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 te
...
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?AnsMr. 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?Ansa. 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.
c. Due to his participation in the workforce he will not have to pay premiums for Part A but he
will pay higher premiums for Part B and Part D due to the amount of his income.
d. Due to his participation in the workforce he will not have to pay premiums for Part A and will
pay reduced premiums for Part B and Part D.
?????
Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for
Medicare & Medicaid Services' communication and Marketing Guidelines to ensure he is
compliant for which type of products?Ans-Medicare Advantage (MA) and Prescription Drug
(PDP) plans Correct
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?Ans-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?Ans-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
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