Mr. Rice is 68, Actively Working and Has Coverage

Mr. Rice 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? a. If his drug coverage through the employer plan is not creditable, his premium for Part D will be increased by the late enrollment penalty, unless he is eligible for the low-income subsidy. 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. Correct: Mr. Rice’s retiree plan is not required to take him back if he drops the coverage it provides. The 63 days refers to the time period a beneficiary can go without creditable drug coverage without incurring a Part D late enrollment penalty. c. If Mr. Rice is eligible for the low income subsidy, it will substantially decrease the cost of drugs and the premium for the Part D portion of his coverage. d. If Mr. Rice drops his coverage through the employer group plan, he may not be able to get it back. Feedback Source: Module 3, Slide - Employer Coverage of Drugs, continued Question 2 Correct Question text Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to? a. Yes, but Mrs. Walters must drop the employer coverage before enrolling in a Medicare prescription drug plan. b. No. As long as her employer offers coverage that is equivalent to that available through Medicare, Mrs. Walters cannot enroll in a Medicare prescription drug plan. c. No. Mrs. Walters will have to enroll in Part B to qualify for enrollment into the Medicare prescription drug program. d. Yes. Mrs. Walters must be entitled to Part A and/or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program. Correct. Mrs. Walters is eligible to enroll in Part D because she is entitled to Part A. An individual is eligible to enroll in Part D if the individual is entitled to Part A and/or enrolled in Part B. Feedback Source: Module 3, Slide - Medicare Part D Eligibility. Question 3 Correct Question text Mrs. Mulcahy, age 65, 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 decide to enroll in Part B prior to selecting a prescription drug plan. b. An individual 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:Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. c. 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. d. Like all Medicare beneficiaries, Mrs. Mulcahy will be automatically enrolled in 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. Feedback Source: Module 3, Slide - Medicare Part D Eligibility Question 4 Correct Question text 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. 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.The drugs the Vaughns are interested in may be covered as supplemental benefits. c. 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. d. 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. Feedback Source: Module 3, Slide - Drugs Excluded from Part D Coverage Question 5 Correct Question text Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan’s formulary he takes several other medications. These include a prescription drug not on his plan’s formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say? a. None of the costs of Mr. Wingate’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. Correct:None of the costs of Mr. Wingate’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. If he receives an exception under which the plan covers the drug, it could count toward TrOOP. b. The cost of all medications bought within the United States not covered by his plan would count toward TrOOP. The cost of the Canadian bought medications would not count toward TrOOP. c. The cost of the prescription drugs that are not on his plan’s formulary as well as the cost of the drug(s) to reduce joint swelling from the Canadian pharmacy will count toward TrOOP but the other medications in question will not count toward TrOOP. d. The cost of the prescription drug that is not on his plan’s formulary will count toward TrOOP but the other medications in question will not count toward TrOOP. Feedback Source: Module 3, Slide - True Out-of-Pocket Costs? (TrOOP): What Counts and Slice - True Out-of-Pocket Costs (TrOOP): What is Excluded? Question 6 Correct Question text 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 could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to 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: Some pharmaceutical manufacturers operate programs that assist low-income individuals. In addition, some states have assistance programs specifically for their residents. Some of the state programs are “qualified” and count toward TrOOP and some do not. b. He should look into the possibility of purchasing his medications through the internet from offshore pharmacies. c. 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. d. 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. Feedback Source: Module 3, Slide - Other Help for Low Income - Pharmaceutical Assistance Programs. Question 7 Correct Question text 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 allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medications 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. Correct: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. 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 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. Feedback Source: Module 3, Slide - Covered Part D Drugs Question 8 Correct Question text 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 could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him. b. Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication. c. 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. d. 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:Formulary exception requests can be used to request coverage of a drug not on a Part D plan’s formulary or to cover a formulary drug at a lower cost formulary tier. Feedback Source: Module 3, Slide - Enrollee Rights: Requesting Exceptions for Drugs. Question 9 Correct Question text Mr. Shapiro gets by on a very small amount of 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. 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. 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. 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. d. The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Correct:If a beneficiary has limited income and resources, they may qualify for a low-income subsidy (LIS) to cover all or part of the Part D plan premium and cost-sharing. Beneficiary income may not exceed 150 percent of the Federal Poverty Level (FPL). Assets may not exceed a limited amount also specified by the government. Feedback Source: Module 3, Slide - Help for Individuals with Limited Income and Limited Resources and Slide - Encourage Individuals with Limited Income/Resources to Apply to the State Medicaid Office Question 10 Correct Question text Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan? a. A Medicare Advantage Prescription Drug (MA-PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone prescription drug plan. Correct: The types of permissible plan options include a MA PFFS plan with Part D benefits obtained through that plan, a PFFS plan with only medical benefits, and a PFFS with enrollment in a standalone prescription drug plan. b. A Medicare Advantage Prescription Drug (MA-PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or PFFS Medigap Supplemental Insurance plan. c. A PFFS plan offering only medical benefits or a PFFS Medigap Supplemental Insurance plan. d. A stand-alone prescription drug plan in combination with a PFFS plan or a PFFS Medigap Supplemental Insurance plan. Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Eligibility Question 11 Correct Question text 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, II, and III only Correct:Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. Also, private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. Additionally, beneficiaries enrolled in an MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. b. I only c. I, II, III, and IV d. I and II only Feedback Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics, Slide - Medicare Part D Eligibility, Slide - Medicare Part D Prescription Drug Eligibility and Slide - Part D Pharmacy Network Question 12 Correct Question text Mrs. Fiore is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan? a. If Mrs. Fiore enrolls in a PDP, Medicare will automatically disenroll her from any other drug or health coverage. b. She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution. Correct:Mrs. Fiore should compare the creditable coverage offered by FEHB to Medicare Part D plans available in her area to see if the plans cover specific drugs of importance to her that are not covered under her FEHB plan and whether they offer any other additional benefits worth the Part D premium costs. c. 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. d. If Mrs. Fiore does not enroll during her initial election period, she will not be able to get Part D at a later date. Feedback Source: Module 3, Slide - Employer/Union Coverage of Drugs Question 13 Correct Question text One of your clients, Lauren Nichols, has heard about a Medicare concept from one of her neighbors called TrOOP. She asks you to explain it. What do you say? a. TrOOP refers to true out-of-pocket expenses paid by a Part D beneficiary for non-prescription over-the-counter (OTC) drugs and vitamins that are not covered by his or her plan. b. TrOOP stands for true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include only expenses paid directly by a Medicare Part D beneficiary. c. TrOOP stands for true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances drug manufacturer discounts. Correct: TrOOP stands for true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances drug manufacturer discounts. d. TrOOP refers to true out-of-pocket expenses paid by drug manufacturers on behalf of Medicare Part D beneficiaries. Feedback Source: Module 3, Slide - Part D Standard Benefits for 2023, Catastrophic Coverage, Slide True Out-of-Pocket Costs? (TrOOP): What Counts and Slide - True Out-of-Pocket Costs (TrOOP): What is Excluded? Question 14 Correct Question text 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 the prescriptions that she has lost. How would you advise her? a. 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. b. 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: There are some circumstances that allow for enrollees to utilize a non-network pharmacy. However, these prescriptions are typically filled at a higher cost to these enrollees. c. She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. d. 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. Feedback Source: Module 3, Slide - Part D Pharmacy Networks. Question 15 Correct Question text 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 for brand name and generic drugs, but they may not restrict access through prior authorization. b. Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market. 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. Correct: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. Feedback Source: Module 3, Slide - Part D Drug Management Tools, Slide - Formularies, and Slide Tiering Question 16 Correct Question text 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. Correct. If a beneficiary has limited income and resources, they may qualify for a low-income subsidy (LIS) to cover all or part of the Part D plan premium and cost-sharing. Such individuals can apply for LIS through the State Medicaid office or the Social Security Administration. b. Those who qualify for the Part D low-income subsidy pay nothing for any of their medications. She should apply if she believes there is any chance of her qualifying. c. 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. d. 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. Feedback Source: Module 3, Slide - Help for Individuals with Limited Income and Limited Resources and Slide - Encourage Individuals with Limited Income/Resources to Apply to the State Medicaid Office Question 17 Correct Question text 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 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. 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:To avoid a late enrollment penalty, Mr. Hutchinson must have “creditable” coverage. If he does not, he must enroll in Medicare Part D during his initial eligibility period to avoid a late enrollment penalty. c. 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. d. If 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. Feedback Source: Module 3, Slide - Employer/Union Coverage of Drugs and Slide - Part D Late Enrollment Penalty. Question 18 Correct Question text Mrs. Roswell 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 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. 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. b. She should use an existing prescription drug coverage to get as large a supply of her existing drugs as possible, and then personally pick new drugs that are covered under her Medicare plan’s formulary. 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. Correct:Mrs. Roswell 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. d. 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. Feedback Source: Module 3, Slide - Transition Requirements Question 19 Correct Question text Mr. Schultz 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. Schultz has lost his employer group coverage within the last two weeks. How would you advise him? a. Mr. Schultz should seek to continue employer group coverage through COBRA because it is likely to have superior benefits at a more permanent solution. 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. Correct:Mr. Schultz should enroll in a Part D plan, or otherwise obtain creditable drug coverage, before he has a 63-day break in order to avoid a premium penalty. c. 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. 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. Feedback Source: Module 3, Slide - Employer Coverage of Drugs and Employer/Union Coverage of Drugs, continued Question 20 Incorrect Question text All plans must cover at least the standard Part D coverage or its actuarial equivalent. Which of the following statements best describes some of the costs a beneficiary would incur for prescription drugs under the standard coverage? a. Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap. Incorrect: There is no longer a coverage gap due to its closure under the Affordable Care Act and the acceleration of the closure through subsequent legislation. Prior to the closure, Part D beneficiaries shouldered substantial costs until their drug costs reached catastrophic levels. b. Standard Part D coverage would require payment of an annual deductible, and once past the catastrophic coverage threshold, the beneficiary pays whichever is greater of either the co-pays for generic and brand name drugs or coinsurance of 5%. c. Standard Part D coverage would require payment of only fixed per-prescription co-payments. d. Standard Part D coverage would require payment of an annual deductible, fixed per-prescription co-payments, and once catastrophic coverage begins, the plan covers 100% of all costs. Feedback Source: Module 3, Slide - Part D Plan Benefits, Slide - Standard Part D Benefits for 2023 and Slide - Part D Standard Benefits for 2023, Catastrophic Coverage