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? - ANSWERMr. 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? - ANSWERThe
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? - ANSWERYou 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? - ANSWERa. 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? - ANSWERII. 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? - ANSWERStep 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? - ANSWERHe 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 plan's payment terms and conditions, which could include balance billing.
Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-
income subsidy. Where might he turn for help with his prescription drug costs? - ANSWERMr. Wu may
still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program.
You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA)
plans you represent. Before you conduct such sales presentations, what must you do? - ANSWER
Mr. Wong is a single individual. He has had a successful business career and is now able to retire with a
comfortable income. Mr. Wong's taxable income is in excess of $100,000. Mr. Wong has health coverage
through his employer but will sign-up Medicare Part A, Part B and Part D when he leaves the workforce.
How would you advise him as he budgets for Medicare premiums? - ANSWERa. Due to the provisions of
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? - ANSWERMr. 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? - ANSWERThe
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? - ANSWERYou 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? - ANSWERa. 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? - ANSWERII. 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? - ANSWERStep 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? - ANSWERHe 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 plan's payment terms and conditions, which could include balance billing.
Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-
income subsidy. Where might he turn for help with his prescription drug costs? - ANSWERMr. Wu may
still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program.
You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA)
plans you represent. Before you conduct such sales presentations, what must you do? - ANSWER
Mr. Wong is a single individual. He has had a successful business career and is now able to retire with a
comfortable income. Mr. Wong's taxable income is in excess of $100,000. Mr. Wong has health coverage
through his employer but will sign-up Medicare Part A, Part B and Part D when he leaves the workforce.
How would you advise him as he budgets for Medicare premiums? - ANSWERa. Due to the provisions of
