AHIP - Final examination with correct
resolutions
, 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? -
correct ans: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? - correct
ans: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? - correct ans: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? - correct ans: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.
resolutions
, 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? -
correct ans: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? - correct
ans: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? - correct ans: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? - correct ans: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.
