or permanent legal resident who
has lived in the United States for at least five years, she should be eligible for Medicare
coverage. Ms. Moore should plan to enroll in Medicare during her initial enrollment period
to avoid any potential late enrollment penalties.
14. 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 should be aware that he generally cannot have both a Medicare
Advantage (MA) plan and a Medigap plan at the same time. These two types of plans provide
different coverage and cannot be used together. If he chooses to enroll in a Medicare
Advantage plan, he will typically receive all of his Medicare benefits through that plan,
including prescription drug coverage if it's included. Alternatively, if he prefers the flexibility
of Original Medicare with additional coverage provided by a Medigap plan, he should forego
enrolling in a Medicare Advantage plan.
15. 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 may be eligible for assistance programs that can help lower her
healthcare costs. She should explore programs such as Extra Help (Low-Income Subsidy)
for prescription drug coverage, Medicaid for healthcare coverage, and Medicare Savings
Programs for assistance with Medicare premiums and cost-sharing. Additionally, she should
consider contacting local social services agencies or non-profit organizations that provide
assistance to seniors with low incomes.
16. 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 Original Medicare, covers
a wide range of healthcare services. This includes hospital care (Part A), medical services
such as doctor visits and outpatient care (Part B), and some preventive services. It also covers
certain durable medical equipment, home health services, and hospice care. Mr. Schmidt
should understand that while Original Medicare provides comprehensive coverage, it does
not cover all healthcare costs, so he may want to consider additional coverage options like
Medicare Supplement Insurance or Medicare Advantage plans.
17. Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify
for the Part D low-income subsidy. Where might he turn for help with his prescription drug
costs?
Answer: Mr. Wu can seek assistance with his prescription drug costs through various
programs and resources. He should explore pharmaceutical assistance programs offered by
pharmaceutical companies, state prescription assistance programs, and patient assistance
programs offered by non-profit organizations. Additionally, he can consider contacting his
local Area Agency on Aging or State Health Insurance Assistance Program (SHIP) for
guidance on available resources and assistance with prescription drug costs.
18. Shirly Thomas was enrolled in Medicaid during the Public Health Emergency (PHE).
This coverage has recently been terminated due to the end of the PHE. While Shirley was
enrolled in Medicaid, she missed an opportunity to enroll in Medicare and now wants Part
B. Which of the following statements best describes Shirley's ability to now enroll in
Medicare Part B?
Answer: Shirley Thomas may qualify for a Special Enrollment Period (SEP) to enroll in
Medicare Part B since her Medicaid coverage was terminated. Losing Medicaid coverage is
considered a qualifying event that triggers an SEP, allowing her to enroll in Part B outside of
her initial enrollment period. She should contact Social Security or Medicare to discuss her
eligibility and enrollment options.

19. Anthony Boniface turned 65 in 2023. He was not receiving Social Security or Railroad
Retirement Benefits on his 65th birthday. He was interested in obtaining Medicare coverage
and is eligible for premium-free Part A. Before he could enroll in Medicare, his entire area
was impacted by a hurricane causing massive flooding and severe wind damage. The Federal
government declared this to be a natural disaster which has recently ended. During this period
Anthony's initial enrollment period expired. Anthony asks you how he can now obtain
Medicare coverage. What should you say?
Answer: Anthony Boniface may qualify for a Special Enrollment Period (SEP) due to the
recent natural disaster impacting his area. SEP rules allow individuals affected by a natural
disaster to have additional time to enroll in Medicare. Anthony should contact Social Security
or Medicare to inquire about his eligibility for an SEP and to enroll in Medicare coverage.
20. Mrs. Lyons is in good health, uses a single prescription, and lives independently in her
own home. She is attracted by the idea of maintaining control over a Medical Savings
Account (MSA) but is not sure if the plan associated with the account will fit her needs. What
specific piece of information about a Medicare MSA plan would it be important for her to
know, prior to enrolling in such a plan?
Answer: Mrs. Lyons should be aware that Medicare MSA plans require enrollment in a highdeductible health plan (HDHP). This means she will need to pay for most of her healthcare
costs out of pocket until she reaches the plan's deductible. If she's comfortable with this
arrangement and believes she can manage her healthcare expenses effectively, then an MSA
plan may be suitable for her.
21. 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?
Answer: Mrs. Ramos should be informed that Medicare Advantage PPO plans typically offer
more flexibility in choosing healthcare providers compared to HMO plans. With a PPO plan,
she can usually see any healthcare provider who accepts Medicare assignment, both innetwork and out-of-network, without needing a referral from a primary care physician.
However, she should be aware that out-of-network care may result in higher out-of-pocket
costs.
22. 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?

Answer: Mr. Romero should carefully compare the coverage and costs of his employersponsored retiree group health plan with the MA-PD plan. While the MA-PD plan may offer
attractive premiums and comprehensive coverage, he should ensure that it provides adequate
coverage for his prescription drugs and that his preferred pharmacies are in-network. He
should also consider any out-of-pocket costs such as copayments and coinsurance associated
with the MA-PD plan.
23. 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?
Answer: Medicare Advantage Special Needs Plans (SNPs) are tailored to individuals with
specific health conditions or characteristics, such as diabetes and heart trouble. Mr. Sinclair
should know that SNPs typically offer specialized care coordination and additional benefits
tailored to his health needs. He should review the benefits, network providers, and costs
associated with SNPs to determine if they meet his healthcare needs and preferences.
24. 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?
Answer: Since Dr. Elizabeth Brennan does not contract with the ABC PFFS plan, she may
bill Mary Rodgers up to 15% more than the plan's Medicare-approved amount for covered
services. Mary Rodgers will be responsible for paying this additional amount, known as
excess charges, out of pocket.
25. 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?
Answer: Mr. Gomez should understand that Private Fee-for-Service (PFFS) plans do not
typically have networks of providers like HMO plans. However, providers must agree to
accept the plan's terms and conditions for payment for each service provided. Mr. Gomez
can generally see any Medicare-approved provider who accepts the PFFS plan's payment
terms, regardless of whether they are in-network or out-of-network. He should confirm with
the plan which providers accept its terms before seeking care.
26. 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?
Answer: Juan Hernandez should be eligible to enroll in a Medicare Advantage plan based
on his work history and contributions to the Medicare system, regardless of his citizenship
status. As long as he meets the eligibility criteria for Medicare, including age and having
worked and paid Medicare taxes for a certain period, he should be able to enroll in the
Medicare Advantage plan you represent. He should review the plan's benefits, network
providers, and costs to ensure it meets his healthcare needs and preferences.
27. Mrs. Radford asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her?
Answer: Mrs. Radford should be informed that the eligibility requirements for Medicare
Advantage are generally the same as those for Original Medicare. To enroll in a Medicare
Advantage plan, individuals must be enrolled in both Medicare Part A and Part B, live in the
plan's service area, and not have end-stage renal disease (ESRD), with some exceptions for
certain Special Needs Plans (SNPs). Additionally, individuals must typically continue paying
their Medicare Part B premium while enrolled in a Medicare Advantage plan.
28. 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-ofpocket 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-ofpocket 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?
Answer: Mr. Barker should review his Medicare Advantage plan's Explanation of Benefits
(EOB) to understand why certain services and items were not fully covered as expected. He
should pay attention to any explanations of coverage limitations, out-of-network charges, or
services that may not be covered under his plan. If he believes there was an error or
misunderstanding, he can contact his plan's customer service department for clarification and
assistance with any billing issues.
29. 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?

Answer: Mrs. Burton may want to consider switching to a different Medicare Advantage
plan that offers better access to care, including shorter wait times for appointments. She
should review the provider network, appointment availability, and member reviews of
different plans in her area to find one that better meets her healthcare needs and preferences.
Additionally, she can contact her plan's customer service department to voice her concerns
and inquire about other options for accessing care.
30. Which of the following statement(s) is/are correct about a Medicare Savings Account
(MSA) Plans?
a. MSAs may have either a partial network, full network, or no network of providers.
b. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits.
c. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of
$500 indexed for inflation.
d. Non-network providers must accept the same amount that Original Medicare would pay
them as payment in full.
Answer: a, b, and d only
Rationale:
Medicare Savings Account (MSA) Plans are a type of Medicare Advantage plan that
combines a high-deductible health plan with a medical savings account. These plans typically
cover Medicare Part A and Part B benefits, providing the same coverage as Original
Medicare. However, they do not include prescription drug coverage (Part D), which means
beneficiaries would need to purchase a standalone Part D plan if they want prescription drug
coverage.
31. 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?
Answer: Mr. Greco should be aware that Medicare Advantage Special Needs Plans (SNPs)
are designed for individuals with specific health conditions or characteristics. If he does not
meet the eligibility criteria for the SNP his friend is enrolled in, he may not be able to join
that plan. However, he can explore other Medicare Advantage plan options in his area to find
one that offers low cost-sharing amounts and meets his healthcare needs and preferences.
32. 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?

Answer: Daniel is likely to benefit most from a Chronic Condition Special Needs Plan (CSNP), which is designed for individuals with specific chronic conditions such as chronic
bronchitis. C-SNPs often offer tailored care management and additional benefits to help
manage the specific health needs associated with chronic conditions like Daniel's.
33. 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?
Answer: Mr. Castillo should be informed that enrolling in a Medicare Advantage (MA) plan
would require him to continue paying his Part B premium. He should also review the benefits,
costs, and provider network of different MA plans available in his area to find one that best
meets his healthcare needs and budget. Additionally, he should ensure he understands any
enrollment deadlines or special enrollment periods he may qualify for.
34. 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?
Answer: Mrs. Chi should consider whether the benefits offered by the MA MSA plan,
including the control over a Medical Savings Account (MSA), outweigh the benefits of her
current coverage under Original Medicare and a standalone Part D plan. She should review
the coverage, costs, and provider network of the MA MSA plan, as well as its prescription
drug coverage options, to ensure it meets her healthcare needs and preferences.
35. 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?
Answer: Mrs. Wang should be informed that benefits under Original Medicare (Part A and
Part B) typically include coverage for hospital care, medical services, and some preventive
services. Medicare Advantage plans, on the other hand, are offered by private insurance
companies and may offer additional benefits beyond what is covered by Original Medicare,
such as prescription drug coverage, vision and dental benefits, and wellness programs.
However, the specific benefits and costs can vary widely between different Medicare
Advantage plans, so she should carefully review the details of each plan before making a
decision.

