AHIP North Carolina 5 — Questions and Answers
Question 1: A North Carolina agent receives a $50 gift card offer from a Medicare Advantage plan to give to any beneficiary who enrolls. What should the agent do?
- Accept and distribute the gift cards as an enrollment incentive
- Decline; CMS prohibits giving cash or gifts of more than nominal value to induce enrollment (Correct answer)
- Report the offer to the North Carolina Department of Insurance only
- Accept the offer only during AEP
Correct answer: Decline; CMS prohibits giving cash or gifts of more than nominal value to induce enrollment
CMS strictly prohibits offering cash or items of more than nominal value ($15 per item, $75 per year) to influence a beneficiary's plan selection.
Question 2: Which Medicare Supplement plan is the most comprehensive and covers virtually all out-of-pocket costs, but is only available to North Carolina beneficiaries who became eligible for Medicare before January 1, 2020?
- Plan G
- Plan N
- Plan C
- Plan F (Correct answer)
Correct answer: Plan F
Medigap Plan F is the most comprehensive plan but was closed to newly eligible Medicare beneficiaries as of January 1, 2020; only those eligible before that date may purchase it.
Question 3: A North Carolina Medicare Advantage enrollee disputes a plan's denial of a medical service. What is the first formal step in the appeals process?
- File a complaint with CMS directly
- Request an Independent Review Entity (IRE) review
- File a redetermination request with the MA plan (Correct answer)
- Submit a grievance to the State Insurance Commissioner
Correct answer: File a redetermination request with the MA plan
The first level of the MA appeals process is a redetermination, which is a formal review of the coverage denial conducted by the MA plan itself.
Question 4: Under CMS rules, within how many calendar days must a North Carolina Medicare Advantage plan respond to a standard (non-expedited) prior authorization request?
- 24 hours
- 3 calendar days
- 14 calendar days (Correct answer)
- 30 calendar days
Correct answer: 14 calendar days
CMS requires MA plans to respond to standard prior authorization requests within 14 calendar days of receiving the request.
Question 5: A North Carolina beneficiary is considering a Medicare Advantage MSA plan. Which statement about MSA plans is correct?
- MSA plans include Part D prescription drug coverage
- The plan deposits money into the beneficiary's savings account and has a high deductible (Correct answer)
- MSA plans are available in all North Carolina counties
- MSA funds can be used only for Medicare-covered services
Correct answer: The plan deposits money into the beneficiary's savings account and has a high deductible
Medicare MSA plans combine a high-deductible health plan with a medical savings account funded by the plan, which the beneficiary can use for qualified medical expenses.
Question 6: Which statement accurately describes how a Medicare Advantage plan's network impacts North Carolina beneficiaries enrolled in an HMO?
- HMO enrollees may see any provider in the country at in-network rates
- HMO enrollees generally must use in-network providers except for emergencies and urgently needed care (Correct answer)
- HMO enrollees may self-refer to specialists without a primary care physician referral
- HMO enrollees pay the same cost-sharing whether in-network or out-of-network
Correct answer: HMO enrollees generally must use in-network providers except for emergencies and urgently needed care
HMO-type MA plans require members to use the plan's network for non-emergency care; emergency and urgently needed care are covered outside the network at any time.
Question 7: A North Carolina Medicare Part D enrollee has not yet reached the deductible. They purchase a 90-day supply of a Tier 2 drug. How is the cost typically calculated at this stage?
- They pay the plan's cost-sharing copay because the deductible does not apply to Tier 2 drugs in most plans
- They pay the full retail price until the deductible is met (Correct answer)
- They pay nothing because preventive drugs are deductible-exempt
- They pay 25% coinsurance automatically for all tiers
Correct answer: They pay the full retail price until the deductible is met
Until a Part D beneficiary meets their deductible, they typically pay the full negotiated cost of non-exempt drugs; many plans exempt lower tiers, but this varies by plan.
AHIP North Carolina 5
A North Carolina agent receives a $50 gift card offer from a Medicare Advantage plan to give to any beneficiary who enrolls.
What should the agent do?