SHINE Certification Exam Answer Key
Note to Regional Directors and Training Staff
The answer key provides the correct answer to each question. In addition, each question references a page number/location to review; however, answers are not exclusively found in these locations. Test takers should be utilizing the Mini-Manual, Charts, Handouts, Lecture Notes, etc. when completing this exam.
1) The Initial Enrollment Period consists of __ months to sign up for Medicare.
a)2
b)3
c)7 (page 29)
d)8
2)Which of these statements about benefit periods in Original Medicare is true?
a)Benefit periods renew on an annual basis
b)Benefit periods limit the number of covered physician visits
c)Benefit periods set the annual deductible for hospital stays
d)Benefit periods are unlimited in number during a lifetime (page 36)
3) Mrs. Lisle has Original Medicare only. A home health nurse visited Mrs. Lisle to monitor the healing of an infected incision and change dressings. Assuming this meets Medicare’s requirements for coverage, how much does Mrs. Lisle owe?
a)$0 (page 49)
b)She will have to pay the full cost herself
c)20 percent of the approved amount
d)None of the above
4) Which of these is a requirement for coverage of Medicare’s SNF benefit for a patient?
a)First seen in a hospital emergency room
b)Receives skilled nursing care at least five days a week
c)Admitted to a nursing facility licensed in Massachusetts
d)Admitted as an inpatient for at least 3 consecutive calendar days in a hospital(page 41)
5) Which of these is a requirement for coverage of Medicare’s home health benefit?
a) The patient is under the care of a doctor
b) The patient is homebound
c)The patient receives intermittent orpart-time skilled care
d)All of the above(page 46)
6) Which of these people would have a Special Enrollment Period, enabling enrollment in Medicare Part B without a penalty?
a)John, 67, who is covered under his wife’s group health plan through her work (page 30)
b)Ophelia, 66, who elected COBRA coverage 13 months ago when her employer ended its employee group health plan
c)Ed, 68, whose son’s small company added him as a participant to its group health planeven though he is not an active employee
d)Esther, 67, who continues to work from time to time as a contractor for a large company but is not on the group health insurance plan
7) To receive Medicare coverage for hospice services, a patient must:
a)Reside in a licensed nursing facility
b)Have terminal cancer
c)Give up her regular Medicare benefits
d)Have a life expectancy of six months or less (page 50)
8) Mr. Sobol was hospitalized for ten days and transferred to a skilled nursing facility (SNF) where Medicare covered a 35 day stay. Four weeks later, Mr. Sobol was re-admitted to a hospital. If he needs SNF care after the hospital stay, how many Medicare-covered SNF days are available to him?
a)25
b)65 (page 42)
c)90
d)100
9) Mr. Wiedenhafer’s doctor asked him to sign an Advance Beneficiary Notice (ABN) form before he received some tests at the office. If Mr. Wiedenhafer signs the form, what will be the result?
a)He cannot receive the tests
b)The doctor won’t submit a claim to Medicare
c)The doctor will waive his liability for the bill
d)He is liable for the bill if Medicare won’t pay (page 65, ABN sheet on Common Resources)
10) Which of these providers is not required to accept assignment?
a)Ambulance service providers
b)Durable medical equipment providers (pages 73& 138)
c)Participating provider physicians
d)None of the above
11) Your appeal rights listed on the Medicare Summary Notice (MSN) include:
a)How you can appeal
b)The time limit for filing your appeal
c)Information about why Medicare didn't pay your bill
d)All of the above (page 140)
12) Ms. Green will be 65 in 3 months. She never worked outside the home. She was married for 20 years, then divorced and never re-married. Her ex-husband passed away just a few months ago at the age of 68. He worked for IBM most of his life. Which of the following statements is true?
a) She is NOT eligible for Medicare because she never worked
b) She is NOT eligible for Medicare based on her ex-husband’s work history since they were divorced before she turned 65
c) She is eligible for Medicare based on her ex-husband’s work history regardless of how long they were married
d) She is eligible for Medicare based on her ex-husband’s work history since they were married over 10 years (page 24)
13)If you believe you are being made to leave the hospital too soon and you call your state
Beneficiary and Family Centered Care Quality Improvement Organization [BFCC-QIO] (Livanta) within the required time-frame, the hospital cannot force you to leave before the BFCC-QIO makes its decision.
