AHIP 2027 FINAL EXAMINATION
QUESTIONS AND VERIFIED
SOLUTIONS|VERIFIED & ALREADY
GRADED A+
Most Studied | Updated
WESTERN GOVERNOR’S UNIVERSITY
2027 VERSION
QUESTIONS & ANSWERS
#Bright_minds #stuvia@2026
, QUESTIONS & ANSWERS
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
QUESTIONS AND VERIFIED
SOLUTIONS|VERIFIED & ALREADY
GRADED A+
Most Studied | Updated
WESTERN GOVERNOR’S UNIVERSITY
2027 VERSION
QUESTIONS & ANSWERS
#Bright_minds #stuvia@2026
, QUESTIONS & ANSWERS
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
