Medicare Advantage plans have a regulatory obligation to maintain accurate, up-to-date provider directories. The correct first step is to formally document and report the inaccuracy to the plan. This triggers their obligation to investigate, update their directory, and potentially assist the enrollee in finding a similar provider or appealing for a continuity of care transition. Other options either overreact, interfere in provider contracting, or fail to uphold the plan’s responsibility.

While individuals with ESRD are generally not eligible to enroll in a standard Medicare Advantage Plan, a key exception exists for Medicare Advantage Special Needs Plans (SNPs) designed specifically for beneficiaries with ESRD. They may also enroll in a plan if they develop ESRD while already a member. The most accurate answer reflects this nuanced eligibility, highlighting the practical pathway (an ESRD SNP) available to them.

The Medicare Annual Election Period (AEP) is correctly defined as October 15 to December 7 annually. Changes made during this period—such as switching between Original Medicare and Medicare Advantage, or changing Part D plans—have an effective date of January 1 of the following year. The other options describe other periods (like the Medicare Advantage Open Enrollment Period or Initial Enrollment Period) or contain incorrect restrictions.

This tests practical, real-world consequences. A key risk when leaving a Medigap plan for Medicare Advantage is the potential loss of guaranteed issue rights to that Medigap plan in the future. If they try to return to Medigap after their trial period ends, they may be subject to medical underwriting and could be denied coverage or charged a higher premium based on health status. This is a crucial counseling point to prevent a client from inadvertently losing valuable, guaranteed coverage.

All Medicare Advantage Special Needs Plans (SNPs), including D-SNPs, are required to provide integrated Medicare Part D prescription drug coverage (MA-PD plans). It is not optional or separate. For dual-eligibles, this Part D coverage coordinates with their Medicaid benefits, often resulting in very low or $0 cost-sharing. Understanding this integration is essential for advising dual-eligible clients accurately.

Agents must avoid making subjective claims about one plan being the “best.” Compliance and ethical guidelines require agents to act as educators and facilitators, helping beneficiaries objectively compare all plans based on their unique circumstances (providers, medications, finances, etc.). The goal is to empower the beneficiary to make an informed choice, not to steer them to a particular plan for any reason, including compensation.

Medicare Advantage Plans can offer supplemental benefits, like fitness memberships, that are not covered under Original Medicare. These benefits are generally made available to all enrollees in the plan, regardless of health status, frequency of use, or provision of health data. They are a feature of the plan and do not individually affect premiums or core benefits based on utilization. This reassures beneficiaries they can use such perks freely.

CMS Star Ratings are a crucial, objective tool for comparing plan quality. The ratings (1 to 5 stars) are based on factors like customer service, member complaints, management of chronic conditions, and drug pricing. A plan’s Star Rating can impact its ability to offer extra benefits and is a key indicator of overall performance and member satisfaction, making it a vital part of a comprehensive plan comparison.

This scenario-based question tests practical counseling skills. A thorough needs assessment includes discussing a beneficiary’s lifestyle, including travel patterns. For someone who regularly spends part of the year elsewhere, a local HMO might be a poor fit. The agent’s role is to proactively ask these questions, explain the difference between HMO (generally local) and PPO (often with nationwide networks) plans, and help the client choose a plan that aligns with their life. Assuming the client knows or relying on travel insurance for routine care is not adequate counseling.

Medicare Advantage plans have a regulatory obligation to maintain accurate, up-to-date provider directories. The correct first step is to formally document and report the inaccuracy to the plan. This triggers their obligation to investigate, update their directory, and potentially assist the enrollee in finding a similar provider or appealing for a continuity of care transition. Other options either overreact, interfere in provider contracting, or fail to uphold the plan’s responsibility.0