AHIP Certification - Part 3

c

All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a beneficiary incur for prescription drugs in 2019 under the standard coverage? a. Standard Part D coverage would require payment of an annual deductible, fixed per-prescription co-payments, 35% of the costs in the coverage gap, and once catastrophic coverage begins, the plan covers 100% of all costs. b. Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap. c. Standard Part D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a portion of costs for both generics and brand-name drugs in the coverage gap, and co-pays or co-insurance after the coverage gap. d. Standard Part D coverage would require payment of only fixed per-prescription co-payments.

d

Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him? a. He should contact his neighbors and family members and let them know that any contributions they make toward his drug expenses will be tax deductible. b. The only option available is to reduce his income so that he can qualify for the Part D extra help or wait until next year to see if the annual limits change. c. He should look into the possibility of purchasing his medications through the internet from off-shore pharmacies. d. He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses.

d

Mr. Rice has coverage for medical services and medications through his employer's retiree plan. He is considering switching to a Medicare prescription drug plan because his retiree plan does not cover two important medications. What should he consider before making a change? a. If his drug coverage through the retiree plan is "creditable" he should not switch, even though it is possible to do so. b. Mr. Rice's retiree plan is required to take him back if, within 63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his Medicare Part D plan. c. Mr. Rice can only receive his prescription drug coverage through a Medicare Advantage prescription drug plan so he should drop his employer coverage. d. If Mr. Rice drops his drug coverage through the retiree plan, he may not be able to get it back and he also may lose his medical health coverage.

a

Mrs. Fields wants to know whether applying for the Part D low income subsidy will be worth the time to fill out the paperwork. What could you tell her? a. The Part D low income subsidy could substantially lower her overall costs. She can apply by contacting her state Medicaid office, or calling the Social Security Administration. b. The Part D low income subsidy is designed for Medicare beneficiaries who also qualify for Medicaid. If she does not qualify for Medicaid, she would likely not qualify for the extra help and therefore should not take the time to apply. c. Those who qualify for the Part D low income subsidy pay nothing for any of their medications. She should definitely apply if she believes there is any chance of her qualifying. d. The Part D low income subsidy will not help her once she reaches the coverage gap, so she need not take the time to apply.

c

Mrs. Quinn has just turned 65, is in excellent health, and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. What could you tell her about the implications of such a decision? a. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, if she does sign up at a later date, she will be required to pay a higher premium during the first year that she is enrolled in the Medicare prescription drug program. After that point, her premium will return to the normal amount. b. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, if she does sign up at a later date, she will have to pay a one-time penalty equal to 10% of the annual premium amount. c. If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered. d. If she does not sign up for a Medicare prescription drug plan, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications.

b

Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him? a. Mr. Carlini can keep Original Medicare, but if he does not sign up for an MA plan that includes prescription drug coverage, he will only be able to obtain prescription drug coverage through a Medigap plan. b. Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. c. Mr. Carlini can obtain drug coverage through the Federal government's fallback plans, which are designed to provide an alternative to privately sponsored Medicare Advantage plans. d. In order to obtain prescription drug coverage, Mr. Carlini must enroll in an MA plan. The plan will cover his Part A and Part B services, as well as provide him with the desired prescription drug coverage.

b

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? a. He will need to enroll in a Medicare prescription drug plan upon becoming eligible for the program in order to avoid a premium penalty. To reduce his expenses, he should look for a plan with a zero premium. b. 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. c. As long as he has any sort of employer coverage, regardless of the level of coverage, he will incur no penalty if he does not enroll in a Part D plan when first eligible. d. He should drop the employer coverage and enroll in a Medicare prescription drug plan. Employer plans are almost always more costly for beneficiaries and most do not cover the same range of drugs available from a Medicare prescription drug plan.

b

Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums and cost sharing. How can you explain this to him? a. The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval. b. Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. c. The Part D standard model's importance is that it is the only type of plan into which low-income beneficiaries can enroll and still receive any extra help for which they may qualify. d. The government bases its payments to Part D plans on the standard benefit model. For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries.

