AHIP Module 3

AHIP Module 3 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? - ANSWERb. 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. Correct 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? - ANSWERd. 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. Correct 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? - ANSWERa. If a Part D benefit is offered through her plan she may choose in enroll in that plan or a standalone PDP. Correct 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. - ANSWERb. I, II, and III only Correct 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? - ANSWERc. 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 coinsurance after the coverage gap. Correct 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? - ANSWERd. 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 socalled "donut hole" for brand name drugs to 2019. Correct 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? - ANSWERa. 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. Correct 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? - ANSWERd. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Correct What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? - ANSWERc. 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. Correct 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? - ANSWERa. 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. Correct 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? - ANSWERb. 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. Correct Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug during the first 60 days of the year? - ANSWERa. When a formulary change is in response to a drug's removal from the market. Correct 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 - ANSWERc. I, II and III only Correct 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? - ANSWERc. 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. 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? - ANSWERa. 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. Correct 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? - ANSWERb. 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. Correct 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? - ANSWERc. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Correct 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? - ANSWERd. Because he reached the coverage gap last year, he will probably reach it again this year close to the same time. Correct 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? - ANSWERa. Prescription drugs she purchases when in the Part D coverage gap. Correct 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? - ANSWERb. The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Correct 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? - ANSWERb. 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. Correct 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? - ANSWERa. 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. Correct 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? ANSWERa. 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. Correct 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? - ANSWERb. 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. Correct 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? - ANSWERc. 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. Correct 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? - ANSWERb. 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. Correct 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? - ANSWERc. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Correct