Recertifcation Answer Key: Medicare Prescription Drug ...



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SHINE Certification Exam

The certification process is a quality assurance measure that enables us to verify, both for our program and for CMS, that our counselors meet the requisite level of expertise to assist clients with their health information needs.

This exam consists of 100 multiple choice questions regarding a number of rules around Medicare and Public Assistance Programs, as well as real life scenarios that you may encounter as a SHINE Counselor.

When completing this exam you may use your SHINE Resource Manual and supplementary charts and handouts.

You will soon receive an email explaining how to complete this exam online. When submitting this exam online you will receive an instant score.

The exam must be submitted online by:

___________________

1) The Initial Enrollment Period consists of __ months to sign up for Medicare.

a) 2

b) 3

c) 7

d) 8

2) Which of these statements about benefit periods in Original Medicare is true?

a) Benefit periods renew on an annual basis.

b) Benefit periods limit the number of covered physician visits.

c) Benefit periods set the annual deductible for hospital stays.

d) Benefit periods are unlimited in number during a lifetime.

3) Mrs. Lisle has Original Medicare only. A home health nurse visited Mrs. Lisle to monitor the healing of an infected incision and change dressings. Assuming this meets Medicare’s requirements for coverage, how much does Mrs. Lisle owe?

a) $0

b) She will have to pay the full cost herself

c) 20 percent of the approved amount

d) None of the above

4) Which of these is a requirement for coverage of Medicare’s SNF benefit?

a) The patient is first seen in a hospital emergency room.

b) The patient receives skilled nursing care at least five days a week.

c) The patient is admitted to a nursing facility licensed in Massachusetts.

d) The patient was admitted for at least 72 consecutive hours in a hospital.

5) Which of these is a requirement for coverage of Medicare’s home health benefit?

a) A physician sets up a care plan.

b) The patient is homebound.

c) The patient receives intermittent or part-time skilled care.

d) All of the above

6) Which of these people would have a Special Enrollment Period, enabling enrollment in Medicare Part B without a penalty?

a) John, 67, who is covered under his wife’s group health plan through her work

b) Ophelia, 66, who elected COBRA coverage 13 months ago when her employer ended its employee group health plan

c) Ed, 68, whose son’s small company added him as a participant to its group health plan even though he is not an active employee

d) Esther, 67, who continues to work from time to time as a contractor for a large company but is not on the group health insurance plan

7) To receive Medicare coverage for hospice services, a patient must:

a) reside in a licensed nursing facility

b) have terminal cancer

c) give up her regular Medicare benefits

d) have life expectancy of six months or less

8) Mr. Sobol was hospitalized for ten days and transferred to a skilled nursing facility (SNF) where Medicare covered a 35 day stay. Four weeks later, Mr. Sobol was re-admitted to a hospital. If he needs SNF care after the hospital stay, how many Medicare-covered SNF days are available to him?

a) 25

b) 65

c) 90

d) 100

9) Mr. Wiedenhafer’s doctor asked him to sign an Advance Beneficiary Notice (ABN) form before he received some tests at the office. If Mr. Wiedenhafer signs the form, what will be the result?

a) He cannot receive the tests.

b) The doctor won’t submit a claim to Medicare.

c) The doctor will waive his liability for the bill.

d) He is liable for the bill if Medicare won’t pay.

10) Which of these providers is not required to accept assignment?

a) Ambulance service providers

b) Durable medical equipment providers

c) Participating provider physicians

d) None of the above

11) Your appeal rights listed on the Medicare Summary Notice (MSN) include:

a) How you can appeal

b) The time limit for filing your appeal

c) Information about why Medicare didn't pay your bill

d) All of the above

12) Ms. Green will be 65 in 3 months. She never worked outside the home. She was married for 20 years, then divorced and never re-married. Her ex-husband passed away just a few months ago at the age of 68. He worked for IBM most of his life. Which of the following statements is true?

a) She is NOT eligible for Medicare because she never worked.

b) She is NOT eligible for Medicare based on her ex-husband’s work history since they were divorced before she turned 65.

c) She is eligible for Medicare based on her ex-husband’s work history regardless of how long they were married.

d) She is eligible for Medicare based on her ex-husband’s work history since they were married over 10 years.