b

Mr. Katz reached the Part D coverage gap in August last year. His prescriptions have not changed, he is keeping the same Part D plan and the benefits, cost-sharing, and coverage of his drugs are all the same as last year. He asked what to expect for this year about his out-of-pocket costs. What could you tell him? a. Because he reached the coverage gap in August last year, he probably will reach it much earlier this year. b. Because he reached the coverage gap last year, he will probably reach it again this year close to the same time. c. Because he reached the coverage gap in August last year, he probably won't reach it until much later this year. d. Because he reached the coverage gap last year, he will not have to go through it again this year.

c

Mr. Shapiro gets by on a very small fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him? a. He must apply for the extra help at the same time he applies for enrollment in a Part D plan. If he missed this opportunity, he will not be able to apply for the extra help again until the next annual enrollment period. b. The government pays a per-beneficiary dollar amount to the Medicare Part D prescription drug plans, to offset premiums for their low-income enrollees in accordance with the plan's set criteria. Mr. Shapiro should check with his plan to see if he qualifies. c. The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. d. The extra help is available only to Medicare beneficiaries who are enrolled in Medicaid. He should apply for coverage under his state's Medicaid program to access the extra help with his drug costs.

b

Mr. Shultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has lost his employer group coverage. How would you advise him? a. Mr. Schultz should immediately enroll in a Part D plan but he can expect to pay a premium penalty because he failed to enroll when first eligible. b. Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty. c. Mr. Schultz should seek to continue employer group coverage through COBRA because it is likely to have superior benefits at a more reasonable price. d. Mr. Schultz can wait up to 180 days after the loss of his creditable employer group coverage before enrolling in a Part D plan without worrying payment a premium penalty.

d

Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him? a. As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding should begin, he can change his method of Part D premium payment and withholding will begin the month after his savings account is exhausted. b. During 2017, many people experienced significant problems with deductions from their Social Security check for their Part D premium. As a result, this method of payment is no longer an option for Part D premium payments c. In general, to pay his Part D premium, he only can have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals. d. In general, he must select a single Part D premium payment mechanism that will be used throughout the year.

c

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? a. Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication. b. Mr. Zachow will have to wait until the Annual Election Period when he can switch Part D plans. In the meantime, he will have to pay for his drug out of pocket. c. 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. d. Mr. Zachow could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him.

c

Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? a. Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmetic purposes. b. Mr. Vaughn's hair growth medication would only be covered under Part D if his balding resulted from an illness or was a side effect of a treatment such as chemotherapy. c. Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn's could look into that possibility. d. The vitamins the Vaughns are taking will be covered under Part D, because their physician suggested they should take vitamins, but the hair loss medication cannot be covered.

b

Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? a. Medicare prescription drug plans are required to include only a certain percentage of brand name drugs among those they cover. It may be possible that plans available in her area have opted not to include in their formularies the brand name drugs she needs. She may need to pay for this particular medication out of pocket. b. Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs. c. When medication costs exceed a certain threshold amount, which rises each year, a Medicare prescription drug plan is permitted to exclude coverage for all but the least expensive of the medications in a given category. Mrs. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives. d. Medicare prescription drug plans are allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medications out of pocket.

a

Mrs. Andrews was preparing a budget for next year because she takes quite a few prescription drugs, she will reach the coverage gap, and wants to be sure she has enough money set aside for those months. She received assistance calculating her projected expenses from her daughter who is a pharmacist, but she doesn't think the calculations are correct because her out-of-pocket expenses would be lower than last year. She calls to ask if you can help. What might you tell her? a. It would not be unusual for her costs to be a bit less because the Bipartisan Budget Act of 2018 moved up the date for closing the so-called "donut hole" for brand name drugs to 2019. b. There is likely an error in the calculations because prescription drug costs continue to rise, so her costs will probably be much higher next year. c. There is likely an error because she will be paying 86 percent of the cost of generic drugs in the coverage gap in 2019. d. It would not be unusual for her costs to be substantially less because a new requirement will result in generic drugs being automatically substituted for brand name drugs in the coverage gap.

