CEC Post-Enrollment and Renewals 4 — Questions and Answers
Question 1: A beneficiary was enrolled in a Medicare Advantage plan that is terminating its contract with CMS. What SEP are they entitled to?
- They must wait until the next Annual Enrollment Period to make changes
- They receive a Special Enrollment Period to choose a new plan before coverage ends (Correct answer)
- They are automatically transferred to Original Medicare with no enrollment options
- They must re-apply during their Initial Enrollment Period
Correct answer: They receive a Special Enrollment Period to choose a new plan before coverage ends
When a Medicare Advantage plan loses its CMS contract, affected enrollees receive a Special Enrollment Period to choose a new MA plan or return to Original Medicare.
Question 2: What is the maximum number of times a beneficiary enrolled in a Medicare Advantage plan can use the MA Open Enrollment Period per calendar year?
- Unlimited times during January 1–March 31
- Once per calendar year (Correct answer)
- Twice per calendar year
- Only if they have a qualifying life event
Correct answer: Once per calendar year
The Medicare Advantage Open Enrollment Period (January 1–March 31) allows currently enrolled MA beneficiaries to make one plan change per calendar year.
Question 3: An enrollment counselor is helping a client understand their rights to appeal a plan's coverage denial. What is the first level of the Medicare appeals process?
- Federal district court review
- Redetermination by the plan (Correct answer)
- Administrative Law Judge (ALJ) hearing
- Qualified Independent Contractor (QIC) review
Correct answer: Redetermination by the plan
The first level of the Medicare appeals process is a redetermination, where the plan reviews its own initial coverage denial decision.
Question 4: A beneficiary complains that their Medicare Advantage plan did not process a claim correctly. What is the difference between a grievance and an appeal in this context?
- A grievance addresses dissatisfaction with plan services or quality; an appeal contests a coverage or payment denial (Correct answer)
- A grievance contests a denied claim; an appeal addresses dissatisfaction with customer service
- There is no practical difference between the two processes
- A grievance is filed with CMS; an appeal is filed directly with the plan
Correct answer: A grievance addresses dissatisfaction with plan services or quality; an appeal contests a coverage or payment denial
A grievance addresses complaints about quality of care, service, or plan conduct, while an appeal specifically contests a plan's decision to deny, reduce, or terminate coverage or payment.
Question 5: Which of the following situations would allow a beneficiary to use the Five-Star Special Enrollment Period?
- They want to enroll in any Medicare Advantage plan at any time of year
- They want to switch to a Medicare Advantage plan that has a 5-star CMS quality rating (Correct answer)
- They qualify for a 5-star Medigap plan during open enrollment
- They have received 5 years of continuous Medicare coverage
Correct answer: They want to switch to a Medicare Advantage plan that has a 5-star CMS quality rating
The Five-Star SEP allows beneficiaries to switch once per calendar year (outside AEP) to a Medicare Advantage plan or Part D plan that holds a 5-star CMS quality rating.
Question 6: A Medicare beneficiary is hospitalized and their Medicare Advantage plan issues a Notice of Medicare Non-Coverage (NOMNC). What does this document inform the beneficiary?
- That their premium is increasing for the next plan year
- That the plan intends to terminate a covered inpatient or skilled nursing stay (Correct answer)
- That they are being disenrolled from the Medicare Advantage plan
- That their physician is leaving the plan's network
Correct answer: That the plan intends to terminate a covered inpatient or skilled nursing stay
The Notice of Medicare Non-Coverage (NOMNC) informs a beneficiary that the plan will stop covering a Medicare-covered service (such as inpatient hospital or SNF care) and explains their right to appeal.
Question 7: A beneficiary moving into a nursing home asks about Medicare coverage for skilled nursing facility care. What is required for Medicare Part A to cover SNF care?
- A physician's recommendation and payment of the Part B deductible
- A qualifying 3-day inpatient hospital stay and a skilled care need (Correct answer)
- Enrollment in a Medicare Advantage plan with SNF benefits
- Prior authorization from Medicare and a minimum of 30 days of Part A enrollment
Correct answer: A qualifying 3-day inpatient hospital stay and a skilled care need
Medicare Part A covers SNF care only after a qualifying 3-consecutive-day inpatient hospital stay and only when skilled nursing or therapy services are medically necessary.
CEC Post-Enrollment and Renewals 4
A beneficiary was enrolled in a Medicare Advantage plan that is terminating its contract with CMS.
What SEP are they entitled to?