36. Agent Suma has recently had several clients request his assistance in completing their
paper enrollment form. What advice would you give him?
Answer: Agent Suma should advise his clients to carefully review the paper enrollment form
and ensure that all sections are completed accurately and legibly. He should emphasize the
importance of providing all required information, including personal details, Medicare
number, plan selection, and signature. Additionally, he should remind his clients to doublecheck the form for any errors or omissions before submitting it to ensure a smooth enrollment
process.
37. Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told
her that there is an excellent Medicare Advantage (MA) plan with a five-star rating serving
her area. On January 15 she comes to you for advice as to what options, if any, she has. What
should you say regarding special enrollment periods (SEPs)?
Answer: Mrs. Wellington should be informed that special enrollment periods (SEPs) allow
individuals to enroll in or make changes to their Medicare coverage outside of the annual
enrollment periods, under certain circumstances. SEPs are typically triggered by life events
such as moving, losing other coverage, or becoming eligible for Medicaid. If Mrs.
Wellington's friend's information is accurate and the MA plan has a five-star rating, she may
be eligible for a SEP to enroll in the plan outside of the annual enrollment period.
38. Mr. Wells is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be the correct description?
Answer: Original Medicare is the traditional fee-for-service program offered directly by the
federal government. It consists of Part A, which covers hospital services, and Part B, which
covers medical services and outpatient care. Medicare Advantage, on the other hand, is an
alternative way to receive Medicare benefits through private insurance companies approved
by Medicare. These plans, also known as Part C, typically include all benefits of Original
Medicare and may offer additional coverage such as prescription drugs, dental, vision, and
hearing services, often for an additional premium.
39. 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?
Answer: To determine Mr. Kelly's eligibility to sign up for a Private Fee-for-Service (PFFS)
plan, Agent Suma should ask Mr. Kelly if he is enrolled in both Medicare Part A and Part B.
PFFS plans require beneficiaries to be enrolled in both parts of Original Medicare.
Additionally, Agent Suma should verify if PFFS plans are available in Mr. Kelly's area and

if he is willing to follow the plan's terms and conditions, including provider acceptance of
the plan's payment terms.
40. 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?
Answer: Ms. Gibson should be informed that she can obtain prescription drug coverage
through a standalone Medicare Part D plan. Since she is enrolling in a PPO plan that does
not include drug coverage, she will need to purchase a separate Part D plan to ensure
coverage for her medications. Agent Suma should advise her to compare different Part D
plans based on their formularies, premiums, deductibles, and copayments to find one that
meets her medication needs and budget.
41. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability
to access providers. What should you tell him?
Answer: Mr. Kumar should be informed that Medicare Advantage HMO plans typically
require members to use providers within the plan's network, except in cases of emergency or
urgent care. He should review the plan's provider network to ensure his current healthcare
providers are included and that he is comfortable with the network's size and accessibility.
Additionally, he should understand any requirements for obtaining referrals to see specialists
within the plan.
42. Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income.
She uses no medications and sees no reason to spend money on a Medicare prescription drug
plan if she does not need the coverage. She currently does not have creditable coverage. What
could you tell her about the implications of such a decision?
Answer: Mrs. Quinn should be informed about the potential consequences of not enrolling
in a Medicare prescription drug plan (Part D) when she is first eligible. If she delays
enrollment and goes without creditable prescription drug coverage for an extended period,
she may face late enrollment penalties if she decides to enroll in a Part D plan later. These
penalties can result in higher premiums for as long as she is enrolled in a Part D plan.
43. Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be
extra help paying for Part D prescription drugs for Medicare beneficiaries with limited
income. He wants to know whether he might qualify. What should you tell him?
Answer: Mr. Shapiro should be advised that there are programs available to help Medicare
beneficiaries with limited income and resources pay for their Part D prescription drug costs.
He may qualify for Extra Help, also known as the Low-Income Subsidy (LIS), which can

help cover premiums, deductibles, and copayments for Medicare Part D plans. Agent Suma
should encourage Mr. Shapiro to contact Social Security or his State Medicaid office to
determine his eligibility and apply for Extra Help.
44. Charles McCarthy is a Medicare beneficiary who suffers from diabetes. Mr. McCarthy is
considering enrollment in a MA-PD plan that you represent. He asks you whether his insulin
costs will be covered. What should you say?
Answer: Charles McCarthy should be informed that insulin costs are typically covered under
Medicare Part D prescription drug plans, including Medicare Advantage plans with
prescription drug coverage (MA-PD plans). He should review the plan's formulary to ensure
his specific insulin medication is covered and inquire about any applicable copayments or
coinsurance.
45. Mrs. Imelda Diaz is a Medicare beneficiary enrolled in a MA-PD plan you represent. Her
neighbor recently suffered from a painful case of shingles. Mrs. Diaz hopes to avoid such an
illness through vaccination. She asks you whether the cost of shingles vaccination will be
covered under the plan you represent. What should you say?
Answer: Mrs. Imelda Diaz should be informed that Medicare Part D plans, including
Medicare Advantage plans with prescription drug coverage (MA-PD plans), typically cover
the cost of preventive vaccines, including the shingles vaccination. She should review the
plan's formulary to ensure the shingles vaccine is covered and inquire about any applicable
copayments or coinsurance.
46. Mr. Schultz was still working when he first qualified for Medicare. At that time, he had
employer group coverage that was creditable. During his initial Part D eligibility period, he
decided not to enroll because he was satisfied with his drug coverage. It is now a year later
and Mr. Schultz has lost his employer group coverage within the last two weeks. How would
you advise him?
Answer: Mr. Schultz should be advised that losing his employer group coverage qualifies
him for a Special Enrollment Period (SEP) to enroll in a Medicare Part D prescription drug
plan. Since he had creditable drug coverage through his employer, he won't face a late
enrollment penalty as long as he enrolls in a Part D plan within two months of losing his
employer coverage. Agent Suma should help Mr. Schultz compare Part D plans based on
their formularies, premiums, deductibles, and copayments to find one that meets his
medication needs and budget.

47. Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service
(PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs.
Roberts consider before selecting a PFFS plan?
Answer: Before selecting a Private Fee-for-Service (PFFS) plan, Mrs. Roberts could
consider several options:
• Review the provider network: PFFS plans may have different networks of providers, so
Mrs. Roberts should ensure that her preferred healthcare providers are included in the plan's
network.
• Compare benefits and costs: Mrs. Roberts should compare the benefits, premiums,
deductibles, copayments, and out-of-pocket maximums of different PFFS plans to find one
that meets her healthcare needs and budget.
• Consider additional coverage: Depending on her healthcare needs, Mrs. Roberts may also
want to consider additional coverage options such as prescription drug coverage (Part D) or
supplemental coverage (Medigap) to complement her PFFS plan.
48. Which of the following individuals is most likely to be eligible to enroll in a Part D Plan?
a. Guy, who has illegally crossed the Canadian border.
b. Jose, a grandfather who was granted asylum and has worked in the United States for many
years.
c. Betsy, a grandmother from overseas who has overstayed her visa. d.Helena, an overseas
college student who has overstayed her visa.
Answer: b. Jose, a grandfather who was granted asylum and has worked in the United States
for many years.
Rationale:
Part D eligibility is based on several factors, including legal residency in the United States.
Individuals who are legally present in the United States, such as those granted asylum, are
typically eligible to enroll in a Medicare Part D prescription drug plan. Asylum status grants
individuals permission to remain in the United States and work legally. Therefore, Jose, who
has been granted asylum and has worked in the United States for many years, is most likely
eligible to enroll in a Part D plan.
49. Mr. Carlini has heard that Medicare prescription drug plans are only offered through
private companies under a program known as Medicare Advantage (MA), not by the
government. He likes Original Medicare and does not want to sign up for an MA product,
but he also wants prescription drug coverage. What should you tell him?

Answer: Mr. Carlini should be informed that Medicare prescription drug plans are indeed
offered by private insurance companies approved by Medicare, but they are not exclusive to
Medicare Advantage (MA) plans. Standalone Medicare Part D prescription drug plans are
available to individuals with Original Medicare who want prescription drug coverage without
enrolling in an MA plan. Mr. Carlini can enroll in a standalone Part D plan while maintaining
Original Medicare coverage.
50. Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through
an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not
cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she
be able to?
Answer: Mrs. Walters will be able to enroll in a Medicare prescription drug plan (Part D)
even though she is not enrolled in Medicare Part B. Since she has creditable coverage through
her employer retiree plan, she won't face a late enrollment penalty for Part D. She should
review standalone Part D plans available in her area and select one that provides coverage
for her prescription drugs.
51. Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is
concerned about the Part D premium penalty if he does not enroll in a Medicare prescription
drug plan, but does not want to purchase extra coverage that he will not need. What should
you tell him?
Answer: Mr. Hutchinson should be aware that while he may not currently need prescription
drug coverage, delaying enrollment in a Medicare prescription drug plan (Part D) could result
in a late enrollment penalty if he decides to enroll later when he needs it. The late enrollment
penalty is calculated based on the number of months he went without creditable drug
coverage since becoming eligible for Medicare. Agent Suma should advise Mr. Hutchinson
to consider his future healthcare needs and the potential financial consequences of delaying
enrollment in Part D.
52. 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?
Answer: Mr. Jacob should understand that although there is a standard Medicare Part D
prescription drug benefit, private insurance companies have flexibility in designing and
pricing their Part D plans. This results in variation in deductibles, premiums, and cost-sharing
among different Part D plans. Mr. Jacob should carefully compare the details of various