b

Mrs. Fiore was in the Army for 35 years and is now retired. She has drug coverage through the VA. What issues might she consider with regard to whether to enroll in a Medicare prescription drug plan? a. Costs under the VA are significantly higher than those under a Medicare Part D plan. b. She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the VA for the specific medications she needs and whether any additional benefits are worth the Part D premium costs. c. The VA will not offer drug coverage to Mrs. Fiore once she qualifies for the Medicare Part D program. d. The VA does not offer creditable coverage and Mrs. Fiore may incur a Part D premium penalty if she enrolls in a Medicare prescription drug plan at some point after her initial eligibility date.

b

Mrs. Grant uses several very expensive drugs and anticipates that she will enter catastrophic coverage at some point during the year. To help her determine when she is likely to qualify for catastrophic coverage, she asked which expenses count toward the out-of-pocket limit that qualifies her for catastrophic coverage. Which one of the following would count? a. Prescription drugs she purchases on her own that are not on her Part D plan's formulary. b. Prescription drugs she purchases when in the Part D coverage gap. c. Prescription drugs she purchases on her vacation to Canada. d. Non-prescription, over-the-counter medications she purchases.

a

Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost creditable coverage previously available through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her? a. If a Part D benefit is offered through her plan she may choose in enroll in that plan or a standalone PDP. b. Mrs. Lopez must first seek COBRA benefits under her husband's plan before she can apply for Part D coverage. c. If a Part D benefit is offered through her plan she must enroll in this plan. d. Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage.

d

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? a. She can change Medicare Part D prescription drug plans only during the annual election period. b. Medicaid will cover all drugs not covered under the Medicare Part D prescription drug plan into which Mrs. McIntire is enrolled. c. She will continue to obtain her drug coverage through Medicaid. d. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.

c

Mrs. Mulcahy is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her? a. To qualify for enrollment into a Medicare prescription drug plan, Mrs. Mulcahy must be entitled to Part A and enrolled under Part B. She should contact her local Social Security office and make arrangements to enroll in Part B prior to selecting a prescription drug plan. b. As long as Mrs. Mulcahy is 65, eligibility for a Medicare prescription drug plan is not dependent on entitlement to Part A or enrollment under Part B, so she should not be concerned. c. Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. d. Like all Medicare beneficiaries, Mrs. Mulcahy will be automatically enrolled into a Medicare prescription drug plan when she turns 65. She will have a six month window during which she can select a plan other than the one into which she has been automatically enrolled.

c

Mrs. Roswell is a new Medicare beneficiary and is interested in selecting a Medicare Part D prescription drug plan. She takes a number of medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her? a. There is no possibility of obtaining coverage for her existing medications once coverage under the Medicare Part D plan begins. She will need to have her physician help her select a new drug that is covered. b. The Medicare Part D drug plan is required to offer her coverage of the exact same drugs that she is currently stabilized on, so she does not need to be concerned about transitioning to any new medications. c. Every Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90 day transition period. d. She should use any existing prescription drug coverage to get as large a supply of her existing drugs as possible, and then pick new drugs that are covered under her Medicare plan's formulary.

c

Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of her prescriptions that she has lost. How would you advise her? a. She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan's network. b. She may fill one prescription out-of-network per year and it will be fully covered. Her second prescription will require her to pay the full cost out-of-pocket. c. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. d. She may fill both prescriptions and they will be fully covered at in-network pricing due the fact that she is traveling.

d

Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year? Choose one answer. a. If the Medicare prescription drug plan can show that reducing coverage early in the year will result in savings for the Part D plan and the Medicare program, generally the plan may make such a change. b. Under no conditions can a Medicare Part D prescription drug plan reduce its coverage for a given drug at any point during the year. c. When the Part D plan can demonstrate to CMS that no enrollee has accessed the medication in the past six months, generally the plan can remove the drug from its formulary within the first 60 days of the year. d. When a formulary change is in response to a drug's removal from the market.

d

What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? a. Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market. b. Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrict access through prior authorization. c. The Federal government establishes a set formulary, or list of covered drugs, each year that the Part D plans must use. Beneficiaries should consult the government's list prior to deciding whether they wish to enroll in a Part D plan during that year. d. Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization.

d

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. a. I and II only b. I only c. I, II, III, and IV d. I, II, and III only

a

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. a. I, II and III only b. I, II, III, and IV c. I and II only d. I only