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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.

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 around Medicare and Public Assistance Programs, as well as real life scenarios that you may encounter 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 (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?
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. (page 41)

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 or part-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 plan even 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 (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 handout)

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
Quality Improvement Organization (Mass-Pro) within the required time-frame, the hospital cannot force you
to leave before the QIO makes its decision.
a) True (page 54-55)
b) False

14) Non-participating physicians 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) A person may delay enrolling into Medicare Part B without penalty if they are covered by COBRA.
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 only Part 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 (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 2014 monthly premium for Medicare Part A for someone who has worked only 20 quarters is
a) $234
b) $426 (Part A & Part B Premiums)
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 Massachusetts for 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 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) 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) A beneficiary can be enrolled in a Medicare Advantage plan and a standalone Prescription Drug Plan at the same time
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 (Medigap Chart, 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 MassHealth benefits.
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), 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 (Extra Help App)

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 2014?
a) Co-pays of 50% during initial coverage period (Part D Standard Benefit)
b) Maximum annual deductible of $310
c) Coverage gap begins when total cost of drugs exceeds $2,850
d) Catastrophic coverage begins when TrOOP (true out-of-pocket costs) exceed $4,550

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. (Special Enrollment Periods)
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 (Medications Excluded by Medicare handout, 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 (CMS document Medicare Prescription Drug Coverage)

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 Coordinated Election 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 National Base Premium for each month the
beneficiary 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 (MA/PDP SEP chart)
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 remainder
of the year.
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
a) True (page 90)
b) False

53) Enrolling into a Medicare Part D plan automatically disenrolls an individual from his/her previous 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 (Special Enrollment Periods)

55) Prior to applying for Prescription Advantage a person 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 a MassHealth 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). (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 (Public Benefits Handout “pink sheet”)
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) Gifts of $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. (MassHealth Application)
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 (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) 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 (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 is 67 and has never enrolled in Part D. You find he is eligible for LIS and help him apply. What program can he use to get his drugs at the Extra Help co-pay amounts before his Part D plan is effective?
a) QIO
b) LINET (LINET handout)

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 (Know Who Pays First Chart from Day 1, page 143)
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 EGHP due to his or spouse’s active employment and the
employer has 20 or more employees, 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.
a) True (page 172)
b) False

74) A person enrolled in One Care will receive:
a) Comprehensive dental coverage
b) Coordinated care
c) Expanded behavioral health services
d) All of the above (page 172)

75) If someone loses her MassHealth coverage in August, her Extra Help coverage will end December 31 of that year.
a) True
b) False (page 105)

Arty Ficial

Mr. Ficial meets with you in April of 2014. He is 70 years old. He retired from his full-time job in June 2013. 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.”

76) He can sign up for Part B in May since he has been covered by a former employer.
a) True
b) False (page 27)

77) He has 63 days from April 30th to sign up for a drug plan without penalty.
a) True (page 103)
b) False

78) He will not have a Part B late enrollment penalty since his coverage was “creditable.”
a) True
b) False (page 27)

79) Arty will have to pay a late enrollment penalty for Part D since he was not covered through “active
a) True
b) False (page 102)

80) If Arty had enrolled in Medicare Part B during the 8 month SEP immediately following his retirement, he
would have avoided the Part B late enrollment penalty.
a) True (page 30)
b) False

81) The earliest Arty can have Part B coverage is July 1, 2015.
a) True (page 32)
b) False

Jill Hill

Mrs. Jill Hill visits the SHINE office. Her husband, Jack, has been admitted into a nursing home. Jill’s income is $550 per month and Jack’s income is approximately $3,000 per month. They own a home and have financial assets totaling $129,000.

