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AHIP 2025 Final Exam 50 questions with
verified Answers
Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met. What could you tell her? - Answer -Original Medicare covers ambulance services. Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her? - Answer -Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because the features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her? - Answer -Part D covers prescription drugs and she should look at her premiums, formulary, and cost-sharing among other factors to see if they have changed. Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance? - Answer -She should contact her state
Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible. Mrs. Quinn recently turned 66 and decided after many years of work to retire and begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she had been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn? - Answer -Part B primarily covers physician services. She will be paying a monthly premium and, except for many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible. Anita Magri will turn age 65 in August 2023. Anita intends to enroll in Original Medicare Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel has told her about the Medigap Plan F in which he is enrolled. It not only provides foreign travel emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What should you tell her? - Answer -You are sorry to disappoint Anita, but a Medigap F plan is no longer available to those who turn age 65 after January 1,
- Anita might instead consider other Medigap plans that offer foreign travel benefits but do not cover the Part B deductible. Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should
Answer -You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Mr. Lombardi 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. Lombardi 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? - Answer -He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. Mr. Lopez 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? - Answer -There are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Mr. Kelly 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? - Answer -You would need to ask Mr. Kelly if he is entitled
to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - Answer -Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Mrs. Lyons is in 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?
- Answer -All MSAs cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling in a separate prescription drug plan. Mrs. Chou 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? - Answer -She could enroll in a PFFS plan and a stand- alone Medicare prescription drug plan. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you
Medicare prescription drug plan cover these drug needs. What should you tell them? - Answer -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 Vaughns could look into that possibility. 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? - Answer -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. 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? - Answer -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. Who is most likely to benefit from the Medicare Prescription Payment Plan? - Answer -Kevin, who suffered
a heart attack at the beginning of the year requiring him to take an expensive brand name blood thinner on a daily, as well as an equally expensive injectable cholesterol medication on a bi-weekly basis for which he incurs high out-of-pocket costs. 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? - Answer -In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Mr. Hildalgo 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? - Answer -The Medicare Prescription Payment Plan helps spread out beneficiary cost-sharing payments but does not decrease the total amount owed. Mrs. Hernandez 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? - Answer -Part D
may make comparisons between plans if you can support them with studies or statistical data and such comparisons are factually based and referenced. Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services (CMS) Communication and Marketing Guidelines to ensure he is compliant with which type of products. - Answer -Medicare Advantage (MA) and Prescription Drug (PDP) plans. A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do? - Answer -You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. Next week you will be participating in your first "educational event" for prospective enrollees. To be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage? - Answer -You should plan to ensure that the educational event is informative and must not conduct a sales presentation or distribute or accept enrollment forms at the event. You are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs. What should you keep in mind? - Answer -You may
request RSVPs, but you are not permitted to require contact information. During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5-star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the best statement to say to her? - Answer -The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4 stars. You will be holding a sales event soon, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation - Answer -Gift cards or gift certificates of $15 or less that can be readily converted to cash. Mr. Yoo's employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a special election period. Mr. Yoo contacted you to find out more about what this means. What can you tell him? - Answer -It means that he qualifies for a one-time opportunity to enroll in an MA-PD or Part D prescription drug plan. Mrs. Pierce would like to enroll in a Medicare Cost plan that offers Part D prescription drug coverage. She comes
and Part D) moves to a new home within the same neighborhood in his existing plan's service area.II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's service area.III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area where no Part D plan was available.IV. Henry makes a permanent move to a new state providing him with new MA and Part D options. - Answer -II, III, and IV only. Mr. Rodriguez is currently enrolled in a MA plan, but his plan doesn't sufficiently cover his prescription drug needs. He is interested in changing plans during the upcoming MA Open Enrollment Period. What are his options during the MA OEP? - Answer -He can switch to a MA-PD plan. Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period (AEP). On December 1, he calls you up and says that he has changed his mind and would like to enroll in a MA-PD plan. What enrollment rules would apply in this case? - Answer -He can make as many enrollment changes as he likes during the Annual Election Period and the last choice made before the end of the period will be the effective one as of January 1. Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him? - Answer - Mr. Chen can disenroll from his employer-sponsored
coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. Mr. Garcia was told he qualifies for a special election period (SEP), but he lost the paper that explains what he could do during the SEP. What can you tell him? - Answer -If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage. You would like to offer gifts of nominal value to potential enrollees who call for more information about a plan you represent. You would then like to offer additional gifts if they come to a marketing event. Each of the gifts meets the CMS definition of nominal value, but together, the gifts are more than the nominal value. Is this permissible? - Answer -Yes, as long as each of the gifts is $10 or less in value, and the total value of all gifts given to an enrollee in a year does not exceed $20. Mr. Polanski likes the cost of an HMO plan available in his area but would like to be able to visit one or two doctors who aren't participating providers. He wants to know if the Point of Service (POS) option available with some HMOs will be of any help in this situation. What should you tell him? - Answer -The POS option might be a good solution for him as it will allow him to visit out-of-network providers, generally without prior approval. However, he should be aware that it is likely he will have to pay higher cost- sharing for services from out-of-network providers.