a) True (page 54-55)
b) False
14)Non-participatingphysicians who do not accept assignment may charge as much as they wish.
a) True
b) False (page 139)
15) No matter how you have chosen to get your Medicare benefits, you can get emergency care
anywhere in the United States.
a) True 9 (page 147)
b) False
16)There are specific time limits for filing Medicare appeals.
a) True (page 148)
b) False
17) In order to get Skilled Nursing Facility (SNF) care covered by Medicare Part A, you must go directly
from the hospital to the SNF.
a) True
b) False (page 41)
18) Medicare will cover home health aide services on a part-time or intermittent basis (like help with
personal care such as bathing, using the toilet, or dressing) if you are also getting skilled care such as
nursing care or other therapy from the home health agency.
a) True (page 47)
b) False
19) Original Medicare covers emergency care during foreign travel.
a) True
b) False (page 39)
20) COBRA coverage protects a beneficiary from the late enrollment Part B penalty.
a) True
b) False (page 180)
21)The penalty for delayed enrollment into Medicare Part B is 1% for each month the individual could have
had it.
a) True
b) False (page 29)
22) When Brad became eligible for Medicare at age 65, he elected to take onlyPart A because he had an employer group health plan (EGHP) through his active employment. At age 67 he retired. How much time does he have to sign up for Medicare Part B without getting a penalty?
a)2 months
b)3 months
c)7 months
d)8 months (page 30)
23) The General Enrollment Period is:
a)November 15 through December 31, coverage effective January 1
b)January 1 through March 31, coverage effective July 1 (page 32)
c)November 15 through December 31, coverage effective July 1
d)January 1 through June 30, coverage effective July 1
24) The 2015 monthly premium for Medicare Part A for someone who has worked only 20 quarters is
a)$224
b)$407 (2015 Medicare Premiums Handout)
c)$104.90
d)Dependent upon income
25)Which is a requirement to join a Medicare Advantage Plan?
a)Enrolled in Part B
b)Enrolled in Part A
c)Live in plan’s service area
d)All of the above (page 78)
26) Ms. Ming is vacationing with her daughter in Massachusettsfor three months. She belongs to a Medicare HMO in California. Recently, she learned that the HMO did not pay for a doctor visit and a series of routine tests she received in Massachusetts. What is the likely reason behind the HMO’s payment denial?
a)Ms. Ming used out-of-network providers for non-urgent care(page 82)
b)Ms. Ming left Medicare when she joined the HMO
c)The providers should have sent the claims to the Part B contractor for Massachusetts
d)None of the above
27) A Medicare Advantage Plan is required to cover:
a)Emergency care
b)Skilled nursing care
c)Urgent care
d)All of the above (page 82)
28) Medicare beneficiaries do not need to continue paying their Medicare Part B premium once they enroll in a Medicare Advantage plan.
a) True
b) False (page 83, 93, & 96)
29) Paul is 47 years old and recently diagnosed with end stage renal disease (ESRD). He is now eligible for
Medicare due to his illness. Once enrolled in Medicare, Paul is eligible to join any Medigap or Medicare
Advantage Plan he chooses.
a) True
b) False (page 78)
30) A PPO allows a beneficiary the freedom to visit non-network providers.
a) True (page 92)
b) False
31)Most Medicare Advantage plans allow a beneficiary to also enroll in a standalone Prescription Drug Plan.
a) True
b) False (page 78)
32)To be eligible for a Medigap Plan you must be enrolled in both Medicare Part A and Part B.
a) True (page 113)
b) False
33)In Massachusetts, all Medigap Plans currently have continuous open enrollment.
a) True (page 120)
b) False
34) Individuals who disenroll from a Supplement Two plan have a Special Enrollment Period to enroll into a Medicare Part D plan.
a) True
b) False (page 116)
35) Individuals will automatically qualify for the Part D extra-help (LIS)if:
a)MassHealth helps pay their Medicare premiums
b)They receive full MassHealthbenefits
c)They receive Supplemental Security Income (SSI)
d)All of the above (page 105)
36) When determining eligibility for the Part D extra-help (LIS), resourcesNOT counted include:
a)The home an individual resides in
b)$1,500/person for funeral/burial expenses
c)The cash-value of life insurance policy
d)All of the above(What Is Extra Help-Social Security Handout)
37) Mr. Arneson turns 65 on May 15. What is the last day during his Initial Enrollment Period that he can enroll in Medicare Part D?