plans, including their formularies and coverage tiers, to find one that best fits his medication
needs and budget.
53. 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?
Answer: Mrs. McIntire can expect that her Medicaid drug coverage will transition to
Medicare Part D prescription drug coverage upon becoming eligible for Medicare. Most
individuals who are dually eligible for Medicare and Medicaid automatically receive Extra
Help, also known as the Low-Income Subsidy (LIS), which helps cover Part D premiums,
deductibles, and copayments. She should review her Part D plan options and select one that
meets her medication needs.
54. 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?
a Her annual PDP deductible
b A drug manufacturer's discount for brand name drugs after her initial coverage period
c The off formulary drug her doctor prescribed but she pays for because the plan denied her
exception request
d Her over-the-counter (OTC) allergy medication.
Answer: a and b only
Rationale:
Mrs. Cantwell's annual Prescription Drug Plan (PDP) deductible counts toward reaching the
catastrophic coverage phase. Deductible expenses are part of the TrOOP (True Out-ofPocket) costs calculation, which helps determine when catastrophic coverage begins. A drug
manufacturer's discount for brand name drugs after her initial coverage period also counts
toward reaching the catastrophic coverage phase. These discounts, provided during the
coverage gap (donut hole), are considered out-of-pocket expenses and contribute to TrOOP
costs.
55. 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?
Answer: Mrs. Fiore should consider several issues when deciding whether to enroll in a
Medicare prescription drug plan:

• Coverage needs: She should review her current FEHB plan's drug coverage and compare it
with Medicare Part D plans to determine if her current coverage meets her medication needs.
• Cost: Mrs. Fiore should compare the premiums, deductibles, copayments, and coinsurance
of Medicare Part D plans with her FEHB plan to assess which option is more cost-effective.
• Coordination of benefits: Mrs. Fiore should understand how her FEHB plan coordinates
with Medicare Part D to avoid duplicative coverage or coverage gaps.
• Late enrollment penalty: If Mrs. Fiore decides not to enroll in a Medicare Part D plan when
first eligible and loses her FEHB coverage or creditable drug coverage, she may face a late
enrollment penalty if she enrolls in a Part D plan later.
56. 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?
Answer: Mrs. Berkowitz can enroll in both a Medicare Advantage plan that does not include
drug coverage and a standalone Medicare prescription drug plan under certain circumstances,
such as:
• The Medicare Advantage plan she selects does not include prescription drug coverage.
• She is eligible for a Special Enrollment Period (SEP) to enroll in a standalone Part D plan,
such as losing creditable drug coverage or moving out of her plan's service area.
• She ensures that enrolling in both plans does not result in duplicative coverage or coverage
gaps.
57. 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?
Answer: Mr. Torres should be informed that he can set up automatic monthly withdrawals
from his savings account to pay for his Part D premiums. Once his savings account is
exhausted, he can request to have his premiums withheld from his Social Security check.
However, he should be aware that if he delays premium payments, he may face a late
enrollment penalty if he does not have other creditable drug coverage.
58. 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?
Answer: Mr. Bickford should explore other options for obtaining help with his considerable
drug costs, such as:

• Patient assistance programs offered by pharmaceutical companies.
• State pharmaceutical assistance programs (SPAPs) that provide additional help with
prescription drug costs for eligible individuals.
• Community resources or non-profit organizations that offer assistance with healthcare
expenses.
59. 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?
Answer: Mrs. Fields should be informed that applying for the Part D low-income subsidy
can be worth the time and effort if she meets the eligibility criteria. The subsidy, also known
as Extra Help, can significantly reduce her out-of-pocket costs for prescription drugs,
including premiums, deductibles, and copayments. She may qualify for Extra Help if she has
limited income and resources. Therefore, filling out the paperwork to apply for the subsidy
could result in substantial savings on her prescription drug expenses.
60. Which of the following statements about Medicare Part D are correct?
a. Part D plans must enroll any eligible beneficiary who applies regardless of health status
except in limited circumstances.
b. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may
choose to have one.
c. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain
Part D benefits through a standalone PDP.
d. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP
or through their plan.
Answer: a, b, and c
Rationale:
a. Part D plans are required to enroll any eligible beneficiary who applies, regardless of their
health status. This is a fundamental aspect of Medicare Part D's design to ensure that
beneficiaries have access to prescription drug coverage when they become eligible for
Medicare.
b. Private fee-for-service (PFFS) plans under Medicare Part D are not mandated to establish
a pharmacy network. They have the flexibility to choose whether or not to use one. This
flexibility allows PFFS plans to negotiate different arrangements with pharmacies, which can
affect beneficiary access to medications.
c. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan typically do not
have prescription drug coverage included in their plan. Therefore, they must obtain Part D

benefits through a standalone Prescription Drug Plan (PDP) if they wish to have prescription
drug coverage. This is because MSA plans are designed to work with a high-deductible health
plan, and prescription drug coverage is typically not included in these plans.
61. 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?
Answer: Mrs. Lopez should be informed that she is eligible for a Special Enrollment Period
(SEP) to enroll in a Medicare Part D prescription drug plan (PDP) due to losing creditable
coverage. She should be advised to enroll in a PDP as soon as possible to avoid any potential
late enrollment penalties.
62. 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?
Answer: Agent Daniel Webber should politely explain to Clara Burton that the appointment
was scheduled specifically for Edward Young and himself to discuss his Medicare Advantage
options. However, he can offer to schedule a separate appointment to discuss Clara Burton's
options at a more suitable time.
63. 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?
Answer: During the appointment with Mrs. Lu, the agent is permitted to discuss and provide
information about Medicare Advantage plans, including benefits, costs, network providers,
and any other relevant details. However, the agent must stay within the scope of the
appointment and refrain from discussing products or services that were not requested by Mrs.
Lu.
64. You have approached a hospital administrator about marketing in her facility. The
administrator is uncomfortable with the suggestion. How could you address her concerns?
Answer: The agent could address the hospital administrator's concerns by emphasizing the
benefits of allowing marketing within the facility, such as providing valuable information to
patients about their Medicare options. The agent could also offer to tailor the marketing
approach to align with the administrator's comfort level, ensuring that it is non-intrusive and
respectful of the hospital's environment.

65. You are working several plans and community organizations to sponsor an educational
event. When putting together advertisements for this event, what should you do?
Answer: When putting together advertisements for the educational event, it is important to
ensure that all materials comply with CMS guidelines and regulations. This includes
accurately representing the event, providing unbiased information about Medicare options,
and avoiding any language or imagery that could be perceived as misleading or deceptive.
66. 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?
Answer: Miguel should advise his clients during the Medicare Advantage Open Enrollment
Period (MA-OEP) to review their current Medicare Advantage plans and consider switching
to a different plan if it better meets their needs. He can also inform them about any new plan
options that may be available to them during this enrollment period.
67. 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?
Answer: Under CMS rules, Agent James Chan may be compensated by the Medicare
Advantage plan for enrolling Wendy Park. This compensation may include initial and
ongoing commissions or bonuses based on Wendy Park's enrollment and continued
participation in the plan.
68. 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?
Answer: Melissa Meadows should advise Best Care to submit any potential social media
posts to CMS for approval to ensure compliance with regulations. In the meantime, she can
focus on providing general information about the Medicare Advantage plan and its
comprehensive dental benefits without specifically promoting enrollment or benefits.
69. Your friend's mother just moved to an assisted living facility and he asked if you could
present a program for the residents about the MA-PD plans you market. What could you tell
him?

Answer: The agent could inform his friend that he is happy to present a program for the
assisted living facility residents about MA-PD plans. During the presentation, he can educate
the residents about the benefits, coverage options, and enrollment process for Medicare
Advantage plans with prescription drug coverage.
70. Your client, Alexis Jones, calls you on December 4th about changing her Medicare
Advantage plan during the annual election period which ends December 7th. What should
you do?
Answer: Alexis Jones should be informed that she has until December 7th to make changes
to her Medicare Advantage plan during the annual election period. The agent should assist
her in reviewing her current plan, exploring alternative options if necessary, and completing
any necessary enrollment or change forms before the deadline.
71. Linda Sanchez is conducting a previously agreed upon appointment with client, Maria
Gomez about a MA-Part D plan she represents. Before an enrollment form is completed,
Linda needs to provide Maria with information about _______
a. whether or not Maria's primary care provider is in the plan's network.
b. whether Maria's current prescriptions are covered by the plan
c. the monthly premium cost(s).
d. the life insurance products that Linda also sells
Answer: b. whether Maria's current prescriptions are covered by the plan.
Rationale:
Before enrolling in a Medicare Advantage-Part D (MA-PD) plan, it's crucial for Maria
Gomez to know whether her current prescriptions are covered by the plan. This information
is essential for her to assess whether the plan meets her healthcare needs and to avoid any
potential disruptions in medication coverage. Knowing which medications are covered can
also help Maria evaluate the plan's formulary and compare it to her current medication
regimen. While options a, c, and d may also be relevant to Maria's decision-making process,
ensuring her prescriptions are covered is a critical aspect directly impacting her healthcare
management and costs.
72. You are seeking to represent an individual Medicare Advantage plan and an individual
Part D plan in your state. You have completed the required training for each plan, but you
did not achieve a passing score on the tests that came after the training. What can you do in
this situation?
Answer: In this situation, if you have completed the required training but did not achieve a
passing score on the tests, you could consider retaking the tests to improve your score. You

