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. 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? - Mr. 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? - 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? - 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. ????? 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? - 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? - 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? - 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 him? - 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. Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him? - Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug coverage. What should you tell her about obtaining drug coverage? - 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.)