(W) Mr. Wells is trying to understand the difference between Original Medicare and Medi-
care Advantage. What would be a correct description? - ANSWER Medicare Advantage is
a way of covering all of the Original Medicare benefits through private health insurance
companies.
Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but is
not sure about what type of plan designs are available through this program. What should
you tell him about the types of health plans that are available through the Medicare Ad-
vantage program? - ANSWER They are Medicare health plans such as HMOs, PPOs, PFFS,
SNPs, and MSAs
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 A
PFFS plan is one of various types of Medicare Advantage plans offered by private entities and
she may enroll in one if it is available in her area.
(W) Mrs. Radford asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her? - ANSWER Mrs. Radford must be entitled to Part A
and enrolled in Part B to enroll in Medicare Advantage
(W) Mrs. Billings enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her
doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does
Mrs. Billings have in regard to her MA plan during the next open enrollment season? - AN-
SWER She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for in-
dividuals suffering from ESRD if one is available in her area
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently
stopped paying his Part B premium. He would like to enroll in a Medicare Advantage (MA)
1
,plan and is still covered by Part A. What should you tell him? - ANSWER He is not eligible
to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him? - ANSWER In most Medicare Advantage
HMOs, Mr. Kumar must obtain his services only from providers who have a contractual rela-
tionship with the plan (except in an emergency).
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which pro-
viders she can go to for her health care. What should you tell her? - ANSWER Mrs. Ramos
can obtain care from any provider who participates in Original Medicare, but generally will
be charged a lower co-payment if she goes to one of the plan's preferred providers.
Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has re-
ceived under Original Medicare, but he would like to know more about Medicare Advantage
Special Needs Plans (SNPs). What could you tell him? - ANSWER SNPs have special pro-
grams for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription
drug coverage that could be very helpful as well
(W) 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 SNPs limit enrollment
to certain sub-populations of beneficiaries. Given his current situation, he is unlikely to qual-
ify and would not be able to enroll in the SNP.
(W) 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 Most individuals who are citizens and over age 65 are covered under Part
A by virtue of having paid Medicare taxes while working, though some may be covered as a
result of paying monthly premiums.
2
,(W) Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the So-
cial Security Administration and has been receiving disability payments. He is wondering
whether he can obtain coverage under Medicare. What should you tell him? - ANSWER
After receiving such disability payments for 24 months, he will be automatically enrolled in
Medicare, regardless of age.
(W) 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 Medi-
care taxes. What should you tell her? - ANSWER In order to obtain Part B coverage, she
must pay a standard monthly premium, though it is higher for individuals with higher in-
comes
(W) Mr. Davis is 49 years old and has been receiving disability benefits from the Social Secu-
rity Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescrip-
tion Drug policy? - ANSWER No, he cannot purchase a Medicare Advantage or Part D pol-
icy because he has not received Social Security or Railroad Retirement disability benefits for
24 months.
(W) 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 will not pay any penalty because he
had continuous coverage under his employer's plan.
(W) 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 cover-
age. What can you tell her? - ANSWER She may enroll at any time while she is covered
under her employer plan, but she will have a special eight-month enrollment period that dif-
fers from the standard general enrollment period, during which she may enroll in Medicare
Part B
(W) Mrs. Kelly is entitled to Part A, but is not yet enrolled in Part B. She is considering enroll-
ment in a Medicare health plan. What should you advise her to do before she will be able to
enroll into a Medicare health plan? - ANSWER In order to join a Medicare health plan,
she also must enroll in Part B
3
, (W) Mr. Yu has limited income and resources so you have encouraged him to see if he quali-
fies for some type of financial assistance. Mr. Yu is not sure it is worth the trouble to apply
and wants to know what the assistance could do for him if he qualifies. What could you tell
him? - ANSWER He might qualify for help with Part D prescription drug costs and help
paying Part A and/or Part B premiums, deductibles, and/or cost sharing.
Mrs. Park has a low, fixed income. What could you tell her that might be of assistance? - AN-
SWER She should contact her state Medicaid agency to see if she qualifies for one of sev-
eral programs that can help with Medicare costs for which she is responsible
(W) Mr. Patel is in good health and is preparing a budget in anticipation of his retirement
when he turns 66. He wants to understand the health care costs he might be exposed to un-
der Medicare if he were to require hospitalization as a result of an illness. In general terms,
what could you tell him about his costs for inpatient hospital services under Original Medi-
care? - ANSWER Under Original Medicare, there is a single deductible amount due for
the first 60 days of any inpatient hospital stay, after which it converts into a per-day amount
through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime,
after which he would be responsible for all costs
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being suc-
cessfully treated for that condition. However, she and her physicians feel that after her
lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What
should you tell them about Original Medicare's coverage of care in a skilled nursing facility? -
ANSWER Medicare will cover Mrs. Shields' skilled nursing services provided during the
first 20 days of her stay, after which she would have a coinsurance until she has been in the
facility for 100 days.
(W) Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be
hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an
inpatient psychiatric hospital stay that Medicare will cover? - ANSWER Medicare will
cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime.
