AHIP - FINAL EXAMINATION WITH 100- FULL UPDATE.

AHIP - FINAL
EXAMINATION WITH
100% FULL UPDATE




Mr.VZachowVhasVaVconditionVforVwhichVthreeVdrugsVareVavailable.VHeVhasVtriedVtw
oVbutVhadVanVallergicVreactionVtoVthem.VOnlyVtheVthirdVdrugVworksVforVhimVandVitVi
sVnotVonVhisVPartVDVplan'sVformulary.VWhatVcouldVyouVtellVhimVtoVdo?V-
VcorrectVanswer-
Mr.VZachowVhasVaVrightVtoVrequestVaVformularyVexceptionVtoVobtainVcoverageVforV
hisVPartVDVdrug.VHeVorVhisVphysicianVcouldVobtainVtheVstandardizedVrequestVformV
onVtheVplan'sVwebsite,VfillVitVout,VandVsubmitVitVtoVhisVplan.

Mr.VPolanskiVlikesVtheVcostVofVanVHMOVplanVavailableVinVhisVarea,VbutVwouldVlikeV
toVbeVableVtoVvisitVoneVorVtwoVdoctorsVwhoVaren'tVparticipatingVproviders.VHeVwant
sVtoVknowVifVtheVPointVofVServiceV(POS)VoptionVavailableVwithVsomeVHMOsVwillVb
eVofVanyVhelpVinVthisVsituation.VWhatVshouldVyouVtellVhim?V-VcorrectVanswer-
TheVPOSVoptionVmightVbeVaVgoodVsolutionVforVhimVasVitVwillVallowVhimVtoVvisitVout
-of-
networkVproviders,VgenerallyVwithoutVpriorVapproval.VHowever,VheVshouldVbeVawar
eVthatVitVisVlikelyVheVwillVhaveVtoVpayVhigherVcost-sharingVforVservicesVfromVout-of-
networkVproviders.

Mr.VBarkerVhadVsurgeryVrecentlyVandVexpectedVthatVheVwouldVhaveVcertainVservic
esVandVitemsVcoveredVbyVtheVplanVwithVminimalVout-of-
pocketVcostsVbecauseVhisVMA-
PDVcoverageVhasVbeenVveryVgood.VHowever,VwhenVheVreceivedVtheVbill,VheVwasV
surprisedVtoVseeVlargeVchargesVinVexcessVofVhisVmaximumVout-of-
pocketVlimitVthatVincludedVaVnumberVofVservicesVandVitemsVheVthoughtVwouldVbeVf

, ullyVcovered.VHeVcalledVyouVtoVaskVwhatVheVcouldVdo?VWhatVcouldVyouVtellVhim?
V-VcorrectVanswer-
YouVcanVofferVtoVreviewVtheVplansVappealVprocessVtoVhelpVhimVaskVtheVplanVtoVre
viewVtheVcoverageVdecision.

Ms.VStuartVhasVheardVaboutVaVspecialVneedsVplanV(SNP)VthatVoneVofVherVfriendsVi
sVenrolledVinVandVisVinterestedVinVthatVproduct.VSheVwantsVtoVbeVsureVsheValsoVh
asVcoverageVforVprescriptionVdrugs.VWouldVsheVbeVableVtoVobtainVdrugVcoverageVi
fVsheVenrolledVinVtheVSNP?V-VcorrectVanswer-
a.VYes.VAllVSNPsVareVrequiredVtoVprovideVPartVDVcoverageVforVprescriptionVdrugs.
b.VYes,VbutVonlyVifVsheVqualifiesVforVPartVDVprescriptionVdrugVcoverageVunderVherV
stateVMedicaidVprogram.
c.VNo.VMedicareVbeneficiariesVwhoVenrollVinVanVSNPVmustValwaysVobtainVtheirVdru
gVcoverageVthroughVaVstand-
aloneVPartVDVMedicareVprescriptionVdrugVplanVthatVtheyVsignVupVforVindependentV
ofVtheirVenrollmentVinVtheVSNP.
d.VMaybe.VSomeVSNPsVofferVPartVDVcoverageVforVprescriptionVdrugsVandVsomeVd
oVnot.
=V?????

PhionaVworksVinVtheVITVDepartmentVofVBestCareVHealthVPlan.VPhionaVisVplacedVin
VchargeVofVBestCare'sVeffortsVtoVfacilitateVelectronicVenrollmentVinVitsVMedicareVAd
vantageVplans.VInVsettingVupVtheVenrollmentVsite,VwhichVofVtheVfollowingVmustVPhi
onaVconsider?V-VcorrectVanswer-
II.VAllVdataVelementsVrequiredVtoVcompleteVanVenrollmentVrequestVmustVbeVcapture
d.
III.VTheVprocessVmustVincludeVaVclearVandVdistinctVstepVthatVrequiresVtheVapplicant
VtoVactivateVanV"EnrollVNow"VorV"IVAgree"VtypeVofVbuttonVorVtool.


Ms.VLewisVunderstandsVthatVMedicareVprescriptionVdrugVplansVmayVuseVvariousVm
ethodsVtoVcontrolVtheVuseVofVspecificVdrugs.VSheVhasVheardVaboutVaVtechniqueVca
lledV"stepVtherapy"VandVisVwonderingVifVyouVcanVexplainVwhatVthatVis.VWhatVshoul
dVyouVtellVher?V-VcorrectVanswer-
StepVtherapyVinvolvesVusingVoneVorVmoreVlowerVpricedVdrugsVbeforeVtryingVaVmor
eVexpensiveVdrugVwhenVallVareVusedVtoVtreatVtheVsameVcondition.

Mr.VGomezVnotesVthatVaVPrivateVFee-for-
ServiceV(PFFS)VplanVavailableVinVhisVareaVhasVanVattractiveVpremium.VHeVwantsVt
oVknowVifVheVmustVuseVdoctorsVinVaVnetworkVasVhisVcurrentVHMOVplanVrequiresVhi
mVtoVdo.VWhatVshouldVyouVtellVhim?V-VcorrectVanswer-
HeVmayVreceiveVhealthVcareVservicesVfromVANYVdoctorVallowedVtoVbillVMedicare,V
asVlongVasVheVshowsVtheVdoctorVtheVplan'sVidentificationVcardVandVtheVdoctorVagr
eesVtoVacceptVtheVPFFSVplan'sVpaymentVtermsVandVconditions,VwhichVcouldVinclu
deVbalanceVbilling.

Mr.VWuVisVeligibleVforVMedicare.VHeVhasVlimitedVfinancialVresourcesVbutVfailedVtoVq
ualifyVforVtheVPartVDVlow-
incomeVsubsidy.VWhereVmightVheVturnVforVhelpVwithVhisVprescriptionVdrugVcosts?V-
VcorrectVanswer-