. 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? - ANSWER Mr. Zachow has a right to request a formulary exception to obt...
AHIP - Final examination Correct 100%
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? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER 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. Hernandez has marketed several different types of insurance products in her home state and has
typically sought approval of her materials from her State Department of Insurance. What would you
advise her regarding seeking such approval for materials she uses to market Medicare Advantage plans?
- ANSWER a. States often volunteer to review marketing materials on behalf of the Medicare agency. She
should check with her Department of Insurance to see if such a review is available and would satisfy CMS
requirements.
b. Materials for marketing Medicare health plans to individuals are subject to Medicare's uniform
national requirements. They do not need to be reviewed by the state, but the company she represents
must obtain approval from the Medicare agency (CMS) for any materials she uses.
c. Obtaining approval of her materials from the State Department of Insurance is a good practice and she
should continue it with materials for the Medicare health plans she represents.
d. Materials need only be reviewed and approved by the company(s) she represents.
Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well.
What can she expect will happen with respect to her drug coverage? - ANSWER Unless she chooses a
Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in
her area.
Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up
costs not covered by that plan. What should you tell him? - ANSWER It is illegal for you to sell Mr.
Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original
Medicare.
Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old.
He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to
sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him? -
ANSWER
Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a
PPO that does not include drug coverage. What should you tell her about obtaining drug coverage? -
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