AHIP MODULE 1

CHEN will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that
entire period. She is concerned that she will not qualify for coverage under Part A because she was not born in the US.
(Medicare Entitlement Part A)
Most individuals who are citizens and over age 65 are covered under Part A by virtue of having paid Medicare taxes
while working, though some may be covered as a result of paying monthly premiums.
BAUER is 49 years old, but eighteen months ago was declared disabled by the SSA and has been receiving disability
payments. He is wonder whether he can obtain coverage under Medicare.
(Medicare Entitlement Part B)
After receiving such disability payments for 24 months, he WILL BE AUTOMATICALLY enrolled in Medicare,
regardless of age.
DAVIS is 49 years old and has been receiving disability benefits from SSA for 12 months. Can you sell him a MA or Part
D Rx policy?
(Medicare Entitlement Part B: Medicare Eligibility Part C/D)
NO, he can't purchase a MA or Part D policy because he has NOT received SSA or RR disability benefits for 24
months.
HENDERSON believes that she will qualify for Medicare coverage when she turns 65, without paying any premiums,
because she has been working for 40 years and paying Medicare taxes.
(Medicare Premiums for Part B)
In order to obtain Part B coverage, she must pay a STANDARD MONTHLY premium , though it is HIGHER for
individuals with higher income.
DIAZ continued working wit his company and was insured under his employer's group plan until he reached 68. He has
heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know
how much he will have to pay.
(Medicare Premiums Part B)
Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan.
PENA is 66 years old, has coverage under an employer plan and will retire next year. She heard she must enroll in Part
B at the beginning of the year to ensure no gap in coverage.
(Medicare Premiums for Part B)
She MAY enroll at any time while she is covered under her employer plan, but she will have a special eight-month
enrollment period that differs from the standard general enrollment period, during which she may enroll in
Medicare Part B.
KELLY is entitled to Part A, but is not yet enrolled in Part B. She is considering enrollment in a Medicare health plan.
What should you advise her to do before she will be able to enroll into a Medicare health plan?
(Medicare Eligibility)
In order to joint a Medicare health plan, she also MUST enroll in Part B
TOMA has a low, fixed income. What could you tell her that might be of assistance?
(help for individuals with Limited Income/Resources)
She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with
Medicare costs for which she is responsible.
YU has limited income and resources so you have encouraged him to see if he qualifies for some type of financial
assistance. Mr. Yu is not sure it is worth the trouble to apply and wants to know what the assistance could do for him if
he qualifies.
(Limited Income/Resources)
He might qualify for help with Part D Rx costs and help paying Part A and/or Part B premiums, deductibles, and/or
cost sharing.
PATEL is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to
understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a
result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under
Original Medicare?
(Original Medicare covers)
Under Original Medicare, there is a single deductible amt. due for the first 60 days of any inpatient hospital stay,
after which it converts into a per day amt. through day 90. After day 90, he would pay a daily amt. up to 60 days
over his lifetime, after which he would be RESPONSIBLE FOR ALL COSTS.
KANOF is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that
condition. However, she and her physicians feel that after her lengthy hospital stay she will need a month or two of
nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled
nursing facility?
(Original Medicare covers)
Medicare will covers Mrs. Kanof''s skilled nursing services provided during the first 20 days of her stay, after which
she would have a copay until she has been in the facility for 100 days.
RAINEY is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell
Mr. Rainey (or representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover?
(Medicare inpatient services)
Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime.
QUIGLEY has just turned 65 and received a letter informing her that she has been automatically enrolled in Medicare
Part B. She wants to understand what this means.
(Medicare premiums and deductibles)
Part B primarily covers physician services. She will be paying a monthly premium and, with the exception of many
preventive and screening tests, generally will have 20% co-pays for these services, in addition to an annual
deductible.
BUCK has several family members who did from different cancers. He wants to know if Medicare covers cancer
screening.
(Medicare covers or not)
Medicare covers periodic performance of a range of screening tests that are meant to provide early detection of
disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered.
TURNER is comparing her employer's retiree ins. to Original Medicare and would like to know which of the following
services Original Medicare will cover if the appropriate criteria are met?
(Medicare covers or not)
Original Medicare covers ambulance services.
BADEAU wears glasses and dentures and has enjoyed considerable pain relief from arthritis through acupuncture. She
is concerned about whether or not Medicare will cover these items and services.
(Medicare covers or not)
Medicare DOES NOT cover acupuncture, or, in general, glasses or dentures.
SINGH would like drug coverage, but does not want to be enrolled into a health plan.

(Original Medicare and Part D)

Mr. Singh can enroll in a stand-alone Rx plan and continue to be covered for Part A and B services through Original
FEE-FOR-SERVICE Medicare.
ALONSO receives some help paying for his two generic Rx's from his employer's retiree coverage, but he wants to
compare it to a Part D Rx plan. He asks you what costs he would generally expect to encounter when enrolling into a
standard Medicare Part D Rx plan.
(Original Medicare and Part D)
He generally would pay a monthly premium, annual deductible, and per-Rx cost sharing.
PATERSON is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell
her about Medigap as an option to address this concern.
(Original Medicare and Part D) MEDIGAP
Medigap plans help beneficiaries cover coinsurance, copayments, and/or deductibles for MEDICALLY NECESSARY
services.
SCHLICK is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would
like to keep the coverage she has, but replace her existing Medigap plan with one that provides drug coverage.
(Original Medicare and Part D) MEDIGAP
Mrs. Schlick CAN'T purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in
a Part D Rx plan.
CAPADONA would like to purchase a MA plan and Medigap plan to pick up costs not covered by that plan. What
should you tell him?
(MA and Part D)
It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap ONLY
works with Original Medicare.
MOORE plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable
income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare.
What could you tell her to address her concerns?
(Medicare Eligibility)
Medicare is a program for people age 65 or older and those under 65 with certain disabilities, end stage renal
disease or Lou Gehrig's disease, so SHE WILL BE ELIGIBLE FOR MEDICARE.
GEISLER'S neighbor told her she should look at her Part D options during the annual Medicare enrollment period
because features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask
what her neighbor was talking about.
(Medicare Part D)
Part D covers Rx and she should look at her premiums formulary, and cost sharing to see if they have changed.
STYLES would like to plan for retirement and has asked you what is covered under Original Fee-for-Service FFS
Medciare?
(Medicare Part D)
Part A, which covers hospital, skilled nursing facility, hospice and home health care and Part B, which covers
professional services such as those provided by a doctor are covered under Original Medicare
HUDSON is concerned that if he signs up for a Medicare health plan, the health plan may, at some time in the future,
reduce his benefits below what is available to Original Medicare. What should you tell him?
Medicare health plans MUST cover all benefits available under Medicare Part A and B. Many also cover Part D Rx
plan.
WEEMS wants to know generally how the benefits under Original Medicare might compare to the benefit package of a
Medicare health plan before she starts looking at specific plans.
Medicare health plans may offer extra benefits that Original Medicare does NOT offer such as vision, hearing, and
dental services and MUST include a maximum out of pocket limit on Part A and B services.
MEONI'S wife has a MA plan, but he wants to understand what coverage Medicare supplement insurance provides
since his health care needs are different from his wife's needs.
Medicare Supplemental ins. would help cover his Part A and B cost sharing in Original fee for service Medicare as
well as possibly some services that Medicare does not cover.