CEC Post-Enrollment and Renewals 5 — Questions and Answers
Question 1: A beneficiary asks about switching from a Medicare Supplement (Medigap) plan to a Medicare Advantage plan. What should the counselor advise regarding guaranteed issue rights?
- They always have guaranteed issue rights when switching from Medigap to MA
- They lose guaranteed issue rights when switching to MA, and may face medical underwriting if they later want to return to Medigap in most states (Correct answer)
- Medigap plans are required to accept them back without underwriting within 12 months
- CMS requires all states to grant guaranteed issue rights for Medigap re-enrollment
Correct answer: They lose guaranteed issue rights when switching to MA, and may face medical underwriting if they later want to return to Medigap in most states
Switching from Medigap to a Medicare Advantage plan generally forfeits guaranteed issue protections, and returning to a Medigap plan in most states is subject to medical underwriting.
Question 2: What is the purpose of the Medicare Advantage plan's Evidence of Coverage (EOC) document?
- To serve as proof of premium payment for tax purposes
- To provide a comprehensive description of covered benefits, costs, and rules for the plan year (Correct answer)
- To notify beneficiaries of changes to their plan for the upcoming year
- To list all in-network providers available in the service area
Correct answer: To provide a comprehensive description of covered benefits, costs, and rules for the plan year
The Evidence of Coverage (EOC) is a detailed document that explains all covered services, costs, prior authorization requirements, and rules for the enrollee's plan during the current benefit year.
Question 3: A client enrolled in a dual-eligible Special Needs Plan (D-SNP) is confused about what additional benefits they receive. What is a key feature of D-SNPs?
- They are only available to beneficiaries with end-stage renal disease
- They coordinate Medicare and Medicaid benefits for dual-eligible beneficiaries and may offer extra benefits (Correct answer)
- They replace both Medicare and Medicaid for enrolled beneficiaries
- They are only available during the Annual Enrollment Period
Correct answer: They coordinate Medicare and Medicaid benefits for dual-eligible beneficiaries and may offer extra benefits
Dual-eligible Special Needs Plans (D-SNPs) are designed to coordinate Medicare and Medicaid benefits for individuals eligible for both programs, often offering additional benefits tailored to this population.
Question 4: A beneficiary enrolled in a Medicare Advantage plan is told their primary care physician (PCP) is leaving the plan's network. What should the counselor recommend?
- Immediately disenroll from the plan to preserve continuity of care
- Check if a SEP applies, review the plan's continuity of care policy, and consider plan options at the next AEP (Correct answer)
- File a grievance with the plan to keep the physician in-network
- Request CMS override the network change to maintain access to the PCP
Correct answer: Check if a SEP applies, review the plan's continuity of care policy, and consider plan options at the next AEP
Counselors should help the beneficiary understand their continuity of care rights, check for applicable SEPs, and plan for a potential switch during the Annual Enrollment Period if the provider change is permanent.
Question 5: What is the role of a State Health Insurance Assistance Program (SHIP) counselor in the post-enrollment process?
- To sell Medicare Advantage and Part D plans to beneficiaries on behalf of insurance companies
- To provide free, unbiased Medicare counseling to help beneficiaries understand their rights and options (Correct answer)
- To process Medicare claims and resolve billing disputes on behalf of CMS
- To administer the Medicare Savings Program enrollment process
Correct answer: To provide free, unbiased Medicare counseling to help beneficiaries understand their rights and options
SHIP counselors provide free, unbiased, one-on-one assistance to Medicare beneficiaries, helping them understand coverage options, appeals rights, and post-enrollment issues.
Question 6: A beneficiary's Medicare Advantage plan denies a prior authorization request for a specialist visit. What immediate right does the beneficiary have?
- They must wait until the AEP to address the denial
- They have the right to request an expedited or standard appeal of the denial (Correct answer)
- They must obtain the service out-of-pocket and seek reimbursement later
- They must ask their PCP to resubmit the authorization request three times before appealing
Correct answer: They have the right to request an expedited or standard appeal of the denial
When a Medicare Advantage plan denies a prior authorization, beneficiaries have the right to file a standard or expedited appeal asking the plan to reconsider the decision.
Question 7: Which statement best describes the Special Enrollment Period available to beneficiaries who involuntarily lose employer-sponsored health coverage?
- They have 30 days from the loss of coverage to enroll in Medicare Parts A and B
- They have an 8-month SEP to enroll in Medicare Part B after losing employer coverage (Correct answer)
- They must wait until the General Enrollment Period running January 1–March 31
- They automatically receive Medicare coverage the day their employer coverage ends
Correct answer: They have an 8-month SEP to enroll in Medicare Part B after losing employer coverage
Beneficiaries who lose employer-sponsored group health plan coverage have an 8-month Special Enrollment Period to enroll in Medicare Part B without a late enrollment penalty.
CEC Post-Enrollment and Renewals 5
A beneficiary asks about switching from a Medicare Supplement (Medigap) plan to a Medicare Advantage plan.
What should the counselor advise regarding guaranteed issue rights?