13) If you believe you are being made to leave the hospital too soon and you call your state

Quality Improvement Organization (Mass-Pro) within the required time-frame, the hospital cannot force you

to leave before the QIO makes its decision.

a) True

b) False

14) Non-participating physicians who do not accept assignment may charge as much as they wish.

a) True

b) False

15) No matter how you have chosen to get your Medicare benefits, you can get emergency care

anywhere in the United States.

a) True

b) False

16) There are specific time limits for filing Medicare appeals.

a) True

b) False

17) In order to get Skilled Nursing Facility (SNF) care covered by Medicare Part A, you must go directly

from the hospital to the SNF.

a) True

b) False

18) Medicare will cover home health aide services on a part-time or intermittent basis (like help with

personal care such as bathing, using the toilet, or dressing) if you are also getting skilled care such as

nursing care or other therapy from the home health agency.

a) True

b) False

19) Original Medicare covers emergency care during foreign travel.

a) True

b) False

20) A person may delay enrolling into Medicare Part B without penalty if they are covered by COBRA.

a) True

b) False

21) The penalty for delayed enrollment into Medicare Part B is 1% for each month the individual could have

had it.

a) True

b) False

22) When Brad became eligible for Medicare at age 65, he elected to take only Part A because he had an EGHP based on active employment. At age 67 he retired. How much time does he have to sign up for Medicare Part B without getting a penalty?

a) 2 months

b) 3 months

c) 7 months

d) 8 months

23) The General Enrollment Period is:

a) November 15 through December 31, coverage effective January 1

b) January 1 through March 31, coverage effective July 1

c) November 15 through December 31, coverage effective July 1

d) January 1 through June 30, coverage effective July 1

24) The 2013 monthly premium for Medicare Part A for someone who has worked only 20 quarters is

a) $248

b) $441

c) $99.90

d) Dependent upon income

25) Which is a requirement to join a Medicare Advantage Plan?

a) Enrolled in Part B

b) Enrolled in Part A

c) Live in plan’s service area

d) All of the above

26) Ms. Ming is vacationing with her daughter in Massachusetts for three months. She belongs to a Medicare HMO in California. Recently, she learned that the HMO did not pay for a doctor visit and a series of routine tests she received in Massachusetts. What is the likely reason behind the HMO’s payment denial?

a) Ms. Ming used out-of-network providers for non-urgent care.

b) Ms. Ming left Medicare when she joined the HMO.

c) The providers should have sent the claims to the Part B MAC for Massachusetts.

d) The HMO only pays for services delivered in its service area.

27) A Medicare Advantage Plan is required to cover:

a) Emergency care

b) Hospice care

c) Urgent care

d) All of the above

28) Medicare beneficiaries do not need to continue paying their Medicare Part B premium once they enroll in a Medicare Advantage plan.

a) True

b) False

29) Paul is 47 years old and recently diagnosed with end stage renal disease (ESRD). He is now eligible for

Medicare due to his illness. Once enrolled in Medicare, Paul is eligible to join any Medigap or Medicare

Advantage Plan he chooses.

a) True

b) False

30) A PPO allows a beneficiary the freedom to visit non-network providers.

a) True

b) False

31) Beneficiaries enrolled in a HMO plan without drug coverage are allowed to choose a stand-alone Part

D Plan.

a) True

b) False

32) To be eligible for a Medigap Plan you must be enrolled in both Medicare Part A and Part B.

a) True

b) False

33) In Massachusetts, all Medigap Plans currently have continuous open enrollment.

a) True

b) False

34) Individuals who disenroll from a Supplement Two plan have a special enrollment period to enroll into a Medicare Part D plan.

a) True

b) False

35) Individuals will automatically qualify for the Part D extra-help (LIS) if:

a) MassHealth helps pay their Medicare premiums.

b) They receive full MassHealth benefits.

c) They receive Supplemental Security Income (SSI).

d) All of the above

36) When determining eligibility for the Part D extra-help (LIS), resources not counted include:

a) The home an individual resides in

b) $1,500/person for funeral/burial expenses

c) The cash-value of life insurance policy

d) All of the above

37) Mr. Arneson turns 65 on May 15. What is the last day during his Initial Enrollment Period that he can enroll in Medicare Part D?

