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 Advantage program? –
They are Medicare health plans such as HMOs, PPOs, PFFS, SNPs, and MSAs
(W) Mr. Wells is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be a correct description? - Medicare Advantage is a way of covering all of
the Original Medicare benefits through private health insurance companies.
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? - 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? - Mrs. Radford must be entitled to Part A and enrolled in Part
B to enroll in Medicare Advantage
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) plan and is still
covered by Part A. What should you tell him? - He is not eligible to enroll in a Medicare Advantage
plan until he re-enrolls in Medicare Part B
(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? - She may remain in her
ABC MA plan or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is
available in her area
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access
providers. What should you tell him? - In most Medicare Advantage HMOs, Mr. Kumar must obtain
his services only from providers who have a contractual relationship with the plan (except in an
emergency).
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? - 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 received
under Original Medicare, but he would like to know more about Medicare Advantage Special Needs
Plans (SNPs). What could you tell him? - SNPs have special programs 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? - SNPs limit enrollment to certain sub-populations of
beneficiaries. Given his current situation, he is unlikely to qualify 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? - 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.
(W) 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? - After receiving such disability
payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.
(W) Mr. Davis is 49 years old and has been receiving disability benefits from the Social Security
Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescription Drug
policy? - No, he cannot purchase a Medicare Advantage or Part D policy because he has not received
Social Security or Railroad Retirement disability benefits for 24 months
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