a)June 30
b)July 15
c)August 15
d)August 31 (page 108)
38) Which of these is not one of the features of Medicare's standard benefit prescription drug plan for 2015?
a)Co-pays of 50% during initial coverage period (2015 Standard Medicare Part D Benefit Handout)
b)Maximum annual deductible of $320
c)Coverage gap begins when total cost of drugs exceeds $2,960
d)Catastrophic coverage begins when TrOOP (true out-of-pocket costs) exceed $4,700
39) Which of these will qualify Mr. Collins for a Special Enrollment Period (SEP) for a Medicare Prescription Drug Plan?
a)His current Medicare drug plan dropped his prescription drug from its list of preferred drugs
b)His union's health plan is ending drug coverage for retirees(Medicare Part D SEP’s Chart)
c)He moved from his home to a senior apartment two miles away (in the same town)
d)He stopped paying premiums after his Medicare drug plan denied an exception for a prescribed drug
40) Which of the following medications is excluded from Medicare drug plan coverage?
a)Drugs used in the treatment of weight loss (page 107)
b)Cholesterol-lowering medications
c)Anti-depressant medications
d)Insulin
41) A Medicare Drug Plan will make an expedited coverage determination on a formulary exceptions request when the plan member:
a)Can't afford to pay for the drug without insurance coverage
b)Has used the same drug successfully for two years
c)Prefers not to wait for a standard determination
d)Faces serious physical harm without the drug(How to Request a Coverage Determination, File an Appeal, of File a Complaint Sheet on Common Resources)
42) If you have MassHealth Standard, you are not eligible to join Prescription Advantage.
a) True (Prescription Advantage Application)
b) False
43) One must have Medicare Part A and Part B to enroll in a Medicare Prescription Drug Plan.
a) True
b) False (page 99)
44)A person with a standard Medicare drug plan can add the plan's monthly premium to the other out-of
pocket costs to meet the threshold for catastrophic drug coverage.
a) True
b) False (page 107)
45) Joining Prescription Advantage provides a SEP for enrolling in a PDP or an MA-PD outside the
Annual Open Enrollment Period.
a) True (page 111)
b) False
46) To receive assistance from LIS, a Medicare beneficiary must be enrolled in a PDP or MA-PD.
a) True (page 105)
b) False
47) The Part D lifetime penalty for late enrollees is 1%of the benchmark (the national base beneficiary premium) for each month thebeneficiary did not have the required coverage.
a) True (page 104)
b) False
48) People receiving extra-help (LIS) can switch Part D plans every month.
a) True (page 110)
b) False
49) Medicare beneficiaries living in LTC facilities can switch Part D plans every month.
a) True (Medicare Part D SEP’s Handout)
b) False
50) If a beneficiary loses creditable drug coverage, they have an 8 month SEP to sign up for a PDP without
incurring a penalty.
a) True
b) False (page 103)
51) Mrs. Smith has been a dual eligible for many years. A month ago, she inherited $20,000 worth of
stocks. She will lose her MassHealth coverage in May, but she will remain eligible for LIS for the remainderof theyear.
a) True (page 105)
b) False
52) If a beneficiary enrolls in a new Part D Plan, he/she is automatically disenrolled from his/her old Part D
plan.
a) True (page 90)
b) False
53) Enrolling into a Medicare Part D plan automatically disenrolls an individual from his/herprevious HMO
Medicare Advantage Plan.
a) True (page 90)
b) False
54)When a Medicare drug plan removes a drug from its formulary, people who are affected have 63 days
to switch to another Part D Plan.
a) True
b) False (Medicare Part D SEP’s Handout)
55) Prior to applying for Prescription Advantage aperson must already have a Medicare Part D plan.