a) June 30

b) July 15

c) August 15

d) August 31

38) Which of these is not one of the features of Medicare's standard benefit prescription drug plan for 2013?

a) Co-pays of 50% during initial coverage period

b) Maximum annual deductible of $325

c) Coverage gap begins when total cost of drugs exceeds $2970

d) Catastrophic coverage begins when TrOOP (true out-of-pocket costs) exceed $4750

39) Which of these will qualify Mr. Collins for a Special Enrollment Period (SEP) for a Medicare Prescription Drug Plan?

a) His current Medicare drug plan dropped his prescription drug from its list of preferred drugs.

b) His union's health plan is ending drug coverage for retirees.

c) He moved from his home to a senior apartment two miles away (in the same town).

d) He stopped paying premiums after his Medicare drug plan denied an exception for a prescribed drug.

40) Which of the following medications is excluded from Medicare drug plan coverage?

a) Drugs used in the treatment of weight loss

b) Cholesterol-lowering medications

c) Anti-depressant medications

d) Insulin

41) A Medicare Drug Plan will make an expedited coverage determination on a formulary exceptions request when the plan member:

a) can't afford to pay for the drug without insurance coverage

b) has used the same drug successfully for two years

c) prefers not to wait for a standard determination

d) faces serious physical harm without the drug

42) If you have MassHealth Standard, you are not eligible to join Prescription Advantage.

a) True

b) False

43) One must have Medicare Part A and Part B to enroll in a Medicare Prescription Drug Plan.

a) True

b) False

44) A person with a standard Medicare drug plan can add the plan's monthly premium to the other out-of

pocket costs to meet the threshold for catastrophic drug coverage.

a) True

b) False

45) Joining Prescription Advantage provides a SEP for enrolling in a PDP or an MA-PD outside the

Annual Coordinated Election Period.

a) True

b) False

46) People enrolled in LIS must be enrolled in a PDP or an MA-PD in order to receive extra help with their

drug costs.

a) True

b) False

47) The Part D lifetime penalty for late enrollees is 1% of the National Base Premium for each month the

beneficiary did not have the required coverage.

a) True

b) False

48) People receiving extra-help (LIS) can switch Part D plans every month.

a) True

b) False

49) Medicare beneficiaries living in LTC facilities can switch Part D plans every month.

a) True

b) False

50) If a beneficiary loses creditable drug coverage, they have an 8 month SEP to sign up for a PDP without

incurring a penalty.

a) True

b) False

51) Mrs. Smith has been a dual eligible for many years. A month ago, she inherited $20,000 worth of

stocks. She will lose her MassHealth coverage in May, but she will remain eligible for LIS for the remainder

of the year.

a) True

b) False

52) If a beneficiary enrolls in a new Part D Plan, he/she is automatically disenrolled from his/her old Part D

plan.

a) True

b) False

53) Enrolling into a Medicare Part D plan automatically disenrolls an individual from his/her previous HMO

Medicare Advantage Plan.

a) True

b) False

54) When a Medicare drug plan removes a drug from its formulary, members will receive a special enrollment period to switch to another Part D plan.

a) True

b) False

55) Prior to applying for Prescription Advantage a person must already have a Medicare Part D plan.

a) True

b) False

56) Qualified Medicare Beneficiary (QMB) benefits include:

a) Medicare's deductibles and coinsurance

b) Part A premium (if applicable)

c) Part B premium

d) All of the above

57) Which of the following statements about CommonHealth is false:

a) CommonHealth is a MassHealth program for adults with disabilities (including adults 65 and older who were deemed disabled prior to turning 65)

b) For working disabled adults there are no income or asset limits for CommonHealth coverage regardless of age, but a premium payment applies on a sliding scale fee basis for those with higher incomes.

c) Those under 65 who do not work at least 40 hours per month may have to meet a one-time deductible (spend-down).

d) Those 65 and older are eligible for CommonHealth only if they work full-time AND are considered disabled (by MassHealth or SSA).

