Entertaining AHIP 2025

How does the Medicare Prescription Payment Plan work?

For beneficiaries facing high costs on their prescriptions, it provides them with the option of paying out-of-pocket drug costs in installments. It does not offer a discount, just manageable payments

Taylor Swiftie's grandma likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her?

An individual enrolled in a MA PFFS plan that does not include a Part D benefit may enroll in a stand-alone Part D prescription drug plan. This is true even if the organization offers another PFFS plan under the same MA contract that includes a Part D benefit.

Medicare Prescription Payment Plan

Beginning in 2025, the prescription drug law, known as the Inflation Reduction Act, requires all Medicare prescription drug plans (Medicare Part D plans) — including both standalone Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage — to offer enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once at the pharmacy.

Happy 420Camper, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollment in a Medicare Advantage plan (Part C). What should you advise Happy to do before she can enroll in a Medicare Advantage plan?

Eligibility to enroll in a Medicare Advantage plan requires entitlement to benefits under Part A and enrollment in Part B.

Mr. Jellyroll wants to know whether he is eligible to sign up for a private fee-for-service (PFFS) plan. What questions would you need to ask to determine his eligibility?

Eligibility to enroll in a PFFS plan is based on entitlement to Medicare Part A and enrollment in Part B. In addition, to enroll in a specific PFFS plan, the individual must reside in the plan's service area.

Hank's Fish Store, Inc. is a small company with just 15 employees located in Florida. Hankie, the store owner, has provided excellent health benefits to the store's workforce. William, one of the store's long-time employees, will soon be reaching age 65 and eligible for Medicare. William is in good health. He intends to remain an active full-time employee, working several years after becoming eligible for Medicare. What type(s) of retiree health benefit will Hank's Fish Store be able to offer William?

Employers with less than 20 employees (as calculated under Medicare secondary payor rules) may be able to offer Medicare Advantage plans to their active employees and their dependents. Larger firms are not able to offer such plans. In many cases, this helps small businesses save on health coverage costs since Medicare becomes the primary payor.

Nick Joynus, your neighbor is a retiree with substantial income. He is enrolled in an MA-PD plan and was disappointed with the service he received from her primary care physician because he was told he would have to wait five weeks to get an appointment when he was feeling ill. He called you to ask what he could do so he would not have to put up with such poor access to care. What could you tell him?

Enrollees or their representatives may file a grievance if they experience problems with their health care services, such as timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item.

Benefits of Medicare Prescription Payment Plan

Expanding benefits, lowering drug costs, and improving the sustainability of the Medicare program

Mr. Weekend 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?

Generally, a Part D beneficiary must stay with a premium payment option for the entire plan year.

Which of the following statement(s) is/are correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. Question 7Answer 1,2,4 a. II and III only b. I, II, and III only c. I, II, and IV only d. I and II only

I, II, and IV only

Tom Cruzie is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr. Lombardi's area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Cruzie likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell him about this situation?

If a beneficiary enrolls in a MA PPO plan that does not include Part D coverage, the beneficiary cannot join a stand-alone Prescription Drug Plan (PDP).

Post Chalone age 75 and enjoys a comfortable but not extremely high-income level. He wishes to enroll in a MA MSA plan that she heard about from her neighbor. He also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, he is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mr. Chalone?

MA MSA plans are prohibited from offering prescription drug coverage. If an MSA member wants prescription drug coverage, the member must enroll in a standalone PDP.

Dolly Pardon is in really good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan?

MSA enrollees must enroll in a stand-alone prescription drug plan (PDP) if they want prescription drug benefits.

A client enjoys a comfortable retirement income. He recently had surgery 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 some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him?

Medicare Advantage (MA) plan enrollees have a right to obtain a review (appeal) to certain decisions about health care payment, coverage of services, or prescription drug coverage. Medicare health plans must provide enrollees with a written description of the appeals process.

Mr. Swells 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 Original Medicare, Part A and Part B benefits, through private health insurance plans.

Mr. Martini 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?

Mr. Martini can stay in Original Medicare and obtain prescription drug benefits through a stand-alone Part D plan. He does not have to enroll in a MA plan.

Mr. Price is 68, actively working, and has coverage for medical services and medications through his employer's group health plan. He is entitled to premium free Part A and thinking of enrolling in Part B and switching to an MA-PD because he is paying a very large part of his group coverage premium, and it does not provide coverage for a number of his medications. Which of the following is NOT a consideration when making the change?

Mr. Price's retiree plan is not required to take him back if he drops the coverage it provides. The 63 days refer to the period a beneficiary can go without creditable drug coverage without incurring a Part D late enrollment penalty.

Mr. Mr. 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?