Mrs. Quinn has just turned 65 and received a letter informing her that she has been auto-
matically enrolled in Medicare Part B. She wants to understand what this means. What
4
care Advantage. What would be a correct description? - ANSWER Medicare Advantage is
a way of covering all of the Original Medicare benefits through private health insurance
companies.
Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but is
not sure about what type of plan designs are available through this program. What should
you tell him about the types of health plans that are available through the Medicare Ad-
vantage program? - ANSWER They are Medicare health plans such as HMOs, PPOs, PFFS,
SNPs, and MSAs
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 A
PFFS plan is one of various types of Medicare Advantage plans offered by private entities and
she may enroll in one if it is available in her area.
(W) Mrs. Radford asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her? - ANSWER Mrs. Radford must be entitled to Part A
and enrolled in Part B to enroll in Medicare Advantage
(W) Mrs. Billings enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her
doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does
Mrs. Billings have in regard to her MA plan during the next open enrollment season? - AN-
SWER She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for in-
dividuals suffering from ESRD if one is available in her area
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently
stopped paying his Part B premium. He would like to enroll in a Medicare Advantage (MA)
1
,plan and is still covered by Part A. What should you tell him? - ANSWER He is not eligible
to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him? - ANSWER In most Medicare Advantage
HMOs, Mr. Kumar must obtain his services only from providers who have a contractual rela-
tionship with the plan (except in an emergency).
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which pro-
viders she can go to for her health care. What should you tell her? - ANSWER Mrs. Ramos
can obtain care from any provider who participates in Original Medicare, but generally will
be charged a lower co-payment if she goes to one of the plan's preferred providers.
Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has re-
ceived under Original Medicare, but he would like to know more about Medicare Advantage
Special Needs Plans (SNPs). What could you tell him? - ANSWER SNPs have special pro-
grams for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription
drug coverage that could be very helpful as well
(W) 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 SNPs limit enrollment
to certain sub-populations of beneficiaries. Given his current situation, he is unlikely to qual-
ify and would not be able to enroll in the SNP.
(W) 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 Most individuals who are citizens and over age 65 are covered under Part
A by virtue of having paid Medicare taxes while working, though some may be covered as a
result of paying monthly premiums.
2
,(W) Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the So-
cial Security Administration and has been receiving disability payments. He is wondering
whether he can obtain coverage under Medicare. What should you tell him? - ANSWER
After receiving such disability payments for 24 months, he will be automatically enrolled in
Medicare, regardless of age.
(W) 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 Medi-
care taxes. What should you tell her? - ANSWER In order to obtain Part B coverage, she
must pay a standard monthly premium, though it is higher for individuals with higher in-
comes
(W) Mr. Davis is 49 years old and has been receiving disability benefits from the Social Secu-
rity Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescrip-
tion Drug policy? - ANSWER No, he cannot purchase a Medicare Advantage or Part D pol-
icy because he has not received Social Security or Railroad Retirement disability benefits for
24 months.
(W) 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 will not pay any penalty because he
had continuous coverage under his employer's plan.
(W) 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 cover-
age. What can you tell her? - ANSWER She may enroll at any time while she is covered
under her employer plan, but she will have a special eight-month enrollment period that dif-
fers from the standard general enrollment period, during which she may enroll in Medicare
Part B
(W) Mrs. Kelly is entitled to Part A, but is not yet enrolled in Part B. She is considering enroll-
ment in a Medicare health plan. What should you advise her to do before she will be able to
enroll into a Medicare health plan? - ANSWER In order to join a Medicare health plan,
she also must enroll in Part B
3
, (W) Mr. Yu has limited income and resources so you have encouraged him to see if he quali-
fies for some type of financial assistance. Mr. Yu is not sure it is worth the trouble to apply
and wants to know what the assistance could do for him if he qualifies. What could you tell
him? - ANSWER He might qualify for help with Part D prescription drug costs and help
paying Part A and/or Part B premiums, deductibles, and/or cost sharing.
Mrs. Park has a low, fixed income. What could you tell her that might be of assistance? - AN-
SWER She should contact her state Medicaid agency to see if she qualifies for one of sev-
eral programs that can help with Medicare costs for which she is responsible
(W) Mr. Patel is in good health and is preparing a budget in anticipation of his retirement
when he turns 66. He wants to understand the health care costs he might be exposed to un-
der Medicare if he were to require hospitalization as a result of an illness. In general terms,
what could you tell him about his costs for inpatient hospital services under Original Medi-
care? - ANSWER Under Original Medicare, there is a single deductible amount due for
the first 60 days of any inpatient hospital stay, after which it converts into a per-day amount
through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime,
after which he would be responsible for all costs
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being suc-
cessfully treated for that condition. However, she and her physicians feel that after her
lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What
should you tell them about Original Medicare's coverage of care in a skilled nursing facility? -
ANSWER Medicare will cover Mrs. Shields' skilled nursing services provided during the
first 20 days of her stay, after which she would have a coinsurance until she has been in the
facility for 100 days.
(W) Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be
hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an
inpatient psychiatric hospital stay that Medicare will cover? - ANSWER Medicare will
cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime.
Mrs. Quinn has just turned 65 and received a letter informing her that she has been auto-
matically enrolled in Medicare Part B. She wants to understand what this means. What
4