may also want to consult with your supervisor or the training coordinator to understand any
additional resources or support available to help you prepare better for the tests. It's essential
to ensure that you have a good understanding of the material covered in the training to
effectively represent the Medicare Advantage and Part D plans.
73. Another agent you know has engaged in misconduct that has been verified by the plan
she represented. What sort of penalty might the plan impose on this individual?
Answer: The penalty imposed on an agent for verified misconduct by the plan they
represented can vary depending on the severity of the misconduct and the policies of the
plan. Possible penalties might include suspension or termination of the agent's contract, fines,
mandatory additional training, or legal action if the misconduct involves fraudulent activities.
74. ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees'
information to market non-health related products such as life insurance and annuities. Which
statement best describes ABC's obligation to its enrollees regarding marketing such
products?
Answer: ABC, as a Medicare Advantage (MA) plan sponsor, has an obligation to its
enrollees regarding marketing non-health related products such as life insurance and
annuities. The best statement describing this obligation is that ABC must adhere to CMS
guidelines and regulations, which generally prohibit the use of enrollees' information for
marketing non-health related products without obtaining explicit consent from the enrollees.
ABC should ensure that any marketing activities comply with privacy laws and regulations
and respect the rights and preferences of its enrollees.
75. You have been providing a pre-Thanksgiving meal during sales presentations in
November for many years and your clients look forward to attending this annual event. When
marketing Medicare Advantage and Part D plans, what are you permitted to do with respect
to meals?
Answer: When marketing Medicare Advantage and Part D plans, you are permitted to
provide meals to potential enrollees as long as certain conditions are met. Meals provided
during sales presentations must be incidental to the presentation, modest in value, and offered
in a group setting. However, providing lavish or extravagant meals or offering them on a oneon-one basis is not allowed.
76. You have sought permission from a hospital to place brochures for your product in their
gift shop and cafeteria. The hospital administration expresses some hesitation about allowing
marketing in a health care facility. What should you tell them?

Answer: When addressing the hospital administration's hesitation about allowing marketing
in a healthcare facility, you should emphasize that the brochures you intend to place in the
gift shop and cafeteria are educational resources aimed at informing patients and visitors
about their Medicare options. You can reassure them that your intention is to provide helpful
information rather than engage in aggressive marketing tactics. Additionally, you can offer
to provide brochures that are reviewed and approved by the hospital to ensure they meet their
standards for educational materials.
77. Another agent working for your agency claims that because you are not employed by the
Medicare Advantage plans that you represent, you are not subject to the same marketing
requirements as the plans themselves. How should you respond to such a statement?
Answer: In response to the statement that you are not subject to the same marketing
requirements as the Medicare Advantage plans themselves because you are not directly
employed by them, you should clarify that as an agent representing these plans, you are still
bound by the marketing guidelines and regulations set forth by the Centers for Medicare &
Medicaid Services (CMS). These regulations apply to all individuals involved in marketing
Medicare Advantage and Part D plans, including agents, brokers, and plan sponsors,
regardless of their employment status.
78. Evan Marsh is a newly appointed agent. Evan intends to conduct an educational session
on Medicare at a senior citizens center near his home. He has advertised the session as an
educational event. Evan asks you what is permissible at such an event. What should you say?
Answer: At the educational session on Medicare that Evan Marsh intends to conduct at a
senior citizens center, he should focus on providing objective information about Medicare,
its various parts, eligibility requirements, coverage options, enrollment periods, and other
relevant topics. Evan should refrain from engaging in sales activities, soliciting or enrolling
attendees in specific plans, or discussing specific plan benefits or premiums. The session
should be purely educational in nature, aimed at empowering seniors to make informed
decisions about their Medicare coverage.
79. Hector Hernandez is an independent agent. Hector sells plans on behalf of three Medicare
Advantage organizations that offer a total of 10 plans but does not represent all Medicare
Advantage organizations offering plans that are available in his area. Which of the following
statements best describes any steps Hector is required to take?
Answer: Hector Hernandez, as an independent agent representing three Medicare Advantage
organizations offering a total of 10 plans, is required to take steps to ensure that he provides
accurate and unbiased information to his clients. This includes disclosing to clients the

limited number of plans he represents and informing them that other plans may be available
in their area. Hector should also make an effort to stay informed about all available plans in
his area to provide comprehensive guidance to his clients, even if he does not directly
represent those plans.
80. Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks
you for advice as to whether this is possible. What should you tell her?
Answer: Agent Martinez should be advised that soliciting Medicare Advantage prospects
through email is generally not permissible under CMS guidelines. Unsolicited emails sent
for the purpose of marketing Medicare Advantage plans are considered prohibited marketing
activities and may violate anti-spam laws as well as CMS regulations. Martinez should
explore other compliant methods of reaching potential enrollees, such as in-person
presentations, educational seminars, or direct mail campaigns that comply with CMS
guidelines for marketing Medicare plans.
81. Sal D'Angelo is new to the Medicare marketplace having previously been focused on life
insurance and disability income protection products. He intends to conduct an educational
seminar during the AEP at a local hotel and then invite those who attend to a subsequent
marketing meeting to discuss the benefits of next year's plans. How would you advise Sal?
Answer: I would advise Sal D'Angelo that while conducting an educational seminar during
the Annual Enrollment Period (AEP) is a good way to provide valuable information to
Medicare beneficiaries, he should ensure that the subsequent marketing meeting complies
with CMS guidelines. Any discussions about specific plan benefits or premiums should be
done in a compliant manner, avoiding aggressive sales tactics or undue pressure on attendees
to enroll in particular plans. It's important to maintain a clear distinction between the
educational seminar and the marketing meeting to ensure transparency and compliance with
regulations.
82. 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?
Answer: During the Medicare Advantage Initial Coverage Election Period (ICEP), Mrs.
Reeves cannot switch from Original Medicare to a Medicare Advantage plan if she already
has Original Medicare. The ICEP allows individuals who are newly eligible for Medicare to
enroll in a Medicare Advantage plan for the first time, but it does not allow for switching
between Medicare Advantage plans or making changes to Part D coverage unless certain
special circumstances apply.

83. 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?
Answer: If Mr. Tully is incapable of understanding the implications of choosing a Medicare
Advantage or prescription drug plan due to advanced Alzheimer's, his daughter may fill out
the enrollment form and sign it for him only if she has legal authority to act on his behalf,
such as power of attorney or guardianship. Otherwise, she would not be authorized to
complete the enrollment form on his behalf.
84. 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?
Answer: Mrs. Kumar's daughter should plan to visit during the Annual Election Period
(AEP) to help her mother complete her enrollment in a Part D plan. The AEP, which runs
from October 15th to December 7th each year, is the designated time when Medicare
beneficiaries can enroll in or make changes to their Part D prescription drug coverage for the
following year.
85. 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?
Answer: Yes, Mr. White can change to a different Part D plan during a Special Enrollment
Period (SEP) for dual eligible individuals. Being newly eligible for Medicaid qualifies him
for a Special Enrollment Period, during which he can make changes to his Medicare
coverage. He should review his options and select a Part D plan that best meets his current
prescription drug needs.
86. 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?
a. Enrollment requests can only be made in face-to-face interviews or by mail.
b. Telephone enrollment request calls must be recorded.

c. Telephonic enrollments must include all required elements necessary to complete an
enrollment.
d. The signature element must be completed via certified mail.
Answer: c. Telephonic enrollments must include all required elements necessary to complete
an enrollment.
Rationale:
Mrs. Parker can enroll in Senior Health's Medicare Advantage (MA) plan over the telephone,
provided that the telephonic enrollment process includes all the required elements necessary
to complete the enrollment. This means that during the telephone call, Mrs. Parker will need
to provide all the necessary information and consent required for enrollment. While some
plans may require additional steps or verification, such as recording the telephone call or
completing a signature element via certified mail, the essential aspect is that all required
elements for enrollment are fulfilled, which option c. specifies.
87. Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action
could you help him take during this time?
Answer: During his Medicare Advantage Initial Coverage Election Period (ICEP), you could
help Mr. Garrett enroll in a Medicare Advantage plan for the first time if he chooses to do so.
The ICEP occurs when an individual first becomes eligible for Medicare and has the
opportunity to enroll in a Medicare Advantage plan.
88. 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?
Answer: I would advise Mrs. Margolis to schedule a meeting with you closer to her Medicare
Initial Enrollment Period (IEP), which typically begins three months before her 65th birthday
and lasts for seven months. Since she is becoming eligible for Medicare in November, she
should plan to meet with you in August or September to discuss her plan choices and ensure
she enrolls in coverage that meets her needs.
89. 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?
Answer: Ms. Gonzales should be informed that there is indeed an open enrollment period
called the Medicare Advantage Open Enrollment Period (MA OEP), which runs from

January 1st to March 31st each year. During this period, individuals enrolled in a Medicare
Advantage plan can switch to another Medicare Advantage plan or return to Original
Medicare with or without a Part D plan. Since she missed the Annual Enrollment Period
(AEP), she may be able to use the MA OEP to make changes to her Medicare coverage if
desired.
90. 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?
Answer: I would advise Mr. Roberts to review his Medicare Advantage plan's coverage
details to determine if it includes post-acute care benefits, such as coverage for skilled
nursing facility care. He should also inquire about any rehabilitation or home health services
covered by his plan that may be needed after discharge. Additionally, if he experienced a
significant change in health status during his stay at Resthaven, he may qualify for a Special
Enrollment Period (SEP) to make changes to his Medicare coverage.
91. 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
(MAPD) plan. What should you say?
Answer: Prior to enrollment in a Medicare Advantage (MAPD) plan, it is essential to discuss
several key topics with the beneficiary. These topics include understanding the plan's
coverage benefits, costs, network providers, prescription drug coverage (if applicable),
limitations, and any additional benefits or services offered by the plan. It's also crucial to
review how the plan coordinates with other coverage, such as Medicaid or employersponsored insurance, and to ensure the beneficiary understands their rights and
responsibilities under the plan.
92. 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?
Answer: Mr. Johannsen's eligibility for the Part D low-income subsidy (LIS) may affect his
ability to enroll or disenroll in a Part D plan outside of the Annual Election Period (AEP).
Specifically, he may qualify for a Special Enrollment Period (SEP) to enroll in a Part D plan
or switch to a different plan at any time throughout the year. This special enrollment
opportunity allows beneficiaries with LIS to make changes to their Part D coverage outside
of the typical enrollment periods.