58) Which of the following statements about the “Frail Elder” Waiver is false:

a) Must be evaluated and deemed “nursing home eligible” by a designated ASAP (Aging Services Access Point)

b) Income level at or below 200% SSI

c) Asset limit of $2,000

d) If married, special provision allows elders to “waive” their spouse’s income and assets to become eligible (must transfer assets over $2000 limit to spouse)

59) Don is admitted to the nursing home on February 1 and is applying for Long Term Care Medicaid.  His wife Dixie is still living at home.  What is the maximum amount of Don's income that can be protected for Dixie?

a) 100%

b) Up to $2,841

c) 50%

d) None

60) Alice lives in a nursing home and is applying for LTC Medicaid this month.  She gifted $10,000 to each of her 5 children six years ago.  The $50,000 will not result in a disqualification period because:

a) Gifts of $10,000 per child are allowed.

b) The look-back period for all transfers is 36 months.

c) The look-back period for all transfers is 60 months.

d) All gifts of money are not disqualifying transfers.

61) The best way to apply for LIS is by calling 1-800-MEDICARE.

a) True

b) False

62) People who are referred to as “dual eligibles” are eligible for both Medicare and VA coverage.

a) True

b) False

63) People with Medicare and MassHealth must use only MassHealth providers in order for MassHealth to

provide secondary coverage to Medicare.

a) True

b) False

64) SLMB and QI-1 help Medicare beneficiaries pay their Medicare Part B premiums and co-pays.

a) True

b) False

65) MassHealth income and asset limits are the same for all individuals regardless of age.

a) True

b) False

66) Mrs. Novotny turns 65 this month and will keep working. She has decided to enroll in Medicare Part B and continue with her employer’s group health plan. Will the employer plan pay first and Medicare second?

a) Maybe, it depends on the number of employees in the group.

b) Yes, employer group plans are always the primary payers for older workers.

c) Yes, Medicare only pays first when the older worker has retired.

d) No, Medicare is the second payer only when an accident is involved.

67) Ross and his husband Ed have been married for 3 years. Ross is Medicare eligible and is about to retire. Ed plans to continue working for 2 more years. Is Ross able to enroll into Ed’s family benefit through work and delay enrolling into Medicare Part B without penalty?

a) Yes

b) No

68) People with VA and Medicare benefits:

a) Can get medical treatment under either program

b) Must choose which benefits to use each time

c) Cannot have a Part D plan

d) Both a and b

69) Veterans who have drug coverage with the VA:

a) Have coverage that is considered as good as Medicare coverage

b) Cannot have a Part D plan

c) Must choose to use VA coverage instead of Part D

d) Both a & b

70) If a beneficiary was in an automobile accident and received medical services as a result of the accident,

health care professionals would be required to attempt to collect payment from the automobile insurance

company before billing Medicare.

a) True

b) False

71) If a beneficiary is covered by workers' compensation and is treated for a work-related illness or injury,

workers' compensation should be billed secondary to Medicare.

a) True

b) False

72) If someone is 65 or older and covered by an EGHP due to his or spouse’s active employment and the

employer has at least 20 employees, Medicare is the secondary payer.

a) True

b) False

73) Commonwealth Care is available to all individuals without medical coverage in Massachusetts.

a) True

b) False

74) Individuals who retire prior to 65 may enroll into a Commonwealth Choice plan regardless of income.

a) True

b) False

Arty Ficial

Mr. Ficial meets with you in April of 2013. He is 70 years old. He retired from his full-time job in 2011. His company generously has been paying his COBRA coverage for him, but now the company is going out of business and his health care coverage is ending as of April 30. He already has Part A, but he wants to sign up for Part B and a drug plan. He has been told that his drug coverage through COBRA is “creditable.”

75) He can sign up for Part B in May since he has been covered by a former employer.

a) True

b) False

76) He has 63 days from April 30th to sign up for a drug plan without penalty.

a) True

b) False

77) He will not have a Part B late enrollment penalty since his coverage was “creditable.”

a) True

b) False

78) Commonwealth Care would be an option for Arty while he’s waiting to enroll in Medicare Part B.

a) True

b) False

79) Arty will have to pay a late enrollment penalty for Part D since he was not covered through “active

employment.”

a) True

b) False

80) If Arty had enrolled in Medicare Part B during the 8 month SEP immediately following his retirement, he

would have avoided the Part B late enrollment penalty.

a) True

b) False

81) The earliest Arty can have Part B coverage is July 1, 2014.

a) True

b) False

Jill Hill

Mrs. Jill Hill visits the SHINE office. Her husband, Jack, has been admitted into a nursing home. Jill’s income is $550 per month and Jack’s income is approximately $3,000 per month. They own a home and have financial assets totaling $129,000.

