SHINE Certification Exam
The certification process is a quality assurance measure that enables us to verify, both for our program and for CMS, that our counselors meet the requisite level of expertise to assist clients with their health information needs.
This exam consists of 100 multiple choice questions regarding a number of rules aroundMedicare and Public Assistance Programs, as well as real life scenarios that you mayencounter as a SHINE Counselor.
When completing this exam you may use your SHINE Resource Manual and supplementary charts and handouts.
You will soon receive an email explaining how to complete this exam online. When submitting this exam online you will receive an instant score.
The exam must be submitted online by:
______
1) The Initial Enrollment Period consists of __ months to sign up for Medicare.
a)2
b)3
c)7
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.
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
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?
a)The patient is first seen in a hospital emergency room.
b)The patient receives skilled nursing care at least five days a week.
c)The patient is admitted to a nursing facility licensed in Massachusetts.
d)The patient was admitted for at least 72 consecutive hours in a hospital.
5) Which of these is a requirement for coverage of Medicare’s home health benefit?
a)A physician sets up a care plan.
b)The patient is homebound.
c)The patient receives intermittent orpart-time skilled care.
d)All of the above
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
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 life expectancy of six months or less
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
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.
10) Which of these providers is not required to accept assignment?
a)Ambulance service providers
b)Durable medical equipment providers
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
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.
13)If you believe you are being made to leave the hospital too soon and you call your state
QualityImprovement Organization (Mass-Pro) within the required time-frame, the hospital cannot force you
to leave before the QIO makes its decision.
a)True
b)False
14)Non-participatingphysicians who do not accept assignment may charge as much as they wish.
a) True
b) False
15) No matter how you have chosen to get your Medicare benefits, you can get emergency care
anywhere in the United States.
a) True
b) False
16)There are specific time limits for filing Medicare appeals.
a) True
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
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
b) False
19) Original Medicare covers emergency care during foreign travel.
a) True
b) False
20) A person may delay enrolling into Medicare Part B without penalty if they are covered by COBRA.
a) True
b) False
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
22) When Brad became eligible for Medicare at age 65, he elected to take onlyPart A because he had an EGHP based on 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
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
c)November 15 through December 31, coverage effective July 1
d)January 1 through June 30, coverage effective July 1
24) The 2013monthly premium for Medicare Part A for someone who has worked only 20 quarters is
a)$248
b)$441
c)$99.90
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
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.
b)Ms. Ming left Medicare when she joined the HMO.
c)The providers should have sent the claims to the Part B MAC for Massachusetts.
d)The HMO only pays for services delivered in its service area.
27) A Medicare Advantage Plan is required to cover:
a)Emergency care
b)Hospice care
c)Urgent care
d)All of the above
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
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
30) A PPO allows a beneficiary the freedom to visit non-network providers.
a) True
b) False
31) Beneficiaries enrolled in a HMO plan without drug coverage are allowed to choose a stand-alone Part
DPlan.
a) True
b) False
32)To be eligible for a Medigap Plan you must be enrolled in both Medicare Part A and Part B.
a) True
b) False
33)In Massachusetts, all Medigap Plans currently have continuous open enrollment.
a) True
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
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
36) When determining eligibility for the Part D extra-help (LIS), resources not 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
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
38) Which of these is not one of the features of Medicare's standard benefit prescription drug plan for 2013?
a)Co-pays of 50% during initial coverage period
b)Maximum annual deductible of $325
c)Coverage gap begins when total cost of drugs exceeds $2970
d)Catastrophic coverage begins when TrOOP (true out-of-pocket costs) exceed $4750
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.
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
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
42) If you have MassHealth Standard, you are not eligible to join Prescription Advantage.
a) True
b) False
43) One must have Medicare Part A and Part B to enroll in a Medicare Prescription Drug Plan.
a) True
b) False
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
45) Joining Prescription Advantage provides a SEP for enrolling in a PDP or an MA-PD outside the
Annual Coordinated Election Period.
a) True
b) False
46) People enrolled in LIS must be enrolled in a PDP or an MA-PD in order to receive extra help with their
drug costs.
a) True
b) False
47) The Part D lifetime penalty for late enrollees is 1%of the National Base Premium for each month the
beneficiary did not have the required coverage.
a) True
b) False
48) People receiving extra-help (LIS) can switch Part D plans every month.
a) True
b) False
49) Medicare beneficiaries living in LTC facilities can switch Part D plans every month.
a) True
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
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 remainder
of theyear.
a) True
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
b) False
53) Enrolling into a Medicare Part D plan automatically disenrolls an individual from his/herprevious HMO
Medicare Advantage Plan.
a) True
b) False
54)When a Medicare drug plan removes a drug from its formulary, members will receive a special enrollment period to switch to another Part D plan.
a) True
b) False
55) Prior to applying for Prescription Advantage aperson must already have a Medicare Part D plan.
a) True
b) False
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
57) Which of the following statements about CommonHealth is false:
a)CommonHealth is aMassHealth program for adults with disabilities (including adults 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).
58) Which of the following statements about the “Frail Elder” Waiver isfalse:
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
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 $2,841
c)50%
d)None
60) Alice lives in a nursing home and is applying for LTC Medicaid this month. She gifted $10,000 to each of her 5 children six years ago. The $50,000 will not result in a disqualification period because:
a)Giftsof $10,000 per child are allowed.
b)The look-back period for all transfers is 36 months.
c)The look-back period for all transfers is 60 months.
d)All gifts of money are not disqualifying transfers.
61) The best way to apply for LIS is by calling 1-800-MEDICARE.
a) True
b) False
62) People who are referred to as “dual eligibles” are eligible for both Medicare and VA coverage.
a) True
b) False
63) People with Medicare and MassHealth must use only MassHealth providers in order for MassHealth to
provide secondary coverage to Medicare.
a) True
b) False
64) SLMB and QI-1 help Medicare beneficiaries pay their Medicare Part B premiums and co-pays.
a) True
b) False
65)MassHealth income and asset limits are the same for all individuals regardless of age.
a) True
b) False
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.
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 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
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
69) Veterans who have drug coverage with the VA:
a)Have coverage that is considered as good as Medicare coverage
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
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
72) If someone is 65 or older and covered by an EGHP due to his or spouse’s active employment and the
employer has at least 20 employees, Medicare is the secondary payer.
a) True
b) False
73) Commonwealth Care is available to all individuals without medical coverage in Massachusetts.
a) True
b) False
74) Individuals who retire prior to 65 may enroll into a Commonwealth Choice plan regardless ofincome.
a) True
b) False
Arty Ficial
Mr. Ficial meets with you in April of 2013. He is 70 years old. He retired from his full-time job in 2011. His company generously has been paying his COBRA coverage for him, but now the company is going out of business and his health care coverage is ending as of April 30. He already has Part A, but he wants to sign up for Part B and a drug plan. He has been told that his drug coverage through COBRA is “creditable.”
75) He can sign up for Part B in May since he has been covered by a former employer.
a) True
b) False
76) He has 63 days from April 30th to sign up for a drug plan without penalty.
a) True
b) False
77) He will not have a Part B late enrollment penalty since his coverage was “creditable.”
a) True
b) False
78) Commonwealth Care would be an option for Arty while he’s waiting to enroll in Medicare Part B.