Part D plans must cover at least the Part D standard benefits or its actuarial equivalent. Part D plans are permitted to offer supplemental benefits that cover certain drugs not covered under Part D. Some Part D plans may offer these supplemental benefits for an additional monthly premium.

What is the Medicare Prescription Payment Plan?

Offers Part D enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once to the pharmacy under the Medicare Prescription Payment Plan.

Mrs. Apparently is one of your clients. She has read that there is a new program that may help her manage prescription drug costs. What do you tell her about the Medicare Prescription Payment Plan?

Part D enrollees can opt into the Medicare Prescription Payment Plan at the beginning of the plan year or any point during the year.

ShaShaSha 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?

Part D formularies must include at least two drugs in each therapeutic category whether or not generic versions are available. Mrs. Allen should be able to find a plan that covers the medications she needs.

What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?

Part D plans are not required to cover all prescriptions on the market. But they have various methods to manage costs including formularies, cost-sharing tiers, step therapy, prior authorization, and substitution.

A beneficiary 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?

She can enroll in a PPO without drug coverage. However, If a beneficiary enrolls in a MA plan that is an HMO or PPO plan that does not include Part D coverage, the beneficiary cannot join a standalone Prescription Drug Plan (PDP).

Mrs. Jaylo is a new Medicare beneficiary who has just retired from retail work. She is interested in selecting a Medicare Part D prescription drug plan. She takes several 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?

She is a new enrollee. Those initially enrolling in Part D, those switching plans, and current enrollees affected by formulary changes must receive coverage of a single one-month fill of their non-formulary drugs.

Gramcicle is enrolled in a cost plan for her Medicare benefits. 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).

She is enrolled in a Cost plan. This provides her with options as to how she secures Part D benefits. Beneficiaries enrolled in a Cost plan may obtain Part D benefits through their plan (if offered) or through a stand-alone (PDP).

Eleanor Rigby is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her?

She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy.

Your mom wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could you tell her?

Some Medicare Advantage Plans offer extra benefits that Original Medicare does not cover. Also, Original Medicare does not have a maximum out-of-pocket limit.

Mr. Flightrisk complains to you that because he takes multiple expensive drugs, he has trouble paying his cost sharing for his prescription drugs, particularly at the beginning of the year during the deductible phase. He is happy with his plan and does not want to change. However, he said he had heard about a new program called the Medicare Prescription Payment Plan and asked whether it might help. What do you tell him?

The Medicare Prescription Payment Plan helps spread out beneficiary cost-sharing payments but does not decrease the total amount owed.

A client is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Advantage (MA) plan?

The client is a dual-eligible. Dual-eligible beneficiaries may enroll in any type of MA plan except a MA Medical Savings Account (MSA) plan.

Mr. and Mrs. Joneses both take a specialized multivitamin prescription each day. Mr. Joneses takes a prescription to help to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them?

The drugs the Joneses are interested in may be covered as supplemental benefits.

Drew Looksatme 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?

The type of Medicare Advantage plans offered vary by employers. Therefore, beneficiaries should compare their employer's retiree plan with other available plan options.

Dua Lippa cares for her frail elderly mother, Maria, who lives in North Carolina. She is worried that without additional support, her mother will need to go into a nursing home. Ms. Lippa asks you if there is any Medicare plan that might allow her mother to remain in the community rather than going into a nursing home. How should you advise Ms. Lippa?

There are Programs of All-Inclusive Care for the Elderly (PACE) for frail elderly beneficiaries certified as needing a nursing home level of care but are able to live safely in the community at the time of enrolment.

A potential client has heard that he can sign up for a product called "Medicare Advantage" but is not sure about what type of plan designs are available through this program. What should you tell him about the types of health plans that are available through the Medicare Advantage program?

There are coordinated care Medicare Advantage plans that include HMOs and PPOs. There are also Private-Fee-for-Service (PFFS), Medicare Savings Account (MSA), and Special Needs Plans (SNPs)

Dr. DoLittle does not contract with the ABC PFFS plan but accepts the plan's terms and conditions for payment. Mary Rodgers sees Dr. DoLittle for treatment. How much may Dr. DoLittle charge?

This doctor can charge Mary Rogers no more than the cost sharing specified in the PFFS plan's terms and condition of payment which may include balance billing up to 15%of the Medicare rate. Because Dr. DoLittle accepts the plan's terms and conditions for payment, she is permitted to charge this amount.

A potential client calls and asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?

To be eligible to enroll in Medicare Advantage, an individual must be entitled (not enrolled) to Part A and enrolled in Part B.

George Clonie has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do?

To be eligible to enroll in a Medicare Advantage plan, a beneficiary must be entitled to Part A and enrolled in Part B.