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AHIP Final Exam Test Questions 2023/
FINAL EXAM
America's Health Insurance Plans (AHIP) Exam
Study Guide Questions & Answers
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through acupuncture. She is concerned about whether or not Medicare will cover these items and services. What should you tell her? - ANSWER Medicare does not cover acupuncture, or, in general, glasses or dentures. 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? - ANSWER 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.
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 in one of the MA plans that include prescription drug coverage or a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. 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. Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational in nature. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational? - ANSWER Yes. When an event has been advertised as "educational," discussing plan-specific premiums is impermissible.
XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong? - ANSWER Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located. Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-Service (FFS) Medicare? What could you tell him? - ANSWER Part A, which covers hospital, skilled nursing facility, hospice and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare. You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation? - ANSWER You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score, although you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing. 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, but he should revaluate if he really wants to drop his employer coverage. Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him? - ANSWER He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Mr. Johannsen is entitled to Medicare Part A and Part B. He gains the Part D low- income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan? - ANSWER He qualifies for a special election period and can enroll in or disenroll from a Part D plan once during that period. Mr. Lopez, who is fairly well-off financially, would like to enroll in a Medicare prescription drug plan you represent and simply give you a check to cover his premiums for the entire year. What should you tell him? - ANSWER Enrollees should pay using automatic withdrawal from a bank account or credit or debit card, direct monthly billing from the plan, or deductions from their Social Security check.
prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? - ANSWER Mrs. Chi may enroll in a MS MSA plan and remain in her current standalone Part D prescription drug plan. Alice is enrolled in a MA-PD plan. She makes a permanent move across the country and wonders what her options are for continuing MA-PD coverage. What would you say to her in regard to a special enrollment period (SEP)? - ANSWER She is likely to qualify for a SEP. She can choose an effective date of up to three months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than the date of her permanent move. Which of the following individuals is most likely to be eligible to enroll in a part d plan? - ANSWER Jose, a grandfather who was granted asylum and has worked in the United States for many years. When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice would you give her? - ANSWER She should remain in Original Medicare until the annual election period running from October 15 to December 7, during which she can select an MA plan.
Mr. Chen has heard about Medical Savings Account (MSA), but wants to know if it is just about saving money, or if he will get insurance coverage for his health care expenditures as well. What should you tell him? - ANSWER Under the Medicare Advantage program. an MSA plan involves the combination of high deductible health plan and savings account for health expenses. Medicare will make contributions to this savings account to help him pay his health care expenses while in the deductible. Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her? - ANSWER Most individuals who are citizens and over age 65 are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums. 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? - ANSWER She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy.
bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do? - ANSWER As long as she is able to do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time. Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for Medicare as well. He is concerned about changes in his cost-sharing. What should you tell him? - ANSWER He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers. Mr. Barker 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 a number of services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? - ANSWER You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. 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. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? - ANSWER Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs 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 and appeal of this initial determination within 120 days of the date she received the MSN in the mail Your friend's mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him? - ANSWER You appreciate the
permanently increased by 1% of the national average premium for every month that she was not covered. Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can go to for her health care. What should you tell her? - ANSWER Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will have a higher cost-sharing amount if she sees a provider who/that is not part of the PPO network. Mr. Sanchez 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? - ANSWER He will have to enroll in Part B. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy? - ANSWER Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.
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? - ANSWER Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application prior the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams? - ANSWER This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form prior to the start of the AEP. Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same requirements as the plans themselves. How should you respond to such a statement? - ANSWER Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules. Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her? -
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? - ANSWER He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. 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. Types of Medicare Advantage Plans - ANSWER PPO, HMO, MSA, Cost Plan, PFFS Medicare-Medicaid plans - ANSWER Serve both Medicare and Medicaid individuals. Include Part D coverage. Individuals sometimes referred to as dual eligibles Medicare Cost Plan - ANSWER Type of Medicare health plan. Have Part B to enroll. Can join anytime plan is accepting new members. A non network provider will can charge higher coinsurances and deuctibles. Different
enrollment/disenrollment periods apply. Can get Part D Rx coverage if available, or apply for a separate PDP. Medicare Entitlement/Enrollment - Part A & Part B - ANSWER Individuals with ESRD may sign up at anytime. Date on which coverage begins is the fourth month after dialysis begins. Medicare Enrollment Period - ANSWER Individuals who do not enroll in Part B when first eligible can enroll during a General Enrollment Period, Jan 1st to Mar 31st each year. Coverage begins July 1st of that year. Medicare Enrollment Period - Group Health Coverage - ANSWER Individuals who have group health coveage through employer may enroll in Part A and/or Part B anytime while on group coverage during a Special Enrollment Period. Occurs during the 8 month period following last month of group coverage. Medicare Part A Premium - ANSWER Free if worked 40 quarters of your life and paid Medicare taxes. Premium is $240.00 for individuals or spouses who paid Medicare taxes for 30 - 39 quarters. Premium is $437.00 for less than 30 quarters.
Part D Low Income Subsidy - ANSWER Do not qualify for Part D Low Income Subsidy, but are of limited means, may qualify for help in Part D costs through State Pharmaceutical Assistance Program. Part A Benefits - ANSWER $1364.00 deductible for each benefit period. Days 1 - 60: $0 coinsurance. Days 61 - 90: $341.00 coinsurance per day. days 91 and beyond: $682.00 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over a beneficiarys lifetime. Beyond lifetime reserve days, all costs. Part A Benefits - ANSWER Blood, hospice, home health care, skilled nursing and rehabilitative care only after a 3 day hospital stay up to 100 days in a benefit period. In 2019, will pay $170.50 coinsurance for days 21 - 100 each benefit period. In patient psychiatric care is 190 lifetime days. Does not cover custodial or long term care. Part D Prescription Drug Coverage - ANSWER Late enrollment penalty of 1% of national standard premium for every month that beneficiary could have had Part D but didn't enroll. No penalty for beneficiaries with low income assistance or who join a Part D within 63 days of losing creditable coverage.
Medigap Prescription Drug Coverage - ANSWER If coverage is not creditable, individual dropping coverage and enrolling in Part D coverage will pay a late enrollment penalty, unless they qualify for "ExtraHelp" or enroll in Part D during Special Enrollment Period for loss of creditable coverage. If informed non Medicare is no longer creditable, will have an SEP to enroll without penalty. Medicare Advantage Eligibility - ANSWER Not eligible if have ESRD unless: MA Plan is a SNP plan for people with ESRD, OR person developed ESRD after enrolling in MA plan. Medicare Advantage Special Needs Plans - ANSWER Three types. Chronic Condition (CSNP) for specific severe or disabling conditions. Dual Eligible (DSNP) for entitlement to both Medicare and Medicaid. Institutionalized (ISNP) for individuals who need services in skilled nursing facility for 90 days or longer. All SNP plans include prescription drug coverage. MA Plan Types - Coordinated Care Plans - HMO's - ANSWER Some HMO's offer Point Of Service option. Allows enrollees to go to no plan doctors/hospitals without prior approval for sertain services. HMO-POS may limit services out of network or put cap on out of network coverage. Cost sharing is generally higher than from network providers
