AHIP - Final examination 1 .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?Mr. Zachow has a right to request a formulary excep-tion to obtain cov-erage for his Part D drug. He or his physician could obtain the stan-dardized request form on the plan's website, fill it out, and submit it to his plan.2 .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?The POS option might be a good solution for him as it will al-low him to vis-it out-of-network providers, gener-ally without pri-or approval. How-ever, he should be aware that it is likely he will have to pay higher cost-shar-ing for services from out-of-net-work providers.3 .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 You can offer to review the plans appeal process to help him ask the plan to review the coverage deci-sion.
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thought would be fully covered. He called you to ask what he could do? What could you tell him?4 .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?
- Yes. All SNPs
are required to provide Part D coverage for pre-scription drugs.b. Yes, but only if she qualifies for Part D prescription drug coverage un-der her state Med-icaid program.c. No. Medicare beneficiaries who enroll in an SNP must always ob-tain their drug cov-erage through a stand-alone Part D Medicare prescrip-tion drug plan that they sign up for in-dependent of their enrollment in the SNP.d. Maybe. Some SNPs offer Part D coverage for prescription drugs and some do not.= ?????5 .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 Ad-vantage plans. In setting up the enrollment site, which of the following must Phiona consider?II. All data ele- ments required to complete an en-rollment request must be captured.
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III. The process must include a clear and distinct step that requires the applicant to ac-tivate an "Enroll Now" or "I Agree" type of button or tool.6 .Ms. Lewis understands that Medicare prescription drug plans may use various methods to control the use of specific drugs. She has heard about a tech-nique called "step therapy" and is wondering if you can explain what that is. What should you tell her?Step therapy in- volves using one or more low-er priced drugs before trying a more expensive drug when all are used to treat the same condition.7 .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?He may receive health care ser-vices from ANY doctor allowed to bill Medicare, as long as he shows the doctor the plan's identifica-tion card and the doctor agrees to accept the PFFS plan's pay-ment terms and conditions, which could include bal-ance billing.8 .Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-in- Mr. Wu may still qualify for help
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