AHIP - Final examination
Mr. Zachow has a condition for which three drugs are available.
He has tried two but had an allergic reaction to them. Only the
third drug works for him and it is not on his Part D plan's
formulary. What could you tell him to do? - ANSWER-Mr.
Zachow has a right to request a formulary exception to obtain
coverage for his Part D drug. He or his physician could obtain
the standardized request form on the plan's website, fill it out,
and submit it to his plan.
Mr. Polanski likes the cost of an HMO plan available in his area,
but would like to be able to visit one or two doctors who aren't
participating providers. He wants to know if the Point of Service
(POS) option available with some HMOs will be of any help in
this situation. What should you tell him? - ANSWER-The POS
option might be a good solution for him as it will allow him to
visit out-of-network providers, generally without prior approval.
However, he should be aware that it is likely he will have to pay
higher cost-sharing for services from out-of-network providers.
Mr. Barker had surgery recently and expected that he would
have certain services and items covered by the plan with
minimal out-of-pocket costs because his MA-PD coverage has
,been very good. However, when he received the bill, he was
surprised to see large charges in excess of his maximum out-of-
pocket limit that included a number of services and items he
thought would be fully covered. He called you to ask what he
could do? What could you tell him? - ANSWER-You can offer
to review the plans appeal process to help him ask the plan to
review the coverage decision.
Ms. Stuart has heard about a special needs plan (SNP) that one
of her friends is enrolled in and is interested in that product. She
wants to be sure she also has coverage for prescription drugs.
Would she be able to obtain drug coverage if she enrolled in the
SNP? - ANSWER-a. Yes. All SNPs are required to provide Part
D coverage for prescription drugs.
b. Yes, but only if she qualifies for Part D prescription drug
coverage under her state Medicaid program.
c. No. Medicare beneficiaries who enroll in an SNP must always
obtain their drug coverage through a stand-alone Part D
Medicare prescription drug plan that they sign up for
independent of their enrollment in the SNP.
d. Maybe. Some SNPs offer Part D coverage for prescription
drugs and some do not.
= ?????
, Phiona works in the IT Department of BestCare Health Plan.
Phiona is placed in charge of BestCare's efforts to facilitate
electronic enrollment in its Medicare Advantage plans. In setting
up the enrollment site, which of the following must Phiona
consider? - ANSWER-II. All data elements required to complete
an enrollment request must be captured.
III. The process must include a clear and distinct step that
requires the applicant to activate an "Enroll Now" or "I Agree"
type of button or tool.
Ms. Lewis understands that Medicare prescription drug plans
may use various methods to control the use of specific drugs.
She has heard about a technique called "step therapy" and is
wondering if you can explain what that is. What should you tell
her? - ANSWER-Step therapy involves using one or more lower
priced drugs before trying a more expensive drug when all are
used to treat the same condition.
Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan
available in his area has an attractive premium. He wants to
know if he must use doctors in a network as his current HMO
plan requires him to do. What should you tell him? - ANSWER-
He may receive health care services from ANY doctor allowed
to bill Medicare, as long as he shows the doctor the plan's
identification card and the doctor agrees to accept the PFFS
Mr. Zachow has a condition for which three drugs are available.
He has tried two but had an allergic reaction to them. Only the
third drug works for him and it is not on his Part D plan's
formulary. What could you tell him to do? - ANSWER-Mr.
Zachow has a right to request a formulary exception to obtain
coverage for his Part D drug. He or his physician could obtain
the standardized request form on the plan's website, fill it out,
and submit it to his plan.
Mr. Polanski likes the cost of an HMO plan available in his area,
but would like to be able to visit one or two doctors who aren't
participating providers. He wants to know if the Point of Service
(POS) option available with some HMOs will be of any help in
this situation. What should you tell him? - ANSWER-The POS
option might be a good solution for him as it will allow him to
visit out-of-network providers, generally without prior approval.
However, he should be aware that it is likely he will have to pay
higher cost-sharing for services from out-of-network providers.
Mr. Barker had surgery recently and expected that he would
have certain services and items covered by the plan with
minimal out-of-pocket costs because his MA-PD coverage has
,been very good. However, when he received the bill, he was
surprised to see large charges in excess of his maximum out-of-
pocket limit that included a number of services and items he
thought would be fully covered. He called you to ask what he
could do? What could you tell him? - ANSWER-You can offer
to review the plans appeal process to help him ask the plan to
review the coverage decision.
Ms. Stuart has heard about a special needs plan (SNP) that one
of her friends is enrolled in and is interested in that product. She
wants to be sure she also has coverage for prescription drugs.
Would she be able to obtain drug coverage if she enrolled in the
SNP? - ANSWER-a. Yes. All SNPs are required to provide Part
D coverage for prescription drugs.
b. Yes, but only if she qualifies for Part D prescription drug
coverage under her state Medicaid program.
c. No. Medicare beneficiaries who enroll in an SNP must always
obtain their drug coverage through a stand-alone Part D
Medicare prescription drug plan that they sign up for
independent of their enrollment in the SNP.
d. Maybe. Some SNPs offer Part D coverage for prescription
drugs and some do not.
= ?????
, Phiona works in the IT Department of BestCare Health Plan.
Phiona is placed in charge of BestCare's efforts to facilitate
electronic enrollment in its Medicare Advantage plans. In setting
up the enrollment site, which of the following must Phiona
consider? - ANSWER-II. All data elements required to complete
an enrollment request must be captured.
III. The process must include a clear and distinct step that
requires the applicant to activate an "Enroll Now" or "I Agree"
type of button or tool.
Ms. Lewis understands that Medicare prescription drug plans
may use various methods to control the use of specific drugs.
She has heard about a technique called "step therapy" and is
wondering if you can explain what that is. What should you tell
her? - ANSWER-Step therapy involves using one or more lower
priced drugs before trying a more expensive drug when all are
used to treat the same condition.
Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan
available in his area has an attractive premium. He wants to
know if he must use doctors in a network as his current HMO
plan requires him to do. What should you tell him? - ANSWER-
He may receive health care services from ANY doctor allowed
to bill Medicare, as long as he shows the doctor the plan's
identification card and the doctor agrees to accept the PFFS