93. 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?
Answer: In response to Mrs. Midler's suggestion about having her medical records available,
you should thank her for her willingness to share information and assure her that you are
there to help her understand her options and make informed decisions about her Medicare
coverage. However, it's important to clarify that you are not a healthcare provider and cannot
interpret medical records or provide medical advice. Instead, you can use the information she
provides to better understand her healthcare needs and preferences as they relate to Medicare
coverage options.
94. 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)?
Answer: Mr. Rockwell should be informed that losing creditable prescription drug coverage
through his employer qualifies him for a Special Enrollment Period (SEP) to enroll in a
Medicare Part D plan. This SEP allows him to enroll in a Part D plan or switch to a different
plan within two months of losing his employer coverage. He should also be advised to review
available Part D plans to ensure he selects one that best meets his prescription drug needs
and budget.
95. 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?
Answer: You should inform the client that enrollment applications for Medicare Advantage
and Part D plans cannot be accepted before the start of the Annual Election Period (AEP),
which runs from October 15th to December 7th each year. Advising him to wait until the
AEP begins to submit his application ensures compliance with CMS regulations and ensures
that his enrollment is processed appropriately.
96. 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?
Answer: Myra can enroll in a Medicare Advantage (MA) plan during the Annual Election
Period (AEP), which runs from October 15th to December 7th each year. Since she is
currently enrolled in Original Medicare, she can use the AEP to switch to a Medicare
Advantage plan that better suits her healthcare needs and preferences. It's important for her
to review available MA plans in her area to find one that offers the benefits and coverage
options she desires.
97. 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?
Answer: Mr. Ziegler can enroll in a Part D plan during his Initial Enrollment Period (IEP)
for Part D, which typically begins three months before his 65th birthday, includes his birthday
month, and continues for three months afterward. If he misses his IEP, he can also enroll
during the Annual Election Period (AEP), which runs from October 15th to December 7th
each year.
98. Edna, Felix, George, and Harriet are Medicare beneficiaries. Edna lives in an area that
has suffered from major flooding that has been declared a major disaster by both the Federal
government and her state. As a result of dealing with the flooding issues and being evacuated
from her home, Edna missed her chance to enroll in MA during her Initial Coverage Election
Period. Felix lives in an area with a Medicare Advantage plan with a 4-star rating that he
would like to join. George dropped his Medigap policy six months ago when he first enrolled
in a Medicare Advantage plan. He now wants to return to Original Medicare. Harriet has
recently developed diabetes and would like to enroll in a Medicare Advantage plan that
focuses on care for those with that disease. Which, if any, of these individuals would qualify
for a special election period (SEP)?
Answer: Among the individuals mentioned:
• Edna may qualify for a Special Election Period (SEP) due to being affected by a major
disaster, allowing her to enroll in a Medicare Advantage plan outside of her Initial Coverage
Election Period (ICEP).
• Felix may not qualify for a SEP based solely on the star rating of a plan.
• George qualifies for a SEP to return to Original Medicare since he voluntarily dropped his
Medigap policy when he first enrolled in a Medicare Advantage plan.
• Harriet may qualify for a SEP to enroll in a Medicare Advantage plan that specifically
focuses on care for individuals with diabetes if such a plan is available in her area.

99. You are doing a sales presentation for Mrs. Pearson. You know that Medicare marketing
guidelines prohibit certain types of statements. Apply those guidelines to the following
statements and identify which would be prohibited.
Answer: Prohibited Statement: "This plan covers all your medical needs without any out-ofpocket costs."
Prohibited Statement: "Medicare guarantees you will never have to pay for medical services
again."
Permitted Statement: "This plan offers comprehensive coverage for a range of medical
services, but it's essential to review the details of the plan to understand any out-of-pocket
costs you may incur."
100. 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?
Answer: Mrs. Gonzalez should be informed that she can switch her existing Medigap plan
to one that includes prescription drug coverage during the Medicare Advantage Open
Enrollment Period (MA OEP), which runs from January 1st to March 31st each year. During
this period, she can switch from her current Medigap plan to a Medicare Advantage plan with
prescription drug coverage, ensuring she has comprehensive coverage for both medical
services and prescription drugs.
101. Mr. Polanski likes the cost of an HMO plan available in his area but would like to be
able to visit one or two doctors who aren't participating providers. He wants to know if the
Point of Service (POS) option available with some HMOs will be of any help in this situation.
What should you tell him?
Answer: The Point of Service (POS) option available with some HMOs allows members to
visit out-of-network providers for certain services, typically at a higher cost compared to innetwork providers. However, it's essential to review the specific details of the POS option
offered by the HMO plan to determine if it meets Mr. Polanski's needs. He should consider
factors such as the availability of the POS option, the associated costs, and any limitations or
restrictions on out-of-network coverage. Additionally, Mr. Polanski should confirm whether
his desired doctors are considered out-of-network providers and how their services would be
covered under the POS option.
102. Able, Baker, and Charles are engaged in the marketing to and enrollment of beneficiaries
into Medicare health plans. Mr. Able is an independent agent paid directly by a health plan.
Ms. Baker is an independent agent paid through a field marketing organization (FMO). Mr.

Charles is an independent agent paid for his work by a third-party marketing organization
(TMO). How do the CMS compensation rules apply to these three agents?
Answer: • Mr. Able, as an independent agent paid directly by a health plan, must comply
with CMS compensation rules, which generally prohibit receiving compensation that varies
based on the plan or coverage chosen by the beneficiary.
• Ms. Baker, as an independent agent paid through a field marketing organization (FMO),
must also adhere to CMS compensation rules. The FMO must ensure that compensation
received by Ms. Baker complies with CMS guidelines, including prohibitions on
compensation that varies based on the plan selected by the beneficiary.
• Mr. Charles, as an independent agent paid by a third-party marketing organization (TMO),
must likewise comply with CMS compensation rules. The TMO must ensure that
compensation provided to Mr. Charles is consistent with CMS regulations to avoid any
violations related to varying compensation based on the plan chosen by the beneficiary.
103. Mr. Landry is approaching his 65th birthday. He has signed up for Medicare Part A, but
he did not enroll in Part B because he has employer-sponsored coverage and intends to keep
working for several more years. But he is considering enrolling in Part D prescription drug
coverage because he believes it is superior to his employer plan. How would you advise him?
Answer: I would advise Mr. Landry that enrolling in Part D prescription drug coverage while
maintaining his employer-sponsored coverage is permissible and may provide him with
additional medication coverage options. However, he should carefully review the details of
his employer plan and compare it with available Part D plans to ensure that enrolling in Part
D would indeed offer superior coverage for his prescription drug needs. Additionally, he
should consider factors such as premiums, copayments, formularies, and pharmacy networks
when making his decision.
104. Who is most likely to be eligible to enroll in a Part D prescription drug plan?
Answer: Individuals who are eligible for Medicare Part A or Part B are most likely to be
eligible to enroll in a Part D prescription drug plan. This includes individuals aged 65 and
older, individuals under 65 with certain disabilities, and individuals of any age with EndStage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
105. Ms. Bushman has two homes in different states and is concerned about restrictions on
where she can get her medications. What should you tell her?
Answer: Ms. Bushman should be informed that Medicare Part D prescription drug plans
typically have a nationwide network of pharmacies, allowing beneficiaries to fill their
prescriptions at participating pharmacies across the United States. Therefore, she should be

able to obtain her medications at any pharmacy within the Part D plan's network, regardless
of which state she is currently residing in. It's important for her to verify the network
pharmacies available under her specific Part D plan to ensure coverage wherever she may be
located.
106. Which of the following statements best describes Section 1557 of the Affordable Care
Act (ACA)?
Answer: Statement: Section 1557 of the Affordable Care Act (ACA) prohibits discrimination
on the basis of race, color, national origin, sex, age, or disability in certain health programs
and activities. It aims to ensure that individuals have equal access to healthcare services and
benefits without facing discrimination based on protected characteristics.
107. Under ACA Section 1557, a health plan premium sold through a state exchange may,
based on an individual's age and charge higher premiums As a result of violations of ACA
Section 1557 non discrimination rules, a health plan may revoke an agent or broker's
appointment with the health plan. Which Medicare programs are covered by ACA Section
1557 under the Biden Administration's Proposed Rule?
Answer: Under the Biden Administration's Proposed Rule, all Medicare programs, including
Medicare Advantage (Part C) and Medicare Part D plans, are covered by ACA Section. This
means that these programs must comply with the non-discrimination rules outlined in Section
1557, including provisions related to premiums, benefits, and access to healthcare services
without discrimination based on protected characteristics.
108. Which of these actions is most likely to be permitted in dealing with a person with
limited English proficiency?
Answer: The most likely permitted action in dealing with a person with limited English
proficiency is to provide language assistance services, such as interpretation or translation
services, to ensure effective communication. This may include offering information and
documents in the individual's preferred language, providing access to qualified interpreters
during interactions, and ensuring that language assistance is available at no cost to the
individual. Effective communication is essential to ensure that individuals with limited
English proficiency can fully understand their Medicare options and make informed
decisions about their healthcare coverage.
109. Under Section 1557, the 2020 Final Rule issued during the Trump Administration sex
was initially defined _________
Answer: male or female as determined by biology.
Rationale:

