CMS Medicare Specialist Enrollment & Eligibility Guidelines 3 — Questions and Answers
Question 1: What penalty applies to a Medicare beneficiary who goes 15 full months without creditable prescription drug coverage after their Part D Initial Enrollment Period ends?
- 1% premium surcharge per month without coverage
- 15% permanent premium increase
- 15 x 1% = 15% added to the national base beneficiary premium, paid for as long as enrolled (Correct answer)
- No penalty if enrolled before age 70
Correct answer: 15 x 1% = 15% added to the national base beneficiary premium, paid for as long as enrolled
The Part D late enrollment penalty is 1% of the national base beneficiary premium for each uncovered month, added permanently to the Part D premium.
Question 2: Which of the following is NOT a qualifying condition for Medicare eligibility based on disability before age 65?
- End-Stage Renal Disease (ESRD)
- Amyotrophic Lateral Sclerosis (ALS)
- Receipt of SSDI for 24 months
- Permanent blindness with no SSDI entitlement (Correct answer)
Correct answer: Permanent blindness with no SSDI entitlement
Blindness alone without SSDI entitlement or ESRD/ALS diagnosis does not qualify someone for Medicare before age 65.
Question 3: A beneficiary with ESRD has a 3-month waiting period before Medicare begins. In which month does Medicare coverage start if their dialysis began in April?
- April
- May
- June
- July (Correct answer)
Correct answer: July
For ESRD patients on dialysis, Medicare begins the 4th month of dialysis treatment, meaning if dialysis starts in April, coverage begins in July.
Question 4: A Medicare beneficiary is hospitalized on November 30. Their Medicare Advantage Annual Enrollment Period change takes effect January 1. Which plan covers the hospitalization?
- The new plan they selected during AEP
- Their current plan in effect on November 30 (Correct answer)
- Original Medicare, since they are in a transition period
- Whichever plan has the lower deductible
Correct answer: Their current plan in effect on November 30
AEP changes take effect January 1, so the plan in force on the date of service (November 30) covers the hospitalization.
Question 5: Which statement accurately describes Medicare Savings Programs (MSPs) in relation to Medicare enrollment?
- MSPs are federal programs that replace Medicare for low-income individuals
- MSPs are state Medicaid programs that help pay Medicare premiums, deductibles, and/or cost-sharing (Correct answer)
- Enrollment in an MSP automatically enrolls a beneficiary in a Medicare Advantage plan
- MSPs are only available to individuals under age 65 with disabilities
Correct answer: MSPs are state Medicaid programs that help pay Medicare premiums, deductibles, and/or cost-sharing
Medicare Savings Programs are state Medicaid programs designed to assist low-income Medicare beneficiaries with their Medicare cost-sharing obligations.
Question 6: When does a beneficiary who signs up for Medicare Part B during the Special Enrollment Period (SEP) following loss of employer coverage have their coverage begin?
- The first day of the month after the SEP form is received
- Retroactively to the date employer coverage ended
- The first day of the following month after enrollment, or any of the preceding 3 months at the beneficiary's request (Correct answer)
- July 1 of the year they enroll
Correct answer: The first day of the following month after enrollment, or any of the preceding 3 months at the beneficiary's request
During an SEP, Part B coverage can be backdated up to 3 months before the month enrollment is requested, or can begin the following month.
Question 7: Which statement about Part A premium-free eligibility is correct?
- A beneficiary needs 40 quarters of Medicare-covered employment for premium-free Part A (Correct answer)
- Premium-free Part A requires 30 quarters of work and paying Medicare taxes
- Any US citizen aged 65 automatically qualifies for premium-free Part A
- Premium-free Part A is only available to those who paid into Social Security for 20 years
Correct answer: A beneficiary needs 40 quarters of Medicare-covered employment for premium-free Part A
Premium-free Part A requires 40 quarters (10 years) of Medicare-covered employment by the beneficiary or their spouse.
CMS Medicare Specialist Enrollment & Eligibility Guidelines 3
What penalty applies to a Medicare beneficiary who goes 15 full months without creditable prescription drug coverage after their Part D Initial Enrollment Period ends?