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AHIP FINAL EXAM TEST
QUESTIONS AND ANSWERS 2025
(VERIFIED ANSWERS)
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? correct answers: He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of15 employees and offers employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employer-sponsored healthcare coverage. How would you respond? correct answers: Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan. 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? correct answers: Medicare Supplemental Insurance would help cover his Part A and Part B deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover. Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her? correct answers: She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period after the last month on her employer plan that differs from the standard general enrollment period, during which she may enroll in Medicare Part B.
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? correct answers: Most individuals who are citizens and age 65 or over 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.
Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to Medicare beneficiaries? correct answers: Beneficiaries under Original Medicare have no cost-sharing for most preventive services which include immunizations such as annual flu shots.
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? correct answers: Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him?correct answersIt is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare. Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance?correct answersShe 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. Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital stay that Medicare will cover? correct answersMedicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime. 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?correct answersPart 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. Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed?correct answersTell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage. Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him?correct answersAfter receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.
What should you tell him?correct answersMedicare covers the periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered. Which of the following statement is/are correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full.correct answersI, II, and IV only 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?correct answersHe 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. 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?correct answersMrs. 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 a part of the PPO network. Mr. Romero is 64, retiring soon, and considering enrollment in his employer- sponsored retiree group health plan that includes drug coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him?correct answersHe should compare the benefits in his employer-sponsored retiree group health plan with the benefits in his neighbor's MA-PD plan to determine which one will provide sufficient coverage for his prescription needs. Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the
plan's terms and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan charge?correct answersDr. Brennan can charge Mary Rogers no more than the cost sharing specified in the PFFS plan's terms and condition of payment which may include balance billing up to 15% of the Medicare rate.
Medicare Advantage. What should you tell her?correct answersMrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. 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?correct answersMedicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers. 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?correct answersHe is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease (ESRD). What options will Mrs. Davenport have regarding her MA plan during the next open enrollment season?correct answersShe may remain in her ABC MA plan, enroll in another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him?correct answersIn most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network).ur clients, Lauren Nichols, has heard about a Medica 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 some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him?correct answersYou can offer to review the plans appeal process to help him ask the plan to review the coverage decision. 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?correct answersSNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well. 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
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?correct answersMr. 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. 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?correct answersHe 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. 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?correct answersMedicare 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. 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?correct answersNone 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. 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?correct answersShe may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in- network pharmacy.
Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. 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?correct answersIf a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP.
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%.
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?correct answersMedicare 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. 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?correct answersMr. 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. Which of the following individuals is most likely to be eligible to enroll in a Part D Plan?correct answersJose, a grandfather who was granted asylum and has worked in the United States for many years. 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?correct answersIf 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. 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 to her drug coverage? correct answersUnless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this?correct answersIf the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. 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
IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan.correct answersI, II, and III only 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?correct answersIn general, he must select a single Part D premium payment mechanism that will be used throughout the year. 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?correct answersGift cards or gift certificates of $15 or less that can be readily converted to cash. 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 marketing requirements as the plans themselves. How should you respond to such a statement?correct answersYour 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. Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you on October 15. During the appointment, what are you permitted to do?correct answersYou may provide her with the required enrollment materials and take her completed enrollment application. One of your colleagues argues that it is better to focus your time and energy exclusively in neighborhoods with single-family homes. He further argues that their older owners are more likely to have higher incomes and purchase the Medicare Advantage products you represent compared to those living in apartment complexes. How should you respond?correct answersThis could be considered discriminatory activity and a prohibited practice. 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?correct answersYou must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. 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?correct answersYou appreciate the opportunity and would be happy to schedule an appointment with anyone at their request.
