AHIP Module 2
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? - ANS-
You would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he
lives in the PFFS plan's service area.
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-of-pocket 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-of-pocket 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? - ANS- You
can offer to review the plans appeal process to help him ask the plan to review the
coverage decision.
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? - ANS- Mrs. Chi may enroll in a MA MSA
plan and remain in her current standalone Part D prescription drug plan.
Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored
retiree group health plan that includes drug coverage with nominal copays. He heard
about a neighbor's MA-PD plan that you represent and because he takes numerous
prescription drugs, he is considering signing up for it. What should you tell him? - ANS-
He should compare the benefits in his employer-sponsored retiree group health plan with
the benefits in his neighbor's MA-PD plan to determine which one will provide sufficient
coverage for his prescription needs.
Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It
is one of three plans operated by the same organization in Mr. Lombardi's area. The MA
PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes
the PPO plan that does not include drug coverage and intends to obtain his drug
coverage through a stand-alone Medicare prescription drug plan. What should you tell
him about this situation? - ANS- He could enroll either in one of the MA plans that
include prescription drug coverage or Original Medicare with a Medigap plan and
standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO
plan and a stand-alone prescription drug plan.
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? - ANS-
You would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he
lives in the PFFS plan's service area.
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-of-pocket 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-of-pocket 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? - ANS- You
can offer to review the plans appeal process to help him ask the plan to review the
coverage decision.
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? - ANS- Mrs. Chi may enroll in a MA MSA
plan and remain in her current standalone Part D prescription drug plan.
Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored
retiree group health plan that includes drug coverage with nominal copays. He heard
about a neighbor's MA-PD plan that you represent and because he takes numerous
prescription drugs, he is considering signing up for it. What should you tell him? - ANS-
He should compare the benefits in his employer-sponsored retiree group health plan with
the benefits in his neighbor's MA-PD plan to determine which one will provide sufficient
coverage for his prescription needs.
Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It
is one of three plans operated by the same organization in Mr. Lombardi's area. The MA
PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes
the PPO plan that does not include drug coverage and intends to obtain his drug
coverage through a stand-alone Medicare prescription drug plan. What should you tell
him about this situation? - ANS- He could enroll either in one of the MA plans that
include prescription drug coverage or Original Medicare with a Medigap plan and
standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO
plan and a stand-alone prescription drug plan.
