Agent Training

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PEAK · Medicare Fundamentals

Practice Scenarios

Five real client situations — work them yourself, then check the reasoning.

Work through each one yourself using the Module 05 framework before you reveal the reasoning. This is where the framework turns into instinct.

Scenario 01
A 68-year-old client has Medicaid QMB+ benefits and is currently enrolled in a standard $0-premium Medicare Advantage plan — not a D-SNP. She just moved states and mentions confusion about costs she didn't expect.
D-SNP candidate

QMB+ is a full dual — broad D-SNP eligibility. Her current plan isn't a D-SNP at all, which likely explains the unexpected costs: she's missing the Medicaid-coordinated cost-sharing a D-SNP would provide. Since she just moved states, her Medicaid enrollment needs to be reverified in the new state first. Once confirmed, look for an integrated (FIDE/HIDE) D-SNP if one's available and aligned with her Medicaid plan.

Scenario 02
A 72-year-old client has been diagnosed with chronic heart failure and Type 2 diabetes. His cardiologist has documentation on file. He wants extra help managing appointments and specialized supplies.
C-SNP candidate

Both conditions are on the CMS-approved list, and some C-SNPs are built specifically around this combination. Confirm a multi-condition C-SNP is available in his area, and set the expectation up front that his provider will need to confirm the condition(s) within the first month of enrollment or the plan will disenroll him. Still compare it against the strongest standard MAPD option on network and cost — don't assume the C-SNP wins by default.

Scenario 03
A 67-year-old client uses VA benefits for his care and has confirmed that coverage includes creditable prescription drug coverage. He wants to add a Medicare Advantage plan for the extra benefits but keep his VA coverage as-is.
MA-only candidate

He's already confirmed creditable coverage he wants to keep — a textbook MA-only case. Before finalizing, confirm with the VA how enrolling in a Medicare Advantage plan (even MA-only) interacts with his VA benefits — coordination rules are specific and worth double-checking. If confirmed compatible, an MA-only plan lets him add the extra benefits without disturbing the drug coverage that's already working.

Scenario 04
A 70-year-old client has no chronic conditions, isn't dual-eligible, and is currently on Original Medicare with no drug plan at all. He wants lower costs and mentions he could use dental and vision coverage.
Standard MAPD

No SNP eligibility on either front, so this runs straight through the standard criteria: match his providers and formulary, lead with dental/vision since he named them, and check his MOOP. Since he currently has no drug coverage at all, MAPD isn't just the default here — it also protects him from a Late Enrollment Penalty down the line.

Scenario 05
A 69-year-old client is on SLMB (Medicaid pays her Part B premium only — no other Medicaid benefits). She asks about the extra dental benefits her neighbor gets "because he's on Medicaid."
Verify before promising anything

SLMB is a partial dual with more limited D-SNP eligibility than a full dual like her neighbor might be. Don't assume she qualifies for the same plan or benefits — check which D-SNPs in her area actually accept SLMB-level eligibility, if any. If none do, she's likely better served by a strong standard MAPD plan, and it's worth explaining clearly why her situation differs from her neighbor's rather than letting the comparison stand unaddressed.

Scenario 06
A 74-year-old client calls in September, past his AEP window from last year, saying his county was under a hurricane evacuation order for two weeks back in July and he never got around to switching plans afterward. He wants to enroll in a new MA plan today.
Verify before promising anything

This sounds like a disaster SEP, but "sounds like" isn't good enough — before telling him anything is confirmed, check his exact county and the declared incident dates against PEAK's Disaster SEP Tracker. The SEP only applies to counties actually named in a FEMA or state declaration, and only for the incident window plus the extra time CMS allows afterward — not indefinitely. If his county and dates check out, document the declaration when you process the enrollment. If they don't, he doesn't have a valid election period yet and needs to wait for AEP or another qualifying SEP.