Under Section 1557, the 2020 Final Rule issued during the Trump Administration initially
defined sex as male or female as determined by biology. This definition was controversial
and faced legal challenges due to its exclusion of gender identity and transgender individuals.
However, it's worth noting that this definition was later reversed under the Biden
Administration's Proposed Rule, which aimed to redefine sex to include gender identity and
sexual orientation, aligning with the broader understanding of discrimination based on sex.
110. Which of the following statements best describes the scope of operations subject to
Section 1557 under the Proposed Rule of the Biden Administration?
Answer: Under the Proposed Rule of the Biden Administration, Section 1557 applies to all
operations of any health program or activity that receives funding from or is administered by
the Department of Health and Human Services (HHS). This includes entities such as
hospitals, clinics, nursing homes, health insurance companies, and any other healthcarerelated entity that receives federal financial assistance from HHS.
111. Which entity enforces Section 1557 for programs that receive funding from on are
administered by HHS?
Answer: The entity responsible for enforcing Section 1557 for programs that receive funding
from or are administered by the Department of Health and Human Services (HHS) is the
Office for Civil Rights (OCR) within HHS. OCR is tasked with ensuring compliance with
Section 1557's non-discrimination provisions and investigating complaints of discrimination
based on race, color, national origin, sex, age, or disability in healthcare programs and
activities covered by the law.
112. 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:
a. large print materials
b. qualified sign language interpreters
c. braille materials and displays
d. screen reader
e. All the above
Answer: e. All the above
Rationale:
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. These
aids and services are essential for ensuring effective communication and equal access to

information. The options listed (a) large print materials, (b) qualified sign language
interpreters, (c) braille materials and displays, and (d) screen reader, are all examples of
auxiliary aids and services commonly used to accommodate individuals with disabilities and
facilitate communication. Therefore, all of the options provided are correct.
113. For a health plan, what are the possible consequences of violations of ACA Section
1557?
Answer: For a health plan, violations of ACA Section 1557 could result in several possible
consequences, including:
•Civil monetary penalties imposed by the Department of Health and Human Services (HHS)
Office for Civil Rights (OCR).
•Corrective action plans requiring the health plan to remedy the discriminatory practices and
implement measures to prevent future violations.
•Loss of federal funding for the health plan's programs or activities found to be in violation
of Section 1557.
•Legal action brought by individuals or advocacy groups alleging discrimination, which
could result in financial settlements, damages, or injunctive relief against the health plan.
114. 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?
Answer: In this situation, it is important to adhere to ethical and legal standards. Ignoring
the Sponsor's process and adjusting or adding risk diagnosis codes for certain individuals as
directed by the immediate supervisor could constitute fraudulent activity. It is essential to
refuse to comply with such instructions and report the incident to appropriate authorities
within the organization, such as compliance officers or human resources. Additionally,
reporting the incident to higher management or regulatory agencies, such as the Centers for
Medicare & Medicaid Services (CMS), may be necessary to ensure compliance and integrity
in data reporting processes.
115. 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?
Answer: If there are concerns about possible forgery regarding a prescription, the next step
would be to follow established protocols and procedures for handling suspected fraudulent
prescriptions. This may include notifying the pharmacist in charge or the pharmacy manager,

contacting the prescriber to verify the prescription, and documenting any suspicions or
concerns. Additionally, the prescription should not be dispensed until its authenticity has
been confirmed through appropriate channels.
116. Which of the following is NOT potentially a penalty for violation of a law or regulation
prohibiting fraud, waste, and abuse (FWA)?
Answer: Not potentially a penalty for violation of a law or regulation prohibiting fraud,
waste, and abuse (FWA): •Being required to complete additional training or education on
compliance and ethics.
117. Which of the following requires intent to obtain payment and the knowledge the actions
are wrong?
Answer: Intent to obtain payment and the knowledge that the actions are wrong are typically
required for actions to be considered fraudulent. Therefore, the element described in the
question is associated with the concept of intent and knowledge in the context of fraud.
118. You are performing a regular inventory of the controlled substances in the pharmacy.
You discover a minor inventory discrepancy. What should you do?
Answer: In the event of a minor inventory discrepancy of controlled substances, it is
essential to follow established protocols and procedures for handling such situations. This
may include conducting a thorough investigation to identify the cause of the discrepancy,
documenting findings, and implementing corrective measures to prevent future
discrepancies. Additionally, any discrepancies should be reported to the appropriate
authorities, such as the pharmacist in charge, pharmacy manager, or regulatory agencies, in
accordance with applicable laws and regulations.
119. 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?
Answer: In this scenario, the discovery of significant disparities in claims submitted by Doe
Diagnostics compared to other diagnostic providers warrants further investigation. It is
crucial to review the claims submitted by Doe Diagnostics carefully, including verifying the
accuracy and legitimacy of the services provided. If suspicions of fraudulent or inappropriate
billing practices arise, appropriate actions should be taken, such as initiating a comprehensive
audit of Doe Diagnostics' claims, notifying relevant compliance or fraud investigation
departments within the organization, and reporting concerns to regulatory authorities, such

as the Centers for Medicare & Medicaid Services (CMS) or the Office of Inspector General
(OIG).
120. 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.
Answer: True
Rationale:
Abuse in the context of healthcare billing involves situations where payment is made 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. This definition
underscores the importance of adhering to legal and ethical standards in billing practices to
ensure that payments are made only for services that are medically necessary and properly
documented. Instances of abuse can result in financial losses to healthcare programs and may
also compromise patient care.
121. 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.
Answer: True
Rationale:
Bribes or kickbacks of any kind in exchange for services that are paid under a Federal
healthcare program, including Medicare, constitute fraud by both the person making and the
person receiving them. This prohibition is enforced to maintain the integrity of Federal
healthcare programs, prevent improper financial incentives in healthcare transactions, and
safeguard taxpayer funds. Any form of bribery or kickback undermines the principles of fair
and transparent healthcare delivery and can lead to significant legal and financial
consequences for all parties involved.
122. 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
Answer: e. All of the above
Rationale:

Reporting potential fraud, waste, and abuse (FWA) is essential for maintaining the integrity
of healthcare programs and protecting patients and taxpayers. Various methods are available
for reporting such concerns, including telephone hotlines, mail drops, and in-person reporting
to the compliance department or supervisor. Additionally, many healthcare organizations
have Special Investigative Units (SIUs) dedicated to investigating allegations of FWA. By
providing multiple reporting options, individuals are encouraged to come forward with any
suspicions or observations of FWA, ensuring that appropriate action can be taken to address
and prevent such activities. Therefore, the correct answer is "All of the above."
123. 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
Answer: True
Rationale:
By engaging in the listed actions, individuals can help prevent fraud, waste, and abuse (FWA)
within healthcare systems. Looking for suspicious activity, conducting oneself ethically,
ensuring accurate billing and data, coordinating with other payers, staying updated on
policies and procedures, and verifying information all contribute to maintaining integrity and
transparency in healthcare practices.
124. 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.
Answer: True
Rationale:
Issues such as suspected fraud, waste, and abuse (FWA), potential health privacy violations,
unethical behavior, and employee misconduct should indeed be reported to a Compliance
Department. Reporting these concerns is crucial for addressing and preventing misconduct,
protecting patient privacy, and upholding ethical standards within healthcare organizations.
125. Once a corrective action plan is started, the corrective action plan must be monitored
annually to ensure they are effective.

Answer: False
Rationale:
Once a corrective action plan is initiated, it must be monitored regularly to ensure its
effectiveness. Monitoring typically involves assessing whether the plan's objectives are being
met, identifying any new issues or challenges, and making adjustments to the plan as
necessary. Monitoring should be ongoing rather than limited to an annual basis to promptly
address any emerging issues.
126. Waste includes any misuse of resources, such as the overuse of services or other
practices that directly or indirectly result in unnecessary costs to the Medicare Program.
Answer: True
Rationale:
Waste in healthcare includes any misuse or squandering of resources, such as overusing
services or engaging in practices that result in unnecessary costs to the Medicare Program.
Identifying and addressing waste is essential for ensuring the efficient use of resources and
maximizing the value of healthcare services provided.
127. What are some of the penalties for violating fraud, waste, and abuse (FWA) laws?
a. Civil Monetary Penalties
b. Imprisonment
c. Exclusion from participation in all Federal health care
programs
d. All of the above
Answer: d. All of the above
Rationale:
Violating fraud, waste, and abuse (FWA) laws can result in various penalties, including civil
monetary penalties, imprisonment, and exclusion from participation in all Federal healthcare
programs. These penalties are imposed to deter improper conduct, protect patients and
taxpayers, and maintain the integrity of healthcare systems. Civil monetary penalties may
involve financial fines, imprisonment can result from criminal charges, and exclusion from
Federal healthcare programs can prohibit individuals or entities from participating in
Medicare, Medicaid, and other government-funded healthcare programs. Therefore, the
correct answer is "All of the above."
128. Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA)
include the Health Insurance Portability and Accountability Act (HIPAA), the Civil False
Claims Act, the Anti-Kickback Statute, and the Criminal Health Care Fraud Statute.

Answer: True
Rationale:
The laws mentioned—Health Insurance Portability and Accountability Act (HIPAA), the
Civil False Claims Act, the Anti-Kickback Statute, and the Criminal Health Care Fraud
Statute—are indeed among the key statutes governing fraud, waste, and abuse (FWA) in
Medicare Part C and Part D programs. Each of these laws addresses different aspects of FWA,
such as false claims submission, kickbacks, patient privacy violations, and healthcare fraud.
Compliance with these laws is essential for ensuring the integrity of Medicare programs and
protecting patients and taxpayers from fraudulent activities. Therefore, the statement is true.
129. You work for a Sponsor. Last month, while reviewing a Centers for Medicare &
Medicaid Services (CMS) monthly report, you identified multiple individuals not enrolled in
the plan but for whom the Sponsor is paid. You spoke to your supervisor who said don't worry
about it. This month, you identify the same enrollees on the report again. What should you
do?
Answer: In this situation, if the same issue persists despite bringing it to the attention of your
supervisor, it is essential to escalate the matter to higher levels of management within the
Sponsor organization. Document the repeated occurrence of individuals not enrolled in the
plan but for whom the Sponsor is being paid, along with your previous communication with
your supervisor. Express your concerns regarding the potential implications of this
discrepancy and emphasize the importance of addressing and rectifying the issue to ensure
compliance with CMS regulations and integrity in payment processes.
130. A sales agent, employed by the Sponsor's first-tier, downstream, or related entity (FDR),
submitted an application for processing and requested two things: 1) to back-date the
enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary.
What should you do?
Answer: When faced with a sales agent's request to back-date the enrollment date and waive
monthly premiums for a beneficiary, it is crucial to adhere to CMS guidelines and the
Sponsor's policies and procedures. Back-dating enrollment dates and waiving premiums may
constitute fraudulent activity and violate CMS regulations. Therefore, the appropriate action
would be to refuse the request, document the request and the reasons for refusal, and report
the incident to compliance officers or other appropriate authorities within the Sponsor
organization. Additionally, the sales agent's behavior may warrant further investigation and
disciplinary action in accordance with the Sponsor's policies and procedures.

