Category 1
Bill calls in about an MAPD plan and wants to know the difference between a HMO and a PPO plan. What can you advise?
PPO plans have some Out-of-Network coverage, along with their In-network coverage, while HMOs you only have the In-network coverage available. Also, in HMO’s you need a referral to see a specialist while in a PPO you do not need that.
For 2022, what is the Maximum - out - of - Pocket (MOOP) for in-network services?
$7,550
You take down a client’s list of doctors and notice one of them is not listed in the client’s HMO plan’s network that you picked for the client. What would happen if the client visited this doctor under this plan?
Since they are not in-network, the plan will not cover them so the client will be responsible for the full cost of that doctor visit.
A consumer calls in wanting to get a Medicare Advantage plan but informs you they only have Medicare part B at the time. What can you advise?
To enroll in a Medicare Advantage plan, you will need both Part A and Part B so they can not enroll in a plan until they get Part A as well.
Thomas would like a Medicare Advantage plan, does he need to pay his Part B premium?
Yes, you must keep and pay for your Part B premium to get an MAPD
After talking to a client, you discover they are also covered fully under Medicaid as well as Medicare. What type of MAPD plan would you try to find them?
A Dual Special Needs Plan (D-SNP) - these are designed for those with Medicaid and Medicare.
A client with ESRD calls in wanting to look at their health plan options. He is worried that his health status may inhibit him from enrolling in a MAPD. What would your response be?
As of 2021. ESRD is not a restriction for clients to be able to enroll in a MAPD plan and ca enroll in any plan they choose.
There is another name for Medicare Advantage plans that relates it back to Medicare. What is this other name?
It is also known as Part C of Medicare.
Ben has diabetes, a chronic condition, and wants an MAPD. What plan type could Ben qualify for?
Chronic Special Needs Plan (C-SNP)
Joshua has a PFFS plan, can he enroll in a stand alone Part D plan?
Yes (as long as his PFFS plan does NOT include drug coverage)
A client calls in wanting to know more about the Part B giveback that is being advertised on some Medicare Advantage plans and you have some plans in their area that offer it. You find out they have Medicaid which is paying their Part B premium currently. Should you enroll them in this plan still for the giveback?
No, you should not. The giveback is intended to only pay for the premium of Part B that is taken out of their Social Security check. If they are not paying that premium currently, there is nothing to refund back so the benefit is null and void.
There are 4 main types of Medicare Advantage plans. What are they?
HMO, PPO, PFFS, SNP
You are speaking to a client that has Medicare as well as VA benefits where he is able to get his medication through the VA and is not interested in any plan that adds in additional prescription drug coverage. What type of plan would you look at for this consumer?
A MA-only plan. This is just a Medicare Advantage plan only with no prescription drug coverage. These are designed for those who have other creditable drug coverage such as VA benefits and still provide added health and medical benefits without the prescription coverage.
You are speaking with a husband and wife who are snow birds that spend 8 months of the year in up-state New York and then other months down in Florida. They are looking at some other MAPD plans to add on their coverage. What type of plan would you recommend for them?
A PPO- plan, this will provide some out-of-network coverage for them when they travel.
When reviewing plan options with a client, where is the appropriate place to quote plan details?
Sunfire/Summary of Benefits
Medicare has no maximum limit that members may have to pay for medical services under Original Medicare. What do all Medicare Advantage plans have to combat and help with this?
Maximum out of Pockets (MOOP’s) - this is a maximum amount a client would have to pay out of their own pocket under the plan.
A client calls in and is looking at Medicare Advantage plans. They tell you they have chronic diabetes though and it is something important that they would need covered. Based on this, what type of plan would you try to find for this client?
A Chronic-Special-Needs-Plan (C-SNP) - these are specialized plans designed for those who have Medicare and a chronic health condition.
Who are Medicare Advantage plans offered by?
They are offered by private insurance carriers who are contracted by and through Medicare.
Under Original Medicare, there are deductibles for both Part A and Part B. What happens to these deductibles if a client were to enroll into a Medicare Advantage plan?
The deductible for the Medicare Advantage plan is what they would pay.
When Using a Special election period (SEP) what date will the new plan begin and take effect?
The first of the next month
A consumer calls in wondering about a MAPD. Throughout their conversation they say that they want to make sure they keep Original Medicare so they can use that as a backup to use when they visit a doctor that is out-of-network for the Medicare Advantage plan that you are working with. What can you advise?
Under a MAPD plan, all health benefits go through the Medicare Advantage plan and you will no longer be able to use just Original Medicare. (Review this concern)
Maye's MA plan has in and out of network services that is covered, she doesn't need a referral for a specialist, and she generally pays higher cost for out of network services. What plan type does Maye have?
A PPO Plan
A customer is asking some questions about an MAPD HMO plan. She asks if there is an emergency while she is out of town, what kind of coverage would she have since these plans have networks?
All Medicare advantage plans provide coverage for medical emergencies that occur outside of the network. Anything else out of network would not be covered, but emergencies will be.
What would you advise a client who calls to enroll into a plan during AEP in October asking if they plan could go into effect as early as the next month of November?
All plans sold during AEP (under the enrollment code of AEP) will go into effect the following January first (2022 AEP = Jan 1st, 2023).
True or False: Dental, vision, hearing and chiropractic services to name a few, are not covered under Original Medicare, unlike most MA plan.
True