AHIP Certification Mod 3 Exam
Questions and Answers
Actuarial Equivalent - ANS-The value of Part D benefits must be at least the same as
standard coverage.
All plans must cover at least the standard Part D coverage or its actuarial equivalent.
Which of the following statements best describes some of the costs a beneficiary would
incur for prescription drugs under the standard coverage? - ANS-Standard Part D
coverage would require payment of an annual deductible, and once past the
catastrophic coverage threshold, the beneficiary pays whichever is greater of either the
co-pays for generic and brand name drugs or coinsurance of 5%
Note:
Standard Part D coverage does require payment of an annual deductible. However,
once catastrophic coverage begins the beneficiary pays either co-pays for generic and
brand name drugs or co-insurance of 5%, whichever is greater. The plan does NOT pay
100% of all costs.
Alternative Coverage - ANS-Not standard coverage
- Prescription drug coverage that is at least equivalent to standard
- Has a deductible & cost sharing that does not exceed standard plan
CARA Program - ANS-Comprehensive Addiction & Recovery Act
- Where plans limit the prescribers or pharmacies a person can use due to drug abuse
issues
Coverage Phases - ANS-- The deductible
- Initial coverage: betwn deductible & initial coverage gap: betwn initial coverage limit &
out of pocket (the "donut hole")
- Catastrophic phase: after annual out of pocket is reached.
** Some phases in "alternative" benefits
Drug plans for HMO or PPO can be obtained by: - ANS-Only through their HMO or PPO
Employer/Union Drug Coverage - ANS-- If the coverage is "creditable", no penalty for
dropping coverage via employer, and joining a Part D program
- If the coverage is "not creditable", employee should wait till open enrollment to join
Part D to avoid penalties.
- If an employee retires, 63 days to avoid late enrollment penalty
- If an employee drops coverage, he may not be able to get it back. Should check first.
, Enhanced Alternative Benefits - ANS-- Part D that may include reduced deductible
- May include reduction of deductible
- May include coverage of excluded drugs or increase in coverage limit.
Formularies - ANS-A list of Part D drugs
- must have 2 drugs in ech category
- can be genetic & brand named
How can beneficiaries of PACE get a stand alone Part D? - ANS-Only through that plan
How can Medicaid beneficiaries obtain a drug plan? - ANS-Only through Medicaid
LIS - ANS-Low Income Subsidy
- Also called "extra help"
- For people in need of financial help who do not exceed 150% of federal poverty level
(FPL)
- Automatic coverage for peeps on full Medicaid, if they get help paying Part B, or if
they're on SSI
Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr.
Vaughn takes a prescription for helping to regrow his hair. They are anxious to have
their Medicare prescription drug plan cover these drug needs. What should you tell
them? - ANS-Medicare prescription drug plans are not permitted to cover the
prescription medications the Vaughns are interested in under Part D coverage,
however, plans may cover them as supplemental benefits and the Vaughn's could look
into that possibility.
Note:
Even if Mr. Vaughn's balding was the result of illness or a side effect of chemotherapy,
by law Part D plans are not permitted to provide coverage for cosmetic purposes.
Mr. Carlini has heard that Medicare prescription drug plans are only offered through
private companies under a program known as Medicare Advantage (MA), not by the
government. He likes Original Medicare and does not want to sign up for an MA
product, but he also wants prescription drug coverage. What should you tell him? -
ANS-Mr. Carlini can stay with Original Medicare and also enroll in a Medicare
prescription drug plan through a private company that has contracted with the
government to provide only such drug coverage to eligible Medicare beneficiaries
Note:
Mr. Carlini can stay in Original Medicare and obtain prescription drug benefits through a
stand-alone Part D plan. He does not have to enroll in a MA plan.
Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is
concerned about the Part D premium penalty if he does not enroll in a Medicare
prescription drug plan, but does not want to purchase extra coverage that he will not
need. What should you tell him? - ANS-If the drug coverage he has is not expected to
pay, on average, at least as much as Medicare's standard Part D coverage expects to
Questions and Answers
Actuarial Equivalent - ANS-The value of Part D benefits must be at least the same as
standard coverage.
