ENTERTAINING AHIP 2025 Q AND A

ENTERTAINING AHIP 2025 Q AND A

MedicarenkPrescriptionnkPaymentnkPlannk-nkanswer--
Beginningnkinnk2025,nkthenkprescriptionnkdrugnklaw,nkknownnkasnkthenkInflationnkReductionn
kAct,nkrequiresnkallnkMedicarenkprescriptionnkdrugnkplansnk(MedicarenkPartnkDnkplans)nk—

nkincludingnkbothnkstandalonenkMedicarenkprescriptionnkdrugnkplansnkandnkMedicarenkAdv

antagenkplansnkwithnkprescriptionnkdrugnkcoveragenk—
nktonkoffernkenrolleesnkthenkoptionnktonkpaynkout-of-

pocketnkprescriptionnkdrugnkcostsnkinnkthenkformnkofnkcappednkmonthlynkpaymentsnkinstea
dnkofnkallnkatnkoncenkatnkthenkpharmacy.

BenefitsnkofnkMedicarenkPrescriptionnkPaymentnkPlannk-nkanswer--
Expandingnkbenefits,nkloweringnkdrugnkcosts,nkandnkimprovingnkthenksustainabilitynkofnkthe
nkMedicarenkprogram



WhatnkisnkthenkMedicarenkPrescriptionnkPaymentnkPlan?nk-nkanswer--
OffersnkPartnkDnkenrolleesnkthenkoptionnktonkpaynkout-of-
pocketnkprescriptionnkdrugnkcostsnkinnkthenkformnkofnkcappednkmonthlynkpaymentsnkinstea
dnkofnkallnkatnkoncenktonkthenkpharmacynkundernkthenkMedicarenkPrescriptionnkPaymentnkPl
an.

HownkdoesnkthenkMedicarenkPrescriptionnkPaymentnkPlannkwork?nk-nkanswer--
Fornkbeneficiariesnkfacingnkhighnkcostsnkonnktheirnkprescriptions,nkitnkprovidesnkthemnkwithn
kthenkoptionnkofnkpayingnkout-of-

pocketnkdrugnkcostsnkinnkinstallments.nkItnkdoesnknotnkoffernkankdiscount,nkjustnkmanageabl
enkpayments

Ankclientnkenjoysnkankcomfortablenkretirementnkincome.nkHenkrecentlynkhadnksurgerynkandnk
expectednkthatnkhenkwouldnkhavenkcertainnkservicesnkandnkitemsnkcoverednkbynkthenkplannk
withnkminimalnkout-of-pocketnkcostsnkbecausenkhisnkMA-
PDnkcoveragenkhasnkbeennkverynkgood.nkHowever,nkwhennkhenkreceivednkthenkbill,nkhenkwa
snksurprisednktonkseenklargenkchargesnkinnkexcessnkofnkhisnkmaximumnkout-of-
pocketnklimitnkthatnkincludednksomenkservicesnkandnkitemsnkhenkthoughtnkwouldnkbenkfullynk
covered.nkHenkcallednkyounktonkasknkwhatnkhenkcouldnkdo?nkWhatnkcouldnkyounktellnkhim?nk-
nkanswer--

MedicarenkAdvantagenk(MA)nkplannkenrolleesnkhavenkankrightnktonkobtainnkankreviewnk(appe
al)nktonkcertainnkdecisionsnkaboutnkhealthnkcarenkpayment,nkcoveragenkofnkservices,nkornkpr
escriptionnkdrugnkcoverage.nkMedicarenkhealthnkplansnkmustnkprovidenkenrolleesnkwithnkank
writtennkdescriptionnkofnkthenkappealsnkprocess.

Ankclientnkisnkenrollednkinnkhernkstate'snkMedicaidnkprogramnkinnkadditionnktonkMedicare.nkW
hatnkshouldnkshenkbenkawarenkofnkwhennkconsideringnkenrollmentnkinnkankMedicarenkAdvan
tagenk(MA)nkplan?nk-nkanswer--Thenkclientnkisnkankdual-eligible.nkDual-
eligiblenkbeneficiariesnkmaynkenrollnkinnkanynktypenkofnkMAnkplannkexceptnkankMAnkMedicalnk
SavingsnkAccountnk(MSA)nkplan.

