Understanding Medicare Advantage and Part D Plans, Exams of Nursing

Download Understanding Medicare Advantage and Part D Plans and more Exams Nursing in PDF only on Docsity! AHIP - Final examination QUESTION AND ANSWER 2024/2025 GRADED A+ UPGRADE 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 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 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? 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? 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. Able, Baker, and Charles are engaged in the marketing to and enrollment of beneficiaries into Medicare health plans. Mr. Able is an independent agent paid directly by a health plan. Ms. Baker is an independent agent paid through a field marketing organization (FMO). Mr. Charles is an independent agent paid for his work by a third-party marketing organization (TMO). How do the CMS compensation rules apply to these three agents? Baker and Charles are subject to CMS compensation rules because they are paid by third parties. Able is not because she is paid directly by a health plan. Agent Willis had several clients who disenrolled from the plans he represents during the AEP to try new Medicare Advantage plans. Agent Willis believes that the choices they made are not ideal for them and would like to get their business back during the Medicare Advantage Open Enrollment Period (MA-OEP). What can agent Willis do? He can wait until October and send them information about the plans he represents. Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost- sharing amounts and Mr. Greco would like to join that plan. What should you tell him? SNPs limit enrollment to certain sub populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. Mrs. Patterson is a new enrollee in the HealthBest Medicare Advantage (MA-PD) plan. She is new to this type of coverage and asks you what materials, if any, she should expect to receive. How would you reply? 1. Plan ratings information, summary of benefits, and pre-enrollment checklist Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern? Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end stage renal disease or Lou Gehrig's disease, so she will be eligible for Medicare. Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same requirements as the plans themselves. How should you respond to such a statement? Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules. This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do? You may go ahead and call them. Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan. I, II AND III ONLY Mr. Albert has heard about something called the Star Rating system for Medicare Advantage plans. He asks you to explain it to him since he is interested in enrolling in a plan that is newly available in his area. After you explain that it is the way for consumers to judge plan performance, what else would you say? ?????? Beneficiaries who live in the service area of a 5-star plan and are enrolled in an MA or PDP plan, or beginning in 2013, a Cost plan Beneficiaries who live in the service area of a 5-star plan, are enrolled in Original Medicare, and meet the eligibility requirements for Medicare Advantage or Part D plans The SEP is available each year beginning on December 8 and may be used once through November 30 of the following year. For example, the SEP for calendar year 2018 can be used from December 8, 2017 through November 30, 2018. Disenroll from an MA plan, PDP or Cost plan or leave Original Medicare Enroll in a 5-star MA plan, PDP or Cost plan Eligible individuals may enroll in a 5-star plan through 1-800-MEDICARE, Medicare.gov, or directly through the 5-star plan. Mr. Davies is turning 65 next month. He would like to enroll in a Medicare health plan, but does not want to be limited in terms of where he obtains his care. What should you tell him about how a Medicare Cost Plan might fit his needs? Cost plan enrollees can choose to receive Medicare covered services under the plan's benefits by going to plan network providers and paying plan cost sharing, or may receive services from non-network providers and pay cost sharing due under Original Medicare. Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this? If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account, Mrs. Berkowitz can do this. Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a meeting so that she can learn about Medicare and the products you represent. How should you respond? Mr. Romero is 64, retiring soon, and considering enrollment in his employer- sponsored retiree group health plan that includes drug coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him? Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep. Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of misusing or abusing frequently abused drugs? I. Identifying at risk individuals by using criteria that includes the number of opioid prescriptions the beneficiary has and the number of prescribers who have written those prescriptions. II. Locking an at-risk beneficiary into one pharmacy. III. Locking an at-risk beneficiary into one prescriber. IV. Increasing deductibles and copays for at-risk beneficiaries. I, II and III only. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation rules apply to this situation? This situation is considered a "dual enrollment" and CMS compensation rules are applied to the two plans at once and independently of each other. Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirements several years ago. Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the first time. Unfortunately, Mrs. Ridgeway has found that many of her providers are not in the MA plan's network. She has come to you for advice? What should you tell her? She qualifies for a special enrollment period (SEP) that will allow her to make a one-time election to return to Original Medicare and she also has a guaranteed eligibility period to rejoin her Medigap plan. This year you decide to focus your efforts on marketing to employer and union groups. Which of the following statements best describes what you can and cannot do in order to stay in compliance? You are not required to submit copies of disseminated materials to CMS at the time of use, but CMS may request and review copies if employee complains occur. Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her? Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him? He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him? If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Next week you will be participating in your first "educational event" for prospective enrollees. In order to be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage? Choose one answer. You should plan to ensure that the educational event is a social event, and must not conduct a sales presentation or distribute or accept enrollment forms at the event. Eleanor takes several high-cost prescription drugs. She would like to enroll in a standalone Part D prescription drug plan that is available in her area. In what type of Medicare Health Plan can she enroll if she also wishes to enroll in the standalone Part D plan?