131. You discover an unattended email address or fax machine in your office receiving
beneficiary appeals requests. You suspect no one is processing the appeals. What should you
do? Contact your compliance department (via compliance hotline or other mechanism)
Correcting non-compliance_________
Answer: Contacting your compliance department (via compliance hotline or other
mechanism) is the correct course of action.
Rationale:
Discovering an unattended email address or fax machine receiving beneficiary appeals
requests raises concerns about potential non-compliance with processing these appeals in a
timely manner. Contacting the compliance department is essential because they are
responsible for ensuring that the organization operates in accordance with applicable laws,
regulations, and internal policies. Reporting this issue promptly allows the compliance
department to investigate the situation, take corrective action if necessary, and ensure that
beneficiary appeals are processed appropriately. Correcting non-compliance helps maintain
the integrity of the organization's operations and promotes adherence to regulatory
requirements. Therefore, contacting the compliance department is the most appropriate
action to address this situation.132. What is the policy of non-retaliation?
Answer: The policy of non-retaliation ensures that individuals who report compliance
concerns, violations, or unethical behavior are protected from retaliation or adverse
consequences as a result of their actions. This policy promotes a culture of transparency,
accountability, and integrity within an organization by encouraging employees to speak up
about potential issues without fear of reprisal. Non-retaliation policies typically include
provisions prohibiting retaliation in any form, such as termination, demotion, harassment, or
discrimination, against individuals who report concerns in good faith.
133. Standards of Conduct are the same for every Medicare Parts C and D sponsor.
Answer: False
Rationale:
Standards of Conduct may vary slightly among Medicare Parts C and D sponsors based on
their specific organizational structures, policies, and risk assessments. While there are
overarching compliance requirements set by CMS (Centers for Medicare & Medicaid
Services), sponsors may implement additional standards tailored to their operations.
134. At a minimum, an effective compliance program includes four core requirements.
Answer: False
Rationale:

An effective compliance program typically includes more than four core requirements. While
there are essential components commonly found in compliance programs, such as policies
and procedures, training and education, monitoring and auditing, and reporting and
investigation mechanisms, the number of core requirements may vary depending on
regulatory guidelines and industry best practices.
135. Compliance is the responsibility of the Compliance Officer, Compliance Committee,
and Upper Management only.
Answer: False
Rationale:
Compliance is not solely the responsibility of the Compliance Officer, Compliance
Committee, and Upper Management. While they play crucial roles in overseeing compliance
efforts and establishing a culture of compliance within an organization, compliance is a
shared responsibility that extends to all employees and stakeholders. Every individual within
the organization has a role to play in upholding ethical standards and adhering to regulatory
requirements.
136. These are examples of issues that can be reported to a Compliance Department:
suspected fraud, waste, and abuse (FWA), potential health privacy violation, and unethical
behavior/employee misconduct.
Answer: True
Rationale:
Suspected fraud, waste, and abuse (FWA), potential health privacy violations, and unethical
behavior/employee misconduct are indeed examples of issues that should be reported to a
Compliance Department. Reporting such concerns helps ensure accountability, address
wrongdoing, and maintain the integrity of healthcare operations.
137. Medicare Parts C and D sponsors are not required to have a compliance program.
Answer: False
Rationale:
Medicare Parts C and D sponsors are required to have a compliance program in place as part
of their obligations to participate in these programs. Compliance programs are essential for
identifying and addressing potential fraud, waste, and abuse, as well as ensuring adherence
to regulatory requirements and promoting ethical conduct.
138. Once a corrective action plan begins addressing non-compliance for fraud, waste, and
abuse (FWA) committed by a Sponsor's employee or first-tier, downstream, or related entity's
(FDR's) employee, ongoing monitoring of the corrective actions is not necessary.

Answer: False
Rationale:
Ongoing monitoring of corrective actions is necessary to ensure their effectiveness and
sustainability in addressing non-compliance for fraud, waste, and abuse (FWA). Monitoring
allows for the evaluation of whether the corrective actions are achieving their intended
outcomes, identifies any new issues or areas of concern, and facilitates adjustments to the
action plan as needed to mitigate risks and promote ongoing compliance.
139. What are some of the consequences for non-compliance, fraudulent, or unethical
behavior?
a. Disciplinary action
b. Termination of employment
c. Exclusion from participating kin all Federal health care programs
d. All of the above
Answer: d. All of the above
Rationale:
Consequences for non-compliance, fraudulent, or unethical behavior can include disciplinary
action, termination of employment, and exclusion from participating in all Federal healthcare
programs. These measures are implemented to hold individuals accountable for their actions,
deter misconduct, protect patients and taxpayer funds, and maintain the integrity of
healthcare programs. Disciplinary action may involve warnings, reprimands, or other
sanctions, while termination of employment may result from serious violations of policies or
regulations. Exclusion from participating in Federal healthcare programs, such as Medicare
and Medicaid, can have significant consequences for individuals or entities, including loss
of licensure and eligibility to receive reimbursement for services rendered. Therefore, the
correct answer is "All of the above."
140. Ways to report a compliance issue include:
a. Telephone hotlines
b. Report on the Sponsor's website
c. In-person reporting to the compliance department/supervisor
d. All of the above
Answer: d. All of the above
Rationale:
Reporting a compliance issue can be done through various channels to ensure accessibility
and confidentiality. Telephone hotlines provide a convenient and anonymous way for

individuals to report concerns. Reporting through the Sponsor's website allows for online
submission of complaints or observations. Additionally, in-person reporting to the
compliance department or supervisor enables direct communication and immediate attention
to the issue. Offering multiple reporting options encourages individuals to come forward with
their concerns and ensures that compliance issues can be addressed promptly and effectively.
Therefore, the correct answer is "All of the above."
141. 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?
Answer: Mary Samuels, who is residing in a rehabilitation hospital outside the geographic
area served by her current Medicare Advantage (MA) plan, may have several options
regarding her health plan coverage:
• She can explore whether her current MA plan offers out-of-network coverage or has a
network of affiliated providers in the area where the rehabilitation hospital is located.
• Mary can also consider switching to a new MA plan that has a broader network of providers,
including those in the area where the rehabilitation hospital is located.
• If she decides not to remain in a Medicare Advantage plan, Mary can choose to return to
Original Medicare (Parts A and B) and enroll in a standalone Part D prescription drug plan
to ensure coverage for her medication needs while in the rehabilitation hospital.
• Depending on her circumstances, Mary may also qualify for a Special Enrollment Period
(SEP) to make changes to her Medicare coverage due to her change in residence or health
status.
142. 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?

Answer: The opt-in simplified enrollment mechanism is available for individuals who are
already enrolled in a Medicare Advantage (MA) plan offered by the same organization as the
MA plan they are newly eligible to enroll in. In this scenario:
• Alice, who is currently enrolled in Spartan Health Plan offered by her employer, qualifies
for the opt-in simplified enrollment mechanism to enroll in Spartan Health Plan's MA plans
upon retirement.
• Bob, who previously had health coverage through Spartan Health Plan, also qualifies for
the opt-in simplified enrollment mechanism upon becoming newly eligible for Medicare to
enroll in Spartan Health Plan's MA plans.
• Charlotte, who has coverage through Athena Health Plan, does not qualify for the opt-in
simplified enrollment mechanism as she is not currently enrolled in Spartan Health Plan's
MA plans.
143. 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?
Answer: Mrs. Wu does not need to have worked and paid Medicare taxes herself to qualify
for Medicare Part A. Instead, she may be eligible for premium-free Medicare Part A based
on her spouse's work history if he paid Medicare taxes while employed. As a spouse of
someone who worked and paid Medicare taxes for a sufficient time, Mrs. Wu may be eligible
for Medicare Part A benefits based on her spouse's work record.
144. 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?
Answer: Mr. Nguyen should be informed that Medicare prescription drug plans establish
their formularies based on guidelines set forth by the Centers for Medicare & Medicaid
Services (CMS). These formularies are designed to provide coverage for a wide range of
prescription drugs while ensuring cost-effectiveness and quality of care. Plans must cover at
least two drugs in each therapeutic category and class, and they regularly review and update
their formularies based on factors such as safety, efficacy, and cost. Additionally, Medicare
beneficiaries have the right to request coverage determinations and appeals if they believe a
specific drug should be covered by their plan.