a) True
b) False (Prescription Advantage Application) also (page 111)
56) Qualified Medicare Beneficiary (QMB) benefits include:
a)Medicare's deductibles and coinsurance
b)Part A premium (if applicable)
c)Part B premium
d)All of the above(page 163)
57) Which of the following statements about CommonHealth is false:
a)CommonHealth is aMassHealth program for individuals with disabilities, including individuals 65 and older who were deemed disabled prior to turning 65
b)For working disabled adults there are no income or asset limits for CommonHealth coverage regardless of age, but a premium payment applies on a sliding scale fee basis for those with higher incomes
c)Those under 65 who do not work at least 40 hours per month may have to meet a one-time deductible (spend-down)
d)Those 65 and older are eligible for CommonHealth only if they work full-time AND are considered disabled by MassHealth or SSA (page 165)
58) Which of the following statements about the “Frail Elder” Waiver is false:
a)Must be evaluated and deemed “nursing home eligible” by a designated ASAP (Aging Services Access Point)
b)Income level at or below 200% SSI (page 168)
c)Asset limit of $2,000
d)If married, special provision allows elders to “waive” their spouse’s income and assets to become eligible (must transfer assets over $2000 limit to spouse)
59) Don is admitted to the nursing home on February 1 and is applying for Long Term Care Medicaid. His wife Dixie is still living at home.What is the maximum amount of Don's income that can be protected for Dixie?
a)100%
b)Up to $2,931(2015 Eligibility Guidelines for Public Benefits Programs “pink sheet” Handout)
c)50%
d)None
60) Alice comes to you as a friend said SHINE helped her get on MassHealth and suggested Alice get on it too as it covers everything. Alice stated that she currently has no insuranceand won’t be eligible for Medicarefor another 2 years so really needs your help. How would you help Alice?
a)Send her a MassHealth application and schedule an appointment to assist her in completing it
b)Refer her to the health connector for insurance optionsas SHINE assists only Medicare beneficiaries (page 154)
c)Assess her income and asset eligibility for MassHealth, Health Safety Net and Extra Help
d)All of the above
61) The best way to apply for LIS is by calling 1-800-MEDICARE.
a) True
b) False (page 105)
62) People who are referred to as “dual eligibles” are eligible for both Medicare and VA coverage.
a) True
b) False (page 110)
63) MassHealth provides primary prescription coverage to people on both Medicare and MassHealth.
a)True
b)False (page 154)
64) SLMB and QI-1 help Medicare beneficiaries pay their Medicare Part B premiums and co-pays.
a) True
b) False (page 163)
65)MassHealth income and asset limits are the same for all individuals regardless of age.
a) True
b) False (page 156)
66) Mrs. Novotny turns 65 this month and will keep working. She has decided to enroll in Medicare Part B and continue with her employer’s group health plan. Will the employer plan pay first and Medicare second?
a)Maybe, it depends on the number of employees in the group (page 179)
b)Yes, employer group plans are always the primary payers for older workers
c)Yes, Medicare only pays first when the older worker has retired
d)No, Medicare is the second payer only when an accident is involved
67) Ross and his husband Ed live in Boston and have been married for 3 years. Ross is Medicare eligible and is about to retire. Ed plans to continue working for 2 more years. Is Ross able to enroll into Ed’s family benefit through work and delay enrolling into Medicare Part B without penalty?
a) Yes (page 27)
b) No
68) People with VA and Medicare benefits:
a)Can get medical treatment under either program
b)Must choose which benefits to use each time
c)Cannot have a Part D plan
d)Both a and b(page 193)
69) Veterans who have drug coverage with the VA:
a)Have coverage that is considered as good as Medicare coverage (page 188)
b)Cannot have a Part D plan
c)Must choose to use VA coverage instead of Part D
d)Both a & b
70) If a beneficiary was in an automobile accident and received medical services as a result of the accident,
health care professionals would be required to attempt to collect payment from the automobile insurance company before billing Medicare.
a) True (page 143, Know Who Pays First If You Have Other Health Insurance or Coverage Handout)
b) False
71)If a beneficiary is covered by workers' compensation and is treated for a work-related illness or injury,
workers' compensation should be billed secondary to Medicare.
a) True
b) False (page 143)
72) If someone is 65 or older and covered by an employer group health plan due to his or spouse’s active employment and theemployer has 20 or moreemployees, Medicare is the secondary payer.
a) True (page 179)
b) False
73) A client who is 50 years old meets with you. He has Medicare and CommonHealth but is still having difficulty paying for his prescription drugs. If he enrolls in One Care, he will have no co-pays for drugs on the plan’s formulary.