All plans must cover at least the standard Part D coverage or its actuarial equivalent.
Which of the following statements best describes some of the costs a beneficiary would
incur for prescription drugs under the standard coverage? - ANS-Standard Part D
coverage would require payment of an annual deductible, and once past the
catastrophic coverage threshold, the beneficiary pays whichever is greater of either the
co-pays for generic and brand name drugs or coinsurance of 5%
Note:
Standard Part D coverage does require payment of an annual deductible. However,
once catastrophic coverage begins the beneficiary pays either co-pays for generic and
brand name drugs or co-insurance of 5%, whichever is greater. The plan does NOT pay
100% of all costs.
Alternative Coverage - ANS-Not standard coverage
- Prescription drug coverage that is at least equivalent to standard
- Has a deductible & cost sharing that does not exceed standard plan
CARA Program - ANS-Comprehensive Addiction & Recovery Act
- Where plans limit the prescribers or pharmacies a person can use due to drug abuse
issues
Coverage Phases - ANS-- The deductible
- Initial coverage: betwn deductible & initial coverage gap: betwn initial coverage limit &
out of pocket (the "donut hole")
- Catastrophic phase: after annual out of pocket is reached.
** Some phases in "alternative" benefits
Drug plans for HMO or PPO can be obtained by: - ANS-Only through their HMO or PPO
Employer/Union Drug Coverage - ANS-- If the coverage is "creditable", no penalty for
dropping coverage via employer, and joining a Part D program
- If the coverage is "not creditable", employee should wait till open enrollment to join
Part D to avoid penalties.
- If an employee retires, 63 days to avoid late enrollment penalty
- If an employee drops coverage, he may not be able to get it back. Should check first.
, Enhanced Alternative Benefits - ANS-- Part D that may include reduced deductible
- May include reduction of deductible
- May include coverage of excluded drugs or increase in coverage limit.
Formularies - ANS-A list of Part D drugs
- must have 2 drugs in ech category
- can be genetic & brand named
How can beneficiaries of PACE get a stand alone Part D? - ANS-Only through that plan
How can Medicaid beneficiaries obtain a drug plan? - ANS-Only through Medicaid
LIS - ANS-Low Income Subsidy
- Also called "extra help"
- For people in need of financial help who do not exceed 150% of federal poverty level
(FPL)
- Automatic coverage for peeps on full Medicaid, if they get help paying Part B, or if
they're on SSI
Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr.
Vaughn takes a prescription for helping to regrow his hair. They are anxious to have
their Medicare prescription drug plan cover these drug needs. What should you tell
them? - ANS-Medicare prescription drug plans are not permitted to cover the
prescription medications the Vaughns are interested in under Part D coverage,
however, plans may cover them as supplemental benefits and the Vaughn's could look
into that possibility.
Note:
Even if Mr. Vaughn's balding was the result of illness or a side effect of chemotherapy,
by law Part D plans are not permitted to provide coverage for cosmetic purposes.
Mr. Carlini has heard that Medicare prescription drug plans are only offered through
private companies under a program known as Medicare Advantage (MA), not by the
government. He likes Original Medicare and does not want to sign up for an MA
product, but he also wants prescription drug coverage. What should you tell him? -
ANS-Mr. Carlini can stay with Original Medicare and also enroll in a Medicare
prescription drug plan through a private company that has contracted with the
government to provide only such drug coverage to eligible Medicare beneficiaries
Note:
Mr. Carlini can stay in Original Medicare and obtain prescription drug benefits through a
stand-alone Part D plan. He does not have to enroll in a MA plan.
Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is
concerned about the Part D premium penalty if he does not enroll in a Medicare
prescription drug plan, but does not want to purchase extra coverage that he will not
need. What should you tell him? - ANS-If the drug coverage he has is not expected to
pay, on average, at least as much as Medicare's standard Part D coverage expects to