145. 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?
Answer: If a beneficiary is enrolled in a stand-alone prescription drug plan (Part D) and
wants to keep that plan, they could also enroll in a Medicare Supplement Insurance
(Medigap) plan without being automatically disenrolled from the stand-alone prescription
drug plan. Medigap plans provide additional coverage to help pay for out-of-pocket costs
associated with Original Medicare, such as copayments, coinsurance, and deductibles, but
they do not provide prescription drug coverage. Therefore, enrolling in both a stand-alone
prescription drug plan and a Medigap plan can provide comprehensive coverage for both
medical services and prescription drugs.
146. 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?
Answer: Permissible under Section 1557: Providing language assistance to limited English
proficiency (LEP) individuals, such as interpretation services or translated materials, free of
charge, to ensure effective communication and access to healthcare services.
147. 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.
Answer: False
Rationale:
While penalties for submitting false claims to the government can indeed be significant, the
statement incorrectly states the penalty amount as five times the government's damages
caused by the violator plus a penalty. In reality, under the False Claims Act (FCA),
individuals who knowingly submit false claims to the government may be liable for civil
penalties and damages. The penalties can range from thousands to millions of dollars per
false claim, with damages typically calculated based on the actual harm caused to the
government. However, there is no fixed multiplier of five times the government's damages
specified in the law. Penalties and damages are determined on a case-by-case basis, taking
into account various factors such as the nature and extent of the violation.
148. 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?

Answer: When putting together advertisements for an educational event sponsored by plans
and community organizations, it's important to ensure compliance with CMS guidelines and
regulations. Here's what you should do:
• Clearly disclose the sponsors of the event, including the names of the plans and community
organizations involved.
• Provide accurate and balanced information about Medicare, including coverage options,
benefits, and enrollment periods.
• Avoid making misleading or deceptive statements about Medicare plans or benefits.
• Include information about the purpose of the event, the topics that will be covered, and any
speakers or presenters.
• Clearly communicate the intended audience for the event, such as individuals approaching
Medicare eligibility or current Medicare beneficiaries.
• Include contact information or instructions for individuals interested in attending the event
or seeking more information.
149. 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?
Answer: Agent Willis can take several steps to attempt to regain the business of his former
clients during the Medicare Advantage Open Enrollment Period (MA-OEP):
• Reach out to his former clients to discuss their reasons for disenrolling from the plans he
represents and any concerns they may have with their current Medicare Advantage plans.
• Provide information about the benefits and features of the plans he represents, highlighting
how they may better meet his clients' needs.
• Assist his former clients in comparing different Medicare Advantage plans available to them
during the MA-OEP, including those offered by competitors.
• Help his former clients understand the enrollment process and any deadlines associated
with making changes to their Medicare coverage during the MA-OEP.
• Advocate for his former clients' best interests and provide personalized support to help them
make informed decisions about their Medicare coverage.
150. 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?

Answer: When asked about Private Fee-for-Service (PFFS) plans, you should inform Ms.
Sullivan that these plans are a type of Medicare Advantage plan that allows beneficiaries to
receive care from any Medicare-approved provider who accepts the plan's terms and
conditions. Here's what you should tell her about PFFS plans:
• PFFS plans offer flexibility in choosing healthcare providers, as beneficiaries are not
required to use a network of providers.
• Providers must agree to accept the plan's payment terms and conditions for each service
they provide to beneficiaries.
• PFFS plans may have different rules and coverage limitations compared to traditional
Medicare, so it's important for beneficiaries to review plan documents carefully.
• Not all areas may have PFFS plans available, so Ms. Sullivan should check if these plans
are offered in her location.
• Ms. Sullivan should also consider other types of Medicare Advantage plans, such as Health
Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), to
compare coverage options and costs.
151. 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?
Answer: Ms. Morris, who will be turning 65 and is entitled to Medicare Part A, can indeed
enroll in a Medicare Advantage (MA) plan that includes prescription drug coverage. Here's
what you should tell her:
• Medicare Advantage plans, also known as Medicare Part C, are offered by private insurance
companies approved by Medicare.
• Many Medicare Advantage plans include prescription drug coverage, also known as
Medicare Advantage Prescription Drug (MA-PD) plans.
• Ms. Morris can enroll in a Medicare Advantage plan that includes prescription drug
coverage during her Initial Enrollment Period (IEP) for Medicare, which begins three months
before the month of her 65th birthday and extends for three months after.
• Alternatively, if Ms. Morris delays enrolling in a Medicare Advantage plan during her Initial
Enrollment Period, she can enroll during the Annual Enrollment Period (AEP), which runs
from October 15th to December 7th each year.

• It's important for Ms. Morris to compare the coverage, costs, and network of providers
offered by different Medicare Advantage plans in her area to find the one that best meets her
healthcare needs and preferences.
152. 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?
Answer: Before conducting in-home presentations to market Medicare Advantage (MA)
plans, there are several steps you must take:
• Ensure that you are properly licensed and appointed to sell Medicare Advantage plans in
the states where you plan to conduct sales presentations.
• Familiarize yourself with the Medicare Advantage plans you represent, including their
benefits, coverage options, costs, and network of providers.
• Comply with all CMS marketing guidelines and regulations, including those related to
presentations, materials, and disclosures.
• Obtain any necessary approvals or certifications required by your agency or the insurance
companies you represent.
• Prepare educational materials and sales presentations that provide accurate and unbiased
information about Medicare Advantage plans and the enrollment process.
• Prioritize the needs and preferences of your clients, and tailor your presentations to address
their specific healthcare concerns and questions.
153. 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?
Answer: Regarding seeking approval for materials used to market Medicare Advantage
plans, I would advise Ms. Hernandez to:
• Check with the Centers for Medicare & Medicaid Services (CMS) and the insurance
companies she represents to understand any specific requirements or guidelines for
marketing Medicare Advantage plans.
• Ensure that her marketing materials comply with all applicable federal and state regulations,
including those related to accuracy, transparency, and consumer protection.
• Submit her marketing materials to the appropriate regulatory authorities, such as the State
Department of Insurance, for review and approval before using them to market Medicare
Advantage plans.

• Make any necessary revisions or updates to her materials based on feedback from regulatory
authorities to ensure compliance with applicable laws and regulations.
• Maintain records of the approval process and any communications with regulatory
authorities regarding her marketing materials for Medicare Advantage plans.
154. 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?
Answer: Ms. Gates, who has recently become dually eligible for Medicare and Medicaid,
may have concerns about how this will affect her prescription drug coverage. Here's what
you should tell her:
• As a dually eligible beneficiary, Ms. Gates may qualify for the Medicare Low-Income
Subsidy (LIS), also known as Extra Help, which helps cover the costs of prescription drugs
under Medicare Part D.
• Medicaid may also provide additional assistance with prescription drug coverage, including
covering drugs not covered by Medicare Part D plans or reducing out-of-pocket costs.
• It's important for Ms. Gates to review her current Medicare and Medicaid coverage to
understand how prescription drugs are covered and any benefits she may be eligible for.
• Ms. Gates can contact her Medicaid caseworker or the Social Security Administration to
inquire about her eligibility for Extra Help and how to apply for assistance with prescription
drug costs.
• Additionally, Ms. Gates should review her Medicare and Medicaid plan documents or
contact her plan administrators for specific details about her prescription drug coverage and
any applicable copayments or limitations.
155. 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?
Answer: Ms. Eisenberg has received a letter from her Medigap carrier informing her that her
drug coverage is not "creditable." Here's what you should tell her:
• The term "creditable coverage" refers to prescription drug coverage that is expected to pay,
on average, at least as much as Medicare's standard prescription drug coverage.
• If Ms. Eisenberg's Medigap plan provides prescription drug coverage that is not considered
creditable, it means that her drug coverage may not meet Medicare's standards for
prescription drug coverage.

• This notification is required by Medicare to inform beneficiaries that they may face a
penalty if they enroll in a Medicare Part D prescription drug plan later and do not have
creditable prescription drug coverage.
• Ms. Eisenberg should carefully review the letter from her Medigap carrier and consider her
options for obtaining creditable prescription drug coverage, such as enrolling in a Medicare
Part D plan or finding alternative coverage that meets Medicare's standards.
• It's important for Ms. Eisenberg to act promptly to avoid potential penalties and ensure she
has adequate prescription drug coverage going forward.
156. 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?
Answer: When Mr. Peters asks his agent to describe a stand-alone prescription drug plan
(Part D plan) that his neighbor told him about, the agent should:
• Provide Mr. Peters with information about stand-alone prescription drug plans (Part D
plans), including how they work, what they cover, and how to enroll.
• Explain that Part D plans are offered by private insurance companies approved by Medicare
and provide coverage for prescription drugs.
• Describe the process for comparing different Part D plans available in Mr. Peters' area,
including costs, formularies, pharmacies in the network, and any coverage limitations or
restrictions.
• Offer to assist Mr. Peters in comparing Part D plans to find the one that best meets his
prescription drug needs and budget.
• Provide impartial and accurate information to help Mr. Peters make an informed decision
about enrolling in a Part D plan.
157. 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?
Answer: No, offering gifts of nominal value to potential enrollees who call for more
information about a plan, and then offering additional gifts if they come to a marketing event,
where the combined value exceeds the nominal value, is not permissible according to CMS
guidelines. Even if each individual gift meets the definition of nominal value, the cumulative
value of the gifts cannot exceed the nominal value. This practice could be seen as an attempt
to incentivize enrollment, which is prohibited by CMS regulations.

158. Ms. Brooks has an aggressive cancer and would like to know if Medicare will cover
hospice services in case she needs them. What should you tell her?
Answer: You should inform Ms. Brooks that Medicare does cover hospice services for
beneficiaries who meet certain eligibility criteria. Here's what you should tell her:
• Medicare covers hospice care for beneficiaries who have been certified as terminally ill
with a life expectancy of six months or less if the illness runs its normal course.
• Hospice services covered by Medicare include medical and nursing care, medications for
symptom management and pain relief, medical equipment and supplies, and support services
for both the patient and their family.
• Medicare will cover hospice care provided in the patient's home, a hospice facility, a nursing
home, or a hospital.
• Ms. Brooks should discuss her specific needs and preferences with her healthcare provider
to determine if hospice care is appropriate for her situation and to initiate the process of
enrolling in hospice care if needed.
• It's important for Ms. Brooks to understand her rights and options regarding hospice care,
including how Medicare covers these services and any out-of-pocket costs she may incur.