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? - 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? - 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? - 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? - 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.
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? - ANS II.
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? -
ANS Step 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? - ANS He 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? - ANS Mr. 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? - ANS
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? - ANS a. Due to the provisions of
MACRA, his Part B and D coverage will be combined and covered through a low-cost
Medigap policy to supplement his Part A coverage.
b. Due to his participation in the workforce he will not have to pay premiums for Part A
and he will pay the lowest monthly premium rates for Part B and Part D.
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? - 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? - 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? - 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? - 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.
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? - ANS II.
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? -
ANS Step 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? - ANS He 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? - ANS Mr. 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? - ANS
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? - ANS a. Due to the provisions of
MACRA, his Part B and D coverage will be combined and covered through a low-cost
Medigap policy to supplement his Part A coverage.
b. Due to his participation in the workforce he will not have to pay premiums for Part A
and he will pay the lowest monthly premium rates for Part B and Part D.
