CEC Post-Enrollment and Renewals 4

Question 1

A beneficiary was enrolled in a Medicare Advantage plan that is terminating its contract with CMS. What SEP are they entitled to?

Accepted Answer

They receive a Special Enrollment Period to choose a new plan before coverage ends

Answer

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?

Accepted Answer

Once per calendar year

Answer

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?

Accepted Answer

Redetermination by the plan

Answer

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?

Accepted Answer

A grievance addresses dissatisfaction with plan services or quality; an appeal contests a coverage or payment denial

Answer

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?

Accepted Answer

They want to switch to a Medicare Advantage plan that has a 5-star CMS quality rating

Answer

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.

(CEC) Certified Enrollment Counselor Practice Test

(CEC) Certified Enrollment Counselor Practice Test

CEC Post-Enrollment and Renewals 4