AHIP – Final examination

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.

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.

You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.

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. = ?????

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.

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.

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 may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program.

a. 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. ?????

Medicare Advantage (MA) and Prescription Drug (PDP) plans Correct

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.

Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.

It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare.

Medicare Advantage HMO or PPO may only obtain Part D benefits through their plan. They may not enroll in a standalone PDP. (Employer group plan enrollees may have additional choices.)

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.

He can wait until October and send them information about the plans he represents.

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.

1. Plan ratings information, summary of benefits, and pre-enrollment checklist

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.

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.

You may go ahead and call them.

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

I, II AND III ONLY

?????? 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.

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.

He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers.

Formularies must be developed with input from pharmacists,doctors, and other experts.

A meal cannot be provided, but light snacks would be permitted.

Plans are required to cover out-of network emergency care.

II, III, and IV only

Organizations sponsoring Medicare health plans are responsible for the behavior of their contracted representatives and will be conducting monitoring activities to ensure compliance with all applicable Federal law and guidance and plan policies. Furthermore, state agent licensure laws are not preempted and he must abide by their requirements.

Mrs. Wellington is eligible for a SEP that may be used once until November 30 to enroll in the fivestar plan.

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.

Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep.

I, II and III only.

Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies.

This situation is considered a "dual enrollment" and CMS compensation rules are applied to the two plans at once and independently of each other.

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.

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.

He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start.

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.

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.