AHIP - Final Examination (Latest Update 2022)
Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic
... [Show More] 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 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? - 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? - 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? - 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? - 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 [Show Less]