Which of the following statements is correct about the appeal
and grievance processes?
I. Enrollees have a right to obtain a review (appeal) of certain
decisions about prescription drug coverage.
II. The grievance process is used for reviews of coverage
decisions on plan benefits.
III. Plans must provide a link to the Medicare.gov website
where an enrollee can enter a complaint.
IV. Enrollees have a right to file complaints (sometimes called
grievances) about the quality of their care.
- Correct Answer - I. Enrollees have a right to obtain a review
(appeal) of certain decisions about prescription drug coverage.
III. Plans must provide a link to the Medicare.gov website
where an enrollee can enter a complaint.
IV. Enrollees have a right to file complaints (sometimes called
grievances) about the quality of their care.
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?
,- Correct Answer - You would need to ask Mr. Kelly if he is
enrolled in Part A and Part B and if he lives in the PFFS plan's
service area.
Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan
available in his area has an attractive premium. He wants to
know what makes them different from an HMO or a PPO. What
should you tell him?
- Correct Answer - Enrollees in a PFFS plan can obtain care
from any provider in the U.S. who accepts Original Medicare,
as long as the provider has a reasonable opportunity to access
the plan's terms and conditions and agrees to accept them.
You are meeting with Ms. Berlin and she has completed an
enrollment form for a MA-PD plan you represent. You notice
that her handwriting is illegible and as a result, the spelling of
her street looks incorrect. She asks you to fill in the corrected
street name. What should you do?
- Correct Answer - You may correct this information as long as
you add your initials and date next to the correction
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?
- Correct Answer - Medicare will cover a total of 190 days of
inpatient psychiatric care during Mr. Rainey's entire lifetime.
, Mrs. Tanner is enrolled in a Medicare Advantage HMO that
offers a point of service option. This allows Mrs. Tanner to do
which of the following?
- Correct Answer - Mrs. Tanner can go to non-plan doctors for
certain services without receiving prior approval.
During a sales presentation, your client asks you whether the
Medicare agency recommends that she sign up for your plan or
stay in Original Medicare. What should you tell her?
- Correct Answer - Tell her that the Medicare agency does not
endorse or recommend any plan.
Phiona works in the IT Department of BestCare Health Plan.
Phiona is placed in charge of BestCare's efforts to facilitate
electronic enrollment in its Medicare Advantage plans. In
setting up the enrollment site, which of the following must
Phiona consider?
I. If a legal representative is completing an electronic
enrollment request, he or she must first upload proof of his or
her authority.
II. All data elements required to complete an enrollment request
must be captured.
III. The process must include a clear and distinct step that
requires the applicant to activate an "Enroll Now" or "I Agree"
type of button or tool.
IV. The mechanism must capture an accurate time and date
stamp at the time the applicant enters the online site.
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