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. Sinclair has diabetes and heart trouble
and is generally satisfied with the care he
has received under
Original Medicare, but he would like to
know more about Medicare Advantage
Special Needs Plans (SNPs).
What could you tell him?
SNPs have special programs for enrollees
with chronic conditions, like Mr. Sinclair,
and they provide prescription drug
coverage that could be very helpful as well.
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?
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.
Mr. Gonzalez is entitled to Part A, but has
not yet enrolled in Part B. If he wants to
enroll in a Medicare
Advantage (MA) plan, what will he have
to do?
He will have to enroll in Part B prior to
enrolling in a MA plan.
Mrs. Andrews asked how a Private Fee-
for-Service (PFFS) plan might affect her
access to services since she
receives some assistance for her health care
costs from the State. What should you tell
her?
Medicaid may provide additional benefits,
but Medicaid will coordinate benefits only
with Medicaid participating providers.
Mr. Olsen is concerned that a Medicare
Advantage plan will not cover the same
range of services that would be
covered under Original fee-for-service
Medicare. What should you tell him?
Though their cost-sharing may differ from
Original Medicare's, Medicare Advantage
plans are required to cover all services
covered by original Medicare.
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. She currently does not have
creditable coverage. What could you tell
her about the implications of
such a decision?
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.
You are doing a sales presentation for Ms.
Duarte and her son. Ms. Duarte has some
cognitive impairment and
her son informs you that he has power of
attorney to make financial decisions for
her. Can he execute the
enrollment for her?
No, he cannot execute the enrollment for
her. He must have a legal authorization,
under state law that explicitly allows him
to make health care decisions for his
mother.