82) Jill was told that her husband will not qualify for LTC MassHealth until they spend down their assets to $2,000. Is this correct?

a) Yes

b) No

83) Ten years ago Jack and Jill transferred $40,000 to their son. Will this money be considered in asset calculations by MassHealth?

a) Yes

b) No

84) Jill is concerned that she will be unable to afford to stay in her home with an income of just $550 per month. Will Jill be entitled to keep a portion of Jack’s monthly income?

a) Yes

b) No

85) Jill’s neighbor told her that Medicaid can take her home, leaving her out on the street. Is this correct?

a) Yes

b) No

Clara Fye

Clara Fye’s daughter, Vera Fye, calls you for assistance. She tells you her parents are both in their mid 80’s and live in their own home. Her mother’s health has declined considerably in recent years, and she is unable to care for herself. Vera helps as much as she can, but she works full-time, travels a great deal on her job, and lives an hour away. She knows that programs like MassHealth/Medicaid only help low-income people but wonders if there are any programs that offer help at moderate cost to middle income seniors. She says her mother’s monthly income is $980 and her father’s is $1,300. They have combined assets of approximately $30,000 along with their house and a car.

86) Identify a program she might be eligible for that could provide coverage for home care services.

a) SSI

b) QMB

c) Frail Elder Waiver

d) LIS

87) Which of the following is an eligibility requirement of the program selected in question 86.

a) Reside in senior housing

b) Aged 60 or over

c) Determined disabled by Social Security

d) None of the above

88) Which agency must she contact for this program?

a) MassMedline

b) MAP

c) ASAP

d) QIO

 89) The benefits from this program include:

a) LIS

b) MassHealth

c) Homemaker and personal care services

d) All of the above

 

Ms. Adams

Ms. Adams comes to SHINE for help in January because she wants drug coverage.  She is in a Medicare Advantage PPO plan without prescription coverage.  When she signed up for the plan she was not taking any drugs and did not want to pay for drug coverage.  Her doctor has just prescribed two very expensive medications, so she would like to get drug coverage. She is happy with her insurance plan and knows that the insurance company offers the same plan with drug coverage. She has a gross monthly income of $1,300. Her only assets are $1,000 in a checking account, $5,000 in a savings account, and a Life Insurance Policy with Cash Value of $7,000.

90) Ms. Adams can switch into the Medicare Advantage plan with drug coverage because she is within the Medicare Advantage Disenrollment Period (MADP)

a) True

b) False

91) Ms. Adams can enroll into a stand-alone Medicare Drug Plan (PDP)

a) True

b) False

92) If Ms. Adams enrolls into a stand-alone Medicare Drug Plan (PDP) she cannot continue to be enrolled in her current Medicare Advantage Plan.

a) True

b) False

93) Ms. Adams is eligible for Prescription Advantage

a) True

b) False

94) Ms. Adams assets are too high to qualify for Extra Help.

a) True

b) False

Ms. Samantha Carson

Samantha Carson has Medicare A and B and AARP MedicareRx Preferred. She can’t afford a supplement since her drug costs are very high, even with her Medicare drug plan. She is single, 62 years old, has gross income of $1,950/month (SSDI) and has assets of $12,000. She says she is unable to work due to her disability, but she does babysit her grandson every day after school.

95) Samantha’s income is low enough to qualify for Prescription Advantage.

a) True

b) False

96) Samantha could qualify for CommonHealth after she meets a one-time deductible based on her income.

a) True

b) False

97) If Samantha provides documentation that she is working 40 hours per month as a babysitter she could

qualify for CommonHealth and not have to meet a one-time deductible.

a) True

b) False

98) If Ms. Carson qualifies for CommonHealth she will automatically have her Part B premium paid for.

a) True

b) False

99) If Ms. Carson qualifies for CommonHealth she will automatically get LIS (Extra Help).

a) True

b) False

100) When Ms. Carson turns 65 can she remain on CommonHealth if she meets another deductible.

a) True

b) False

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