2022/2023 AHIP FINAL EXAM QUESTIONS WITH ANSWERS (100%
CORRECT)
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? Correct 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? Correct 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? Correct
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? Correct 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? Correct 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? Correct 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.
CORRECT)
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? Correct 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? Correct 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? Correct
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? Correct 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? Correct 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? Correct 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.