, Ankbeneficiarynkrecentlynklostnkhernkemployernkgroupnkhealthnkandnkdrugnkcoveragenkandnk
nownkshenkwantsnktonkenrollnkinnkankPPOnkthatnkdoesnknotnkincludenkdrugnkcoverage.nkWhatn
kshouldnkyounktellnkhernkaboutnkobtainingnkdrugnkcoverage?nk-nkanswer--

ShenkcannkenrollnkinnkankPPOnkwithoutnkdrugnkcoverage.nkHowever,nkIfnkankbeneficiarynkenr
ollsnkinnkankMAnkplannkthatnkisnkannkHMOnkornkPPOnkplannkthatnkdoesnknotnkincludenkPartnkDnk
coverage,nkthenkbeneficiarynkcannotnkjoinnkankstandalonenkPrescriptionnkDrugnkPlannk(PD
P).

Ankpotentialnkclientnkhasnkheardnkthatnkhenkcannksignnkupnkfornkankproductnkcallednk"Medicar
enkAdvantage"nkbutnkisnknotnksurenkaboutnkwhatnktypenkofnkplannkdesignsnkarenkavailablenkth
roughnkthisnkprogram.nkWhatnkshouldnkyounktellnkhimnkaboutnkthenktypesnkofnkhealthnkplansnk
thatnkarenkavailablenkthroughnkthenkMedicarenkAdvantagenkprogram?nk-nkanswer--
TherenkarenkcoordinatednkcarenkMedicarenkAdvantagenkplansnkthatnkincludenkHMOsnkandn
kPPOs.nkTherenkarenkalsonkPrivate-Fee-for-

Servicenk(PFFS),nkMedicarenkSavingsnkAccountnk(MSA),nkandnkSpecialnkNeedsnkPlansnk(
SNPs)

Ankpotentialnkclientnkcallsnkandnkasksnkwhethernktherenkarenkanynkspecialnkeligibilitynkrequir
ementsnkfornkMedicarenkAdvantage.nkWhatnkshouldnkyounktellnkher?nk-nkanswer--
TonkbenkeligiblenktonkenrollnkinnkMedicarenkAdvantage,nkannkindividualnkmustnkbenkentitlednk
(notnkenrolled)nktonkPartnkAnkandnkenrollednkinnkPartnkB.

YournkmomnkwantsnktonkknownkgenerallynkhownkthenkbenefitsnkundernkOriginalnkMedicarenk
mightnkcomparenktonkthenkbenefitsnkpackagenkofnkankMedicarenkAdvantagenkPlannkbeforenk
shenkstartsnklookingnkatnkspecificnkplans.nkWhatnkcouldnkyounktellnkher?nk-nkanswer--
SomenkMedicarenkAdvantagenkPlansnkoffernkextrankbenefitsnkthatnkOriginalnkMedicarenkdo
esnknotnkcover.nkAlso,nkOriginalnkMedicarenkdoesnknotnkhavenkankmaximumnkout-of-
pocketnklimit.

Whichnkofnkthenkfollowingnkstatement(s)nkis/
arenkcorrectnkaboutnkankMedicarenkSavingsnkAccountnk(MSA)nkPlans?
I.nkMSAsnkmaynkhavenkeithernkankpartialnknetwork,nkfullnknetwork,nkornknonknetworknkofnkprov
iders.
II.nkMSAnkplansnkcovernkPartnkAnkandnkPartnkBnkbenefitsnkbutnknotnkPartnkDnkprescriptionnkdr
ugnkbenefits.
III.nkAnnkindividualnkwhonkisnkenrollednkinnkannkMSAnkplannkisnkresponsiblenkfornkankminimalnk
deductiblenkofnk$500nkindexednkfornkinflation.
IV.nkNon-
networknkprovidersnkmustnkacceptnkthenksamenkamountnkthatnkOriginalnkMedicarenkwouldnk
paynkthemnkasnkpaymentnkinnkfull.
Questionnk7Answernk1,2,4
a.nkIInkandnkIIInkonly
b.nkI,nkII,nkandnkIIInkonly
c.nkI,nkII,nkandnkIVnkonly
d.nkInkandnkIInkonlynk-nkanswer--I,nkII,nkandnkIVnkonly

Happynk420Camper,nkagenk65,nkisnkentitlednktonkPartnkAnkbutnkhasnknotnkyetnkenrollednkinnkP
artnkB.nkShenkisnkconsideringnkenrollmentnkinnkankMedicarenkAdvantagenkplannk(PartnkC).nk
WhatnkshouldnkyounkadvisenkHappynktonkdonkbeforenkshenkcannkenrollnkinnkankMedicarenkAd
vantagenkplan?nk-nkanswer--