82) Jill was told that her husband will not qualify for LTC MassHealth until they spend down their assets to $2,000. Is this correct?
a) Yes
b) No (197)

83) Ten years ago Jack and Jill transferred $40,000 to their son. Will this money be considered in asset calculations by MassHealth?
a) Yes
b) No (MassHealth Application)

84) Jill is concerned that she will be unable to afford to stay in her home with an income of just $550 per month. Will Jill be entitled to keep a portion of Jack’s monthly income?
a) Yes (197)
b) No

85) Jill’s neighbor told her that Medicaid can take her home, leaving her out on the street. Is this correct?
a) Yes
b) No (page 197)

Clara Fye

Clara Fye’s daughter, Vera Fye, calls you for assistance. She tells you her parents are both in their mid 80’s and live in their own home. Her mother’s health has declined considerably in recent years, and she is unable to care for herself. Vera helps as much as she can, but she works full-time, travels a great deal on her job, and lives an hour away. She knows that programs like MassHealth/Medicaid only help low-income people but wonders if there are any programs that offer help at moderate cost to middle income seniors. She says her mother’s monthly income is $980 and her father’s is $1,300. They have combined assets of approximately $30,000 along with their house and a car.

86) Identify a program she might be eligible for that could provide coverage for home care services.
a) SSI
b) QMB
c) Frail Elder Waiver (page 167)
d) LIS

87) Which of the following is an eligibility requirement of the program selected in question 86.
a) Reside in senior housing
b) Aged 60 or over (page 167)
c) Determined disabled by Social Security
d) None of the above

88) Which agency must she contact for this program?
a) MassMedline
b) MAP
c) ASAP (page 168)
d) QIO

 89) The benefits from this program include:
a) LIS
b) MassHealth
c) Homemaker and personal care services
d) All of the above (page 167)

Ms. Adams

Ms. Adams comes to SHINE for help in January because she wants drug coverage.  She is in a Medicare Advantage PPO plan without prescription coverage.  When she signed up for the plan she was not taking any drugs and did not want to pay for drug coverage.  Her doctor has just prescribed two very expensive medications, so she would like to get drug coverage. She is happy with her insurance plan and knows that the insurance company offers the same plan with drug coverage. She has a gross monthly income of $1,300. Her only assets are $1,000 in a checking account, $5,000 in a savings account, and a Life Insurance Policy with Cash Value of $10,000.

90) Ms. Adams can switch into the Medicare Advantage plan with drug coverage because she is within the Medicare Advantage Disenrollment Period (MADP)
a) True
b) False (page 81)

91) Ms. Adams can enroll into a stand-alone Medicare Drug Plan (PDP)
a) True (page 81)
b) False

92) If Ms. Adams enrolls into a stand-alone Medicare Drug Plan (PDP) she cannot continue to be enrolled in her current Medicare Advantage Plan.
a) True (page 90)
b) False

93) Ms. Adams is eligible for Prescription Advantage
a) True (PA Rate Sheet)
b) False

94) Ms. Adams assets are too high to qualify for Extra Help.
a) True
b) False (Extra Help Application)

Ms. Samantha Carson

Samantha Carson has Medicare A and B and AARP MedicareRx Preferred. She can’t afford a supplement since her drug costs are very high, even with her Medicare drug plan. She is single, 62 years old, has gross income of $1,950/month (SSDI) and has assets of $12,000. She says she is unable to work due to her disability, but she does babysit her grandson every day after school.

95) Samantha’s income is low enough to qualify for Prescription Advantage.
a) True
b) False (PA Rate Sheet)

96) Samantha could qualify for CommonHealth after she meets a one-time deductible based on her income.
a) True (page 164)
b) False

97) If Samantha provides documentation that she is working 40 hours per month as a babysitter she could
qualify for CommonHealth and not have to meet a one-time deductible.
a) True (page 165)
b) False

98) If Ms. Carson qualifies for CommonHealth she will automatically have her Part B premium paid for.
a) True
b) False (Public Benefits Eligibility Chart)

99) If Ms. Carson qualifies for CommonHealth she will automatically get LIS (Extra Help).
a) True (page 164)
b) False

100) When Ms. Carson turns 65 can she remain on CommonHealth if she meets another deductible.
a) True
b) False (page 165)

How do you get Medicare Part D? Basics. Medicare offers prescription drug coverage, or Part D, to everyone with Medicare. To get Part D, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and the drugs covered, and plans can change from year to year.